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Interviewer: For men who have been diagnosed with an enlarged prostate, there are a lot of treatment options, but it can be a little overwhelming. And some men fear about the side effects of those treatment options. We're going to sort through that today.

Dr. Stephen Summers is a urologist at University of Utah Health, and he's going to help us better understand the treatment options available for an enlarged prostate and, more importantly, understand what you would want to weigh as a patient when you're having a discussion with your physician or urologist about those different treatment options. So you were telling me that sometimes men put off treating an enlarged prostate because of the fear of side effects. So let's start there. Treatment options have side effects. Do they all have side effects?

Dr. Summers: Unfortunately, any treatment option will have side effects. So the first one, I guess, that has the fewest side effects is lifestyle modification. So if you can lose weight and improve your diet, cut out caffeine, you may have some benefit. But once we start talking about medications and surgical treatment, it's a matter of weighing the side effect with the benefit that you expect to see.

Interviewer: Okay. So can you talk us through that a little bit? So, if I understand, the hierarchy is lifestyle changes first. And you've given us a great reason to want to do that to avoid the side effects of medication. But then it would be medication next. So talk us through, what are some of the options there?

Dr. Summers: Yeah. There are three categories of medications. But primarily, we start with alpha blockers. And the most common medication used is a medication called Flomax or tamsulosin. It works to open up the prostate and the bladder neck to allow the urine to flow through a little bit easier. For the most part, it's well tolerated, but the side effects that bother men with taking that medication can be dizziness. And so you get up all of a sudden, you may have some lightheadedness or a possibility of fainting. And the other one is something called retrograde ejaculation or a sexual side effect. And that is when a man orgasms, instead of having the semen come forward out the end of the penis, it goes backwards into the bladder. And that certainly can be concerning to a lot of men and is one of the main side effects of a lot of different treatments for prostate enlargement.

Interviewer: Is that something I should be concerned about?

Dr. Summers: No. It is a concern if you're planning to father more kids. Obviously, that is an important part of reproduction. But in terms of your overall health, it doesn't make a big difference. It doesn't impact the sensation of orgasm too much, but it's highly individual. In some men, that can be a real bother.

Interviewer: Yeah. Sure. Like I would imagine a lot of these side effects are going to be very individual.

Dr. Summers: Sure. Yeah. The other medications that we use, there is a medication that falls into a class called 5α-reductase inhibitors. There's a medication called finasteride or Proscar or Avodart or dutasteride,. These medications get at the effect of testosterone on the prostate. So they block the effect of testosterone on the prostate growth and over time can cause some shrinkage of the prostate. They are very slow medications to work, and you have to continue on those medications for life once you start them if you're going to experience the benefit of the treatment for them. The main side effects with those can be erectile dysfunction, problems with mood, energy level. It can cause occasional breast enlargement in men. And it does have the side effect of causing hair regrowth. So the medication that was commonly prescribed called Propecia is in this class of drugs. But there are more substantial sexual side effects, I will say.

Interviewer: Why would a man choose this particular treatment then over maybe the first one?

Dr. Summers: No. That's a good question. So, oftentimes, they're combined. So we will use both medications. There's pretty good data out there to suggest that both of them work almost synergistically together than using either one alone. The other advantage with the finasteride, that we were just talking about, is it does reduce the progression of symptoms and severity of the disease, and so you can reduce the risk of progression to the point where one might need surgery by about half. And so there are clear benefit with that.

Interviewer: And you said the one that you have to take for life, say I started, at six months later, I'm like, "Ah, these side effects, I can't live with these." Am I able to then take a different treatment option?

Dr. Summers: Sure. You can always change the treatment option. There is some controversy though, and I think it's important for men to know that there have been some men that have had persistent side effects even after stopping that medication.

Interviewer: Okay.

Dr. Summers: So some of those sexual side effects have lasted even once they've come off of it. Now, that's a very small percentage of men, but certainly, if you're one of those patients, that's going to be a concern for you.

Interviewer: Yeah. And then there's a third category of drugs as well?

Dr. Summers: Yeah. The other category of drugs works primarily on the bladder. It relaxes the bladder, so it treats the symptoms of the disease, but does nothing really to the prostate. And so you're really putting a Band-Aid on treating the symptom, the frequency, the urgency, the getting up at night, but you're not really addressing the problem. So a lot of times we'll use those medications in combination with these other drugs to help lessen or minimize the symptoms as we're focusing on the problem of the prostate itself.

Interviewer: All right. So it sounds like that, you know, you need to have a conversation with your physician about the risks and benefits of the medication. At that point, if that doesn't work or is it possible that a man just might not choose to do the medications because of the side effects that they would move on to surgery. Let's talk about that as a treatment option.

Dr. Summers: You bring up a great point. Sometimes we consider surgery even before medications when you're trying to minimize some of those side effects. So there are a couple of new or recently developed treatments that I think are important to highlight here. And I highlight them specifically because they do not have those sexual side effects that are so common with the medications. And we call them minimally invasive surgical treatments. They're done in the office with a local anesthetic. So it's a very quick recovery with little downtime or little missed work.

The first of those treatments is something called a UroLift. That is a device that is implanted in the prostate that holds back that prostate obstructing tissue and opens up the channel to allow the urine to flow through easier. The advantage with it is it's done relatively quickly in the office. A lot of men do not even have to have a catheter following that procedure, and it doesn't have any of the sexual side effects. So there's no risk of erectile dysfunction, there's no risk of retrograde ejaculation, and there's no risk of urinary incontinence following that procedure. Unfortunately, not all men are candidates for that procedure. It depends a little bit on prostate size and anatomy. But it can be a great option for a lot of men.

Interviewer: And are there other surgical options that you discuss with your patients?

Dr. Summers: Sure. I think it's important to really know all of the options, and so I like to review everything with my patients prior to entertaining any one of them. Another office-based procedure that we do is something called Rezūm. Rezūm uses steam or water vapor therapy in an effort to shrink or ablate and remove prostate tissue. And so, similarly, it's done in the office under a local anesthetic and with some mild sedation. We go in and I inject the prostate with the steam. And depending on the size of the prostate, you may get anywhere from 4 to 10 or even higher injections. And that steam destroys the prostate tissue, shrinks it down and opens up the urinary channel. Men following that procedure do have to have a catheter for a few days. The recovery can be a little bit longer, but there are no restrictions. You're able to go back to work as soon as you're able to tolerate things. It similarly does not have any risk of sexual side effects, including erectile dysfunction or retrograde ejaculation, and no risk of incontinence.

Interviewer: Is this one a little bit more of an option for men than the previous one? Because you said the previous one, you know, some men would not necessarily be a good candidate for it.

Dr. Summers: Yeah. So it has the ability to tailor the treatment a little bit more to a broader range of prostate anatomy, so different prostate sizes and three-dimensional constructs of the prostate. But both of them are, you know, often used interchangeably, and both are good options for a lot of men that are hopeful to avoid some of the bigger surgeries.

Interviewer: Is there a reason why a man might pick one surgery over the other if they were eligible for either one?

Dr. Summers: A lot of times it comes down to the recovery. It comes down to experience, provider preference too, and duration, you know, how long we've been doing those treatments and what's the long-term data and retreatment rates for each of those. So, you know, it gets into a little bit more in-depth discussion that I try to tailor to the individual. When they come seeking one of those treatments, we kind of look at the data and say, you know, "This is what I have that's published based on this treatment. And how does that fit with kind of your expectations and the symptoms that we're looking to treat?"

Interviewer: Getting close to wrapping this up, are there other options that we haven't covered yet that we should?

Dr. Summers: You know, I think one of the common questions I get in surgical treatments that a lot of men that talk about it is the TURP, and that stands for transurethral resection of the prostate. For some reason, men affectionately call it the rotor-rooter. It's an older treatment -- it's better around, you know, almost 100 years -- where urologists go in and using a resection knife in the operating room, with the patient asleep, we hollow out the prostate. It's still a commonly practiced procedure. Most urologists do a lot of them. It still has its place. And technology, of course, has improved as have the side effects. So we've, you know, gotten better at that procedure. But I think a lot of men come thinking that is their only option. And, unfortunately, they have, you know, all had a friend that has had this done and has had maybe a complication, and they fear and procrastinate putting off treatment because of some of the side effects of this older treatment option.

Interviewer: So did I miss something there? I guess I assumed that the surgeries would remove the prostate. And I don't know that I heard any of the things you talked about actually explicitly say removing the prostate.

Dr. Summers: Yeah. That's a common question we get too, and it's a bit confusing when you look at pictures of the prostate. So most of the treatment for benign prostate disease does not remove the entire prostate. We're removing the inside glandular portion of the prostate that's obstructing the urine flow. That is contrasted and much different than an operation that we do for prostate cancer. So if a man has prostate cancer, most of the time that cancer is on the outside of the prostate, and we have to remove the entire prostate. Whereas with benign prostate disease or BPH, that growth or enlargement is on the inner part of the prostate that's obstructing and pushing on the urethra.

Interviewer: And then does that affect the function of the prostate? Is it no longer functional at that point?

Dr. Summers: Once you remove the whole prostate, yeah. Certainly, it's no longer functional. In terms of removing a portion of it, you do lose some function. The function of the prostate is to secrete supporting fluid in your semen for sperm. And so, for most men that were treating prostate enlargement, that is less of an issue. But certainly, if you're a younger patient still planning on fertility or have fertility concerns, then we need to weigh that in with what treatment options we're considering.

Interviewer: Final question. How can a man go into this meeting with their urologist, armed and ready to have this conversation, other than listening to this great interview, of course?

Dr. Summers: Yeah. I think just being open and honest about what your symptoms are, kind of what your priority is, knowing that there are side effects and risks with any of these treatments, what's important for you. Is it that we're treating your nighttime symptoms? Are we improving your flow or your frequency? If you can identify what really bothers you the most, then I can tailor the treatment to fix or improve that symptom. It's really hard to certainly change things and reverse things to make it a 100% better, but if you can tell me what bothers you most, then I can highlight that and incorporate that into our treatment.

Interviewer: Frequent urination, the feeling that you always need to go to the bathroom, a weak stream dribbling, waking up in the night to go to the bathroom could all be the symptoms of an enlarged prostate. It's called benign prostatic hyperplasia, or an enlarged prostate, and it's more common than a lot of men realize.

Dr. Stephen Summers is a urologist at University of Utah Health and he's going to give us the information we need to help you if you're suffering from any of those symptoms.

So the first question that I do want to ask has nothing to do with the symptoms, but it has to do with a kind of a misconception. Is an enlarged prostate and prostate cancer the same?

Dr. Summers: No, they're not. It's interesting because I get this question frequently and a lot of men come to me with concern for possible prostate cancer with some of those urinary symptoms you were just talking about.

Certainly, you can have both conditions at the same time. You can have prostate cancer as well as an enlarged prostate causing urinary obstruction and the symptoms that we relate with that. But they're really two separate issues that both need to be addressed and handled often simultaneously. The age groups that are at risk for prostate cancer also happen to be the men that are most often suffering from lower urinary tract symptoms or the symptoms that we most commonly associated with BPH.

Interviewer: Just because I have those symptoms doesn't necessarily mean that it's prostate cancer. That sounds like it could be a fear that men have. Out of the men that come to you with those symptoms, how often is it prostate cancer versus just an enlarged prostate?

Dr. Summers: Yeah, prostate cancer is an extremely common cancer. That said, most of the men that I see with those symptoms do not have prostate cancer. And so, certainly, we ask questions to find out more history and evaluate them for prostate cancer, but we're also looking at other things. Aside from benign prostate enlargement, men can have infections that can cause similar symptoms. You can have a scar or a blockage in the urethra that causes similar symptoms.

BPH is the most common thing that causes all those symptoms and the most common thing I see with men, but it's important that you speak with your doctor and even see a urologist to evaluate for some of those other causes as well.

Interviewer: Sure. Is this true? Some men with those symptoms just figure that it's a part of getting older and there's really not anything that can be done about it. Does that happen a lot?

Dr. Summers: Yeah, so just as we were talking about the increased prevalence of it, a lot of men may not be bothered by the disease itself and their symptoms are very mild. And at that point, they may be right. It's a fact of getting older and their symptoms wouldn't lead to any long-standing problems.

The hard thing is there is a subset of men who have worsening symptoms and maybe have those symptoms younger. If those symptoms are left unchecked or untreated, it can lead to long-term problems.

For example, if a person has a prostate enlargement that obstructs the bladder from emptying, over time the bladder changes and the muscle itself gets thickened, it becomes stiff, it's less pliable, and ultimately the bladder fails and doesn't work. And so then a person is left without a functional bladder and they cannot urinate. Even if we were to go on and treat the prostate, they still cannot urinate and they may be dependent upon a catheter.

Interviewer: Wow, that is a reason to get that thing looked at, isn't it?

Dr. Summers: It certainly is. And I can't tell you how many times I've had men come in who have ignored the symptoms for a long time, thought it was no big deal. Maybe they have a work environment where they can use the bathroom as is out in the wild or whatever. And lo and behold, they have a pretty significant problem. And at some point, those changes become irreversible and no matter what I do, I can't change that.

The other step even further than that is if once the bladder fills, then the urine backs up and you start having kidney problems as a result. And I've seen men with kidney failure that need to go on and have dialysis or even a kidney transplant all because of their prostate problems and their urinary problems that they've neglected for so long.

Interviewer: The symptoms that we talked about, the frequent urination, feeling that you always need to go to the bathroom, a weak stream, dribbling, waking up in the middle of the night, do these all kind of come on at once, or is this more of a gradual thing, so much so that maybe some men don't even notice that there's an issue right away?

Dr. Summers: That's a great question, Scot. It's that gradual, insidious onset that I think can be deceiving to a lot of men. Symptoms may start out very mild and they're so slow changing that you get used to it. You adapt to it. And it may be that you don't even notice that you're having those symptoms, and it's a loved one often that will point out and say, "Boy, you're going the bathroom a lot more frequent than you used to," or, "It's taking you a lot longer," or, "It seems like we can't go through the store without you looking for a restroom." And it's those kinds of comments that I think are very important to hone in on and remind people that there may be a problem that needs to be evaluated.

Interviewer: So it can oftentimes be just kind of this slow onset, so much so that you don't even notice. Then when it becomes to the point where it's critical, does that kind of generally hit just all at once? How does that play out? Do you get what I'm asking?

Dr. Summers: I get what you're asking. Yeah, it can go both ways. So sometimes men may not have . . . they may have symptoms that they ignore for any number of years, and then there's an inciting event that triggers a major problem. So that event can be in a urinary infection, it can be surgery, it can be the start of a new medication, and all of a sudden, they get to the point where they may go into what we call urinary retention, where they cannot urinate at all. And that becomes an emergency and one where we see patients in the emergency room in extreme discomfort.

Other patients, it's very slow and they get to the point where they're getting up four or six times a night. And that's when they come in kind of seeking help because the symptoms have just gone on for so long that it's interfering with their sleep.

So it goes both ways. Certainly, I think the earlier that you can address the problems, the much easier it is to fix. And more importantly, you can avoid some of those long-term effects that we talked about on the bladder and the kidney function.

Interviewer: I was reading some stuff online that some men that get this that it kind of just all of a sudden hits, then you're using a catheter to help drain the bladder, and that doesn't sound like a whole lot of fun. And it sounds like if you kind of get in early enough, not only can you avoid some of the potential downsides you talked about earlier, but maybe a lot of pain in a particular moment if you get to it early enough. Is that true?

Dr. Summers: That's certainly true.

Interviewer: Yeah. Okay. It doesn't sound like a lot of fun.

So it sounds like one of the major risk factors is just, as you get older, the prostate just naturally starts growing. So I saw something . . . I think you said, what, 60% of all men over 60 tend to get it, and then the older you get, it goes up and up and up, right?

Dr. Summers: It does.

Interviewer: So, other than that, are there any risk factors that might cause a man to get this?

Dr. Summers: The prostate continues to grow as we age, and it's highly influenced by androgen levels. And that is, in large part, influenced by genetics. And so, if a person has a higher genetic predisposition or family history of prostate disease, they're much more likely to have similar type symptoms.

Interviewer: Lifestyle too can impact it, right? Because I know that that is one of the treatment options, which we'll get to in a second briefly, because we do have a special podcast we're going to do just on treatment options. But like obesity or diabetes or not enough exercise, those types of things can contribute as well. Is that a major contributor or not so much?

Dr. Summers: Yeah, it certainly can be. Take obesity for example. So obesity, it's unfortunately very common in our society. And with that, you get increased pressure that's put on the bladder, which is only going to make those symptoms worse. And so, if a person can lose weight, then you can markedly reduce some of the frequency and urgency symptoms.

Similarly, different diets. Caffeine is a common culprit for many of us. And the more caffeine that you consume, it has both a diuretic effect as well as an irritant to the bladder and will only cause increased frequency. And so, if you're already having some baseline urinary frequency and difficulty with those symptoms, you add any of these lifestyle components onto that, things are only going to get worse.

Interviewer: And some of those lifestyle changes you have seen make a difference for some men.

Dr. Summers: Yes. So weight loss, exercise helps, limiting caffeine, limiting alcohol. Spicy foods can wreak havoc on the bladder.

Interviewer: So everything but the spicy foods is just stuff that should be doing anyway, right?

Dr. Summers: Yeah. I mean, it's interesting. Healthy living really translates into so many different things across the spectrum of our health.

Interviewer: So lifestyle changes, is that generally the first thing you do, or what's that hierarchy in general look like?

Dr. Summers: Yeah, you're exactly right. So oftentimes we'll talk about lifestyle modification, losing weight, changing diet. Exercise is our first-line therapy because it's low risk, and it has other benefits. When that fails or your symptom improvement isn't where you would like, then we talk about medications. Once you start getting into medications, it's a balance of dealing with side effects with the benefit of the medication. And there are several different classes of medications we use to treat prostate disease. And then we move on toward office-based procedures and surgical treatments for the prostate.

Interviewer: So, when it comes to an enlarged prostate, it's something that all guys are going to get. Maybe some will start showing the symptoms we talked about and some will go on affected. It sounds like you want to go to somebody as soon as you start noticing those symptoms. The quicker, the better. I would imagine you run some tests just to verify that that's actually what's going on, and then you would discuss some treatment options. So it sounds like it's not a one-size-fits-all sort of a treatment.

Would you recommend going to a urologist first if you're noticing these symptoms, or start out with your general practitioner or family doctor?

Dr. Summers: I think you can certainly start with your general family doctor or general practitioner and at least raise the question about your urinary symptoms. Some of the early interventions, the medication and the lifestyle modification, can certainly be prescribed by your general practitioner. I think when your symptoms are more severe a urologist is more ideally suited to treat your disease at that point.