For most urologists, the pesky prostate gland occupies most of our clinic day. The prostate gland in men is an organ that makes fluid for semen. It is positioned between the bladder and the urinary sphincter in the pelvis. The urethra, the tube that carries urine from the bladder down and out of the body, goes right through the middle of the prostate.
There are three main types of problems that occur with the prostate. The first involves prostate infections or painful prostate conditions. The second involves benign prostatic hyperplasia (BPH), or overgrowth of the prostate that occurs as men age beyond their 30s. The third category of prostate problems is prostate cancer. One of these categories of problems does not lead to a problem in another category. In other words, there is not a cause-effect relationship between having an enlarged prostate or an infected prostate and prostate cancer.
It is perfectly normal for a man’s prostate to enlarge. In fact, it is an expected part of aging. The prostate can enlarge or expand in size outward and/or inward. The patient can have a really big enlarged prostate and not have any urination difficulties or a patient can have a mildly enlarged prostate and need an operation. Everybody is different.
Seventy percent of men over age 60 have some symptoms of having an enlarged prostate. Because of the urethra being squeezed by the enlarged prostate, the bladder may have to work harder to get urine out during voiding. This can result in a weak or slowed urinary stream. Sometimes the bladder cannot empty because of the constriction. This may result in increased frequency of urination, both during the day and possibly while the patient is trying to sleep. Patients can have a sense of not completely emptying the bladder with BPH. There can be a delay in the start of urine flow once the patient is trying to urinate. The urine stream can start and stop if the bladder is trying to push urine through.
If a man begins to have symptoms of having an enlarged prostate, we have several options in managing it. Historically, surgery was the only answer.
But in the early 1990s we developed two classes of medications that can help with BPH therapy. First, there was a pair of medications called the 5-ARIs. Finasteride and dutasteride actually over time shrink the prostate, as they change the hormonal mechanism by which the prostate continues to grow. A small percentage of men have sexual side effects from this medication. However, we have demonstrated that - with long-term use - they confer a 30 percent decrease in the incidence of prostate cancer developing. Together with alpha blocker medications that relax the prostate capsule and bladder neck, men can have significant improvements in their voiding parameters with medical therapy.
Sometimes this is not effective enough or the patient’s prostate requires a surgical option. Classically we performed removal of tissue to include the prostatic urethra and impinging prostate tissue using a scope with the patient under anesthesia. This is called Transurethral Resection of the Prostate, or TURP. In the early 1970s this was the most commonly performed surgery in the United States. Over time we have developed several other procedures whereby different energies, to include microwave heat, laser vaporization and now most recently steam pressure, to cause a similar defect. These procedures do not remove as much tissue as a TURP does. The TURP remains the gold standard and of all treatments patients who have had a TURP are from a voiding standpoint the happiest long term.
Ten to 15 percent of patients who have a TURP require other therapy at some point in their lives. With the lesser tissue removal procedures, more patients need something done at another point in their lives than with a TURP.
The new procedure
About 12 years ago, a group of engineers got together and tried to come up with a new way of approaching an enlarged prostate. Their brain child was approved by the FDA about five years ago. It is called the UroLift. With the UroLift procedure, we place small filaments of thread that are attached to anchors outside the prostate and on the inside of the prostatic urethra that open the prostatic urethra and can effect a significant amount of relief from BPH for men who have a mildly to moderately enlarged prostate. A really neat aspect of this device is that it can be done without any tissue removal and therefore the anesthesia requirements are less. Frequently we can do it with just local anesthesia and possibly sedation via an IV. It is therefore an outpatient surgery and can happen quite quickly with a very early recovery.
Patients ride home after the procedure and can do pretty much whatever they want the following day. For the first 2 to 4 weeks they can have a sense of urinary urgency and frequency, but this goes away once the prostate gets used to having tissue compressed.
One of the biggest differences between the tissue removal procedures and the UroLift is that the bladder neck, the dividing line between the bladder and the top of the prostate, is not touched. Men who have had surgery and some men who have alpha blocker medical therapy can have what is called retrograde ejaculation, where seminal fluid goes up into the bladder as opposed to out of the urethra with an orgasm. UroLift preserves this function, so a lot of men look upon the UroLift as a way to manage their early BPH symptoms without sexual side effects.
When the UroLift procedure first came out, there were concerns amongst urologists that the procedure would not last very long or there could be complications of having the inner filaments calcify with material. Over a five-year period of following patients who were initially involved in the FDA-approved trials five years ago, we have seen a very low complication risk and a very impressive set of data regarding durability of symptom improvement.
Again, a main point to catch here is that every man is different and every man’s anatomy is different. Every patient with BPH requires an evaluation and a tailoring for therapy to work on their specific problem. It is really great in the urologist’s office to have more and more tools to take care of this significant problem.
Find more information about an enlarged prostate at http://www.idurology.com/enlarged-prostate/
About Dr. Williams
Dr. Joe Williams was named the 2017 Physician of the Year by the Ada County Medical Society. He also recently received the Idaho Medical Group Management Association Leadership Award.
He is a board-certified urologist and founding member of the Idaho Urologic Institute and the Medical Director of the Surgery Center of Idaho. A native Idahoan, he also served in the military for 10 years and is a decorated Naval veteran in the Persian Gulf during Operation Desert Storm and Desert Shield.
He has been involved in a variety of medical and community groups, including Idaho Board of Medicine, Rotary Club International and Boy Scouts of America.