Treating an enlarged prostate: from watchful waiting to surgery

The moment the word prostate comes up, many men jump straight to surgery. That is usually skipping ten rungs at once.

Most men with an enlarged prostate are never operated on. Here is the whole ladder, from the bottom.

What follows is explanation, not advice. Which step suits you is decided with your GP or urologist, not with an article.

Does an enlarged prostate always need treating?

No. With mild symptoms, watchful waiting is a legitimate choice, and the Dutch NHG guideline on urinary symptoms in men says so explicitly. An enlarged prostate is benign, does not become cancer, and does not worsen in everyone. If your symptoms barely bother you, nothing needs to happen.

Watchful waiting does not mean doing nothing. It means following: how are your symptoms developing, and are they starting to run your life?

Use the IPSS questionnaire from the pillar as your measuring stick. A score that stays stable is a perfectly good reason to change nothing.

What can you do yourself?

More than you would think, and it is less dull than it sounds. The biggest gains sit in your evening: drink less after about eight, cut back coffee and alcohol (both irritate the bladder and drive urine production), and take your time on the toilet instead of straining.

Two techniques urologists often hand out: double voiding (wait a moment after urinating and try again) and bladder training (do not obey urgency instantly, stretch it out).

Does this work for everyone? No. But it costs you nothing and it can postpone a drug.

And saw palmetto, because everyone asks

It does not work. Saw palmetto (serenoa repens) is the best known prostate supplement in the world, and Cochrane pooled the randomised trials: no better than placebo for urinary symptoms, not even at higher doses (Tacklind, 2012).

That is an awkward message for a shelf full of tubs, but it is where the evidence stands.

More on what diet and supplements do and do not do is in keeping your prostate healthy.

What medications exist?

Two main classes, working in completely different ways. Alpha blockers relax the muscle around your urethra and work within days, without shrinking your prostate. 5-alpha reductase inhibitors block DHT and genuinely shrink the prostate over months. Sometimes they are combined.

The detail your doctor needs to know

If you take a 5-alpha reductase inhibitor, your PSA falls by roughly half (Guess, 1993). A result of 2.0 ng/ml therefore actually means around 4.0 in your case.

Always say so before you have PSA measured. Including when you use finasteride purely for your hair.

Without that information, someone reads a normal result where it is not warranted. How to interpret a PSA number further is in PSA levels by age.

When does surgery come into view?

When medication is not helping enough, or when damage is threatened. The classic reasons are repeated urinary retention (suddenly you cannot pass urine at all), recurring bladder infections, bladder stones, blood in the urine from the prostate, and kidney function starting to suffer under the obstruction. At that point waiting is no longer a neutral choice.

The best known procedure is TURP, in which the tissue squeezing the urethra is removed from the inside. There are also laser techniques and minimally invasive methods with less impact on ejaculation.

Which technique fits depends on the size of your prostate, your symptoms and your own priorities. That conversation happens with a urologist.

Picture two men of 64, both with a 60 ml prostate. One scores 5 on the IPSS and sleeps fine. The other scores 22 and is up three times a night.

Same prostate, and yet a completely different conversation. Size does not drive the choice. Bother does.

I think watchful waiting gets dismissed as doing nothing far too often, when it is a real option.

What does this mean for your sex life?

More than the leaflets suggest, and you would rather hear it beforehand. Alpha blockers mainly affect ejaculation, 5-alpha reductase inhibitors more often affect desire and erection, and after a TURP retrograde ejaculation is the rule rather than the exception.

Retrograde ejaculation is medically harmless: the semen goes into your bladder instead of out. For fertility it does matter, so that is a separate question if you still want children.

We set out the side effects per drug in enlarged prostate and erectile problems. Take that table to your appointment.

Where to start today

First work out how bad it actually is. Score yourself for a week with the IPSS questions in the prostate guide and write down your total.

Below 8, there is rarely any hurry. Above it, you have a concrete conversation to have.

If you want your kidney function and PSA in view before that conversation, the prostate health check measures those values in a single draw. And if the trouble is mainly at night, read frequent urination at night: the prostate is not always the culprit there.

References

• Tacklind J, MacDonald R, Rutks I, Stanke JU, Wilt TJ. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2012;12:CD001423. PMID 23235581.
• Guess HA, Heyse JF, Gormley GJ, Stoner E, Oesterling JE. Effect of finasteride on serum PSA concentration in men with benign prostatic hyperplasia. Urol Clin North Am. 1993;20(4):627-636. PMID 7505970.
• Barry MJ, Fowler FJ Jr, O'Leary MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. J Urol. 1992;148(5):1549-1557. PMID 1279218.
• Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol. 1984;132(3):474-479. PMID 6206240.
• NHG. NHG-Standaard Mictieklachten bij mannen (Dutch GP guideline on urinary symptoms in men). richtlijnen.nhg.org
• Farmacotherapeutisch Kompas. Tamsulosin, finasteride and dutasteride. farmacotherapeutischkompas.nl

Every blood test result at Caliber includes a professional assessment by a BIG-registered doctor. For treatment decisions, always discuss your results with your GP.