Dr. Dhir’s guide to sorting through the many options of treating enlarged prostate, and why he feels The UroLift System is the best combination of symptom relief and preservation of Bladder Health.
For some clinical context, I’d like you all to know that I have been treating Benign Prostatic Hyperplasia (BPH), otherwise known as enlarged prostate, for over 10 years. There are many technologies that have come and gone, and personally I feel it is quite confusing for patients suffering from BPH to know what actions need to be taken. Hopefully this post will provide men with some clarity.
Should I Take Medications?
Medical therapy for BPH is usually started when bothersome urinary symptoms are mentioned to a primary care doctor.This includes symptoms such as weak urine flow, urinating frequently during the day or night, and an urgency to urinate often.
There are three classes of drugs used for BPH:
- Alpha-blockers: these are usually the medications of choice due to quick onset of symptom-relief. These medications include tamsulosin (Flomax), silodosin (Rapaflo), terazosin (Hytrin), and alfuzosin (Uroxatral). A-blockers work to decrease the muscle tone of the prostate and relax compression on the urinary channel; unfortunately, these medications must be continued for life. If you forget a dose or want to stop an a-blocker, your symptoms will return. These medications commonly cause dizziness or nasal congestion; there are also new studies indicating a possible association of long-term use with early dementia.
- 5-Alpha Reductase Inhibitors (5-ARIs): these include finasteride (Proscar) and dutasteride (Avodart). These medications work to shrink the size of the prostate. Despite good intentions, makers of finasteride and dutasteride are now involved in class action lawsuits due to harmful long-term side effects seen in those experiencing post-finasteride syndrome . I never prescribe these medications for healthy men looking for BPH solutions; in fact, I commonly remove these medications during consultation.
- Anticholinergics / B3-agonists: these drugs help with storage urinary symptoms like urgency, involuntary leakage of urine, and going frequently to the bathroom. Anticholinergics (like Vesicare and Detrol) and B3-agonists (Myrbetriq) can cause side effects such as dry mouth, constipation, blurry vision, elevations in blood pressure, and more. Anticholinergics in particular can be very dangerous to use in the elderly and should be avoided.
When I see patients in the office, they are usually on an a-blocker and/or 5-ARI; some are even on a third medication to calm the bladder down as mentioned above. 3 medications for a problem of prostate obstruction? That is truly ridiculous in my opinion. Most men do not want to even take 1 much less 3 medications for anything! The analogy that comes to mind is that your sink is clogged, so every week you pour Drano to fix the problem for the rest of your life. Does that make sense?
The fact of the matter is that medications are simply band-aids for symptom-relief, they carry harmful side effects, they can be expensive, and they do not fix the actual problem. As the prostate blockage inevitably progresses over time, medications become less helpful and Bladder Health can deteriorate.
What is Bladder Health?
In my office, I make every attempt to explain the concept of Bladder Health to my patients. The bladder is like any other muscle in the body. It squeezes to drain urine when we go to the bathroom. If the prostate is enlarged and blocking urine flow, the bladder muscle over time will thicken, or hypertrophy. The consequences of this are a decreased ability to hold urine and the inability for the bladder muscle to mount sufficient pressure to completely empty. This leads to the well-known BPH symptoms of weak stream, urgency, and frequency of urination that typically will worsen as men age.
My analogy for Bladder Health is that the bladder is like a pump, and if this pump is straining for years it will eventually give out. We want to remove the obstruction before the pump, or your bladder, permanently deteriorates. If BPH is left unaddressed, the bladder can fail and a catheter will be needed to drain urine. There is a reason there are so many catheter commercials on late-night TV: BPH affects most men and often these symptoms are being ignored.
As previously reviewed, the medications listed above may offer some symptom relief, but it is not relieving the strain on the bladder. Bladder Health is still deteriorating since the obstruction has not been treated. Medications, to use the previous analogy, are acting like Drano. They are a temporary measure but not the solution.
What are Procedural Treatments to BPH?
In-office and surgical procedures to treat BPH are plentiful, but all are not created equal.
Options include minimally-invasive procedures like UroLift or Rezum ; more invasive day-procedures like GreenLight Laser Therapy or Plasma Button Vaporization; and finally, the most invasive “gold standard”: Transurethral Resection of the Prostate (TURP).
I have extensive experience with all the modalities listed above. I have performed hundreds of TURPs in my career, which is a very effective procedure when done in expert hands. TURP, despite not involving any incisions, is still major surgery with a 6-week recovery time. During recovery, you cannot take aspirin or blood thinners, you cannot lift anything over 10 pounds, and you cannot participate in any strenuous exercising. The surgery includes a night in the hospital to monitor bleeding with a large catheter which can be quite uncomfortable. TURP often leads to worsening of erectile dysfunction, and dry orgasms (retrograde ejaculation) are inevitable. TURP is appropriate in more severe BPH cases and has a significant period of recovery with multiple sexual side effects. Symptom improvements are often not seen for months after this procedure. For most men, this is simply not the procedure of choice.
Alternatives to TURP are quicker day-procedures like GreenLight Laser Therapy or Plasma Button Vaporization. These two options are preferred by patients to TURP as there is no hospitalization time after the procedure, and bleeding risks are minimal. Disadvantages include significant irritative symptoms (urgency, frequency, burning with urination) that can persist for weeks to months after the procedure. Urinary catheters are still necessary for a period of time. Finally, the procedures carry extra risk of scar tissue development at the bladder neck and in the urethra. This common complication can lead to repeat surgeries in the future to incise scar tissue.
UroLift to the Rescue?
The UroLift System has been performed for over 15 years, but recently in 2018 the American Urological Association (AUA) added this procedure as an effective option in its BPH Surgical Management Guidelines . I consider myself fairly conservative in adopting new technology as patient safety is of the utmost importance. Once the UroLift System became validated by the AUA, based on their extensive research and experience with the technology, I began to perfect my technique.
I have performed roughly 100 UroLifts with great results. In the past, the majority of my surgeries for BPH were TURPs or Plasma Button Vaporizations. Now, the amount of TURPs I perform has dramatically reduced in favor of UroLift. Why? Because UroLift combines the strong outcomes of TURP, minimizes recovery time, and eliminates the threat of sexual side effects. It also takes about 5 minutes in comparison with the other procedures that take 1-2 hours under general anesthesia. UroLift is a the first real “game changer” I have encountered in Urology.
The UroLift System can be performed in the office or while under twilight sedation in the hospital or surgery center. Developed my MIT engineers, it uses small implants to push the blocked prostate tissue away from the urinary channel in a very short procedure time. What is remarkable is that there is usually no need for a urinary catheter, no significant bleeding, no post-operative pain, and the recovery time is measured in days not weeks.
When faced with a decision to either ignore the symptoms, take medications, or fix the issue, my answer would personally to be treat BPH with UroLift. All things equal, it is the quickest and most effective solution with the least amount of post-operative complications, and most importantly no sexual side effects.
To learn more about UroLift click here . Do not hesitate to schedule a consultation with me in office to see if you are a candidate for this optimal treatment technique. The UroLift procedure is fully covered by Medicare and all major commercial insurers.
Dr. Dhir has no financial investment or paid partnership with the makers of the UroLift System.