BPH treatment options when drugs are not enough

Most men develop some degree of prostate enlargement as they age. In many cases, the enlarged gland presses against the passage that leads out of the bladder, making it hard to urinate. This noncancerous condition, called benign prostatic hyperplasia (BPH), is treatable with medications and lifestyle changes (such as limiting fluids before bed). But if urinary symptoms worsen despite these strategies, or if treatment side effects become too bothersome, the next step is surgery.

Surgical procedures physically remove or reposition prostate tissues that block urine flow, and they can provide lasting relief. With the number of surgical options growing steadily, choosing among them can be a daunting prospect.

“There isn’t one surgical approach that’s right for all men,” says Dr. Heidi Rayala, an assistant professor of surgery at Harvard Medical School and a urologist at Beth Israel Deaconess Medical Center. “Men really need to think about their priorities and do a bit of self-education, then sit down with a urologist to talk through which options make the most sense for them.”

A question of trade-offs

All BPH procedures involve a tradeoff between benefits and side effects. Many men are especially concerned about ejaculation. Because the prostate helps produce semen and contracts during orgasm, many BPH treatments can reduce the amount of semen released during orgasm or cause “dry” orgasms (retrograde ejaculation). Erections and sexual pleasure are usually preserved. Dr. Rayala explains that the BPH procedures that offer the longest-lasting relief of urinary symptoms are also the ones most likely to disrupt ejaculation.

Size matters

The best procedure for BPH depends in part on the size and shape of the prostate. A normal adult prostate weighs between 20 and 30 grams, but an enlarged gland in someone with BPH can weigh 200 to 300 grams or more. Men whose prostates are moderately enlarged — up to 80 or 90 grams — have more diverse options for procedures, such as the following.

Transurethral resection of the prostate (TURP). For decades, TURP was considered the gold standard surgical treatment for BPH. During TURP, a surgeon inserts instruments through the urethra and removes obstructing prostate tissue with an electrified wire loop. TURP remains an effective option for men with small- to moderate-sized prostates and has one of the longest track records of follow-up data. However, most men who have the procedure develop retrograde ejaculation.

Laser procedures. Several laser-based procedures are now available. Photoselective vaporization of the prostate (known by the brand name GreenLight) vaporizes obstructing tissue and can be a good option for men who take blood thinners. Holmium laser enucleation of the prostate (HoLEP) removes the entire obstructing portion of the prostate and can be used for prostates of almost any size, including very large glands that previously required open surgery. Like TURP, HoLEP commonly affects ejaculation. But HoLEP is also, as Dr. Rayala puts it, a “one-and-done” procedure offering symptom relief that can last several decades.

Aquablation. Aquablation uses robotically guided jets of pressurized salt water to remove prostate tissue. It is particularly attractive for men who place a high priority on preserving ejaculation, which remains intact in most patients. Aquablation can be used for prostates ranging from moderate to relatively large size, though long-term data are not yet as extensive as for TURP or HoLEP.

Most of these procedures are performed in an operating room under general or regional anesthesia. Many patients go home the same day or after an overnight stay, often with a temporary urinary catheter. During recovery, symptoms such as burning with urination, urinary frequency, urgency, and blood in the urine are common and usually improve over several weeks. Long-term urinary incontinence is uncommon.

Minimally invasive procedures

The latest trend in BPH treatment entails office-based procedures such as water vapor thermal therapy (Rezum), prostatic urethral lift (UroLift), and prostatic artery embolization. These procedures are often appealing to men who wish to avoid major surgery and preserve sexual function, particularly ejaculation. However, they are generally best suited for men with smaller prostates and may not provide the same degree or duration of symptom relief as more definitive procedures. Dr. Rayala suggests they’re suitable mainly for younger, sexually active men who accept that they might need a bigger procedure later, or older men who are too frail for more invasive surgery.

Final thoughts

Dr. Rayala urges men to keep in mind that BPH is a progressive condition. “Unfortunately, the prostate is the one organ in the body that continues to grow as men age,” she says. “Many men want to delay treatment as long as possible, but long-term obstruction can cause strain and damage to the bladder. Earlier treatment may help prevent long-term bladder problems while also improving quality of life.”

For more information, check out the Harvard Special Health Report Guide to Prostate Diseases.

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