Benign prostatic hyperplasia - Treating prostate enlargement

If you have an enlarged prostate, your treatment plan will be determined by how severe your symptoms are.

If your symptoms are mild to moderate, you will receive no immediate medical treatment but will be given regular check-ups to carefully monitor your prostate. This is often referred to as "watchful waiting".

You will probably also be advised to make changes to your lifestyle to see if they improve your symptoms. These lifestyle changes are explained below, along with the training and treatments than can later be tried, if necessary.

Lifestyle changes

You may be advised to:

• Stop drinking any liquids for one to two hours before going to bed. This will help to prevent nocturia (waking up during the night to pass urine).
• If you've been prescribed medication (see below), experiment with the time you take this. For example, taking it at 7pm may help prevent nocturia.
• Stop drinking alcohol and caffeine, or limit your consumption of them. They can irritate your bladder and make your symptoms worse.
• Exercise regularly. Research has shown that moderate exercise, such as walking for 30 to 60 minutes a day, can improve symptoms (although it is unclear exactly why this is). Read more information on ways to get regular exercise.
• Join a patient support group (your doctor should be able to recommend one), which may help you manage mild symptoms without the need for medication.

Bladder training

Bladder training is an exercise programme to increase the time between urination and to increase the amount of urine your bladder can hold.

You will be given a target, such as waiting for at least two hours between each time you urinate. It's a good idea to use a bladder training chart, which allows you to record each time you pass urine and record the volume of urine passed (you'll need a plastic jug to measure this). Your doctor should give you a chart to take home.

You will also be taught a number of exercises, such as breathing, relaxation and muscle exercises, to help take your mind off the need to urinate.

Over time, your target time will be increased and at the end of the programme you should find that you are able to go for longer without urinating.

Bladder training should only be tried under medical supervision.

Medication

Medication, in combination with the lifestyle changes above, is usually recommended to treat moderate to severe symptoms of prostate enlargement.

Finasteride or dutasteride

Finasteride and dutasteride are widely used to treat prostate enlargement. They block the effects of a hormone called DHT (see causes of prostate enlargement) on the prostate gland, which can reduce the size of the prostate and improve your associated symptoms.

If you are prescribed one of these medications, you may experience an immediate improvement in symptoms. However, you'll need to take it for at least six months to get the maximum benefit, and your doctor will need to monitor you every year.

Use condoms if you are sexually active, because both finasteride and dutasteride can have an adverse affect on your sperm. If you get a woman pregnant, there is a risk the baby could develop birth defects.

Side effects can also include:

• impotence (inability to get an erection)
• little or no sperm when you ejaculate

In many cases, these side effects will improve as your body gets used to the medication. See your GP if the side effects are troubling you.

Alpha blockers

Alpha blockers help relax the muscles of your bladder, making it easier to pass urine.

You may be given alpha blockers as your primary treatment or in combination with finasteride.

Tamsulosin and alfuzosin are two alpha blockers commonly used to treat prostate enlargement. Side effects of tamsulosin and alfuzosin are uncommon and usually mild. They include:

• dizziness
• headaches
• weakness
• little or no sperm when you ejaculate

You should only begin taking alpha blockers over a restful weekend when you're not planning to drive, as there's a risk these could cause low blood pressure and fainting.

Generally, if you experience dizziness while on this medication, avoid driving or operating heavy machinery until it has passed.

Surgery

Surgery is usually only recommended for moderate to severe symptoms of prostate enlargement that have failed to respond to medication.

Trans-urethral resection of the prostate (TURP)

Trans-urethral resection of the prostate (TURP) is a surgical procedure where excess prostate tissue is removed to reduce the pressure on your bladder.

The surgeon will insert a small instrument into your urethra (the tube through which urine passes). An electric wire loop heated by radio waves is moved across to slice away excess tissue.

TURP is not painful because it is performed using either a general anaesthetic (where you are asleep) or a regional anaesthetic (where you are awake, but the lower half of your body is numbed).

Most men are well enough to leave hospital two to three days after the operation.

A common complication of TURP is that you will no longer produce semen when you ejaculate. This is known as retrograde ejaculation. It results in sperm going into your bladder rather than out of your penis during ejaculation.

However, you will still experience the physical pleasure associated with ejaculation (the climax).

Alternative techniques

There are a number of newer surgical techniques that may lead to fewer side effects, or a quicker recovery, than a TURP.

However, as these treatments are still fairly new they may not be available and their long-term effectiveness is not always clear.

These alternative techniques are explained below.

• Bipolar transurethral resection of the prostate - different instruments are used to perform the procedure, which allow saline water to be pumped into the urethra rather than a fluid called glycine. This is thought to lead to a lower risk of TURP syndrome (see risks of a TURP).
• Holmium laser enucleation of the prostate - a laser is used to remove excess prostate tissue using a similar route to a TURP. The procedure has shown good results in medium-term follow up (five to seven years) and is emerging as a promising alternative. It does not use glycine and hence there is no risk of TURP syndrome.
• KTP laser vaporisation - a small tube known as a cystoscope is inserted into your urethra. The cystoscope fires pulses of laser energy to burn away prostate tissue.

Open prostatectomy

This procedure may be more effective than a TURP if you have severe prostate enlargement.

However, open prostatectomy is now very rarely used, even for larger prostates, due to the development of other techniques such as holmium laser enucleation of the prostate (see above).

The procedure carries a higher risk of complications, such as erectile dysfunction and urinary incontinence. There is also a greater chance these complications will become permanent than if they occur following a TURP.

During an open prostatectomy, an incision is made in your abdomen and the outer portion of your prostate is removed.