If you’re a man over 40, you should know that prostate enlargement is as common as your kids asking for money. 

When a man’s prostate becomes enlarged, it may signal a condition known as benign prostatic hyperplasia, or BPH, which is common in men over 40.

The most usual symptoms involve urination and include: 

• an urgent need to urinate
• a hesitant or weak urine stream
• and frequent urination, especially at night

If you’re experiencing symptoms like these, see a doctor. Your doctor will be able to check you for, and potentially rule out, other conditions such as prostate cancer.

Treatment of BPH can reduce urinary symptoms and may help you avoid more serious health problems. 

The prostate is a walnut-shaped gland that is part of the male reproductive system. The main function of the prostate is to make a fluid that goes into semen. Prostate fluid is essential for a man’s fertility. The gland surrounds the urethra at the neck of the bladder. The bladder neck is the area where the urethra joins the bladder. The bladder and urethra are parts of the lower urinary tract. The prostate has two or more lobes, or sections, enclosed by an outer layer of tissue, and it is in front of the rectum, just below the bladder. The urethra is the tube that carries urine from the bladder to the outside of the body. In men, the urethra also carries semen out through the penis.

Benign prostatic hyperplasia—also called BPH—is a condition in men in which the prostate gland is enlarged and not cancerous. Benign prostatic hyperplasia is also called benign prostatic hypertrophy or benign prostatic obstruction.

The prostate goes through two main growth periods as a man ages. The first occurs early in puberty, when the prostate doubles in size. The second phase of growth begins around age 25 and continues during most of a man’s life. Benign prostatic hyperplasia often occurs with the second growth phase.

As the prostate enlarges, the gland presses against and pinches the urethra. The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the ability to empty completely, leaving some urine in the bladder. The narrowing of the urethra and urinary retention—the inability to empty the bladder completely—cause many of the problems associated with benign prostatic hyperplasia.

Benign prostatic hyperplasia is the most common prostate problem for men older than age 50. In 2010, as many as 14 million men in the United States had lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Although benign prostatic hyperplasia rarely causes symptoms before age 40, the occurrence and symptoms increase with age. Benign prostatic hyperplasia affects about 50 percent of men between the ages of 51 and 60 and up to 90 percent of men older than 80.

What is the prostate?

The prostate is a gland in the male reproductive system. It lies just below the bladder. It makes fluid that is part of semen.

What is an enlarged prostate (BPH)?

An enlarged prostate is when your prostate gland becomes larger than normal. It's also called benign prostatic hyperplasia or BPH for short. Benign means not cancer. And hyperplasia means too much cell growth. BPH isn't cancer and it doesn't increase your risk of getting prostate cancer.

Usually, the prostate gland continues to grow during adult life. That's why BPH is the most common prostate condition in people over age 50. As the prostate gets bigger, it may press against the bladder and pinch the urethra. This can slow or block the flow of urine out of your bladder.

Over time, the bladder muscle may become weak from trying to pass urine through a narrow urethra. When this happens, your bladder may not empty completely when you urinate. A narrowed urethra and weak bladder cause many of the urinary problems you may have with BPH.

What causes an enlarged prostate (BPH)?

Researchers aren't sure why the prostate keeps growing. Some researchers think changes in hormones with aging may cause the prostate to get bigger.

Who is more likely to develop BPH?

You're more likely to develop BPH if you:

• Are age 40 or older. The chance of getting BPH increases as you get older.
• Have family members who have had BPH.
• Have certain health conditions such as:
  • Obesity.
  • Heart disease and problems with blood circulation.
  • Type 2 diabetes.
  • Erectile dysfunction.
• Don't get enough physical activity.

What are the symptoms of BPH?

Symptoms of BPH include:

• Having a frequent or urgent need to urinate
• Waking up many times to urinate
• Having problems with urine flow, such as:
  • Trouble starting to urinate
  • A stream that's weak, slow, or stops and starts
  • Dribbling after urination
  • Urinary incontinence
  • Feeling that you can't completely empty your bladder
• Pain after ejaculation or during urination
• Urine with an unusual color or smell

It's important to see your health care provider if you have any of these symptoms because they could be from a more serious health problem.

You should get medical help right away if you:

• Can't urinate at all
• Have fever and chills with urination that's painful, frequent, and urgent
• Have blood in your urine
• Have pain in your lower abdomen (belly) and urinary tract

What other problems can BPH cause?

For most people, BPH doesn't cause other problems. But BPH increases your chance of developing serious conditions, including:

• Acute urinary retention. With this condition, you suddenly can't urinate at all. This a medical emergency. Acute urinary retention is common in older males and the chance of having it increases with age. It may be triggered by:
  • Taking certain over-the-counter cold or allergy medicines
  • Drinking alcohol
  • Cold temperatures
  • Not moving enough over a long period of time
• Urinary tract infections (UTIs)
• Bladder damage and bladder stones
• Kidney damage

How is BPH diagnosed?

To find out if you have BPH, your provider will:

• Ask about your medical history. Be sure to tell your provider about all the medicines you take, because certain medicines can make BPH symptoms worse.
• Ask about your family health history.
• Examine you. The exam may include a digital rectal exam (DRE) of your prostate. In a DRE, your provider inserts a gloved finger into your rectum to check if your prostate is large, tender, or irregular in any other way.
• Order medical tests, if needed, such as:
  • Urine tests.
  • A PSA blood test (prostate-specific antigen test).
  • Urodynamic testing to see how well you can hold and release urine.
  • Cystoscopy to look inside your urethra and bladder.
  • Ultrasound pictures of your prostate and urinary tract.
  • A prostate biopsy to diagnose or rule out prostate cancer.

What are the treatments for BPH?

Not everyone needs treatment for BPH. Treatment options depend on how much your symptoms bother you, your health, age, and the size of your prostate:

• Lifestyle changes may improve mild symptoms. They include:

  • Drinking less before bedtime or going out
  • Avoiding or cutting back on beverages with caffeine and alcohol
  • Bladder training and exercising the muscles that control urine flow
  • Preventing or treating constipation

• Medicines can help mild to moderate symptoms by:

  • Stopping the prostate from growing
  • Shrinking the prostate
  • Relaxing muscles to improve urine flow

  Sometimes combining 2 types of medicine helps more than taking just one type of medicine.

• Medical procedures can help improve moderate to severe BPH symptoms when medicines don't help enough. There are several different types of procedures. They all use an instrument inserted into the urethra to either:

  • Widen the urethra
  • Destroy part of the prostate with heat

• Surgery may be helpful when symptoms are severe, other treatments haven't helped, or you have another problem, such as bladder damage. Different types of surgery are used to:

  • Remove part or all of the prostate
  • Make cuts in the prostate to take pressure off the urethra

  Most BPH surgery is done with tools inserted into the urethra.

Your provider can explain the possible benefits and side effects of your treatment options so you can decide what's best for you.

Can BPH be prevented?

Researchers haven't found ways to prevent BPH. You can take care of your prostate health by:

• Talking with your provider about your risk for developing an enlarged prostate
• Getting regular checkups
• Paying attention to your symptoms so you can get treatment early if you see signs of BPH

Men with the following factors are more likely to develop benign prostatic hyperplasia:

• age 40 years and older
• family history of benign prostatic hyperplasia
• medical conditions such as obesity, heart and circulatory disease, and type 2 diabetes
• lack of physical exercise
• erectile dysfunction

The cause of benign prostatic hyperplasia is not well understood; however, it occurs mainly in older men. Benign prostatic hyperplasia does not develop in men whose testicles were removed before puberty. For this reason, some researchers believe factors related to aging and the testicles may cause benign prostatic hyperplasia.

Throughout their lives, men produce testosterone, a male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in their blood decreases, which leaves a higher proportion of estrogen. Scientific studies have suggested that benign prostatic hyperplasia may occur because the higher proportion of estrogen within the prostate increases the activity of substances that promote prostate cell growth.

Another theory focuses on dihydrotestosterone (DHT), a male hormone that plays a role in prostate development and growth. Some research has indicated that even with a drop in blood testosterone levels, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage prostate cells to continue to grow. Scientists have noted that men who do not produce DHT do not develop benign prostatic hyperplasia.

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia may include

• urinary frequency—urination eight or more times a day
• urinary urgency—the inability to delay urination
• trouble starting a urine stream
• a weak or an interrupted urine stream
• dribbling at the end of urination
• nocturia—frequent urination during periods of sleep
• urinary retention
• urinary incontinence—the accidental loss of urine
• pain after ejaculation or during urination
• urine that has an unusual color or smell

Symptoms of benign prostatic hyperplasia most often come from

• a blocked urethra
• a bladder that is overworked from trying to pass urine through the blockage

The size of the prostate does not always determine the severity of the blockage or symptoms. Some men with greatly enlarged prostates have little blockage and few symptoms, while other men who have minimally enlarged prostates have greater blockage and more symptoms. Less than half of all men with benign prostatic hyperplasia have lower urinary tract symptoms.

Sometimes men may not know they have a blockage until they cannot urinate. This condition, called acute urinary retention, can result from taking over-the-counter cold or allergy medications that contain decongestants, such as pseudoephedrine and oxymetazoline. A potential side effect of these medications may prevent the bladder neck from relaxing and releasing urine. Medications that contain antihistamines, such as diphenhydramine, can weaken the contraction of bladder muscles and cause urinary retention, difficulty urinating, and painful urination. When men have partial urethra blockage, urinary retention also can occur as a result of alcohol consumption, cold temperatures, or a long period of inactivity.

A person may have urinary symptoms unrelated to benign prostatic hyperplasia that are caused by bladder problems, UTIs, or prostatitis—inflammation of the prostate. Symptoms of benign prostatic hyperplasia also can signal more serious conditions, including prostate cancer.

Men with symptoms of benign prostatic hyperplasia should see a health care provider.

Men with the following symptoms should seek immediate medical care:

• complete inability to urinate
• painful, frequent, and urgent need to urinate, with fever and chills
• blood in the urine
• great discomfort or pain in the lower abdomen and urinary tract

The complications of benign prostatic hyperplasia may include

• acute urinary retention
• chronic, or long lasting, urinary retention
• blood in the urine
• urinary tract infections (UTIs)
• bladder damage
• kidney damage
• bladder stones

Most men with benign prostatic hyperplasia do not develop these complications. However, kidney damage in particular can be a serious health threat when it occurs.

A health care provider diagnoses benign prostatic hyperplasia based on

• a personal and family medical history
• a physical exam
• medical tests

Personal and Family Medical History

Taking a personal and family medical history is one of the first things a health care provider may do to help diagnose benign prostatic hyperplasia. A health care provider may ask a man

• what symptoms are present
• when the symptoms began and how often they occur
• whether he has a history of recurrent UTIs
• what medications he takes, both prescription and over the counter
• how much liquid he typically drinks each day
• whether he consumes caffeine and alcohol
• about his general medical history, including any significant illnesses or surgeries

Physical Exam

A physical exam may help diagnose benign prostatic hyperplasia. During a physical exam, a health care provider most often

• examines a patient’s body, which can include checking for
  • discharge from the urethra
  • enlarged or tender lymph nodes in the groin
  • a swollen or tender scrotum
• taps on specific areas of the patient’s body
• performs a digital rectal exam

A digital rectal exam, or rectal exam, is a physical exam of the prostate. To perform the exam, the health care provider asks the man to bend over a table or lie on his side while holding his knees close to his chest. The health care provider slides a gloved, lubricated finger into the rectum and feels the part of the prostate that lies next to the rectum. The man may feel slight, brief discomfort during the rectal exam. A health care provider most often performs a rectal exam during an office visit, and men do not require anesthesia. The exam helps the health care provider see if the prostate is enlarged or tender or has any abnormalities that require more testing.

Many health care providers perform a rectal exam as part of a routine physical exam for men age 40 or older, whether or not they have urinary problems.

Medical Tests

A health care provider may refer men to a urologist—a doctor who specializes in urinary problems and the male reproductive system—though the health care provider most often diagnoses benign prostatic hyperplasia on the basis of symptoms and a digital rectal exam. A urologist uses medical tests to help diagnose lower urinary tract problems related to benign prostatic hyperplasia and recommend treatment. Medical tests may include

• urinalysis
• a prostate-specific antigen (PSA) blood test
• urodynamic tests
• cystoscopy
• transrectal ultrasound
• biopsy

Urinalysis. Urinalysis involves testing a urine sample. The patient collects a urine sample in a special container in a health care provider’s office or a commercial facility. A health care provider tests the sample during an office visit or sends it to a lab for analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color to indicate signs of infection in urine.

PSA blood test. A health care provider may draw blood for a PSA test during an office visit or in a commercial facility and send the sample to a lab for analysis. Prostate cells create a protein called PSA. Men who have prostate cancer may have a higher amount of PSA in their blood. However, a high PSA level does not necessarily indicate prostate cancer. In fact, benign prostatic hyperplasia, prostate infections, inflammation, aging, and normal fluctuations often cause high PSA levels. Much remains unknown about how to interpret a PSA blood test, the test’s ability to discriminate between cancer and prostate conditions such as benign prostatic hyperplasia, and the best course of action to take if the PSA level is high.

Urodynamic tests. Urodynamic tests include a variety of procedures that look at how well the bladder and urethra store and release urine. A health care provider performs urodynamic tests during an office visit or in an outpatient center or a hospital. Some urodynamic tests do not require anesthesia; others may require local anesthesia. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely and may include the following:

• uroflowmetry, which measures how rapidly the bladder releases urine
• postvoid residual measurement, which evaluates how much urine remains in the bladder after urination
• reduced urine flow or residual urine in the bladder, which often suggests urine blockage due to benign prostatic hyperplasia

Cystoscopy. Cystoscopy is a procedure that uses a tubelike instrument, called a cystoscope, to look inside the urethra and bladder. A urologist inserts the cystoscope through the opening at the tip of the penis and into the lower urinary tract. A urologist performs cystoscopy during an office visit or in an outpatient center or a hospital. The urologist will give the patient local anesthesia; however, in some cases, the patient may require sedation and regional or general anesthesia. A urologist may use cystoscopy to look for blockage or stones in the urinary tract.

Transrectal ultrasound. Transrectal ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. The health care provider can move the transducer to different angles to make it possible to examine different organs. A specially trained technician performs the procedure in a health care provider’s office, an outpatient center, or a hospital, and a radiologist—a doctor who specializes in medical imaging—interprets the images; the patient does not require anesthesia. Urologists most often use transrectal ultrasound to examine the prostate. In a transrectal ultrasound, the technician inserts a transducer slightly larger than a pen into the man’s rectum, next to the prostate. The ultrasound image shows the size of the prostate and any abnormalities, such as tumors. Transrectal ultrasound cannot reliably diagnose prostate cancer.

Biopsy. Biopsy is a procedure that involves taking a small piece of prostate tissue for examination with a microscope. A urologist performs the biopsy in an outpatient center or a hospital. The urologist will give the patient light sedation and local anesthetic; however, in some cases, the patient will require general anesthesia. The urologist uses imaging techniques such as ultrasound, a computerized tomography scan, or magnetic resonance imaging to guide the biopsy needle into the prostate. A pathologist—a doctor who specializes in examining tissues to diagnose diseases—examines the prostate tissue in a lab. The test can show whether prostate cancer is present.

Treatment options for benign prostatic hyperplasia may include

• lifestyle changes
• medications
• minimally invasive procedures
• surgery

A health care provider treats benign prostatic hyperplasia based on the severity of symptoms, how much the symptoms affect a man’s daily life, and a man’s preferences.

Men may not need treatment for a mildly enlarged prostate unless their symptoms are bothersome and affecting their quality of life. In these cases, instead of treatment, a urologist may recommend regular checkups. If benign prostatic hyperplasia symptoms become bothersome or present a health risk, a urologist most often recommends treatment.

Lifestyle Changes

A health care provider may recommend lifestyle changes for men whose symptoms are mild or slightly bothersome. Lifestyle changes can include

• reducing intake of liquids, particularly before going out in public or before periods of sleep
• avoiding or reducing intake of caffeinated beverages and alcohol
• avoiding or monitoring the use of medications such as decongestants, antihistamines, antidepressants, and diuretics
• training the bladder to hold more urine for longer periods
• exercising pelvic floor muscles
• preventing or treating constipation

Medications

A health care provider or urologist may prescribe medications that stop the growth of or shrink the prostate or reduce symptoms associated with benign prostatic hyperplasia:

• alpha blockers
• phosphodiesterase-5 inhibitors
• 5-alpha reductase inhibitors
• combination medications

Alpha blockers. These medications relax the smooth muscles of the prostate and bladder neck to improve urine flow and reduce bladder blockage:

• terazosin (Hytrin)
• doxazosin (Cardura)
• tamsulosin (Flomax)
• alfuzosin (Uroxatral)
• silodosin (Rapaflo)

Phosphodiesterase-5 inhibitors. Urologists prescribe these medications mainly for erectile dysfunction. Tadalafil (Cialis) belongs to this class of medications and can reduce lower urinary tract symptoms by relaxing smooth muscles in the lower urinary tract. Researchers are working to determine the role of erectile dysfunction drugs in the long-term treatment of benign prostatic hyperplasia.

5-alpha reductase inhibitors. These medications block the production of DHT, which accumulates in the prostate and may cause prostate growth:

• finasteride (Proscar)
• dutasteride (Avodart)

These medications can prevent progression of prostate growth or actually shrink the prostate in some men. Finasteride and dutasteride act more slowly than alpha blockers and are useful for only moderately enlarged prostates.

Combination medications. Several studies, such as the Medical Therapy of Prostatic Symptoms (MTOPS) study, have shown that combining two classes of medications, instead of using just one, can more effectively improve symptoms, urinary flow, and quality of life. The combinations include

• finasteride and doxazosin
• dutasteride and tamsulosin (Jalyn), a combination of both medications that is available in a single tablet
• alpha blockers and antimuscarinics

A urologist may prescribe a combination of alpha blockers and antimuscarinics for patients with overactive bladder symptoms. Overactive bladder is a condition in which the bladder muscles contract uncontrollably and cause urinary frequency, urinary urgency, and urinary incontinence. Antimuscarinics are a class of medications that relax the bladder muscles.

Minimally Invasive Procedures

Researchers have developed a number of minimally invasive procedures that relieve benign prostatic hyperplasia symptoms when medications prove ineffective. These procedures include

• transurethral needle ablation
• transurethral microwave thermotherapy
• high-intensity focused ultrasound
• transurethral electrovaporization
• water-induced thermotherapy
• prostatic stent insertion

Minimally invasive procedures can destroy enlarged prostate tissue or widen the urethra, which can help relieve blockage and urinary retention caused by benign prostatic hyperplasia.

Urologists perform minimally invasive procedures using the transurethral method, which involves inserting a catheter—a thin, flexible tube—or cystoscope through the urethra to reach the prostate. These procedures may require local, regional, or general anesthesia. Although destroying troublesome prostate tissue relieves many benign prostatic hyperplasia symptoms, tissue destruction does not cure benign prostatic hyperplasia. A urologist will decide which procedure to perform based on the man’s symptoms and overall health.

Transurethral needle ablation. This procedure uses heat generated by radiofrequency energy to destroy prostate tissue. A urologist inserts a cystoscope through the urethra to the prostate. A urologist then inserts small needles through the end of the cystoscope into the prostate. The needles send radiofrequency energy that heats and destroys selected portions of prostate tissue. Shields protect the urethra from heat damage.

Transurethral microwave thermotherapy. This procedure uses microwaves to destroy prostate tissue. A urologist inserts a catheter through the urethra to the prostate, and a device called an antenna sends microwaves through the catheter to heat selected portions of the prostate. The temperature becomes high enough inside the prostate to destroy enlarged tissue. A cooling system protects the urinary tract from heat damage during the procedure.

High-intensity focused ultrasound. For this procedure, a urologist inserts a special ultrasound probe into the rectum, near the prostate. Ultrasound waves from the probe heat and destroy enlarged prostate tissue.

Transurethral electrovaporization. For this procedure, a urologist inserts a tubelike instrument called a resectoscope through the urethra to reach the prostate. An electrode attached to the resectoscope moves across the surface of the prostate and transmits an electric current that vaporizes prostate tissue. The vaporizing effect penetrates below the surface area being treated and seals blood vessels, which reduces the risk of bleeding.

Water-induced thermotherapy. This procedure uses heated water to destroy prostate tissue. A urologist inserts a catheter into the urethra so that a treatment balloon rests in the middle of the prostate. Heated water flows through the catheter into the treatment balloon, which heats and destroys the surrounding prostate tissue. The treatment balloon can target a specific region of the prostate, while surrounding tissues in the urethra and bladder remain protected.

Prostatic stent insertion. This procedure involves a urologist inserting a small device called a prostatic stent through the urethra to the area narrowed by the enlarged prostate. Once in place, the stent expands like a spring, and it pushes back the prostate tissue, widening the urethra. Prostatic stents may be temporary or permanent. Urologists generally use prostatic stents in men who may not tolerate or be suitable for other procedures.

Surgery

For long-term treatment of benign prostatic hyperplasia, a urologist may recommend removing enlarged prostate tissue or making cuts in the prostate to widen the urethra. Urologists recommend surgery when

• medications and minimally invasive procedures are ineffective
• symptoms are particularly bothersome or severe
• complications arise

Although removing troublesome prostate tissue relieves many benign prostatic hyperplasia symptoms, tissue removal does not cure benign prostatic hyperplasia.

Surgery to remove enlarged prostate tissue includes

• transurethral resection of the prostate (TURP)
• laser surgery
• open prostatectomy
• transurethral incision of the prostate (TUIP)

A urologist performs these surgeries, except for open prostatectomy, using the transurethral method. Men who have these surgical procedures require local, regional, or general anesthesia and may need to stay in the hospital.

The urologist may prescribe antibiotics before or soon after surgery to prevent infection. Some urologists prescribe antibiotics only when an infection occurs.

Immediately after benign prostatic hyperplasia surgery, a urologist may insert a special catheter, called a Foley catheter, through the opening of the penis to drain urine from the bladder into a drainage pouch.

TURP. With TURP, a urologist inserts a resectoscope through the urethra to reach the prostate and cuts pieces of enlarged prostate tissue with a wire loop. Special fluid carries the tissue pieces into the bladder, and the urologist flushes them out at the end of the procedure. TURP is the most common surgery for benign prostatic hyperplasia and considered the gold standard for treating blockage of the urethra due to benign prostatic hyperplasia.

Laser surgery. With this surgery, a urologist uses a high-energy laser to destroy prostate tissue. The urologist uses a cystoscope to pass a laser fiber through the urethra into the prostate. The laser destroys the enlarged tissue. The risk of bleeding is lower than in TURP and TUIP because the laser seals blood vessels as it cuts through the prostate tissue. However, laser surgery may not effectively treat greatly enlarged prostates.

Open prostatectomy. In an open prostatectomy, a urologist makes an incision, or cut, through the skin to reach the prostate. The urologist can remove all or part of the prostate through the incision. This surgery is used most often when the prostate is greatly enlarged, complications occur, or the bladder is damaged and needs repair. Open prostatectomy requires general anesthesia, a longer hospital stay than other surgical procedures for benign prostatic hyperplasia, and a longer rehabilitation period. The three open prostatectomy procedures are retropubic prostatectomy, suprapubic prostatectomy, and perineal prostatectomy. The recovery period for open prostatectomy is different for each man who undergoes the procedure.

TUIP. A TUIP is a surgical procedure to widen the urethra. During a TUIP, the urologist inserts a cystoscope and an instrument that uses an electric current or a laser beam through the urethra to reach the prostate. The urologist widens the urethra by making a few small cuts in the prostate and in the bladder neck. Some urologists believe that TUIP gives the same relief as TURP except with less risk of side effects.

After surgery, the prostate, urethra, and surrounding tissues may be irritated and swollen, causing urinary retention. To prevent urinary retention, a urologist inserts a Foley catheter so urine can drain freely out of the bladder. A Foley catheter has a balloon on the end that the urologist inserts into the bladder. Once the balloon is inside the bladder, the urologist fills it with sterile water to keep the catheter in place. Men who undergo minimally invasive procedures may not need a Foley catheter.

The Foley catheter most often remains in place for several days. Sometimes, the Foley catheter causes recurring, painful, difficult-to-control bladder spasms the day after surgery. However, these spasms will eventually stop. A urologist may prescribe medications to relax bladder muscles and prevent bladder spasms. These medications include

• oxybutynin chloride (Ditropan)
• solifenacin (VESIcare)
• darifenacin (Enablex)
• tolterodine (Detrol)
• hyoscyamine (Levsin)
• propantheline bromide (Pro-Banthine)

Researchers have not found that eating, diet, and nutrition play a role in causing or preventing benign prostatic hyperplasia. However, a health care provider can give information about how changes in eating, diet, or nutrition could help with treatment. Men should talk with a health care provider or dietitian about what diet is right for them.

The complications of benign prostatic hyperplasia treatment depend on the type of treatment.

Medications

Medications used to treat benign prostatic hyperplasia may have side effects that sometimes can be serious. Men who are prescribed medications to treat benign prostatic hyperplasia should discuss possible side effects with a health care provider before taking the medications. Men who experience the following side effects should contact a health care provider right away or get emergency medical care:

• hives
• rash
• itching
• shortness of breath
• rapid, pounding, or irregular heartbeat
• painful erection of the penis that lasts for hours
• swelling of the eyes, face, tongue, lips, throat, arms, hands, feet, ankles, or lower legs
• difficulty breathing or swallowing
• chest pain
• dizziness or fainting when standing up suddenly
• sudden decrease or loss of vision
• blurred vision
• sudden decrease or loss of hearing
• chest pain, dizziness, or nausea during sexual activity

These side effects are mostly related to phosphodiesterase-5 inhibitors. Side effects related to alpha blockers include

• dizziness or fainting when standing up suddenly
• decreased sexual drive
• problems with ejaculation

Minimally Invasive Procedures

Complications after minimally invasive procedures may include

• UTIs
• painful urination
• difficulty urinating
• an urgent or a frequent need to urinate
• urinary incontinence
• blood in the urine for several days after the procedure
• sexual dysfunction
• chronic prostatitis—long-lasting inflammation of the prostate
• recurring problems such as urinary retention and UTIs

Most of the complications of minimally invasive procedures go away within a few days or weeks. Minimally invasive procedures are less likely to have complications than surgery.

Surgery

Complications after surgery may include

• problems urinating
• urinary incontinence
• bleeding and blood clots
• infection
• scar tissue
• sexual dysfunction
• recurring problems such as urinary retention and UTIs

Problems urinating. Men may initially have painful urination or difficulty urinating. They may experience urinary frequency, urgency, or retention. These problems will gradually lessen and, after a couple of months, urination will be easier and less frequent.

Urinary incontinence. As the bladder returns to normal, men may have some temporary problems controlling urination. However, long-term urinary incontinence rarely occurs. The longer urinary problems existed before surgery, the longer it takes for the bladder to regain its full function after surgery.

Bleeding and blood clots. After benign prostatic hyperplasia surgery, the prostate or tissues around it may bleed. Blood or blood clots may appear in urine. Some bleeding is normal and should clear up within several days. However, men should contact a health care provider right away if

• they experience pain or discomfort
• their urine contains large clots
• their urine is so red it is difficult to see through

Blood clots from benign prostatic hyperplasia surgery can pass into the bloodstream and lodge in other parts of the body—most often the legs. Men should contact a health care provider right away if they experience swelling or discomfort in their legs.

Infection. Use of a Foley catheter after benign prostatic hyperplasia surgery may increase the risk of a UTI. Anesthesia during surgery may cause urinary retention and also increase the risk of a UTI. In addition, the incision site of an open prostatectomy may become infected. A health care provider will prescribe antibiotics to treat infections.

Scar tissue. In the year after the original surgery, scar tissue sometimes forms and requires surgical treatment. Scar tissue may form in the urethra and cause it to narrow. A urologist can solve this problem during an office visit by stretching the urethra. Rarely, the opening of the bladder becomes scarred and shrinks, causing blockage. This problem may require a surgical procedure similar to TUIP.

Sexual dysfunction. Some men may experience temporary problems with sexual function after benign prostatic hyperplasia surgery. The length of time for restored sexual function depends on the type of benign prostatic hyperplasia surgery performed and how long symptoms were present before surgery. Many men have found that concerns about sexual function can interfere with sex as much as the benign prostatic hyperplasia surgery itself. Understanding the surgical procedure and talking about concerns with a health care provider before surgery often help men regain sexual function earlier. Many men find it helpful to talk with a counselor during the adjustment period after surgery. Even though it can take a while for sexual function to fully return, with time, most men can enjoy sex again.

Most health care providers agree that if men with benign prostatic hyperplasia were able to maintain an erection before surgery, they will probably be able to have erections afterward. Surgery rarely causes a loss of erectile function. However, benign prostatic hyperplasia surgery most often cannot restore function that was lost before the procedure. Some men find a slight difference in the quality of orgasm after surgery. However, most report no difference.

Prostate surgery may make men sterile, or unable to father children, by causing retrograde ejaculation—the backward flow of semen into the bladder. Men flush the semen out of the bladder when they urinate. In some cases, medications such as pseudoephedrine, found in many cold medications, or imipramine can treat retrograde ejaculation. These medications improve muscle tone at the bladder neck and keep semen from entering the bladder.

Recurring problems. Men may require further treatment if prostate problems, including benign prostatic hyperplasia, return. Problems may arise when treatments for benign prostatic hyperplasia leave a good part of the prostate intact. About 10 percent of men treated with TURP or TUIP require additional surgery within 5 years. About 2 percent of men who have an open prostatectomy require additional surgery within 5 years.²

In the years after benign prostatic hyperplasia surgery or treatment, men should continue having a digital rectal exam once a year and have any symptoms checked by a health care provider. In some cases, the health care provider may recommend a digital rectal exam and checkup more than once a year.

Benign prostatic hyperplasia—also called BPH—is a condition in which the prostate gland is enlarged but not cancerous. It’s the most common prostate problem for men over 50. As the prostate enlarges, it presses against and pinches the urethra (the tube that takes urine away from the bladder). This can cause symptoms such as a frequent and urgent need to urinate, especially at night, or trouble starting to urinate.

Treatment options for BPH generally include lifestyle changes, medications, minimally invasive procedures, or surgery. Several dietary supplements and other complementary health approaches have also been studied for BPH. If you’re considering a complementary health approach for BPH symptoms, here are 5 things you should know:

1. Several studies have suggested that the herb saw palmetto (Serenoa repens) may have modest benefits for urinary symptoms associated with BPH, and some recent evidence suggests its benefits might be comparable to those of one type of drug therapy. However, in other studies, saw palmetto was no more effective than a placebo (an inactive substance), even when given at higher-than-usual doses.

2. There is some limited evidence that Urtica dioica (stinging nettle), alone or in combination with saw palmetto, and Pygeum africanum (African plum tree) may improve some symptoms of BPH.

3. There isn’t sufficient evidence to support the use of lycopene for the prevention or treatment of BPH.

4. There’s limited evidence that acupuncture may have short-term benefits for BPH symptoms, but longer and more rigorous studies are needed before definite conclusions can be drawn.

5. Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.

UroLift uses small implants to lift and hold prostate tissue out of the way of the urinary tract. It works almost immediately after procedure.

Rezum uses steam to kill prostate cells. The body naturally removes the dead cells, shrinking the prostate and opening the urinary tract. Patients start to see the effects within a few weeks, and see peak effect about six months after the procedure. The shape of a man’s prostate dictates the method a doctor will use.

Introduction

Water vapor thermal ablation of the prostate (WVAP) is a minimally invasive surgical therapy for symptomatic benign prostatic hyperplasia (BPH). WVAP was introduced and approved by the United States Food and Drug Administration in 2015. The incidence of BPH increases with age; 50% to 75% of men 50 years and older and 80% of men 70 years and older report clinically significant lower urinary tract symptoms due to BPH.] Lower urinary tract symptoms from BPH-induced extrinsic compression of the prostatic urethra include but are not limited to urinary urgency, frequency, hesitancy, intermittency, incomplete bladder emptying, nocturia, and a diminished urinary stream. BPH is also associated with considerable morbidity characterized by urinary retention, recurrent urinary tract infections, urolithiasis, persistent hematuria, and renal insufficiency.

Standard therapies for symptomatic BPH include continuous oral medications and various surgical procedures. The goal of WVAP is to relieve extrinsic compression of the prostatic urethra by inducing coagulative necrosis of hyperplastic prostatic tissue via the directed application of radiofrequency-generated thermal energy in the form of water vapor or steam. Water vapor has a lower mass and density than prostatic tissue and moves easily through cellular interstitial spaces. However, water vapor cannot pass through natural barriers such as the tissue planes separating prostatic zones. This inherent characteristic of water vapor promotes the specific targeting of the prostatic transition zone where most BPH occurs, minimizing the risk of necrosis to the bladder neck, striated urinary sphincter, prostatic capsule, seminal vesicles, prostatic vascular supply, and rectum.

WVAP may be performed in the office or operating room. While the procedure requires an average of 10 minutes to perform, complete resorption of necrotic prostatic tissue may take up to 12 months. The resolution of lower urinary tract symptoms occurs progressively, and optimal results may not be achieved until tissue resorption is complete.

The effectiveness of WVAP in alleviating clinically significant lower urinary tract symptoms has been reviewed in more than 20 published series and reports, including 5 prospective randomized studies and 2 randomized-controlled trials involving more than 2,000 patients followed for up to 5 years. Significant improvements were noted consistently in troubling symptoms, overall quality of life, post-void residual volumes, and peak urinary flow rates. Additionally, WVAP is the only minimally invasive surgical therapy with proven efficacy for reducing lower urinary tract symptoms in patients with prostatic volumes of greater than 80 mL or obstructing median prostatic lobes.

Anatomy and Physiology

Anatomy of the Prostate Gland

The conically-shaped prostate gland is located inferior to the bladder, posterior to the pubic symphysis, and anterior to the rectum; this anatomic location makes the prostate clinically accessible via digital rectal examination. The base of the prostate is at the bladder neck, and its apex is close to the external urethral sphincter. Prostate size varies widely among individuals and tends to increase with time; the average prostate weighs approximately 33 g.

Lobes of the prostate gland

The prostate is clinically divided into 5 lobes: the anterior, median, posterior, and left and right lateral lobes. The prostate surrounds the prostatic urethra; as BPH progresses, the median and lateral lobes of the gland enlarge and encroach on the urethral lumen and bladder outlet, causing increasing degrees of obstruction to urine outflow, and symptoms result.

Zones of the prostate gland

The human prostate is divided by function into major glandular regions or zones: the transitional, central, and peripheral zones (see Image. Prostate zones). A fourth region called the anterior fibromuscular stroma may also be considered a zone but is not glandular.

The transitional zone surrounds the urethra between the bladder and the verumontanum. The transitional zone typically comprises only 5% of the volume of the normal prostate but is the principal site of the pathogenesis of BPH. When the transitional zone is enlarged and the nodules advance, the peripheral and central zones undergo compression and displacement towards the base of the prostate, where they may overlap the enlarged transitional zone. Enlarged lateral lobes originate in the transitional zone of the prostate.

The central zone of the prostate is a wedge of tissue that constitutes most of the base of the prostate, is located between the peripheral and transitional zones, and surrounds the ejaculatory ducts. The central zone ducts run proximally to and closely follow the ejaculatory ducts. The median lobe of the prostate is located between the ejaculatory ducts and the urethra within the central zone, extending proximally to the bladder neck and trigone. Median lobe enlargement may interfere with voiding, especially if an intravesical extension is large enough to create a ball-valve effect by blocking the bladder outlet during micturition. In such cases, this median lobar tissue must be eliminated to optimize voiding.

The peripheral zone comprises the remainder of the prostate gland. The peripheral zone surrounds most of the central zone and extends caudally, partially surrounding the distal portion of the urethra. The peripheral zone ducts exit exactly laterally from the posterolateral recesses of the urethral wall. Most of the prostatic glandular tissue is found in the peripheral zone; this is the principal site of prostatitis and 70% of prostatic carcinomas. The peripheral zone includes the proximal urethral segment of the prostate.

The anterior fibromuscular stroma is a strip of fibromuscular tissue anterior to the transitional zone. This stroma is adjacent to the smooth muscle of the bladder superiorly and the skeletal muscle of the external sphincter inferiorly.

Neurovascular supply to the prostate gland

The primary arterial vascular supply to theprostate gland is the prostatic arteries, the terminal branches of the inferior vesical arteries. The inferior vesical arteries arise from various branches of the internal iliac artery, including the internal pudendal inferior vesical and middle rectal arteries. The prostatic arteries are short and branch into the capsular and urethral groups of arteries. The urethral branches of the prostatic arteries enter the prostate at the bladder neck at the 5- and 7-o’clock positions, running caudally along the urethra.

The most common sites of arterial bleeds in other endoscopic procedures, such as transurethral resection of the prostate (TURP) and holmium laser enucleation of the prostate (HoLEP), originate from arteries derived from the capsular branch of the prostatic artery. These capsule branch derivative arteries enter the capsule and run along the outer prostate surface at the 2-, 5-, 7-, and 11-o’clock positions. The risk of bleeding in WVAP is lower than for TURP or HoLEP because these arteries are generally not encountered.

The prostatic venous plexus surrounds the prostate gland and drains into the internal iliac vein via the inferior vesical vein. The prostatic venous plexus provides the primary venous drainage for the prostate gland.

The neurovascular bundle of the prostate gland is necessary for processes involved in erection, ejaculation, and urinary continence. This bundle is within the space enclosed by the prostatic, lateral pelvic, and Denonvillier fascias. Localized electrosurgical currents employed in procedures like TURP can sometimes cause damage to these nerves and contribute to postprocedural erectile dysfunction. This bundle is external to the prostate and is, therefore, unaffected by WAVP.

Important Surgical Landmarks

Surgical landmarks critical to WVAP include the location of the ureteric orifices, bladder neck, median and lateral prostatic lobes, verumontanum, and urinary sphincter. The anterior or ventral edge of the external sphincter muscle is more proximal than the posterior or dorsal edge; these locations should be noted, as should the distance from the bladder neck to the verumontanum.

Physiology of the Prostate Gland

The sole function of the prostate is to produce secretions for the seminal vesicles that nourish the sperm and promote fertility. The prostatic fluid contains citric acid, fibrolysin, acid phosphatase, and proteolytic enzymes, which improve the liquefaction of semen. These secretions also provide most of the immunoglobulin A in the seminal fluid. Prostatic secretions account for approximately 30% of the total semen volume.

Pathophysiology of Benign Prostatic Hyperplasia

The pathophysiology of BPH is not fully understood; testosterone has been implicated. Dihydrotestosterone is a potent biological derivative; androgen receptor signaling in the prostate is regulated by 5α-reductase isoenzymes that convert testosterone to dihydrotestosterone. It has been hypothesized that intraprostatic dihydrotestosterone levels increase with age despite falling serum testosterone levels. Metabolic or inflammatory insults may also initiate BPH.

Symptomatic BPH typically involves the lateral lobes from the transitional zone but may also involve the median lobe from the central zone. The successful surgical treatment of symptomatic BPH may depend on effectively eliminating all obstructive tissue interfering with urine outflow; this includes the median lobe when it is involved in the hyperplastic process.

Indications

General Indications for the Treatment of Symptomatic Benign Prostatic Hyperplasia

The general indications for the treatment of symptomatic BPH include subjectively bothersome symptoms, such as a weak or intermittent urinary stream, incomplete bladder emptying, and nocturia, which significantly impact the quality of life. Treatment should be offered when patients have moderate-to-severe symptoms indicated by an International Prostate Symptom Score greater than 8 with age-stratified increases in prostate size and postvoid residual volume and a decrease in maximum urine flow rate (Qmax).

There are many options available to manage symptomatic BPH. Clinicians must understand each option's indications, distinctions, advantages, and disadvantages to counsel and guide patients toward optimal therapy properly. The initial management of symptomatic BPH is almost universally pharmacological with α-blockers, with or without adding 5α-reductase inhibitors. However, when or if the patient experiences symptoms refractory to pharmacologic therapy, cannot tolerate the adverse effects of such therapy, or wishes to proceed to a more permanent or effective therapy, reasonable therapeutic options are available.

Therapeutic options beyond pharmacologic therapy can be classified as minimally invasive surgical treatments, traditional cavitating endoscopic procedures, simple prostatectomy, or prostatic artery embolization. A discussion of traditional cavitating endoscopic procedures and simple prostatectomy is beyond the scope of this activity. Prostatic artery embolization is technically demanding, not widely available, offers marginal results with a retreatment rate of 21%, and is intended only for very select patients deemed unacceptable candidates for all other therapeutic options.

Indications for Minimally Invasive Surgical Therapies for Symptomatic Benign Prostatic Hyperplasia

Minimally invasive surgical therapies include WVAP, prostatic urethral lift, Optilume^® BPH, and the temporarily implanted nitinol device (iTind™). All available minimally invasive surgical therapies preserve sexual function, provide measurable relief of lower urinary tract symptoms, have low perioperative morbidity with mild and transient adverse effects, and can generally be performed under a range of anesthetic options in either the clinic or operating room. The optimal therapeutic option is influenced by the prostatic size and morphology, the severity of lower urinary tract symptoms, patient preference and comorbidities, and the risk and benefit profile of each treatment. A comparison of these minimally invasive surgical therapies is shown in Table. A Comparison of Minimally Invasive Surgical Therapies for Symptomatic BPH.

Table

Table. A Comparison of Minimally Invasive Surgical Therapies for Symptomatic BPH.

WVAP is recognized as an effective therapeutic option for symptomatic BPH by the American Urological Association. WVAP appears to be the optimal minimally invasive therapeutic option in men with moderately enlarged prostates up to 100 cm³ in size who want to preserve sexual function and are willing to accept the potential risk of slightly reduced efficacy and longevity afforded by traditional cavitating procedures. WVAP requires approximately 10 min of operative time and is ideal for patients in whom a prolonged anesthetic or a more invasive surgical option is deemed too risky. While TURP and hOLEP have retreatment rates of less than 3%, these traditional cavitating procedures are more aggressive, more invasive, require longer operative times, and carry increased anesthesia risks.

WVAP is proven effective in all prostate morphologies, including enlarged or obstructing median lobes; all other minimally invasive prostatic therapies are largely ineffectual or not recommended. While symptom relief takes longer following WVAP and the prostatic urethral lift, WVAP has a superior long-term retreatment rate and does not increase the risk of infection or stone formation.

Contraindications

There are absolute and relative contraindications to WVAP as a treatment for symptomatic BPH. A thorough evaluation of the clinical history of potential surgical candidates is required to identify these contraindications and optimize procedural selection.

Absolute contraindications to WVAP include the presence of urinary sphincter or penile prosthetic implants and a personal history of prostatic radiotherapy. The WVAP procedure may damage sphincter or penile prostheses. Prostatic radiotherapy induces interstitial scarring that limits the dispersion of water vapor.

A comprehensive perioperative evaluation may minimize or eliminate many of the relative contraindications for WVAP. All patients considering any surgical intervention for symptomatic BPH should be evaluated for inadequate bladder contractility and urinary retention with urodynamic testing.

WVAP does not produce tissue samples for histological analysis; patients with suspected prostate cancer should be thoroughly evaluated with traditional diagnostic methods before undergoing WVAP for symptomatic BPH. Additionally, all patients considering WVAP should be assessed for an active urinary tract infection, and sterilization of bacteriuria is required before the procedure is performed. Limited data exists regarding the efficacy of WVAP in patients with a prostatic volume greater than 120 cm³; caution in this patient population is recommended. Patients who have undergone a prostatic urethral lift will have implants and clips that can become infected and predispose to stone formation following WVAP; perioperative evaluation with rigid cystoscopy is recommended.

Patients with stenosis of the bladder neck or Marion disease may not be optimal candidates for WVAP. WVAP acts in the lateral lobes of the transitional zone and median lobe of the central zone; it is ineffective at the bladder neck. Some experts have suggested performing a bladder neck incision in selected patients with smaller prostates and high or tight bladder necks to minimize the need for retreatment later.

Equipment

The equipment required to perform WVAP typically includes:

• Convective water vapor generator system and delivery device
• Bed to support lithotomy position
• Sterile skin preparation solution
• Sterile patient drapes
• Warmed normal saline and tubing with an IV pole
• Topical lidocaine gel
• 4-mm, 30-cm, 30-degree cystoscope lens with monitor and light source
• 2-way urinary catheter with drainage bag
• Transrectal ultrasound (optional; for local prostatic anesthesia)
• Local anesthetic (optional).

Personnel

When WVAP is performed in the clinic setting, only the primary surgeon and an assistant are required.

If WVAP is performed in an operating room, the personnel required typically include:

• Surgeon
• Surgical technician or operating room nurse
• Circulating or operating room nurse
• Anesthesia personnel.

Preparation

Medical History and Physical Examination

A comprehensive medical history must be obtained from all patients considering surgical intervention for lower urinary tract symptoms secondary to BPH. Symptoms of urinary frequency and urgency, incomplete bladder emptying, intermittency, straining, and nocturia should be fully explored; an AUA or IPSS can facilitate a discussion of these symptoms, promote an understanding of the patient's perception of these symptoms, and serve as a baseline for comparison following an intervention. Dysuria, hematuria, incontinence, and a history of urolithiasis must be clarified. Previous medical or surgical interventions for lower urinary tract symptoms should be identified.

Additionally, inquiries must be made about the medical and surgical history, specifically on anesthetic fitness, urological intervention, or prostatic radiotherapy. Erectile function should be scored with a measurable tool such as the International Index of Erectile Function-5 (IIEF-5). Risk factors for urological disease, such as a personal history of tobacco use, occupational exposures to aromatic amines, and a family history of BPH or prostate cancer, should be assessed.

A physical examination should include an inspection of the external genitalia with particular attention to the presence of metal stenosis, lichen sclerosis, and phimosis. A digital rectal examination to estimate prostate size and aid in prostate cancer screening is required.

Preprocedural Investigations

Laboratory testing: Urinalysis with microscopy, culture, and sensitivity analysis is required. The prostate-specific antigen (PSA) should be measured; if elevated, prostate cancer should be excluded.

Uroflowmetry and urodynamic testing: Uroflowmetry should be performed to determine the severity and etiology of lower urinary tract symptoms and should include the maximum urinary flow (Qmax), postvoid residual volume, and voiding pattern analysis. Urodynamic studies are not essential for all patients but are indispensable when alternate or coexisting pathologies like detrusor failure are suspected. Men who present with urinary retention should have urodynamic studies for this reason.

Transrectal ultrasonography: Transrectal ultrasonography provides an accurate and objective prostatic size and morphology assessment. WVAP is most efficacious in men with a prostatic volume of 80 cm³ or less; the procedure can be offered to select men with prostatic volumes of no more than 120 cm³.

Flexible cystoscopy: Flexible cystoscopy is recommended for all patients to assist in planning the number and position of WVAP injections; planning requires assessing the distance from the bladder neck to the verumontanum, the size of the lateral lobes, and the presence of an obstructing median lobe or high bladder neck. Flexible cystoscopy allows retroflexion to inspect the bladder neck, ureteric orifices, and intravesical protrusion of the prostate lobes. Finally, a preoperative flexible cystoscopy will help establish the pain tolerance of patients considering a procedure under local anesthesia.

Shared Decision-Making and Patient Selection of Therapy

Clinicians should employ multiple methods of communication beyond verbal consultation, such as images, videos, and print materials, to ensure patients are thoroughly informed of the logistics, risks, benefits, and expected clinical course of WVAP. Attempts should be made to understand the therapeutic goals of the patient to the greatest extent possible. The patient should be counseled about reasonable alternative therapeutic options, including but not limited to watchful waiting, medical management, other minimally invasive surgical therapies, and endoscopic cavitating procedures.

Technique or Treatment

Mechanism of Action

The WVAP system comprises 2 primary components: a radiofrequency power supply generator and a single-use transurethral delivery device. The delivery device has a standard rigid cystoscope lens, permitting direct visualization during the procedure. Thermal energy is generated by applying radiofrequency current to an inductive coil, which heats the water and creates vapor. The device administers the heated water vapor at a consistent energy setting of approximately 208 J directly into prostatic tissues through a retractable needle. WVAP employs the principle of convection, which is the transfer of heat by moving a gas or liquid within a space. Conversely, conductive energy transfer employs heat applied directly to a stationary object that moves through the object along a gradient from higher to lower temperature. Thermodynamically, conductive heat transfer requires long treatment times and considerable energy deposition to affect thermal tissue destruction and ablation with an obligatory temperature gradient.

Heated water vapor, injected directly into the prostate at 217.4° F (103 °C), rapidly and evenly disperses throughout the interstitium. Heated water vapor condenses into liquid when it contacts cellular membranes, releases thermal energy to the tissue, and increases tissue temperatures to 158 to 176 °F (70 to 80 °C). This temperature increase causes instantaneous cell death and the formation of a spherical-shaped ablated lesion.

Preoperative Protocols

A preprocedural timeout should be performed. The patient should be placed in the lithotomy position.] Ensure the space beneath the table is free of obstruction. The external genitalia and perineum should be thoroughly cleansed with a povidone-iodine solution. Administer intravenous antibiotic prophylaxis based on preoperative urine culture results. If the preoperative urine is sterile, administer prophylactic antibiotics based on local guidelines for transurethral surgery; a first-generation cephalosporin is typical. Alternative regimens, especially in patients with allergies to cephalosporins, include quinolones and gentamicin.

Anesthesia and Pain Management

Convective water vapor thermal ablation is feasible and appropriate within the ambulatory setting. However, the subjective experiences of discomfort, pain, and anxiety, as well as institutional capabilities, may preempt an ambulatory procedure. The choice of anesthesia and pain management should be a collaborative decision involving the urologist, patient, and anesthetist. Anesthetic options include general anesthesia, oral or intravenous sedation, or a local anesthetic prostate block with lidocaine or bupivacaine.] A prostate block should be performed with ultrasound guidance approximately 10 min before beginning the procedure.

Operative Technique

Lateral lobes: Administer 10 mL of 2% lidocaine jelly into the urethra, irrespective of other anesthetic methods. Insert the treatment device with the rod lens into the urethra. Perform cystoscopy to assess the prostate size and contours, the presence of an obstructing median lobe, the bladder mucosa, and ureteric orifices.

Position the delivery device 1 cm distal to the bladder neck at the bulk of the targeted tissue. Deploy the retractable needle, which deploys at 90°, measures 10.25 mm in length, and has 12 emitter holes to release the heated water vapor in a spherical array. Deploying the needle permits the activation of the injection mechanism. Each injection is a single treatment and takes 9 seconds to deliver completely. It is recommended to leave the needle in place for another 1 to 2 seconds to allow the water vapor to change phase and release its thermal energy completely. Each injection creates a spherical thermal lesion of approximately 4 cm³

Administer additional injections every 0.5 to 1.0 cm from the initial injection site, progressing caudally down the length of the prostatic urethra until the proximal edge of the verumontanum is reached. The goal is the creation of an approximate 1.5 to 2.0 cm lesion within the obstructing median and lateral lobes of the central and transitional zones of the prostate. The number of treatments for each lobe depends on the distance between the bladder neck and the verumontanum. This distance can be closely estimated; the visible length of the cystoscopic view through the delivery device is 0.5 cm.

An estimated distance of less than 2.0 cm typically requires 1 or 2 injections, distances between 2.0 and 3.0 cm typically require 2 or 3 injections, and distances greater than 3.0 cm may require 3 or 4 injections. Injections should be performed to create contiguous, overlapping lesions aligned with the natural slope of the urethra.

The injections should be completed fully on one side of the gland before proceeding to the opposite side or median lobe. This sequential approach maximizes the latent heat from prior treatments on one side, enhancing the overall effectiveness of the procedure.

If treatment of the median lobe is not required, remove the device and place an indwelling Foley catheter.

Median lobe: Insert the needle at a 45-degree angle halfway between the base and apex of the median lobe. One treatment angled toward either side is sufficient in most patients requiring median lobe therapy. However, if an intravesical protrusion is present, the treatment should be initiated 1.0 cm from the protrusion. When the injection(s) are complete, remove the device and place an indwelling Foley catheter.

Postoperative Protocols

The Foley catheter typically should remain in situ for 2 to 14 days and will vary according to the number of injections; most patients can undergo catheter removal and a voiding trial on the third or fourth postoperative day. A personal history of bladder hypotonicity, preoperative urinary retention, and higher preoperative postvoid residual urine volumes increases the risk of voiding trial failure. Patients with preprocedural urinary retention should receive continuous bladder drainage with an indwelling catheter for 4 weeks to allow for completion of coagulative necrosis and tissue resorption.

Patients should expect storage-type lower urinary tract symptoms for up to 4 weeks; a short course of nonsteroidal anti-inflammatories may benefit. Patients should cease their oral BPH medications as voiding symptoms improve. All patients should be evaluated at 1 to 3 months following WVAP.

Complications

Performing WVAP requires approximately 10 minutes of operative time, and intraoperative complication rates are low. A literature review of 17 studies evaluating 1481 patients undergoing WVAP described no intraoperative complications.

Most postoperative complications of WVAP can be classified as Clavien Dindo Grade 1 or 2. Necrotic prostatic tissue is eradicated through normal inflammatory processes, contributing to dysuria, urinary urgency, and hematuria. In patients with indwelling catheters, these processes also predispose to lower urinary tract infections. There is a risk of urinary retention following WVAP; this risk is increased for men with preoperative urinary retention. The resolution of lower urinary tract symptoms typically takes a minimum of 3 months; men with a history of prior surgical interventions for symptomatic BPH are at increased risk of persistent lower urinary tract symptoms following WVAP.

Recurring lower urinary tract symptoms are the most significant long-term complication following WVAP; 4.4% of men undergoing WVAP require surgical retreatment within 5 years, and 11% of men require prostatic medication within 5 years. Patients requiring surgical retreatment are more likely to have an obstructing or high bladder neck, lateral lobe asymmetry, a persistently obstructive median lobe, or unexpected prostatic cysts, cavities, or recesses. Men with an obstructing or high bladder neck who require surgical retreatment tend to have smaller prostates and may benefit from a simple bladder neck incision.

Long-term complications other than recurrent lower urinary tract symptoms are rare and include but are not limited to urethral strictures and bladder neck contractions.

Clinical Significance

BPH is a commonly encountered pathologic process; the incidence increases with age. BPH can cause bothersome lower urinary tract symptoms and increase morbidity in affected men. WVAP is an elective minimally invasive surgical treatment for symptomatic BPH that delivers radiofrequency-generated thermal energy to the prostate to induce coagulative necrosis of hyperplastic tissue, thereby relieving obstruction of the prostatic lumen. Thermal ablation stays within the transitional and central zones with a very low risk of injury to the peripheral zone, prostatic capsule, bladder neck, urethral sphincter, or rectum. Electrosurgical stimulation, stimulation, and disruption of the bladder neck are avoided so ejaculatory and erectile functions are preserved. Additionally, the procedure takes approximately 10 minutes to complete and can be performed in various settings.

Compared to other minimally invasive therapies for symptomatic BPH, WVAP provides prolonged symptom relief and is efficacious across a wider range of prostatic volumes. Furthermore, WVAP is the only minimally invasive therapeutic option for symptomatic BPH with proven efficacy in patients with obstructing median prostatic lobes.

While prostate cancer is not an absolute contraindication to WVAP treatment, the procedure is not a treatment for prostatic malignancies and is strictly for symptomatic outlet obstruction in suitable candidates. However, WVAP is especially useful in men with moderately enlarged prostates who want to preserve sexual function and wish to avoid more invasive surgical therapies. WVAP is also appropriate for patients at increased anesthetic risk and for whom medical therapy is ineffective or poorly tolerated.

Objective improvements in lower urinary tract parameters are routinely noted. The median improvements are:

• Increase in peak urinary flow rate of 5 mL/sec
• Postvoid residual volumes decrease by 100 mL
• Bladder Outlet Obstruction Index decreases by 53.8
• Prostatic volume decreases by 40%, with the decrease preferentially occurring in areas of urinary flow obstruction
• IPSS symptom score is typically reduced by 50%.

Enhancing Healthcare Team Outcomes

The counseling and education of patients considering WVAP requires an interprofessional team approach. Urologists and advanced practice providers should possess the clinical expertise to effectively communicate the advantages, risks, limitations, and alternatives to WVAP to promote shared decision-making and establish realistic expectations regarding postoperative urinary control.

Nurses guide patients through procedural details, recovery expectations, and postoperative care. Pharmacists guide the appropriate dosages and regimens of oral BPH medications and prophylactic antibiotic therapy. Intraoperative communication between urologists, assistants, nurses, and anesthesia personnel ensures patient safety and reduces complication rates. Efficient communication and coordination among team members ensure consistent patient education and seamless care transitions before, during, and after WVAP. Regular postoperative appointments promote patient satisfaction and optimize outcomes.

Researchers have not found a way to prevent benign prostatic hyperplasia. Men with risk factors for benign prostatic hyperplasia should talk with a health care provider about any lower urinary tract symptoms and the need for regular prostate exams. Men can get early treatment and minimize benign prostatic hyperplasia effects by recognizing lower urinary tract symptoms and identifying an enlarged prostate.