HLN recently had the pleasure of sitting down with UTMC urologic oncologist Firas Petros, MD, and Puneet Sindhwani, MD, chairman of the UTMC department of urology, to discuss various aspects of prostate health. In part 1 of this series, which appeared in the April 2020 issue of Healthy Living News, Dr. Petros shared his expert insights on prostate cancer diagnosis and genetic testing. This month, Dr. Sindhwani discusses the diagnosis, symptoms, and advanced treatment options for benign prostatic hyperplasia, or BPH.
HLN: What exactly is the prostate and what causes it to become enlarged?
Dr. Sindhwani: The prostate is a small gland, about the size of a walnut, located at the base of the bladder. Its role is to help nourish sperm as it passes through the reproductive channel. The prostate is the one organ in men that is hormone dependent, meaning its growth and function are related to hormonal status.
Enlargement of the prostate tends to occur naturally as men age, which is a condition known as benign prostatic hyperplasia, or BPH. Prostate enlargement can also occur as a result of inflammation, infection, or cancer. A genetic component may also be involved, as BPH usually runs in families. Some studies show that environmental and dietary factors can influence prostate enlargement as well.
HLN: What are some common symptoms of BPH, and why is prostate enlargement a cause for concern?
Dr. Sindhwani: The prostate gland is located around the urethra, so when it becomes enlarged, it can cause obstruction of the urinary stream. As a result, men with this condition may have to stand and wait to start urinating, strain to empty the bladder, have a weak and/or intermittent stream, and dribble for a long time toward the end of urination. If it goes on too long, it can also lead to increased frequency of urination, causing them to wake up multiple times during the night, as well as urgency, or feeling the need to run to the bathroom to urinate.
These symptoms can significantly impact quality of life, the ability to get a good night’s sleep, and job performance. If left untreated, the back pressure associated with prostate enlargement can also do irreparable harm to the bladder and can even be transmitted to the kidneys, causing damage.
It’s important to be aware that many other conditions can overlap and have similar symptoms to BPH, for example narrowing of the urethra due to previous infection or injury; bladder problems such as a stone, inflammation, or infection; or something as serious as cancer around the bladder. So, if you experience symptoms, it’s important to get checked out to determine why.
HLN: What testing is available for patients with symptoms of enlarged prostate?
Dr. Sindhwani: When you go to your urologist, he or she will typically perform an exam to check the size of the prostate and do a simple test called a uroflow study, which involves urinating into a special funnel-shaped machine that’s hooked up to a computer. The test measures the flow and force of the urine stream and helps determine whether the bladder is emptying properly. You’ll also have bloodwork done to check your kidney function and prostate-specific antigen, or PSA, level.
HLN: Can BPH be treated effectively with medications?
Dr. Sindhwani: If the BPH is early stage and the enlargement is minimal, treatment typically begins with medication. In the past, this meant life-long treatment with medications such as Flomax or Rapaflo, which help the prostate relax so urine can flow more easily. However, these medications treat the symptoms, not the underlying problem, and they’re not without side effects. For example, they can cause dizziness, muscle weakness, and drop in blood pressure, increasing the patient’s fall risk.
There are other medications that are slow-acting and work by taking the active hormone away from the prostate so it starts to shrink. This happens slowly over time, and it can take six months to a year to see the full benefit. These medications can also cause a hormonal imbalance, mainly in the form of sexual dysfunction, enlargement or tenderness of the breasts, and problems with ejaculation.
Both forms of medication have their advantages and disadvantages, so patients have to work with their urologist to determine which is best for them.
HLN:When is surgery appropriate for treating BPH, and what are the latest surgical options?
Dr. Sindhwani:If symptoms aren’t improving with medications or the patient wants to come off medication due to side effects, surgery may be appropriate. In the past, doctors went straight to a procedure called transurethral resection of the prostate, or TURP, which involves scraping away prostate tissue from the inside. The downside to TURP is that it has to be done in a hospital under general anesthesia. Also, some patients having the procedure require transfusion, and there can be issues with electrolyte imbalance. Many elderly patients can’t undergo TURP, especially if they are on blood thinners.
The good news is, thanks to advances in technology, there are now minimally invasive surgical techniques for treating enlarged prostate that can be done without general anesthesia and, in many cases, right in the office. Furthermore, the majority of patients who undergo a minimally invasive procedure maintain the ability to ejaculate, which is not the case with older surgical techniques.
The newest of these minimally invasive procedures is Rezum water vapor therapy. Rezum is performed in the office under local anesthesia and involves inserting a scope with a needle into the prostate and injecting steam at high pressure. The steam destroys prostate tissue, causing the prostate to shrink, and the dead tissue is absorbed naturally by the body. The number of sites injected depends on the size of the prostate, but typically ranges between four and six.
The procedure takes from 15 minutes to a half hour, and most patients require no pain meds, blood transfusion, or lab work post surgery. Some do need a catheter for a short time afterward, but we can usually remove it in the office after two to five days. Also, there’s no need to stop taking blood thinners before undergoing water vapor therapy.
Another minimally invasive option is UroLift, which is also done in the office under local anesthesia with no requirement to stop blood thinners. With this procedure, clips are used to move the lobes of the prostate laterally and hold them apart—sort of like tying back curtains—so they no longer block the urethra and urine can flow more easily. UroLift provides good temporary relief for high-risk anesthesia patients, and the majority of patients do not need to be catheterized afterward. However, it’s not as durable as Rezum because the prostate can regrow and re-obstruct the urethra.
Both Rezum and UroLift are available at The University of Toledo Medical Center. In fact, we were the first in the area to offer these procedures. There are categories of patients that will benefit more from either technique, and which one we choose depends on the anatomy and overall health of the patient among other factors.
For more information or to schedule a consultation with a UTMC urologist, call 419-383-3578 or 419-473-3446.