TURP vs medication for an enlarged prostate

The prostate surrounds the urethra just below the bladder and often enlarges with age. This benign prostatic enlargement can narrow the channel and irritate the bladder, causing a weak or interrupted stream, hesitancy, dribbling, frequent urination and getting up several times at night. It is not cancer, though cancer can coexist, so assessment includes examination and sometimes PSA testing after counselling.

Treatment depends on how bothersome symptoms are, how large the prostate is and whether complications such as infection, bladder stones, kidney effects or urinary retention have developed.

Alpha blockers relax muscle in the prostate and bladder neck, improving flow often within a short time. Side effects include dizziness on standing, tiredness and, with some, ejaculation changes. 5-alpha reductase inhibitors reduce the hormone effect that drives prostate growth, shrinking the gland over several months, mainly helpful for larger prostates; side effects can include reduced sex drive, erectile problems and breast tenderness. Other medicines can address overactive bladder symptoms or night-time urine production, after assessment.

Medicines are non-invasive and reversible, and many men find symptoms acceptable with them. Their limits are partial improvement and the need for continued use.

In TURP (transurethral resection of the prostate) a surgeon passes a scope through the urethra and cuts away prostate tissue using an electrical loop, under spinal or general anaesthetic. Newer options include laser enucleation, laser vaporisation, water-jet ablation and others, which vary in bleeding risk, hospital stay and preservation of ejaculation. A catheter is usually in place for a day or two.

Surgery typically gives the largest improvement in urine flow and symptoms and can reduce or stop the need for tablets. Risks include bleeding, infection, temporary urinary leakage, urethral narrowing, and retrograde (dry) ejaculation, which is common after TURP. A small number of men develop persistent incontinence or erectile changes.

NICE guidance on lower urinary tract symptoms in men (CG97) recommends conservative advice and medicines for most men, with surgery offered to those whose symptoms are moderate to severe and have not responded to medicines, or who have complications such as recurrent infection, stones or retention. Choice of operation depends on prostate size, anaesthetic fitness, anticoagulant use and preference regarding ejaculation.

Before treatment, clinicians confirm the cause of symptoms, since some men have bladder or nerve problems rather than prostate obstruction, and may use flow tests or ultrasound. The choice of surgery is increasingly individual because several techniques exist.

• Mild to moderate symptoms: try lifestyle advice and medicines first, and review.

• Symptoms still bothersome or side effects unacceptable: ask about surgical options and which technique suits your prostate.

• Unable to pass urine, recurrent infections, bladder stones or kidney effects: urgent specialist review; surgery is more likely.

• Wish to preserve ejaculation: discuss newer techniques and medicines with the urologist.

• Taking blood thinners: tell the team, since this affects the choice of operation.

An enlarged prostate is not cancer and does not lead to cancer, though both can be present. Surgery is not a first step for everyone, and tablets do not cure enlargement, they ease symptoms. Also, TURP does not cause impotence in most men, though dry ejaculation is common.

Another misconception is that symptoms are an inevitable part of ageing and must be tolerated. Effective treatments exist.