Prostate Health in Focus: What’s New in Treatments for Enlargement

King Charles III recently made news for his cancer diagnosis, which came after he underwent a procedure for an enlarged prostate, or benign prostatic hyperplasia (BPH). At Charles’s age of 75, BPH, a noncancerous condition, is extremely common. In fact, 80% of men over 70 have BPH. While there isn’t a cure for BPH, there are treatment options that can relieve symptoms, including medications, lifestyle modifications, and surgery, most commonly transurethral resection of the prostate. The latest treatments include water vapor thermal therapy, prostatic urethral lift, prostate artery embolization, and laser therapy.

Why does BPH lead to urinary symptoms?

The prostate is a walnut-sized gland located between the bladder and penis in front of the rectum. The prostate surrounds the top portion of the urethra (the tube urine travels through when you pee). It’s normal for the prostate to enlarge gradually with age.

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As the prostate enlarges, it presses against and pinches the urethra. This can cause a range of urinary issues, such as needing to pee frequently, urine leakage, and having a weak stream. It’s important to note that BPH is not associated with cancer and does not increase your risk of prostate cancer. However, the symptoms of BPH and prostate cancer can be similar.

While transurethral resection of the prostate (TURP) has for decades been considered the 'gold standard' surgical treatment for BPH, newer therapies are less invasive, offer quicker recovery times, and carry fewer risks and side effects. These minimally invasive alternatives are generally conducted in outpatient settings under local anesthesia and have become especially popular with patients who have high surgical risk due to pre-existing medical conditions.

Water vapor thermal therapy

Water vapor thermal therapy (WVTT), a minimally invasive surgical procedure used to treat BPH, involves using a special instrument that uses steam to shrink the prostate. During the procedure, a scope equipped with a specialized camera is inserted into the urethra up to the prostate gland. A needle is released from the instrument, which delivers a small amount of water converted to steam onto the prostate tissue. The steam kills some of the prostate tissue, the dead cells are reabsorbed into the body, and the prostate shrinks. The procedure is fast and is almost always done in a urologist’s office. It rarely requires an overnight stay in the hospital.

According to a 2020 meta-analysis, WVTT provided improvement in enlarged prostate symptoms by up to 54% (as reported in one of the studies), preserved sexual function, and was associated with a low surgical retreatment rate (7%) over the course of four years. Side effects of WVTT are rare but may include painful or frequent urination, blood in the urine, decrease in ejaculatory volume, and urinary tract infection (UTI).

Prostatic urethral lift

The prostatic urethral lift (UroLift) is a minimally invasive procedure that involves delivering tiny stainless-steel implants that lift the enlarged prostate tissue out of the way so that it doesn’t block the urethra. There is no cutting, heating, or removal of prostate tissue, and no general anesthesia or catheter is needed for the procedure.

You won’t have to stay at the hospital. It’s usually a one-time procedure as the implants stay in permanently. However, the implants can be easily removed for medical reasons if necessary.

A 2021 real-world analysis of UroLift outcomes at hospitals in the U.K. found that the in-hospital complication rate was 3.4%, and slightly less than 12% of people required further retreatment for enlarged prostate two years after undergoing prostatic urethral lift.

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Prostate artery embolization

Prostatic artery embolization (PAE) is a nonsurgical, minimally invasive outpatient procedure that involves the insertion of tiny catheters into arteries to limit blood flow to the prostate. Performed by an interventional radiologist, the process is guided by an arteriogram (an X-ray in which dye is injected into blood vessels) and can lead to relief of lower urinary tract symptoms associated with BPH.

General anesthesia is not used. Typically, the patient will not see immediate results because the procedure does not involve surgery or physical removal of any part of the prostate. Improvements in urinary symptoms are most common 1–2 months after the procedure, with continued improvement up until six months afterward.

Complications are rare. However, 'post-PAE syndrome' may occur for days following the procedure. This may include nausea, fever, pelvic pain, or painful urination. Other risks include bleeding at the incision site, blood in the urine, and infection of the prostate.

Laser therapy

Laser therapy helps reduce moderate to severe urinary symptoms caused by BPH. During prostate laser therapy, the doctor inserts a scope through the tip of the penis into the urethra. A laser, which uses concentrated light to generate precise and intense heat, passes through the scope, removing excess tissue from the prostate.

One study found GreenLight laser treatment of the prostate to be an effective option for BPH, with a sustained efficacy of 76.1% at 5-year follow-up. Laser treatment generally has shorter hospital stays and fewer complications than traditional prostate surgery. However, sexual side effects may occur, including retrograde ejaculation (when semen goes into the bladder during ejaculation) and, in rare instances, erectile dysfunction. Urinary incontinence and urethral strictures (scar tissue buildup in the urethra) are rare but can occur following laser treatment.

Treatment with medication

Doctors generally first try medications before surgery when treating BPH. A class of drugs known as alpha-blockers are typically the first-line treatment. Alpha-blockers work by relaxing muscles, including muscles in the bladder neck and prostate, making it easier to urinate. Another common class of medications for BPH symptoms is 5-alpha reductase inhibitors. These drugs stop the production of hormones that contribute to making the prostate larger. In some cases, they may even shrink the prostate.

Tadalafil, a type of phosphodiesterase type 5 (PDE5) inhibitor most commonly prescribed for erectile dysfunction (ED), may be used to treat BPH. Tadalafil increases the levels of a chemical that regulates smooth muscle relaxation in the penis and relaxes the bladder and prostate muscles, therefore potentially easing symptoms of BPH.

Medications for BPH are generally well tolerated. However, as with all drugs, side effects are possible. Common side effects of alpha-blockers include low blood pressure and ED, among others. 5-alpha reductase inhibitors may cause decreased sexual desire, ED, ejaculatory disorder, and enlargement of breast tissue. The most common side effects of tadalafil are heartburn, indigestion, and stomach discomfort.

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Can supplements help with an enlarged prostate?

Supplements have not been conclusively shown to treat or cure enlarged prostate. However, limited studies suggest that some supplements may lessen the symptoms associated with BPH. Pumpkin seed oil may be more effective than a placebo in improving symptoms associated with BPH. A 2021 clinical trial found that pumpkin seed oil relieved BPH symptoms with no side effects. However, the pumpkin seed oil was not as effective as tamsulosin, a commonly prescribed alpha-blocker.

Other studies, while dated, have suggested both beta-sitosterol, a substance found in many plants, and Pygeum africanum, an herbal extract from the African cherry tree, may reduce symptoms of BPH.

Bear in mind that supplements are not approved for safety and efficacy by the U.S. Food and Drug Administration (FDA). Before you purchase a supplement, discuss it with your doctor, as it could interfere with medications, treatments, or tests.

Can lifestyle changes help prevent an enlarged prostate?

Having an overall healthy lifestyle, getting regular exercise, and maintaining a healthy body weight all contribute to a healthier prostate. Aim for normal blood glucose levels, as diabetes is a risk factor for BPH, and eat whole, unprocessed foods. Decreasing your fluid intake before bedtime and avoiding drinks that irritate the bladder, such as alcohol and coffee, can help reduce symptoms.

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