Treatments for an Enlarged Prostate

An enlarged prostate (otherwise known as benign prostatic hyperplasia (BPH)) is a common issue faced by older men. While it is not cancerous, if growth continues unrestrained, your urinary function may continue to worsen. Thankfully, now you can select from an array of effective options when considering BPH therapy.

The growth in prostate size is generally driven by male sex hormones such as testosterone. However, testosterone works only when activated by the enzyme 5-alpha reductase, which can be blocked by inhibitors. As such, 5-alpha reductase inhibitors are a useful treatment for an enlarged prostate. These include Finasteride (Proscar®) and Dutasteride (Avodart®).

Notably, these treatments lower prostate-specific antigen (PSA) levels significantly, and will be considered when assessing your risk for prostate cancer in the future. Generally, your prostate size may decrease by around 20 to 40% after 6 months of treatment.

Alpha blockers work by relaxing the muscles in your bladder and prostate, allowing your urine to flow with ease. The latest treatments for an enlarged prostate include tamsulosin (Flomax®), alfuzosin (Uroxatral®), and silodosin (Rapaflo®). These are generally used for those with smaller prostates or younger men.

If your situation is severe, alpha blockers may be better for you as they work faster than 5-alpha reductase inhibitors. For those at significant risk of complications due to an enlarged prostate, combined therapy with 5-alpha reductase inhibitors and alpha blockers may be necessary.

In the past, surgery used to be the only solution available to treat an enlarged prostate. Now, it serves as a reliable alternative if drug therapies prove to be ineffective for you, and continue to affect your quality of life significantly.

However, if you face recurrent urinary infections, complete urinary retention (being unable to empty your bladder fully) or bladder stones despite medical treatment, surgery may become mandatory in such cases. Transurethral resection of the prostate (TURP) is the current gold standard to treat an enlarged prostate. TURP removes parts of the prostate blocking the urethra without needing to make any incisions. This is done by inserting an electric wire loop into the penis that will reach the prostate via the urethra. The loop will then be heated in order to simultaneously cut the excess prostate tissue and seal the wounds, to limit any bleeding during the procedure.

While TURP has minimal effects on incontinence and erectile dysfunction, you may need to prepare for ejaculation issues. This can occur due to the potential disruption of the bladder muscles used to hold in urine. If the opening between the bladder and urethra is unable to close completely, there is a risk of semen flowing backwards into the bladder, rather than out through the penis. As such, although you will likely be able to experience climax after the surgery, you may still face dry ejaculation.

Beyond TURP, there are various techniques to surgically treat an enlarged prostate. Those with a low risk of losing ejaculation include:

• Incision of bladder neck (with laser or electric wire loop)

Small cuts will be made in the outlet of the bladder that leads to the urethra. This would help to relieve obstructions and improve urine flow. However, while this method is less invasive than TURP, this may only be suitable for certain patients, depending on where the obstruction is located.

• Prostatic urethral lift procedure (e.g. UroLift)

Rather than removing prostate tissue, UroLift places implants which hold and prevent the prostate from blocking the urethra, in order to improve urine flow.

• Water vapor thermal therapy (e.g. Rezum)

Rezum treats an enlarged prostate by injecting steam into the prostate, for a few moments, in order to break down prostate cancer tissue gently. By removing the blockage from the urethra, your urine flow will improve.

However, some of these treatments are still new (e.g. Urolift or Rezum), with limited data on how effective they are in the long run.

Other alternatives may carry a higher risk of losing ejaculation, including:

• Laser vaporization of excess prostate tissue
• Laser or bipolar resection of the prostate
• Open/laparoscopic/robotic prostatectomy

Ultimately, the best treatment for an enlarged prostate should be tailored based on underlying clinical conditions, gravity of symptoms, presence of complications, prostate volume and your personal preferences (e.g. how much risk you are comfortable with).

Rest assured, immediate treatment is not always necessary for an enlarged prostate. If your tests do not raise any major concerns and your symptoms don’t bother you very much, annual monitoring by a physical examination, blood and urine tests and symptom observation may be enough to manage an enlarged prostate.