Treatments Abound for Enlarged Prostate
Michael Lasalandra Beth Israel Deaconess Medical Center correspondent
NOVEMBER 01, 2015
As men age, their prostates enlarge. By the time men are in their 40s or 50s, many are already experiencing symptoms, such as having to get up at night to urinate. Into their 60s and 70s, they may have to get up two or three times.
In addition, an enlarged prostate can also result in other urinary symptoms such as having to go frequently during the day, having a weak stream or having to go urgently. The reason is that as the prostate grows, it can squeeze or partly block the urethra, the tube that allows urine to pass out of the body.
“Some of my patients say they know where every bathroom is on their route from home to work,” says Abraham Morgentaler, MD, a urologist at Beth Israel Deaconess Medical Center and director of Men's Health Boston, a men’s health center. “Some guys even carry a jug in their car because once they have to go they have to go right away.”
The “gold standard” treatment for this condition, known as benign prostatic hyperplasia (BPH), has been around for nearly 100 years. It is called a transurethral resection of the prostate (TURP), where an instrument is inserted up the urethra to remove prostate tissue that is blocking urine flow. It is sometimes colloquially referred to as a “roto-rooter” procedure.
“TURP is much better now than it was in the past with advances in technology,” says Dr. Morgentaler.
The idea is to carve out the inner portion of the prostate and leave just the shell.
“It is the most effective treatment we have,” he says. “It allows a much stronger stream and men who have it will have to urinate much less frequently.”
However, the procedure requires general anesthesia and a hospital stay. While it does not usually interfere with the ability to have an erection, about half of those who undergo TURP will experience “retrograde ejaculation,” meaning that no fluid comes out of the penis during orgasm. Instead, the fluid goes into the bladder, where it is eliminated during urination.
Similar procedures known as GreenLight Laser Treatment, which uses a high-energy laser to vaporize prostate tissue, and holmium laser enucleation of the prostate (HoLEP), which also uses a laser to destroy prostate tissue, are also available.
“They are pretty much the same in terms of outcomes,” Dr. Morgentaler says. “They just use different energy sources.”
Side effects may vary.
In recent years, there have been a number of medications brought to market that can deal with the problem of BPH without surgery.
Alpha blockers, such as Flomax, work to relax muscles around the opening of the bladder as it joins the prostate, reducing resistance. These medications can also result in retrograde ejaculation.
Another type of medication, called alpha reductase inhibitors, such as Proscar or Avodart, work to shrink the prostate. They take several months to start working and may cause sexual side effects, such as reduced desire or ability to get an erection, in some men.
Yet another type of medication, particularly for those with frequency and urgency issues, is called an anticholinergic, which blocks a nervous system neurotransmitter to help relax the bladder. These medications are typically prescribed for a condition known as overactive bladder syndrome. Brands include Ditropan and Detrol.
More recently, one brand of drug for erectile dysfunction, Cialis, has also been found to help treat the symptoms of BPH. It must be taken at a low dose on a daily basis for this purpose. The mechanism for how it works is not entirely clear.
“We use many of these medications in combination,” says Dr. Morgentaler. “The advantage of pills is they are easy to take and convenient. The downside is they don’t cure the problem. They just manage it.”
Treatments, by contrast, may eliminate the need for medications entirely, he adds.
A newer outpatient procedure, called transurethral needle ablation or TUNA, involves insertion of a scope through the tip of the penis into the urethra. Using the scope, the doctor guides tiny needles into the prostate tissue that is pressing on the urethra. Then radio waves are passed through the needles to heat and destroy prostate tissue, opening up the channel so that urine can flow more easily.
TUNA is done in the doctor’s office under local anesthesia. It takes about 30 minutes. The risk of erectile problems or retrograde ejaculation is extremely remote, says Dr. Morgentaler.
“The results are very good,” he says. “Not as good as TURP, but better than pills.”
The procedure is also known as radiofrequency ablation or RF therapy.
A study is currently underway at Men’s Health Boston investigating the effectiveness of yet another treatment that involves the injection of a chemical that has the potential to kill prostate cells and targets prostate-specific antigen or PSA, a protein produced by prostate cells. When the chemical is exposed to light that is introduced into the prostate through a probe via the penis, the tissue dies. Data is not yet available on the effectiveness of the treatment.
“The message to men is that if you are 60 or older and you have any of these symptoms and they are bothersome, talk to your doctor,” says Dr. Morgentaler. “We have a number of treatments that are effective and safe.”