By Garrett D. Pohlman

Benign prostatic hyperplasia (BPH), otherwise known as an enlarged prostate, is a common condition that can affect a man’s quality of life and cause side effects such as the urgent need to urinate, nocturia (nighttime urination), bladder damage, urinary tract infections, blood in the urine, incontinence and more. The prevalence of BPH and lower urinary tract issues rises markedly with increased age, affecting 70% of men 60-69 years of age and 80% of those 70 years of age or older.

For many years, medication was the next step in the progression for treatment for BPH symptomsand is still widely used today, despite low efficacy and poor patient compliance. One might even say BPH medications only act as a Band-Aid for symptoms – though they may provide some symptom relief for some people, they don’t address the underlying cause of the issue – bladder obstruction. And in fact, long-term bladder outlet obstruction puts pressure on the bladder causing it to give out and may result in irreparable damage to the bladder. Thankfully for physicians and patients, and widely due to their demand for better treatment options, today there are a plethora of new and emerging minimally invasive treatment options that can be used alongside or in place of medication.

A brief historical overview of BPH medication usage
There are a few main categories of medications that have historically been used to treat BPH symptoms, including a1-blockers, 5-alpha reductase inhibitors, phosphodiesterase-5 inhibitors, Beta-3 agonists, Muscarinic receptor antagonists (MRAs) and combination therapy. Though these medications can be somewhat successful in providing symptom relief for some patients, they are also associated with a number of serious side effects like cardiovascular events (postural hypotension, asthenia and dizziness), ejaculatory dysfunction, decreased libido, gynecomastia, erectile dysfunction, acute urinary retention, urinary tract infection, hypertension, headache, constipation and nasopharyngitis (Frontiers in Pharmacology, 2020). Facing these side effects, along with difficulty maintaining proper medication adherence, patients have increasingly struggled to find true relief from BPH symptoms with medication.

Changing views on BPH medication use
In addition to the long list of potential side effects, there is also a growing body of research that supports shifting away from medications as a first-line treatment when comparing them to the efficacy and safety profiles of other options.

With tamsulosin, there’s an increased risk of falls which is the leading cause of injury for adults ages 65 years and older. And while there’s more research that needs to be done, studies have shown a link between 5-ARIs, alpha-blockers, and anticholinergics potentially causing significant neurocognitive and psychiatric side effects, including dementia and depression.

Patients prescribed these medications need to take them daily for the rest of their lives and frequently have multiple prescriptions to treat BPH symptoms, leading to stacking of numerous medications. Potential negative impacts of long-term BPH medication use also include increases in blood glucose, glycated hemoglobin, total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels, liver enzymes and reduced testosterone, according to a 2017 retrospective study of 460 men comparing long-term dutasteride to tamsulosin use. While no changes were seen in the cohort of men taking tamsulosin, the study suggests that dutasteride may cause a negative imbalance of metabolic function.

Historically, urologists have downplayed BPH medication side effects, but the reality is that men care about them and it’s just one of the reasons why compliance with these medications is so low. It’s important for physicians to help patients understand all of the potential long-term risks prior to prescribing them.

Improved options
Urologists and patients are taking note that today there are safe and effective, minimally invasive technologies that don’t cause the same side effects as medications, don’t impact men’s sexual function and address the root issue of bladder obstruction.

While the transurethral resection of the prostate (TURP) surgical procedure has been the gold standard in BPH treatments, it is an invasive surgery and there are significant risks involved including sexual side effects, incontinence, bleeding, and a much longer recovery time.

Over the past 10-15 years, we have seen the introduction of a brand new category of BPH treatments called minimally invasive surgical therapies (MISTs). This category was created to provide treatment options with many benefits compared to medication therapy, including one-time treatment versus a lifetime of medications, lower risk for side effects, and improved efficacy because they can actually fix the problem instead of just kicking the can down the road by with medication. MIST options that are cleared by the U.S. Food and Drug Administration to be safe and effective include:

• Optilume BPH catheter system: This is the newest MIST available, combining mechanical dilation with concurrent delivery of paclitaxel for treating BPH. Mechanical dilation with a double-lobe balloon technology achieves an anterior commissurotomy (split) releasing the constricting lateral lobes, while the delivery of paclitaxel prevents re-fusion of the lobes during healing, keeping the prostate open, restoring the flow of urine and relieving bothersome BPH symptoms. With this procedure, there is no cutting, heating, burning, lasering, steaming or implantations.
• Prostatic urethral lift: Permanent implants lift the prostate and hold it away from the urethra, allowing urine to flow more freely.
• Water vapor thermal therapy: Water vapor (steam) is used to destroy targeted prostate tissue, shrinking the enlarged area of the prostate and improving urine flow.
• Temporarily implanted nitinol device: A temporary device made from a shape-memory alloy is implanted and gradually expands within the prostate to reshape the tissue over 5-7 days. After this period, the device is removed, leaving an expanded pathway for urine flow.
• Robotic waterjet treatment: A robotically guided camera and ultrasound imaging is used to map the prostate and precisely direct a heat-free high-pressure water jet to destroy excess prostate tissue.

It’s important to consider severity of symptoms, prostate size and medical history when evaluating MIST options.

With the advent of these MIST options, a new era has arrived, providing BPH sufferers with treatments that minimize potential side effects, and improve patient comfort and efficacy.

The bottom line
Medications may be a good option for some patients with BPH, but for others, MIST options will likely be more effective and only require a one-time treatment with lower risk of side effects. Having a good understanding of the many different treatment options available today is the key to ensuring patients find relief and improve their quality of life quickly, with as few side effects as possible and avoiding irreparable bladder damage. There are a number of helpful resources out there with comprehensive overviews of the different options, links to clinical study data, etc. Some I’d recommend include my own Prostate Health Podcast, Grand Rounds in Urology and the American Urological Association.

The tide is turning. Not just in urology but across many areas of medicine. Advances in science are making it possible to meet patient demand for safe, effective, minimally invasive treatment options that don’t require a lifetime of medication usage with problematic side effects.

About the author: Dr. Garrett D. Pohlman is a board certified urologist with the Kearney Urology Center and host of the Prostate Health Podcast.