The prostate: ‘The urgency, when it hits, can be pretty scary’

Ed Goldman, who says he's "pushing 80", does not let his age or enlarged prostate curtail his physical activities and desire to travel. He walks the streets of his beloved New York for about two miles a day, five or more days a week, and knows every possible bathroom stop along his usual routes.

When arriving in foreign territory, he immediately checks out the location of lavatories to avoid an embarrassing accident. “The urgency, when it hits, can be pretty scary.”

Goldman, like up to 90 per cent of men in their 70s, has benign prostatic hyperplasia, or BPH, a nonmalignant growth of the prostate gland. As the prostate enlarges with age, it squeezes the urethra that passes through it and can disrupt normal urinary function.

The prostate is a walnut-shaped gland that produces the seminal fluid in a man’s ejaculation. The gland typically starts to enlarge in men’s 40s as smooth muscle and lining cells proliferate. As the gland gradually increases in size, nearly half of men develop moderate to severe symptoms of the lower urinary tract by their eighth decade of life.

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These symptoms can include hesitancy starting to urinate; weak flow; incomplete emptying of the bladder resulting in urinary retention; a frequent urge to urinate; and for some, an urgency that can cause incontinence, especially when lacking immediate access to a bathroom.

The result is often a serious diminution in quality of life, for example, when one has to make a sudden dash to the restroom in the middle of a meeting, golf game, concert or lecture that perhaps lasted longer than expected. The urgent need to urinate makes getting stuck in traffic even more stressful.

Goldman says he uses the bathroom every one to three hours and at least once during the night, adding that “it’s very unusual for me to sleep for more than six hours at a time”. He knows he’s lucky so far. For some men who awaken every few hours to use the bathroom while trying not to disturb a bed partner (if they have one), a six-hour stint of sleep would be considered a blessing.

Common risk factors for developing BPH include, in addition to age, a family history of the condition, obesity, metabolic syndrome, a sedentary lifestyle and diabetes. Diets high in starches and meat have been linked to progression of BPH, while a vegetable-rich diet has been associated with less severe symptoms.

The good news

The good news is there are now quite a number of ways to alleviate the symptoms of BPH short of surgery to remove part or all of the prostate, which can cause other problems, including erectile dysfunction.

The first approach to relieving the symptoms of BPH, and perhaps even preventing or slowing the progression of prostatic enlargement, are focused on lifestyle changes. They include reducing weight; minimising liquid intake late in the day; getting regular physical activity; avoiding smoking and consumption of alcohol, caffeine and highly seasoned foods; and treating constipation.

Also helpful for men (and women) who have difficulty emptying their bladder and soon have to return to the bathroom is a technique called double-voiding. After urinating normally, wait about 20 to 30 seconds and try again. Men are likely to have more success emptying their bladders by sitting on the toilet and leaning forward instead of standing.

The traditional “gold standard” remedy for BPH known as TURP, for transurethral resection of the prostate, involves inserting a scope through the penis and cutting away excess prostate tissue to relieve pressure on the urethra. Though TURP is the most effective remedy for troublesome BPH, in addition to causing sexual complications, this surgery incurs a risk of bleeding that limits its usefulness for men such as Goldman who take anticoagulants.

In a less invasive version of TURP with fewer complications, a bipolar current is used to ream out the prostate. Another minimally invasive technique, called HoLEP, uses laser irradiation to remove excess tissue.

Experts say aggressive surgical treatment like TURP should now be necessary to treat an enlarged prostate only in certain circumstances. These might include inadequate kidney function, recurrent urinary tract infections, bladder stones, blood in the urine, or the patient’s unwillingness to take a daily medication or failure to get relief through drugs. Among currently preferred treatments are several categories of drugs, including alpha blockers, 5ARIs and PDE5 inhibitors. There is also a combination drug of an alpha blocker and a 5ARI that is said to work better than either one alone. While the sexual side-effects of surgery are usually permanent, if such effects are caused by a medication, they may be reversed by stopping the drug and perhaps switching to another one.

There are also now minimally invasive techniques to reduce the pressure exerted on the urethra by an enlarged prostate. In one, called the UroLift System, a telescopelike instrument is inserted through the penis and one or more small bands are inserted to retract the part of prostate that is pressing on the urethra. – The New York Times