If you are an older guy and have been going to a doctor for regular checkups, you probably know something about the prostate.
The prostate is a part of the male reproductive system. It is about the size of a walnut and located just below your bladder. It surrounds the urethra (the tube that empties urine from the bladder). Its primary role is to help produce semen.
Ash Tewari, MBBS, MCh, FRCS (Hon.)
The problem is that as a man ages, the prostate tends to increase in size. This can cause the urethra to narrow and decrease urine flow. Doctors call this noncancerous condition benign prostatic hyperplasia, or BPH. Most know it simply as an enlarged prostate.
This condition is not connected to prostate cancer, which is a significant concern for a growing number of men. (In fact, benign means “not cancer,” while hyperplasia means abnormal cell growth.)
However, BPH does affect a large number of men: about 50 percent of men between the ages of 51 and 60 have an enlarged prostate to some degree, and up to 90 percent of men 85 or older have an enlarged prostate that is causing symptoms.
BPH can cause a wide variety of urinary symptoms, such as frequency of urination, especially at night, or difficulty urinating. Cases of BPH can range from those with mild symptoms that may call for just regular monitoring to more severe symptoms that may call for medication or a surgical procedure.
Ash Tewari, MBBS, MCh, FRCS (Hon.), Professor and Chair, Milton and Carroll Petrie Department of Urology and a leading expert on prostate health, says recent media reports about prostate heath and BPH can be helpful by encouraging men to talk with their doctors.
“If it can happen to a king, it can happen to you,” he says, referring to media reports that Britain’s King Charles III, 75, was diagnosed with an enlarged prostate and was to have a procedure at a hospital. “It is very difficult for a man to go through their whole life without having prostate issues.”
Dr. Tewari notes that Mount Sinai’s Benign Prostatic Hyperplasia Center is “dedicated to pioneering advanced treatments and offering comprehensive care, setting a new standard in men’s health.” The Center is part of Mount Sinai’s Lizzie and Jonathan Tisch Center for Prostate Health.
In fact, Mount Sinai’s approach to BPH goes beyond just medical or surgical treatments. “Recognizing the profound impact BPH can have on a person’s life, our Center offers a comprehensive care plan that includes patient education, nutritional guidance, and psychological support,” he says. “This holistic approach underscores our commitment to treating the patient, not just the disease.”
Here are answers to some of the most frequently asked questions about BPH:
What are the symptoms of BPH, or an enlarged prostate?
“People often come to me when they can’t sleep, and they wake up three to four times at night to go to the bathroom,” says Dr. Tewari, referring to a condition known as nocturia. Men with BPH may also experience these symptoms:
- Feeling an urgent need to urinate shortly after urinating
- Experiencing difficulty starting to urinate or maintaining the flow
- Decreased force of urinary stream
- Having a stop-start pattern in urinating (intermittency)
- Feeling as though there is urine left in the bladder after urinating
- Blood in the urine (called hematuria)
How do you diagnose BPH?
A diagnosis begins with a discussion with a physician who can evaluate your symptoms and your medical history. You may be asked to complete a questionnaire to assess your symptoms. There are a number of different tests that can be used to diagnose and track BPH. These include testes to measure your urine flow and look for abnormalities; taking a urine sample to rule out an infection or other condition; and conducting scans to see the size and shape of your prostate and urinary tract, such as an ultrasound or cystoscopy.
What about prostate cancer?
BPH is not linked to cancer and does not increase your risk of getting prostate cancer. However, the symptoms for BPH and prostate cancer can be similar, according to the National Cancer Institute. As part of the diagnosis, doctors may conduct a prostate specific antigen (PSA) test to help exclude suspicions of prostate cancer. You can read more about prostate cancer here.
What causes BPH, and who is at risk?
It is not clear what causes BPH. Older men are at risk, as well as those whose father had the condition and those who are overweight or obese. The condition may relate to hormones.
If I have an enlarged prostate, do I need treatment?
Not everyone with an enlarged prostate needs treatment. Treatment begins with a thorough evaluation of each patient’s condition. For men with less severe symptoms, “watchful waiting” might be the initial action. This involves close monitoring without any immediate medical or surgical intervention. Watchful waiting includes recommendations for lifestyle changes that can help ease or circumvent symptoms. These changes include advice about the volume and timing of fluid consumption; avoiding caffeine and avoiding drinking alcohol at night; and regulation of bowels.
What if that’s not enough?
As symptoms progress, more proactive treatments are considered. If the enlarged prostate is blocking the bladder outlet and giving symptoms severe enough to affect daily activity—such as slowing the urine stream, making it harder to empty the bladder, and causing it to empty incompletely—then it needs to be treated. Most cases can be managed with medications. If the enlarged prostate is not treated, the bladder is constantly fighting the obstructed prostate. This can lead to worsening symptoms such as urinary tract infections and kidney problems.
What types of medications are used?
The aim of medications is to improve your symptoms, lower the risk of progression, and improve your quality of life. There are many options with guidelines and algorithms available to help guide your selection. There are three primary types of medications:
- Alpha blockers help the bladder neck and prostatic urethra to dilate and open, which improves urine flow. This approach is most effective for people with mild to moderate symptoms.
- 5 Alpha reductase inhibitors slow or stop the growth of the prostate. These medications are often used with alpha blockers. This approach is best for prostates that are significantly enlarged.
- Phosphodiesterase 5 inhibitors allow relaxation of smooth muscle in the bladder neck, urethra, and prostate.
When might I need surgery?
If medication is not giving sufficient relief of the symptoms, or if complications develop due to the enlarged prostate, then you may need surgery. Mount Sinai’s Department of Urology offers a wide range of minimally invasive surgical treatment procedures. The optimal treatment needs to be individualized depending upon the size of the prostate, any associated conditions, your age, and severity of the symptoms.
Here are the procedures:
Transurethral resection of the prostate (TURP): This minimally invasive procedure involves inserting a resectoscope (a special tube) into the tip of the penis to the urethra. The resectoscope delivers an electrical current that cuts excess prostate tissue from inside and seals up blood vessels, relieving pressure on the urethra. This procedure remains the gold standard for BPH, and most men are suitable candidates for this procedure.
Transurethral bipolar resection/enucleation of the prostate: This is like a traditional TURP and involves the insertion of a resectoscope into the penis but uses a plasma “button,” which uses bipolar energy to melt prostate tissue. The advantage of bipolar over conventional TURP is that it can work in saline irrigation so there is less chance of fluid absorption. Thus, bipolar can be used to resection even large prostate glands.
Holmium laser enucleation of prostate (HoLEP): Lasers for endoscopic prostate surgery have revolutionized the procedures and are an equally effective alternative to TURP. In HoLEP, the prostate tissue is enucleated (peeled off from the capsule), sliced into smaller pieces, and removed. HoLEP has the edge over conventional TURP in terms of less bleeding, more efficient gland removal, and the ability to remove large prostate glands.
Thulium laser enucleation of the prostate (ThuLEP): This minimally invasive technique is similar to HoLEP except that the laser energy source is a Thulium laser. Holmium and Thulium lasers have minimal tissue penetration and are effectively absorbed by water, thus minimizing the chances of surrounding tissue damage.
Greenlight™ Laser or photo selective vaporization of the prostate (PVP): This minimally invasive procedure uses a state-of-the-art laser to melt prostate tissue. The Greenlight laser wavelength has some advantages for patients with a bleeding disorder.
Robotic water jet treatment (RWT) or Aquablation: This minimally invasive procedure is one of the newest techniques available and involves no incisions. An instrument is inserted into the tip of the penis to the urethra. The instrument delivers a high-pressure water jet that removes excess prostate tissue and is guided by a robotic camera and ultrasound machine.
Water vapor thermal therapy (WVTT) or Rezum™: This is a minimally invasive, outpatient, and in-office procedure in which a small device is passed through the urethra to the prostate. Sterile water vapor is released into the prostate, where the steam causes prostate cells to die. The dead cells are absorbed as part of your body’s natural healing process, shrinking the prostate, and taking pressure off the urethra.
Prostatic urethral lift (PUL) or Urolift™: This is a minimally invasive, outpatient, and in-office procedure in which specialized staples are placed into the obstructed prostate through the urethra. The staples relieve the pressure from the bladder, and the effects are generally immediate. There are no sexual side effects.
Prostate artery embolization (PAE): This procedure helps improve urinary symptoms caused by an enlarged prostate without the risk of sexual side effects. It starts with a small puncture in the groin. A catheter is inserted through the artery and directed toward the prostate. The catheter is positioned in the artery supplying blood to the prostate. Small particles that plug up the artery are injected, blocking blood flow. This is called embolization.
Temporary implanted prostatic device (TIPD) or iTIND: The iTind (Temporarily Implanted Nitinol Device) treatment is a new, minimally invasive treatment that takes five to seven days with immediate results. The treatment gently restructures the prostate by widening the opening through which urine can flow.
Robotic simple prostatectomy: This procedure removes the obstructing part of the prostate. Robotic instruments are passed through small incisions in the lower abdomen and remove the inner core of the prostate, leaving the outer shell. This is generally performed for large prostates that won’t respond well to other treatments.