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I'm 63 with a slightly enlarged prostate and the most bothersome or main symptom is getting up on average of 1-3x a night to urinate; it would be nice to sleep through the night (I already limit fluids in the p.m.). I don't want to start the usual meds, like Flomax, mainly because I read that drugs in that class can cause 'Floppy Iris Syndrome' resulting in complications with cataract surgery, something I will likely need done at some point. I also want to stay away from supplements I see advertised that contain the herb Saw Palmetto, because that has some of the same properties as Flomax. Would either laser or 'Transurethral Microwave Thermotherapy (TUMT)' be good options, or would those be overkill at this stage and best to wait until the p.m. urination gets more frequent, if it does?  Thanks

Answer
Lee, almost all men your age have some enlargement of the prostate gland, so called BPH (benign prostatic hyperplasia or hypertrophy).  One of the earliest symptoms of this is getting up at night to void (nocturia).  Before answering your question specifically, let me  give you some basic information on this condition.  

As mentioned, benign enlargement of the prostate gland occurs to varying degrees in all men as they age.  The prostate surrounds the urinary canal (urethra) just after its connection to the urinary bladder.  Inward growth of the prostate either into the bladder neck (opening) or into the urethra itself can cause difficulty with urinating.  The prostate is checked by digital examination through the rectum.  This gives the doctor an idea as to the size and benignity of the gland.  However, it does not always correlate to symptoms as a small gland may have significant inward growth and a large glands enlargement may be entirely peripheral.   

The ability to urinate involves the urinary bladder muscle actually becoming stronger as it works against increasing resistance from the prostate.  This delicate balance can be upset by any factor that decreases the bladder muscles ability to contract with sufficient force to open the prostate (such as medications, anesthesia, too much alcohol, ignoring the desire to urinate, etc.) or those factors that might cause the prostate to suddenly swell (ie acute prostatitis, sitting  for extended periods of time, biking,
horseback riding, etc.). The typical symptoms that occur include diurnal frequency (daytime), nocturia (night-time frequency), urgency, hesitancy, slow stream and dribbling after voiding.  This complex of symptoms is termed “prostatism”.  If the obstruction to flow progressively worsens, the bladder eventually may not be able to empty completely.  This leads to the accumulation of “residual urine” which may predispose to urinary infections and  kidney damage from back pressure.

However, relatively asymptomatic men with BPH do NOT necessarily require therapy.  Treatment is indicated to relieve symptoms and prevent complications.  In many cases medications can be used.  Alpha - blockers (ie Hytrin, Cardura, Flomax, Uroxatral etc.) work by relaxing the bladder neck and urethra so the pressure generated by a bladder contraction has less resistance to work against.  Natural herbal products such a saw palmetto and pygeum often provide symptomatic relief but the exact mechanism of action has not yet been defined.  The prescription drugs Proscar and Avodart actually shrink the prostate.  They work best in the larger glands and improvement may not be noted for up to 6 months.   In cases refractory to medication, interventional measures are indicated.  The “gold standard” for treatment is the time honored transurethral resection (TUR) of the prostate.  For huge glands, open surgery may be necessary.  In the past 20 years a number of other less invasive interventional therapies have been developed to reduce the obstructing prostate tissue utilizing various forms of energy.   These include laser prostatectomy (green light), microwave (TUMP or transurethral microwave of the prostate), and radiofrequency (TUNA or transurethral needle ablation of the prostate).  TUMP & TUNA are minimally invasive & out-patient treatment that can be tried initially if the patient's gland size is appropriate.  

Here is an explanation of a TUR of the prostate gland.  The prostate gland can be thought of as being composed basically of three parts which from inside to out are: the prostatic portion of the urethra (urinary canal), the prostatic glandular tissue causing the obstruction (adenoma) and the compressed capsule of the prostate.  In a TUR, the prostatic urethra and adenoma are removed leaving only the capsule.  This surgery can be likened to coring out an apple from the inside leaving only the skin.  The prostate is resected into many tissue slivers which wash into the bladder and then are removed at the end of the operation by suction.  This leaves a raw bed, which, over a period of 6-8 weeks, regenerates a new urethra!  At the termination of the procedure, one can look from the far end of the prostate into the bladder without residual obstruction.  A catheter is left in for a few days to drain the bladder and to initiate the healing process.

Green light laser gives very similar results to TURP.  The advantages are that it can usually be done as an out-patient, there is less bleeding, one returns to work in a few days and full activity in 4-6 weeks.  The main disadvantage that urinary frequency and urgency are greater in the first month.  

Now to answer your questions more specifically.  As your only symptoms seems to be nocturne, I would not recommend TUMT, laser therapy, TURP, etc. at this time.  Of the alpha blockers, Flomax is the one most likely to produce "floppy iris syndrome" but this potential exists for all of the medications in this group.  I could find only 2 documented cases of this syndrome occurring in patients who took saw palmetto.  With the latter, therefore, the risk is much less but still exists.  The only suggestions that might help your nocturne are limiting your fluid intake in the evening and avoiding those activities that might irritate your prostate gland. These include too frequent or too infrequent ejaculation, sexual arousal without ejaculation, withdraw at the time of ejaculation, aggressive bike or horse back riding, and excessive spicy foods, alcohol, and caffeine in the diet.   Good luck.

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Arthur Goldstein, M.D.

Expertise

Problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, etc. I no longer answer questions related to erection problems or male sexual dysfunction.

Experience

I am retired from the active practice of urology. My 34 years was totally in the clinical field and involved the entire gamut of genitourinary problems, with special interest in endourology.

Organizations
American Medical Association, American Urological Association, American College of Surgeons

Education/Credentials
College degree - BS Medical degree - MD Master of Science - MS

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