Benign Prostatic Hyperplasia (BPH)

An enlarged prostate can block urine flow through the urethra — similar to a clamp around a garden hose.

As the bladder struggles to pass urine, the bladder wall thickens, causing symptoms such as:

• Increased urination frequency
• Weak urine stream
• Start-and-stop flow of urine
• Hesitancy starting to urinate, or straining to do so
• Incomplete emptying
• Nocturia, having to wake at night to urinate

These symptoms can range from mild to severe.

At Houston Methodist, your urologist will also ask you about how BPH symptoms are affecting your quality of life. Using symptom and quality of life scoring, our experts holistically assess the severity of your condition in order to recommend the most effective treatment option for your specific condition and lifestyle needs.

If your doctor suspects you may have benign prostatic hyperplasia (BPH), he or she may use one or more of the following tests to diagnose your condition, identify the cause, and plan the best course of treatment:

• Digital rectal exam (DRE) – typically part of an annual exam, but may be done between checkups if your doctor suspects a prostate problem. The doctor inserts a gloved, lubricated finger in the lower part of your rectum to feel the prostate and estimate the size and shape of the prostate.
• Urine flow study – measures urine flow speed as you urinate into a special device. Slow speed could indicate BPH.
• Blood tests – can uncover kidney issues (a potential complication of BPH associated with urinary retention). Prostate-specific antigen (PSA) levels may also be evaluated since elevated PSA can occur with BPH. The larger the prostate, the higher PSA level typically rises.
• Ultrasound – called transrectal ultrasound, a finger-sized probe is inserted into the rectum to visualize and measure the prostate.
• Cystoscopy – more accurately checks the urethra, prostate and bladder for the site of obstruction. After giving you a local anesthetic, your doctor will insert a small, flexible tube called a cystoscope through your urethra. The tube contains a lens and light, which allow your doctor to see inside the urethra and bladder.

The best treatment for BPH depends on your symptom severity and personal needs, with options ranging from lifestyle changes and medications to medical procedures. Urologists at Houston Methodist work with you to help you understand which treatment option or options are right for you.

Mild BPH symptoms can sometimes be managed with lifestyle changes, including:

• Urinating as soon as you first feel the urge
• Urinating regularly throughout the day, whether or not you have an urge
• Avoiding alcohol and caffeine
• Spreading fluid intake throughout the day and limiting fluids two hours before bedtime
• Avoiding decongestants and antihistamines
• Reducing stress

Medications to Treat BPH Symptoms

Your doctor may recommend one or a combination of medications that help reduce the symptoms of BPH, including:

• Finasteride and dutasteride – inhibit metabolism of hormones within the prostate, preventing further prostate growth
• Alpha 1 blockers – include terazosin, doxazosin, tamsulosin, alfuzosin and silodosin, which improve urination issues by relaxing your prostate and bladder muscles. However, these medications do not reduce the size of the prostate.
• PDE5-inhibitors – includes tadalafil, which can be taken daily to reduce urinary urgency associated with prostate enlargement
• Beta-3 agonists – such as mirabegron or virabegron, which allow the bladder to store more urine comfortably and reduce urgency and frequency of urination
• Antibiotics – may be prescribed to treat chronic prostatitis (prostate inflammation), another prostate problem that sometimes accompanies BPH

If medications don't relieve your symptoms or your condition is more advanced, your doctor may recommend a minimally invasive procedure or surgery to help open up the urethra or remove obstructing prostate tissue.

Office-Based Procedures for BPH

For men with only mildly enlarged prostates who are looking for symptom reduction slightly beyond what medications can provide and without the need to continue medications, several minimally invasive, in-office procedures can be considered for symptom relief.

The benefits of these procedures include:

• No incisions
• No general anesthesia
• No hospital stay
• Preservation of sexual function

Our urologists have expertise in all of the currently available minimally invasive procedures used to treat BPH, including:

• Prostatic urethral lift procedure, also called Urolift® – uses small implants to help open up the urethra by tacking back the prostate tissue the way curtain ties can hold up curtains
• Water vapor therapy, including Rezum™ – uses the natural energy stored in steam to reduce the centrally-enlarged portions of the prostate
• Temporarily implanted nitinol device, also called the iTIND™ procedure – uses a temporary stent to reshape the urethra, widening the opening for urine to flow
• Prostate artery embolization (PAE) – performed by experienced radiologists, may help shrink the enlarged prostate by injecting small particles that reduce blood supply into the blood vessels of the prostate

Surgical Procedures for BPH Treatment

The surgical procedures used for BPH treatment are more effective than office-based therapies and also offer longer-term relief of BPH symptoms. These prostate surgeries are most effective in cases where medications are not sufficiently alleviating symptoms or obstruction. However, they are performed in an operating room and may require an overnight hospital stay.

The expert urologic surgeons at Houston Methodist offer all of the minimally invasive surgical procedures used to treat BPH. These less invasive procedures require only small incisions or no incisions at all, and some also make use of robotic and laser technology. These advancements reduce the risk of complications and shorten the time it takes to recover after surgery.

Surgical procedures for BPH treatment include:

• Photoselective vaporization of the prostate (PVP) with GreenLight™XPS™ – an incisionless procedure that uses a catheter-delivered laser to superheat targeted prostate tissue and vaporize it, creating a channel for urine to flow more freely
• GreenLight™ laser enucleation of the prostate (GreenLEP) – an incisionless procedure that uses a catheter-delivered laser to sculpt out the enlarged prostate tissue blocking urine flow. It is particularly useful in large prostates, even in men taking anticoagulants, because the risk of bleeding is lower compared to traditional prostate surgeries like TURP.
• Holmium laser enucleation of the prostate (HoLEP) – an incisionless procedure that uses a catheter-delivered laser to sculpt out the enlarged prostate tissue blocking urine flow.  It is particularly useful in large prostates.
• Transurethral resection of the prostate (TURP) – a well-established, traditional minimally invasive procedure that uses a resectoscope and loop, similar to a hot wire, to carve out the enlarged tissue blocking urine flow
• Transurethral incision of the prostate (TUIP) – a minimally invasive procedure for small to moderate enlargement of the prostate that uses either a laser or an electrosurgical wand to make relaxing incisions into the interface of the bladder with the prostate, which can help restore urine flow.
• Aquablation therapy – an incisionless transurethral robotic procedure to remove prostate tissue using heat-free water, which is guided with precision real-time ultrasound imaging. This surgical treatment has less risk of ejaculatory dysfunction than traditional surgeries like TURP.
• Robotic simple prostatectomy (RASP) – a minimally invasive procedure in which a surgeon uses an advanced surgical system to pass robotically controlled instruments through small incisions in the abdomen to remove the prostate

Of these surgical procedures, the one that is best for you varies based on how enlarged your prostate has become and whether you're experiencing complications, such as renal failure, bladder stones, chronic infections or blood in the urine.