Benign Prostatic Hyperplasia (BPH) is a non-malignant enlargement of the prostate gland that becomes increasingly common as men age. The proliferation of prostate tissue often restricts the flow of urine through the urethra, leading to bothersome lower urinary tract symptoms (LUTS). BPH affects 50 to 60 percent of men in their sixties, rising to 80 to 90 percent in men over 70. Symptoms, such as frequent urination, a weak stream, and nocturia, significantly impact quality of life. Treatment has evolved from traditional surgery to a broad spectrum of medical and advanced, minimally invasive procedures.
Initial Steps and Drug-Based Treatment
For men with mild symptoms, the initial approach involves watchful waiting and lifestyle adjustments. These modifications include fluid management, such as reducing intake before bedtime, and timed voiding. When symptoms become moderate or severe, pharmacotherapy is the first line of defense, utilizing two main classes.
Alpha-blockers work quickly to relax the smooth muscle fibers in the prostate and bladder neck. By targeting alpha-1 adrenergic receptors, these drugs reduce the tension constricting the urethra, allowing for easier urine passage. Common examples include tamsulosin (Flomax), alfuzosin (Uroxatral), and silodosin (Rapaflo). While effective at alleviating symptoms, alpha-blockers do not reduce the actual size of the enlarged prostate tissue.
The second class, 5-alpha reductase inhibitors (5-ARIs), addresses the prostate’s physical size by altering the hormonal environment. These medications block the enzyme that converts testosterone into dihydrotestosterone (DHT), the hormone stimulating prostatic growth. Drugs like finasteride (Proscar) and dutasteride (Avodart) shrink the prostate over time, typically requiring three to six months for noticeable improvement. This class is often reserved for men with larger prostates, generally exceeding 30 cubic centimeters. Combination therapy, pairing an alpha-blocker with a 5-ARI, offers more comprehensive symptom control when a single medication is insufficient.
Traditional Surgical Options for Severe Enlargement
When medical therapy fails to manage symptoms, or if complications such as recurrent urinary retention arise, surgical intervention becomes necessary. Transurethral Resection of the Prostate (TURP) served as the benchmark for surgical BPH treatment for decades. This procedure involves inserting an instrument through the urethra to remove obstructing prostate tissue using an electrified wire loop, creating a wide channel. A common side effect of TURP is retrograde ejaculation, where semen enters the bladder.
Laser procedures are prominent alternatives to traditional resection, offering similar efficacy with a reduced risk of bleeding. Holmium Laser Enucleation of the Prostate (HoLEP) uses a laser to precisely carve out the inner prostate tissue, separating it from the outer capsule. This tissue is then removed using a morcellator, making HoLEP suitable for prostates of virtually any size. Photoselective Vaporization of the Prostate (PVP) uses a high-power laser to rapidly vaporize the obstructive tissue, often resulting in shorter catheterization times. For extremely large prostate glands, a simple prostatectomy, performed either openly or robotically, may be needed to remove the bulk of the tissue.
Minimally Invasive and Advanced Procedures
Minimally invasive surgical treatments (MISTs) are the most significant developments in BPH management. These procedures focus on quick recovery and preserving ejaculatory and erectile function, often performed in an outpatient setting.
Prostatic Urethral Lift (PUL)
PUL, commonly known as UroLift, uses a purely mechanical approach to relieve obstruction. Small, permanent implants are placed to hold the enlarged prostate lobes apart, lifting the tissue away from the central urethra. This mechanical widening offers immediate relief and consistently preserves normal sexual function because it does not involve cutting, heating, or removing tissue. The mechanism relies on tissue compression, which can lead to focal tissue atrophy over time, maintaining the open channel.
Water Vapor Thermal Therapy (Rezūm)
Water Vapor Thermal Therapy, known commercially as Rezūm, uses convective heat transfer through steam to treat the enlarged tissue. A device inserted through the urethra injects targeted bursts of sterile water vapor into the obstructive areas. The steam’s thermal energy causes the prostate cells to undergo necrosis. This damaged tissue is then naturally reabsorbed by the body over several weeks, leading to gland shrinkage and symptom improvement.
Temporary Implantable Nitinol Device (iTind)
The Temporary Implantable Nitinol Device (iTind) reshapes the prostatic urethra without permanent implants. The nickel-titanium device is inserted into the prostatic urethra and expands gradually over five to seven days. Its gentle outward pressure creates small longitudinal incisions and furrows in the prostate tissue, which remain after the device is removed, widening the urethral channel. This temporary mechanism is promoted for its short implantation time and preservation of sexual health.
Prostate Artery Embolization (PAE)
PAE is a non-surgical, image-guided procedure performed by an interventional radiologist. A small catheter is navigated through an artery to the blood vessels supplying the prostate. Tiny microspheres are then injected to block the blood flow to the enlarged gland (embolization). By reducing the blood supply, the procedure causes the prostate tissue to shrink due to induced ischemia. PAE offers a viable alternative for men who are not suitable candidates for general anesthesia or traditional surgery.
Waterjet Ablation (Aquablation)
Waterjet Ablation, or Aquablation, employs a robotic-assisted, heat-free water jet for precise tissue removal. The surgeon uses real-time ultrasound imaging to create a detailed, customized map of the prostate. The robotic system precisely follows this map to remove the obstructive tissue with a high-velocity saline stream. This robotic precision ensures that sensitive structures, such as the ejaculatory ducts and sphincter muscle, are avoided, making it an option for prostates of any size while maintaining a low risk of sexual side effects.