Enlarged Prostate Treatment

July 1, 2024

This page was reviewed under our medical and editorial policy by Wesley Yip, M.D., assistant professor, Division of Urology and Urologic Oncology, Department of Surgery, and Tanya Barauskas Dorff, M.D., professor, Department of Medical Oncology & Therapeutics Research, City of Hope^® Cancer Center Duarte

Many treatment options exist for men with an enlarged prostate, ranging from lifestyle changes to medications, surgeries and minimally invasive procedures. Treatment depends on several factors, including the patient’s age, overall health, the prostate’s size and the degree to which symptoms affect day-to-day life.

Lifestyle Changes

Simple lifestyle changes may positively impact an enlarged prostate diagnosis. Some helpful techniques for patients with an enlarged prostate, also called benign prostatic hyperplasia (BPH), include those listed below.

Timed voiding: The goal of timed voiding is to empty the bladder on a regular basis, rather than waiting for the urge to urinate. Patients should urinate every two hours, even if they experience no urge.

Caffeine and alcohol avoidance: Caffeine and alcohol not only act as diuretics (pulling extra water into the bladder to trigger the urge to urinate), they are also a direct irritant to the lining of the bladder.

Double void: Often, people do not completely empty their bladder, resulting in the bladder filling more quickly. With this technique, the patient urinates normally, then waits about 10 seconds before attempting to urinate again.

Decrease fluids at night: When people eat and drink, the fluid in the food consumed ultimately gets converted to urine. If you drink fluid at night, they will continue to make urine that will then fill the bladder. When the bladder is full at night, it is harder for the brain to silence the signals that it sends during sleep. This often results in nocturia, or getting up at night to urinate. To help prevent this, it is helpful to cut back on fluids three hours before bedtime.

Kegel exercises and urge suppression techniques: To exercise Kegel muscles, squeeze and hold for 10 seconds, then relax for 10 seconds. Repeat this process 10 times once a day. When the urge to urinate comes, the best thing to do is squeeze and hold the muscle until the urge passes.

BPH Medications

Medications may be appropriate for treating symptoms caused by an enlarged prostate. These drugs work by stopping prostate growth, shrinking the prostate or relaxing urinary tract muscles to improve the flow of urine. These drugs include:

• Alpha-blockers
• Phosphodiesterase-5 inhibitors
• 5-alpha reductase inhibitors
• Combination medications

Alpha blockers: These drugs help urine to flow more easily by relaxing muscles in the prostate and the bladder neck. Alpha-blockers tend to be the first-line treatment if symptoms from an enlarged prostate are mild to moderate. Common alpha-blockers are terazosin (Hytrin^®), doxazosin (Cardura^®), tamsulosin (Flomax^®), alfuzosin (Uroxatral^®) and silodosin (Rapaflo^®).

Phosphodiesterase-5 inhibitors: Typically used to treat erectile dysfunction (ED), these drugs, such as tadalafil (Cialis^®), work by relaxing the muscles in the prostate and bladder. These drugs might be prescribed for people with mild or moderate symptoms whether or not they have erectile dysfunction.

5-alpha reductase inhibitors: These drugs block an enzyme that makes the prostate grow. This stops the prostate from getting larger and may sometimes cause it to shrink. 5-alpha reductase inhibitors tend to be prescribed for men who have a very large prostate. Common 5-alpha reductase inhibitors are finasteride (Proscar^®) and dutasteride (Avodart^®).

Combination medications: Sometimes doctors may prescribe a combination of two types of medications that have been shown to be successful together. The 5-alpha reductase inhibitor finasteride may be prescribed with the alpha-blocker doxazosin. Alpha-blockers and antimuscarinics, a type of medication that may help treat overactive bladder, may also be prescribed together. And a combination of the alpha-blocker tamsulosin and the 5-alpha reductase inhibitor dutasteride may be prescribed as one pill, Jalyn^®.

Enlarged Prostate Surgery

When performing surgery for an enlarged prostate, the goal is to remove or displace tissues that cause obstructions so that the bladder is able to empty more easily. After most operations, both obstructive and irritative symptoms will improve, but the degree of improvement is dependent on the severity of symptoms before the surgery.

Several surgical options are available for an enlarged prostate. Some of the procedures available include:

• Transurethral resection of the prostate (TURP)
• Transurethral incision of the prostate (TUIP)
• Laser enucleation of the prostate
• Transurethral electrovaporization of the prostate (TUVP)
• Photoselective vaporization of the prostate (PVP)
• Prostatectomy
• Minimally invasive surgical therapies (MIST)

Transurethral resection of the prostate (TURP): This is a common surgery for an enlarged prostate, accounting for more than 90% of enlarged prostate surgeries. During TURP, a doctor inserts a tool called a resectoscope through the penis and urethra to reach the prostate. Prostate tissue is cut away using electricity, then flushed into the bladder with fluid and removed via a catheter. While TURP has long been considered the “gold standard” for an enlarged prostate with urinary symptoms, there is a risk of bleeding and ejaculation and urination problems, prompting the development of other surgical approaches. Men who have TURP usually stay in the hospital overnight and may need to use a catheter for a few days.

Transurethral incision of the prostate (TUIP): This surgery widens the urethra to help urine flow better. It is used when the prostate is small but causing a blockage. During TUIP, a doctor makes small incisions in the bladder neck and prostate to relieve pressure without removing any tissue. This procedure will likely require one to three days in the hospital. Like other surgeries of the prostate, possible risks include retrograde ejaculation, erection problems and urinary problems.

Laser enucleation of the prostate: Two procedures — Holmium laser enucleation of the prostate (HoLEP) and Thulium laser enucleation of the prostate (ThuLEP) — are similar processes using different types of lasers. The lasers destroy prostate tissue, which is then removed with very little blood loss compared to other procedures like TURP. Men with very large prostates or those taking blood-thinning medications may be appropriate candidates for laser enucleation, but it may be considered for all prostate sizes. Urine control issues, bleeding after surgery and damage to nearby structures during surgery are possible.

Transurethral electrovaporization of the prostate (TUVP): This procedure uses an electrical current to destroy, or vaporize, prostate tissue between two electrodes. Bleeding is minimal. Men who have this procedure need a catheter afterward for at least a few hours to help drain urine, and some may continue to use it at home during recovery.

Photoselective vaporization of the prostate (PVP): Similar to the TUVP procedure, PVP uses a high-energy green light laser to destroy excess prostate tissue with very little blood loss. The procedure has few side effects, but bleeding and the need for a repeat procedure in the future are possible.

Prostatectomy: This is the most invasive surgical procedure performed to remove part or all of the prostate. In an open simple prostatectomy, the surgeon removes prostate tissue through an incision in the skin. Laparoscopic or robotic-assisted surgery, which uses very small incisions, is a less invasive approach to removal. A prostatectomy is typically performed when the prostate is very enlarged, the bladder is damaged or because other procedures cannot be done. It has the greatest risk of urinary and erectile complications compared to other surgical options. It is likely to resolve the problem over the long term, but recovery time may be lengthy. A catheter will be needed for one to two weeks, and activities will need to be limited for several weeks.

Minimally invasive surgical therapies (MISTs) are also available to some men based on individual factors.

Most minimally invasive surgeries for an enlarged prostate, which are typically performed as outpatient procedures, have less risk of sexual dysfunction, less risk of urinary problems and low risk of bleeding, but those risks are still possible. Because these procedures do not require an incision, they tend to have a shorter recovery time. However, men who have these procedures are more likely to need surgery again in five to 10 years. They may also have urinary symptoms, such as burning during urination or blood in the urine, for a while afterward.

These procedures include:

• Prostatic lift (UroLift^™)
• Water vapor thermal therapy (WVTT), sold as Rezum^®
• Transurethral microwave thermotherapy (TUMT)
• Transurethral needle ablation (TUNA)
• Aquablation

Prostatic lift (UroLift^™): Also called prostatic urethral lift or PUL, this procedure uses a device to widen the urethra, allowing urine to flow more easily. The surgeon also places small implants to lift and hold the prostate away from the urethra. This procedure has an especially low risk of sexual dysfunction.

Water vapor thermal therapy (WVTT): This procedure uses water vapor (steam) to damage prostate tissue that is blocking the urethra. The body then works to remove the dead cells as part of its normal healing process, resulting in a smaller prostate. This procedure has an especially low risk of sexual dysfunction.

Transurethral microwave thermotherapy (TUMT): This procedure uses microwaves to destroy excess prostate tissue. A catheter is inserted through the urethra and an attached antenna disperses microwaves to the surrounding prostate tissue, producing heat that destroys excess tissue. After this procedure, a catheter might be needed for three to five days. This procedure may improve specific urinary symptoms, such as an urgent need to urinate, difficulty urinating or urinating very slowly.

Transurethral needle ablation (TUNA): Radio waves sent through small needles produce high heat to destroy prostate tissue. After this procedure, a catheter might be needed for three to five days.

Side Effects of BPH Surgery

Bleeding: All prostate surgery carries a risk of bleeding. Normally the bleeding is mild, but in rare cases it can be severe, requiring reoperation and blood transfusion.

Retrograde ejaculation: This phenomenon occurs when climax is achieved, but rather than the body emitting semen, the semen goes backward into the bladder, impacting fertility.

Urethral strictures: Urethral stricture is a condition where the urethra narrows. This is a rare complication, but when scopes are placed into the urethra, the procedure can cause damage and lead to scar tissue formation and strictures. All procedures carry about a 1-2% chance of strictures.

Bladder neck contractures: The rate of bladder neck contractures is low for prostate surgery, but some procedures have a higher rate than others. Bladder neck contractures occur when scar tissue develops at the base of the bladder as it leads into the prostate.

Stress urinary incontinence: This rare complication is characterized by leakage from the bladder during coughing or sneezing. In some of the more complex procedures, men leak urine for the first few weeks of recovery.

Erectile dysfunction (ED): Depending on the type of operation, between 0% and 10% of patients experience erectile dysfunction as a result of enlarged prostate procedures. The severity of ED is usually mild after these surgeries.

Temporary worsening of symptoms: After surgery, it is not uncommon for some patients to experience a worsening of their symptoms, particularly frequency of urination, pain when urinating and urgent urination. These usually resolve over the first two weeks.

Other BPH Procedures

The care team may also recommend nonsurgical procedures to treat BPH. For example, prostate artery embolization (PAE) is an image-guided outpatient procedure which may be used to treat urinary symptoms that BPH causes, particularly if other BPH treatments haven’t been successful. During the PAE procedure, the care team halts blood flow to the prostate, which reduces the size of the prostate gland with the goal of improving the flow of urine.

Patients should talk to their care teams for information about which BPH treatment might be right for them.