Prostates often enlarge with age, due to a variety of causes. Tune in and hear leading experts discuss what guys should be concerned about (urinary issues); what treatments exist (many, including new ones); whether supplements work (medically, no); and more.
Kevin McVary, M.D., Professor, Department of Surgery, Division of Urology Southern Illinois University School of Medicine, Chair of the American Urologic Association Guidelines on BPH, Director of the Male Pelvic Health Fellowship at Southern Illinois University School of Medicine.
During This Episode We Discuss:
- What happens to the aging prostate?
- Lifestyle issues associated with increasing BPH.
- Signs and symptoms of BPH: Slowing urinary stream, urinary urgency, increasing urinary frequency, hesitancy, post urination dribbling.
- What potentially happens if ignored?
- How is benign prostatic enlargement different from prostate cancer?
- How is it diagnosed and treated?
“The vast majority of men with these types of symptoms, it really isn’t cancer it is this gradual enlargement of the prostate, maybe some bladder changes with age.”
“It is a sign that perhaps they should seek evaluation by their primary care physician or by a urologist.”
Kevin McVary, M.D.
Dr. Pelman (00:06):
A baseball game, a day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures, whatever you do, whatever you enjoy, you need your health. The Guide to Men’s Health is presented by the Washington State Urology Society to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your financial future, why not invest in your body? After all, makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body? If you know you shouldn’t but haven’t yet, the information in these podcasts contain some easy recommendations for where, when, and how to get started. Follow the podcast as we explore men’s health with renowned experts and embark on a journey towards better health.
Dr. Pelman (01:07):
Hey guys, if you’ve been wondering about some changes in your urinary habits, perhaps you’re going a little more frequently, a little more urgently, perhaps the stream is slowing down. Well, this episode is for you. Today’s podcast is about BPH or benign prostatic hypertrophy*, and we’re going to be speaking with a true expert, Dr. Kevin McVerry. So if you’re wondering about some of those urinary changes, listen, because BPH is coming your way through the Washington State Urologist Society Guide to Men’s Health.
*Benign Prostatic Hypertrophy/Hyperplasia (BPH): https://www.urologyhealth.org/urology-a-z/b/benign-prostatic-hyperplasia-(bph)
Dr. Pelman (01:46):
It is my pleasure to introduce Dr. Kevin McVerry. Dr. McVerry is a professor in the department of surgery, division of urology, Southern Illinois University School of Medicine. Dr. McVerry has vast knowledge of benign prostatic hypertrophy. He in fact was chair of the American Urological Association (AUA) guidelines on benign prostatic hypertrophy, commonly referred to as BPH. He is also a director of the male pelvic health fellowship at Southern Illinois University School of Medicine. Dr. McVerry has vast knowledge about benign prostate hypertrophy, a common affliction of men, and we’d like to interview Dr. McVerry today regarding BPH as it’s commonly called. What should we know about BPH? What should men be concerned about? And what are some treatments, both standard medical, upcoming, and his thoughts also on concerns that men have about standard therapies? And do supplements work? Dr. McVerry, thank you for joining us today.
Dr. McVerry (02:59):
It’s great to be here, Dr. Pelman. Thank you for the invitation. I’m happy to speak on this topic to your listening audience.
Dr. McVerry (03:07):
So what is BPH?
Dr. McVerry (03:08):
Well, I’ll tell you. As men age, the prostate* grows slowly, starting at about age 30, age 35, and continuing through most a man’s life. As this prostate begins to enlarge, it slowly sometimes secretly, begins to crimp off a flow, urinary flow, from the bladder to the outside world. Men may appreciate that by changes sometimes subtle in their urinary qualities like getting up in the middle of the night; feeling that the force of the urinary stream isn’t what it was; taking a long time to empty the bladder when it’s time to go; or emptying and having to come back five minutes later and doing it again. Or a start, stop, start, start stream, and sometimes, you know, a sense of urgency. When you get the urge to go, you got to call, you got heed the call right then and there. Those are kind of the classic, what I call the seven cardinal symptoms of BPH**.
Dr. Pelman (04:10):
When we have men come in concerned about some changes in urinary symptoms, I think one of the first things that they worry about is there cancer.
Dr. McVerry (04:18):
And that’s really common, but the vast majority of men with these types of symptoms it really isn’t cancer. It’s this gradual enlargement of the prostate, Maybe some bladder changes with age. And also, as we’re understanding now more recently, things that we do in our lifestyle which may actually worse than these kinds of symptoms. So it’s probably multifactorial, but I would want to reassure your audience on, Dr. Pellman, that the vast majority of men with those symptoms, it’s not a sign of cancer. It is a sign that maybe they should seek evaluation by their physician or the urologist. But I hope they’re not losing sleep at night over that question.
Dr. Pelman (05:04):
I think we have some fairly easy determinations that are not extensive or invasive to reassure men that it’s a benign issue. And then when you have a man who presents with the symptoms and you’ve reassured him, it’s not prostate cancer, not everyone needs to be treated initially?
Dr. McVerry (05:22):
Yeah, no, no. In fact, when a man comes to see a physician, a urologist or someone who’s interested in what we call lower urinary tract symptoms secondary (LUTS)* to BPH, that’s a terrible word, LUTS BPH. But when a man comes to a visitation with LUTS, there’s an assessment on physical examination including, you know, prostate assessment, a digital rectal exam**. Importantly, there’s a examination of the urine, a urinalysis, to look for contributing things in the urine which might be mimicking prostate trouble like lots of sugar in the urine, or lots of protein. Maybe evidence of infection, which can mimic these symptoms. Those things should be done. But really critical, a good history. What’s this guy doing that may be contributing to some of his symptoms, like his fluid intake? Does he have diabetes that he’s not managing right? Does he have…is he a couch potato? Do we know…we do know that physical activity can go a long way in reducing symptoms and also maybe preventing symptoms. So it’s kind of a global health assessment that needs to be done, which is in part partial of normal, good primary care and primary urology care I like to say.
*Lower urinary tract symptoms secondary (LUTS): https://umiamihealth.org/en/treatments-and-services/urology/lower-urinary-tract-symptoms-(luts)-
**Digital rectal exam: https://www.mayoclinic.org/diseases-conditions/prostate-cancer/multimedia/digital-rectal-exam/img-20006434
Dr. Pelman (06:45):
So lifestyle changes can impact lower urinary tract symptoms?
Dr. McVerry (06:49):
Yes, it’s absolutely clear. We know that men with heart disease, cardiovascular disease are at higher risk of having prostate urinary problems. We know that diabetics are more likely to have BPH and lower urinary tract symptoms. We know that men who don’t exercise, men who have a family history of BPH all have an increased risk of developing symptomatic BPH and actually an increased chance of needing an intervention, medicine or surgery.
Dr. Pelman (07:25):
I see a recurring theme as we have spoken about testosterone. We’ve spoken about erectile dysfunction. A lot of it goes back to just lifestyle. Ability to have a man take care of himself, begin to exercise, to carry appropriate weight, and to have some reasonable expectations as he ages of some normal changes.
Dr. McVerry (07:45):
That’s right. So it’s…I wouldn’t want someone to think that you can run your way out of BPH or weight lift your way out of it. But with those lifestyle modifications, you can really take the edge off of symptoms enough that it doesn’t compromise your health, and it doesn’t compromise the quality of your life, and probably doesn’t compromise the quality of your sex life.
Dr. Pelman (08:06):
So we have a man who, let’s put him in his later fifties, early sixties, we’ve reassured him through examination that he doesn’t have prostate cancer, perhaps a laboratory test as well. And he has some moderate symptoms. Let’s say that he’s a trial attorney and he finds his urination symptoms to be bothersome because his urgency is causing him to interrupt court proceedings. We have another similar age man, similar symptoms, but he was lucky enough to retire. And at this scenario, he has chosen to watch his symptoms. Are either at danger or risk? The man who’s retired says, “Hey, I got urgency. I’m out in the garden. I just watered the roses.”Is he going to be himself or how do you reassure him that if he wants to watch this condition it’s okay?
Dr. McVerry (09:00):
Yeah. So that comes down to the issue of bother. So the lawyer guy you described, he’s got bothered because of the way it impacts his life. The gardener, you know, he’s just killing the weeds more efficiently. So he doesn’t have the same sense of bother. And that’s an important factor in determining, “Hey, are we going to try to do something more than just a lifestyle alterations for this guy?” So is it safe for everyone to choose one or the other? Well it goes down to at that assessment, the assessment of symptoms. The urologist would look for things which would mandate more intensity. But if you don’t find compromises in urologic health in that evaluation, then it’s highly likely that he could just watch his symptoms and reassess the symptoms later. What kinds of things are we referring to? Well, is he getting his bladder reasonably empty? Is there any evidence that he has some kidney/renal insufficiency? Things like that would really want the urologist to do a more active intervention. But if he doesn’t have compromise to his health, then the vast majority of men can just be reassessed later. They don’t have to have intervention.
Dr. Pelman (10:15):
I tell patients if you just been sent here because you were in the emergency room two nights ago, with the inability to urinate and had a catheter in, that would be a different story. If your primary had sent you because you’d had a number of recurring urinary tract infections, that would be a different story. But most men, it’s just symptom driven. So let’s take the attorney who is bothered by his symptoms and he comes to you and says, “Well, what can we do?” What would you offer him?
Dr. McVerry (10:39):
Well, you know we would look at the behavior stuf, the stuff in his life, his fluid management. Is he drinking a six pack of beer before he goes to bed? We’d look at those types of things. Can that be altered? But let’s just assume we did all that, and it didn’t really improve situation. What are the options? Well one option, an early or an easy option is medications. There are several different classes of medications that could be tried in such a person. One most commonly is alpha blockers*. They go by things like tamsulosin, terazosin, doxazosin, there’s a whole class of these alpha blockers. They all work about the same. They do have alterations in improvements in the majority of men and their urination symptoms and their force of urinary stream. They lower the residual urine in the bladder, that sense of post void residual.
*Alpha blockers: https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/alpha-blockers/art-20044214#:~:text=Alpha%20blockers%20are%20a%20type,flow%20and%20lowers%20blood%20pressure.
Dr. McVerry (11:32):
They improve those things in most men. So you would try a medication such as that. Alternatively, there are medications that actually shrink the prostate. They’re called 5-alpha reductase inhibitors (5-ARIs)*. Finasteride and dutasteride are the drugs commonly used. Their approach is different. It’s trying to approach the prostate by affecting the hormonal acess. They have distinct strengths, but one weakness is that they are slow onset. Alpha blockers work relatively rapid. 5-ARIs, the finasterides of the world, that prostate shrinking pill, they take six, maybe 12 months before you really get a substantial improvement in symptoms. So it’s like a different tempo, and that has to be tailored to our patient. Anything else? Yeah, there’s this new new class, the PDE-5 inhibitors, phosphodiesterase type five inhibitors. The sildenafils, the Viagras, does the tadalafils of the world.
*Five alpha reductase inhibitors: https://www.ncbi.nlm.nih.gov/books/NBK555930/
**PDE-5 Inhibitors: https://www.ncbi.nlm.nih.gov/books/NBK549843/
Dr. McVerry (12:37):
It turns out that those medications also improve urinary symptoms. So it’s very common for men to even try those or sometimes in combination with other things. So we, there are several different medications that are easily taken. And it would be a trial, it’s not a marriage. You’re going to try it and see if it helps. See if you like the effect in it, or are there adverse events that may otherwise make you not want to stay on the medications? So that’s generally the first approach. Now there are interventions. There’s minimally invasive interventions, minimally invasive surgeries. There’s more standard surgeries. But most patients, if given the choice will say, “Hey, let’s just try the pill doctor.” And we’ll start with that and see how things work. And I actually advocate for that position as well.
Dr. Pelman (13:25):
So many patients bring in supplements. THey have prostate vitamins, or they see an ad on TV and bringing it clipping about the prostate supplement and go, “Does this help?” So how do you counsel patients who bring in either the supplement or an ad and ask you if these medicines, most contain saw palmetto, are useful?
Dr. McVerry (13:45):
So that’s been studied many times in rigorous ways. And when you study it scientifically, with a placebo*, you know, with a control doing it objectively, there’s no impact. Zero. So if patients say that they want to try it, then I say, “Well, I just want you to know there’s no objective evidence.” They’re really practicing more of a philosophy than they are a medicine, and there’s nothing wrong with them taking it because they looked to be safe. In my own view it’s a waste of resources, but that’s a personal view.
Dr. Pelman (14:20):
So the data shows that it really doesn’t outperform what we call placebos. I make certain patients aware that these drugs do not prevent prostate cancer. That they really don’t prevent prostate growth. If they feel like they want to take them, I say, “Go ahead.” But we have really stronger interventions in the medications that you already spoke about. So let’s say someone is not able to take the medications because they’re perhaps on a beta blocker* and their blood pressure is too labile**. And when they try one of these alpha blockers their blood pressure drops, or some people just don’t like taking medication. Or they took it and they didn’t respond or they progressed and they want to do more. So I know that you are an expert in minimally invasive and traditional interventions on behalf of the prostate. Why don’t you give us a little overview in those two categories?
Dr. McVerry (15:12):
So when the man comes back and he still has symptoms. The easier things didn’t work; he wants to move on. Then the discussion at that time is really about well, what are the options? And, one class of options is called MIST, minimally invasive surgical treatments*. There are several MISTs available to us. But more recently the ones which are being endorsed in the AUA* guidelines, the AUA guidelines which we released in the middle of May this year at the AUA, is a procedure called prostatic lift**. It has a branded name of Urolift. People may know about that, and another one called convective water vapor therapy or Rezum***. These are the two newer MIST therapies which looked to have impact. The older MIST therapies have pretty much fallen in disuse because of different factors with concerns about durability.
*AUA: American Urological Association
***Convective water therapy/Rezum: https://www.rezum.com/what-is-rezum/how-does-it-work.html
Dr. McVerry (16:16):
And that would be treatments known as microwave treatment. And those are largely discontinued in America, actually worldwide. And TUNA, or Prostiva*, those are another MIST which is discontinued. So the urologist is likely not to talk about those two. He’s more likely talk about the lift or the, uh, water vapor treatment. The way those would work, it’s a quicker, easier, in a sense patient friendly technique. They are interventions. They are manipulations of the prostate. And their advantages, they are relatively quick. Some are under local, some can be done under just a light sedation. They’re usually done in the office with them awake, patient awake, or in a surgery center with them slightly sedated like if you’re going to have a colonoscopy or something to that degree. So not terribly deep anesthesia. They take just a number of minutes, 10 to 15 minutes to perform.
Dr. McVerry (17:18):
They’re done as an outpatient; the patients go home the same day. Their response I’d say is a more moderate impact on symptoms, a more moderate impact on increasing the urinary flow and lowering the post void residual. Their advantage is that they have less side effects. It’s a classic trade off, not so much an impact on the symptoms but there’s less risk. What do you mean less risk? Well, really when we say less risk in BPH, we’re talking about sexual function compromise. So with these newer techniques, they are unlikely, highly unlikely to impact erection. They’re highly unlikely to impact ejaculation. They don’t seem to impact desire in any way anyway. So their advantages: this easier recovery, faster procedure, faster back to the activities of daily life, and virtually no risk in sexual function that makes them attractive.
Dr. Pelman (18:26):
Can these be done as office-based procedures?
Dr. McVerry (18:29):
Most are done. With the steam it’s about 90%, the vapor, it’s 90% of those are actually done in the office. That’s after 20,000 cases done in America. With the lift, the prostatic urethra lift procedure, that is most commonly done in a surgery center.
Dr. Pelman (18:49):
Now the durability of these is yet to be seen, or how far out have we been able to follow patients who have had these procedures?
Dr. McVerry (18:56):
That’s a great question, and this is the data. The lift procedure is a more mature technology. So we have 5-year data. Retreatment, surgical retreatment, falls into the category or the percentage of someplace around 15% in 5 years. But there’s also a sizable minority of men once responded, tend to recur symptoms. They go back on medication and if you tally it up at the 5-year mark, it’s about 33% of men being retreated in one way or another. So there are, there are…Durability is an issue, and time will tell us that for sure. So that’s going to come, but that’s where it is with lift. With Rezum or the convective water vapor, the steam as it’s otherwise known, that isn’t as mature technology. The data is only three years mature. Overall retreatment rates are someplace around 9%. So you know, that’s probably better, probably than the lift. But we need to be objective, and follow the data, follow the outcomes, follow the patients to see where are they in five years, where are they in 10 years. Cause this could erode, these good results could erode then. We just gotta be objective.
Dr. Pelman (20:19):
Now, If we see progression of symptoms, can somebody have these procedures redone?
Dr. McVerry (20:25):
It depends on why didn’t they work because there are situations where you could say, “Well, you need more of the same.” And then there’s types of situations where you would say, “Well, you know, if I didn’t hit it with the technology the first time, why would I do it a second time?” And so you have, there’s a re-evaluation process and it’s rather logical. And you could, the urologists could figure out if we need, if he needs to move to a different technology, which he certainly can, or is there a rationale to try the same old thing again?
Dr. Pelman (20:59):
So let’s move the patient into a gold standard, the more traditional therapies. Let’s say you’ve discussed those, and this person says, “You know, I just want to have one procedure for my lifetime.” Is there a procedure that could be done that would generally take care of most of the urination symptoms that are bothersome to this man and have him really have that one procedure that fulfills resolution for perhaps most of his life?
Dr. McVerry (21:28):
Yeah. So, there is such a procedure, obviously. There are actually likely two such procedures, or three depending on how you slice the pie. So the classic is the T-U-R-P*, the TURP. Those in the listening audience remember their grandfather, he might’ve called it the “roto-rooter.” But it’s a surgical procedure done under some type of significant anesthesia. Not always with an overnight hospital stay, but certainly done in a hospital type setting where there’s an instrument that, once the patient’s asleep of course, removes the blocking part of the prostate or resects it we say, opens up the channel. T-U-R-P. And that’s a standard, long tested technique. It’s what everything else is compared to it cause we’ve done it since the 1930s. And we’re pretty well acquainted with the outcomes. There’s a variation of that called a photo vaporization of the prostate, a laser T-U-R-P or by another name, it’s okay to say brands here.
Dr. McVerry (22:36):
I guess it is, I’ve been saying them, is a Greenlight procedure*. And this is a laser technique where instead of the cutting tool used on the old “roto-rooter” device, a laser energy beam as pointed into the prostate through a scope and the obstructing tissue is removed. The outcomes of those two procedures are very similar, and we believe the durability to be good and also very similar. The chances that a man if he had such a procedure would have a repeat procedure in a lifetime is someplace around 15%. So it’s durable. It is, you know, invasive in that sense that it’s a general anesthesia and it’s potentially of overnight hospital stay in some circumstances. Although most men can go home the same day. They do have an impact on sexual function. The risk of having an impact on erection with the standard roto-rooters someplace reported between 14% and 10%, so maybe double digits. Impact with the laser on erection is probably half that, like 5%. The other issue with it is ejaculation. And the chances that either one of those would impact ejaculation is greater than 50%. So, some men are very concerned about that. Some, they’re not concerned. So that’s part of the discussion and choice process.
Dr. Pelman (24:00):
They would still have a sense of orgasm, but the fluid just doesn’t go forward, right?
Dr. McVerry (24:04):
Yes, there’s some qualitative things with it. But orgasm has said to be unchanged, it’s the emission which is absent.
Dr. Pelman (24:12):
And that can happen with the tamsulosin, the alpha blocker?
Dr. McVerry (24:16):
It can happen with medications as well.
So there are some trade-offs here as to durability, as to the side effects, as to tolerability, and what the patient seeks as a goal. So it’s a discussion between the patient and the urologist. Do you have any thoughts about when it’s time to take a patient off of medication and move them towards surgery?
Dr. McVerry (24:41):
Well, one goes back to this sense of bother. That if the medications aren’t improving his symptoms and he’s bothered by it, that’s a good time. If there’s been medical compromise, like the bladder isn’t getting as empty as it ought to to make it safe for good bladder function and good urinary function, then that’s a must. That’s when you really do need to move to a more surgical approach, mandated. If it’s led to repeat urinary tract infections*, or if it’s led to bladder stone** formation, not confused with kidney stones but bladder stones, that’s also in a sense a must. It’s time to move on to something more definitive, but the urologist could detail those to the patient pretty well.
*Urinary tract infections: https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447
**Bladder stones: https://www.mayoclinic.org/diseases-conditions/bladder-stones/symptoms-causes/syc-20354339
Dr. Pelman (25:24):
And with the minimal, going back to the minimally invasive therapies, did they require catheters* afterwards?
Dr. McVerry (25:30):
It depends on the approach of the surgeon and the patient. The lift, in the trials of the lift procedure, 32% of the men went home with the catheter. In my own practice using steam, I send everybody home two days with a catheter and then have either the patient remove the catheter himself at home or to come back into the office to remove it. That is my personal practice. There’s variation according to urologist. I’d say most urologists would keep a catheter in at least overnight with the steam, and probably most urologists are trying not to use a catheter at all with the lift.
Dr. Pelman (26:08):
In reviewing the AUA guidelines, were there any issues that rose in these recent guidelines, which are marvelous and can be found at https://www.auanet.org/. Go to education, and then go to guidelines and policies, and you will find the new BPH guidelines. Is there anything that came up that was very controversial that were concerning?
Dr. McVerry (26:28):
Well I won’t say controversial, but I will say that are substantial departures from the past. One is the necessary estimation of prostate volume before a technology is chosen. As we’ve got more technologies available, these MIST therapies, this laser, the “roto-rooter,” these different technologies, the outcome can be predicted in part based on how big the prostate was to begin with. Some technologies work very well within a certain limited zone of prostate size. And as you get away from that ideal siz, the outcomes becomes less certain or recovery less fast. So for that reason doing volume measurements, it’s essentially an ultrasound* or an MR**, or a cystoscopy***, are suggested that they be done, and that’s new. There’s some other what we call urodynamics, some other testing done on the bladder or testing done on the force of urinary stream to estimate the probability that the prostate is a source of the problem.
Dr. McVerry (27:41):
We’ve also added that into the guidelines. The other things in the guideline is there are older technologies, which we actually don’t recommend be done. So that’s a departure. Part of the reason they were recommended not to be done is that the data is stale. There’s no progress, there’s no innovation. And we have options. which are new, seem to be better. So why would we ask patients to do old technology? That doesn’t make sense. And then as part of the guidelines, we clearly outline when we think these MIST therapies would be appropriate, and the types of warnings that patients should be given before surgery, kind of mandating to surgeons that they discuss these issues before choices are made.
Dr. Pelman (28:27):
Well Dr. McVerry, I thank you. You’ve always been so generous with your time, your knowledge and your willingness to help patients through the ability to disseminate that. Anything else you’d like to leave the men who are listening to this, or their significant others who wish the men would seek care?
Dr. McVerry (28:47):
I think 80% of male office visits are made by the partner, so yeah. So ladies and partners, get that guy in there. These symptoms are bothersome. They affect the quality of life. I don’t want to tell you how many times patients afterwards have said, “Why did I wait?” I wish I’d done something sooner, and that’s typical. So bring it up, bring it up with your doctor.
Dr. Pellman (29:12):
Thank you. Such a pleasure having you
Dr. McVerry (29:15):
All right, Rich. Thanks.
Dr. Pelman (29:17):
This completes another podcast chapter of the Washington State Urology Society’s Guide to Men’s Health. This is Dr. Richard Pelman reminding you to take care of yourself. Washington State Urology Society wishes to thank all contributors who volunteered their time and knowledge. The information presented is the opinion of the speakers. The society also wishes to thank Shawn Fox for his invaluable technical assistance, music theme, San Juan Bells, written and performed by Dr. Dave Whiting. The podcasts are the property of the Washington State Urology Society. Reproduction and use without the express consent of the society is strictly prohibited. For more information about men’s health, visit wsus.org or visit your physician or care provider.