Rezum and UroLift for an enlarged prostate: options and how to choose

The prostate is a small gland below the bladder that makes semen and controls the flow of pee from the bladder to the penis. The NHS explains that when it gets bigger it can put pressure on the urethra, the tube that carries pee, which causes problems with peeing. It is thought to be caused by changes in hormone levels as you get older, and you may be more likely to get it if you are over 50 or if others in your family have it. An enlarged prostate is not caused by prostate cancer and does not increase your risk of getting prostate cancer.

The NHS lists the main symptoms as difficulty starting to pee or having to push or strain; a weak flow, stopping and starting, and taking longer to empty the bladder; feeling you cannot fully empty the bladder; dribbling after finishing; and needing to pee more often or urgently, including at night. Symptoms usually develop slowly and may gradually worsen with age.

The NHS says it is important to get these symptoms checked by a GP because they can sometimes be caused by other more serious conditions, such as prostate cancer. It advises asking for an urgent GP appointment or getting help from NHS 111 if you have blood in your pee, pain when peeing, or cannot pee at all.

A GP will ask about symptoms, may examine the tummy and penis and feel inside the bottom with a finger to check the size of the prostate (rectal examination), and will usually ask you to keep a record for at least 3 days of how much you drink and how often and how much you pee. Tests may include a urine sample and a PSA blood test, with referral for a urine flow test, an ultrasound scan of the bladder or a cystoscopy.

The NHS says that if symptoms are not causing many problems doctors will usually recommend trying lifestyle changes first: cutting down on alcohol and caffeine; reducing how much fluid you drink before bed or before going out while still drinking enough during the day; eating enough fibre; keeping to a healthy weight; waiting a few moments after peeing and trying again; and checking with a doctor or pharmacist whether any medicines you take for other conditions could be making symptoms worse. It advises not straining and not cutting down too much on fluids, which can cause problems such as urinary tract infections. Bladder training and pelvic floor muscle training are also offered.

For moderate or severe symptoms the NHS lists medicines that help you pee (tamsulosin, doxazosin or alfuzosin), medicines for needing to pee more often or urgently (oxybutynin or tolterodine), and medicines that help stop the prostate growing by reducing hormone levels if you are at high risk of the condition getting worse (finasteride or dutasteride). It says these can cause side effects, which your doctor will explain, and that you will have regular check-ups.

The NHS says you might be offered surgery if medicines have not helped or your symptoms are severe. The most common surgery is transurethral resection of the prostate (TURP), which removes part of the prostate through a thin tube passed up the penis. It says sometimes you may be offered a different procedure, which may not be suitable for everyone, including removing or destroying part of the prostate using lasers, an electrical current, steam or a jet of water; holding part of the prostate open and widening the urethra using a small implant; making small cuts in the prostate around the opening to the bladder; and removing part of the prostate with surgery.

Rezum and UroLift belong to this group of alternatives to TURP. NICE published medical technologies guidance on Rezum for treating lower urinary tract symptoms secondary to benign prostatic hyperplasia (MTG49, published June 2020) and on UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia (MTG58, published May 2021). NICE has since moved both to its HealthTech guidance series, with the guidance itself unchanged.

Rezum is generally described as using steam to destroy excess prostate tissue and UroLift as using small implants to hold the prostate open, which matches the steam and implant options in the NHS list above. The NHS stresses that the surgeon will explain your options, the risks and benefits of the procedure and what will happen.

The NHS points to an NHS England decision support tool for making a decision about an enlarged prostate, and to Prostate Cancer UK information about how it is treated. Because the NHS says the alternative procedures may not be suitable for everyone, the choice depends on the size and shape of the prostate, symptoms, other health conditions and medicines, and personal priorities.

Useful questions for the specialist include which options are suitable for you, what the aim of each is, how likely you are to need further treatment, the effect on sexual function and ejaculation, whether a catheter is needed afterwards, and how soon you can return to normal activities. The NHS notes that medicines and surgery can have side effects and that your doctor will explain the benefits and possible side effects.

The NHS says there is treatment and support available to help with symptoms, including pads, pants or sheaths for leaks or dribbling, a urinary catheter if you cannot empty your bladder, bladder training and pelvic floor muscle training. It says to try not to be embarrassed about seeing a GP, because the GP will be used to talking about these symptoms.

On the NHS, an enlarged prostate is assessed by a GP, with urology referral for tests and procedures. The NHS notes that procedures other than TURP may not be suitable for everyone.

Whichever service you use, the sequence in the NHS guidance, lifestyle and medicines first, then procedures, with a full discussion of risks and benefits, is the framework against which options such as Rezum and UroLift are weighed.