Benign prostatic hyperplasia (BPH), commonly known as an enlarged prostate, is a widespread, non-cancerous condition affecting aging men. This growth can significantly narrow the urethra, leading to bothersome lower urinary tract symptoms (LUTS) that impair quality of life. The prevalence of BPH symptoms increases with age, affecting over 50% of men in their 50s and up to 90% in their 80s. Modern treatment options have evolved significantly, moving toward less invasive procedures that offer durable symptom relief with fewer side effects, aiming to preserve sexual function and minimize recovery time.
Understanding Initial Management Options
For men with mild symptoms, the initial approach often involves “watchful waiting” or active surveillance, which includes regular monitoring without immediate intervention. This strategy is suitable when symptoms are not significantly affecting daily life, focusing instead on lifestyle modifications such as fluid management and timed voiding. When symptoms become bothersome, medical therapy is the next step, primarily using two distinct classes of oral medications.
The first class of drugs, alpha-blockers, targets the smooth muscles within the prostate and the bladder neck. By relaxing these muscles, they reduce resistance to urine flow through the urethra, leading to rapid symptom improvement, often within days to weeks. A common side effect is retrograde ejaculation, where semen flows backward into the bladder.
The second class, 5-alpha reductase inhibitors (5-ARIs), addresses the physical enlargement of the gland. These medications block the enzyme that converts testosterone into dihydrotestosterone (DHT), which stimulates prostate growth. By reducing DHT levels, 5-ARIs can physically shrink the prostate, particularly in men with larger glands, but their effect requires several months of consistent use. This drug class can cause sexual side effects, including reduced libido and erectile dysfunction. In some cases, a combination of both an alpha-blocker and a 5-ARI is used to target muscular tension and prostate size, a strategy effective for men with larger prostates and more severe symptoms.
Minimally Invasive Procedural Treatments
For patients who do not respond adequately to medication or prefer to avoid daily drug use, minimally invasive surgical treatments (MISTs) have emerged as a modern alternative. These procedures are typically performed in an outpatient setting and aim to relieve obstruction with minimal disruption to anatomy and sexual function. A primary example is Prostatic Urethral Lift (PUL), known as UroLift, which does not involve cutting or destroying prostate tissue.
During a PUL procedure, a specialized device is inserted through the urethra to deliver small, permanent implants into the prostate lobes. These implants mechanically pull the obstructive prostate tissue away from the center, widening the urethral channel. The primary advantage of this approach is the preservation of both erectile and ejaculatory function. Patients typically experience a fast recovery, often returning to normal activities within a few days, and many do not require a catheter after the procedure.
Another advanced MIST is Water Vapor Thermal Therapy, known as Rezūm, which uses convective thermal energy to ablate the obstructive tissue. A handheld device delivers controlled, nine-second bursts of sterile water vapor (steam) directly into the enlarged areas of the prostate. The steam rapidly disperses through the tissue, and as it condenses, it releases thermal energy that destroys the targeted prostate cells.
Over several weeks to months, the body’s natural healing response reabsorbs the destroyed tissue, causing the prostate to shrink and the urethra to open. Rezūm is effective for prostates ranging from 30 to 80 cubic centimeters and can treat men with an obstructive median lobe. Similar to PUL, this therapy is designed to preserve erectile and ejaculatory functions, and it is usually performed under local anesthesia with sedation.
Advanced Surgical Techniques
When MISTs are unsuitable, such as for men with very large prostate glands, or when a patient desires definitive, long-term tissue removal, advanced surgical techniques are utilized. Holmium Laser Enucleation of the Prostate (HoLEP) has become the standard for high-volume tissue removal, supplanting older methods. HoLEP is a minimally invasive procedure that uses a high-powered holmium laser to precisely separate the entire inner portion of the prostate gland (the adenoma) from the outer capsule.
The laser effectively “peels” the obstructing tissue, pushing the intact lobes into the bladder, a process that minimizes blood loss due to the laser’s hemostatic properties. The removed tissue is then broken down into smaller fragments using a morcellator and suctioned out through the urethra. This comprehensive tissue removal allows HoLEP to be effective for virtually any size prostate, including those exceeding 80 to 100 grams.
HoLEP offers superior long-term results compared to traditional transurethral resection of the prostate (TURP), with significantly lower retreatment rates (approximately 1 to 2% at five years compared to 5 to 10% for TURP). While highly effective, the procedure is more invasive than MISTs, often requiring general anesthesia and an overnight hospital stay. A likely side effect of HoLEP is retrograde ejaculation, the backward flow of semen into the bladder.
Factors Influencing Treatment Selection
The selection of the appropriate BPH treatment is an individualized decision driven by patient-specific and clinical factors. The severity of symptoms, often quantified using the International Prostate Symptom Score (IPSS), is a primary determinant; a score of 10 or greater suggests the need for active treatment beyond watchful waiting. Patients with moderate symptoms (IPSS 10-19) might be suitable for medication or MISTs, while those with severe symptoms (IPSS 20-35) may require a definitive surgical option.
Prostate size, determined by ultrasound, guides the choice. MISTs like Rezūm are indicated for glands up to 80 cubic centimeters, and PUL is best for moderate sizes. HoLEP is reserved for larger prostates, particularly those exceeding 80 grams, where less invasive procedures may be less durable. Patient health status and comorbidities also play a role; MISTs are preferred for men with significant health issues who may not tolerate general anesthesia or a lengthy recovery.
The desire to preserve sexual function, especially ejaculation, is a major factor. Procedures like PUL and Rezūm are designed to minimize or avoid sexual side effects, making them attractive to men who prioritize the preservation of antegrade ejaculation. In contrast, HoLEP, while effective at tissue removal, carries a high likelihood of causing retrograde ejaculation. The ultimate treatment path is a shared decision between the patient and urologist, balancing symptom relief, prostate anatomy, and quality-of-life goals.