Lower urinary tract symptoms in men are amongst the most common reasons for a urological visit. In this post, I explore ten questions that every man must ask when seeking urological help for these symptoms.
1. Are my symptoms related to my prostate?
The natural assumption is that urinary symptoms in men are related to a growing prostate. This may be true, but other variables need evaluation. First, is there excessive fluid intake? Secondly, primary bladder problems often mimic prostate symptoms. For instance, overactive bladder, neurogenic, or underactive bladder can cause urinary symptoms.
2. Could my symptoms represent prostate cancer?
Prostate cancer can present with new-onset urinary symptoms such as urgency, pain, and difficulty with voiding. A good prostate exam and a screening blood test (PSA) are vital to helping distinguish between cancer and enlarged prostate.
3. Will I need to be on medications?
The decision to start on medications is very individualized as each patient’s tolerance for their symptoms is different.
4. Which medications are most useful?
The prostate and bladder opening are innervated with alpha nerve fibers from the autonomic nervous system. Alpha-blockers, such as Tamsulosin, relax these muscles easing urine flow. Common side effects of these drugs include dizziness and a diminished ejaculate.
5-alpha-reductase inhibitors (Finasteride), inhibit the conversion of testosterone to dihydrotestosterone, which promotes prostate growth. Blocking this reduces the size of the prostate, which can often take upwards of six months to be effective. Common side effects can be a decline in libido and hair growth.
5. What tests are used to evaluate my urinary symptoms?
Questionnaires like the International Prostate Symptom Score (IPSS) are useful in evaluating the severity. Urinalysis will determine whether blood is present or a urinary tract infection, and a PSA blood test can help determine prostate cancer risk. A urinary flow test (voiding into a machine that captures the speed of the urinary flow and how long it takes to empty) can also help to quantify the degree of urinary problems.
Urologists may also perform bladder ultrasounds to evaluate how much residual urine is present and to determine the size of the prostate in three dimensions. A prostate can feel normal but have a significant protrusion into the bladder causing severe symptoms. Finally, a urodynamics (UDS) test, where a small catheter is placed in the bladder and rectum, may be used to determine bladder capacity, bladder pressure, and flow rate, especially if there are co-existing neuro-muscular diseases such as Parkinson’s, multiple sclerosis or diabetes.
6. Will treatment affect my sex life?
The prostate is a sexual gland primarily involved in the ejaculatory function. As a result, any medicine or procedure may affect sex and in particular ejaculation. Most surgical approaches to the prostate, from open surgical removal to a laser procedure, will likely cause “retrograde ejaculation,” where little or no ejaculate is expelled. This is not harmful.
Medications may have similar results. Impotence is rare with medications, surgery, or procedures.
7. When is surgery required for an enlarged prostate?
Refractory symptoms despite medications usually warrant surgery. Inability to urinate and needing a catheter will usually require surgery. Further, if the kidneys are blocked from prostate enlargement resulting in early kidney failure, surgery is required. Finally, the development of bladder stones, recalcitrant urinary tract infections, and gross hematuria (blood in the urine) may also require surgery.
8. What are the different surgical options?
Exceedingly large prostates usually require surgery via the abdomen. This can be done via an open surgical incision or via robotic surgery. In my practice, I perform this operation when the prostate is above 200 grams, or the prostate length is above 7 cm. This results in a more complete removal of the obstructing prostate tissue. The disadvantages include invasive surgery, longer time to have a urethral catheter (10-14 days), longer hospital stay, and increased risk for bleeding requiring a blood transfusion.
Transurethral resection of the prostate (“TURP”) is considered the “gold standard” surgery. This is an endoscopic approach requiring shaving down the prostate in “piecemeal” fashion. This approach requires hospitalization, a urinary catheter (5-7 days), and usually overnight stay in the hospital. I usually perform this operation if the prostate size is above 120-200 grams.
Laser surgery such as Greenlight vaporizes the prostate enlargement. Advantages include surgery as an outpatient, less bleeding, ability to perform surgery while maintaining anticoagulation (“blood thinners,” seen in many of our cardiac patients), fewer days with the catheter (2-3 days). Disadvantages include more significant dysuria (or burning with urination) in the recovery phase. I typically perform this surgery in patients whose prostate is 80-150 grams.
9. Are there office-based procedures for my urinary problems?
Office-based procedures bridge a gap between surgery and medications. They can be done with local anesthesia or typically sedation.
Deploys surgical clips to compress the obstructive prostatic tissue. A catheter can usually be avoided, and if needed, usually can be removed after 1-2 days. There is no retrograde ejaculation with this procedure. Men whose prostate size is 80 grams or above and or have an obstructive median lobe (growth of prostate into bladder opening) preclude placement of these.
A minimally invasive procedure employing steam into the prostatic tissue. Essentially heat is used to kill the enlarged areas. No risk of retrograde ejaculation. It is best utilized for men with prostate gland 100 grams or less. A catheter is placed for 3-5 days.
10. Will I need any other treatments after choosing surgery or an office procedure?
It’s unlikely to need more treatment with open procedure or TURP. Laser procedures have a higher rate of retreatment than TURP. The newer office-based procedures have been on the market for less than ten years. It’s safe to assume that the retreatment for these procedures over a five-year period is higher than lasers or other surgical approaches, including the need to start medications, and has been estimated to be as high as 30 percent.
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