Ask the Doctors: Less invasive procedures for prostate symptoms

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Q: Is there any treatment besides surgery that can reliably help an older man urinate when he is experiencing difficulty due to prostate enlargement?

A: This common problem becomes all the more common as men get older. In fact, 40 to 50 percent of men ages 51 to 60 — and up to 80 percent of those over 80 — have prostate enlargement. Slightly more than half suffer symptoms, which include poor urine flow, frequent urination, incomplete emptying of the bladder and, most irritatingly, waking up multiple times at night to urinate. Some of these symptoms can be improved by decreasing alcohol and caffeine and by decreasing evening fluid intake.

Drug treatment is the first line of therapy. Alpha-1 receptor blockers work to relax the smooth muscles in the prostate and the lower portion of the bladder. This relaxation allows the urine to flow more easily from the bladder. The biggest side effect is lightheadedness, because the drug also lowers blood pressure. This lightheadedness has not been reported as much with newer formulations — tamsulosin, alfuzosin and silodosin — that improve urine flow and reduce frequency because they're more selective to the urinary tract.

Another option is to decrease prostate size with a medication — finasteride or dutasteride — that reduces the formation of the hormone dihydrotestosterone, or DHT. This hormone stimulates the prostate to grow; the medications work by inhibiting the enzyme that produces it. Note, however, that these drugs can take six months to one year to reduce symptoms; the biggest side effects are a lowered libido and, less commonly, erectile dysfunction.

A daily 5-milligram dose of the erectile dysfunction drug Cialis can also reduce symptoms of an enlarged prostate. Lastly, in those who don't retain urine in the bladder, anticholinergic medications such as tolterodine and oxybutynin help relax the bladder and decrease the desire to urinate. The problem with these medications is that they have more side effects, including dry mouth, blurred vision, drowsiness, constipation and impairment of mental function.

Because you mention surgery, I assume that you've already been given medication for your symptoms and are now confronting the prospect of a more radical intervention. The most common surgery for prostate enlargement is a transurethral prostatectomy. In this surgery, a urologist removes a portion of the prostate via the urethra. The transurethral prostatectomy is well-tolerated with minimal side effects, but if you're looking for a less invasive procedure, there are alternatives.

One alternative form of surgery — known as focused laser ablation — vaporizes prostate tissue with light waves. This eases symptoms immediately, has less blood loss than traditional surgery and has a recovery time of only two to three days. Although this procedure treats a smaller portion of the prostate, and symptoms may occur again at a later time, early research is supportive of this option. A European study in 2016, for example, showed that the benefits of this treatment lasted more than two years. Similar procedures use water vapor or even microwaves. All of these have fewer side effects than traditional surgery and have been shown to be effective.

Medications are obviously the first choice for symptoms of prostate enlargement. But if those don't work, there are less invasive procedures than traditional surgery.

Robert Ashley, M.D., is an internist and assistant professor of medicine at the University of California, Los Angeles. Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.

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