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Watchful Waiting

If you have benign prostatic enlargement (BPE) with mild/moderate bothersome lower urinary tract symptoms (LUTS), you may not need drugs or surgery for your condition. Instead, the urologist will explain your condition to you, how it can develop, and how you can adjust your lifestyle to reduce your symptoms and cope with them. The urologist will closely observe your condition over the following months or years and will start active treatment when needed. This is called Watchful Waiting.

Watchful Waiting is a good option if your symptoms are mild/moderate and if you feel that your quality of life has not declined. Despite how it may feel, this is not a passive approach because it includes regular check-ups to make sure your condition does not get worse.

Most men with BPE are offered a period of Watchful Waiting before starting any treatment. It is widely recommended because severe complications during this time are very rare. In fact, some symptoms can improve on their own while others may remain stable for years.

A Watchful Waiting programme includes:

  • Evaluation of your symptoms
  • A physical examination
  • Blood and urine tests
  • Education about your condition
  • Support and reassurance
  • Lifestyle and self-management advice

Lifestyle advice

  • Drink at least 1 litre every day and discuss with your doctor if you can drink more
  • Drink more if you live in a hot climate or do a lot of physical exercises
  • Drink less before and during long trips
  • Drink less in the evening to avoid getting up at night to urinate
  • Avoid alcohol and caffeine because they increase urine production and irritate the bladder
  • Try to exercise 2 or 3 times a week. Lack of movement can make it more difficult to urinate and cause urinary retention
  • Have a balanced and varied diet
  • Always try to keep your lower abdomen dry and warm. If you go swimming, bring an extra set of dry clothes and change as soon as you are out of the water. Dampness and cold may increase the need to urinate and can cause a urinary infection
  • Sometimes urine sprays and it can wet the toilet seat or the bathroom floor. Some men prefer to sit down when urinating to avoid this, while others prefer to urinate in a cup and empty it in the toilet

Self-management

Apart from following general lifestyle advice, you can actively manage the symptoms caused by BPE in your everyday life. Self-management can reduce symptoms and keep your condition stable.

  • Completely empty your bladder each time you urinate. It may help if you sit down
  • If you feel your bladder is not empty after urinating, try again after 5 minutes
  • Use a small pad to catch involuntary urine loss
  • After urinating, press under the scrotum with your fingers onto the urethra and then slide your fingers from the base to the tip of the penis to squeeze out the last drops of urine. This will help to avoid wetting your underwear
  • Use breathing exercises to distract yourself from the feeling of urgency
  • Apply pressure to your penis or perineum (Fig. 1) to divert your attention from urination
  • Encourage yourself to “hold on” longer when you feel the urgency to urinate. This will train your bladder to keep more urine so that you will urinate less often
  • Avoid constipation by adapting your diet
  • Avoid sudden exposure to cold weather and always try to keep your lower abdomen warm
  • Keep a bladder diary

Drug treatment for LUTS in men with BPE

You have been diagnosed with benign prostatic enlargement (BPE) and your doctor recommends drug treatment. This treatment is advised when the symptoms are bothersome and affect your quality of life. This section describes different drug treatments, which you should discuss with your doctor. Together you can decide which approach is best for you.

Factors which influence this decision include:

  • Your symptoms
  • The size of your prostate
  • Your medical history
  • Drugs available in your country
  • Your personal preferences and values

There are several groups of drugs to treat the symptoms caused by BPE:

  • Beta-3 agonist
  • Alpha-blockers
  • 5alpha-reductase inhibitors (5ARIs)
  • Muscarinic receptor antagonists (MRAs)
  • Phosphodiesterase 5 inhibitors (PDE5Is)
  • A combination of drugs
  • Herbal drugs

Each group of drugs works in a different way and can have different results and side effects.

Surgical treatment of LUTS in men with BPE

You have been diagnosed with benign prostatic enlargement (BPE) and your doctor recommends surgery. This section describes different treatment options, which you should discuss with your doctor. Together you can decide which approach is best for you.

Factors which influence this decision include:

  • Your symptoms and quality of life
  • The size of your prostate
  • Your medical history
  • The kind of treatment available at your hospital and the expertise of your doctor. Ask your urologist about his or her experience with the recommended treatment option. You have the right to know the complication rate of the surgeon who will do the operation
  • Your personal preferences and values. There is no single treatment which is ideal for all patients

When should I consider surgery?

  • When your symptoms get worse, even if you already receive drug treatment
  • When you have complications of BPE or if you are at risk of getting them. Complications include:
    • Kidney failure
    • Dilatation of your kidneys
    • Inability to urinate (urinary retention)
    • Recurring urinary tract infection
    • Recurring blood in the urine
    • Bladder stone
  • If you do not tolerate drug treatment very well
  • If you prefer surgery over drug treatment

During surgical treatment, the doctor will remove the enlarged part of your prostate (also known as adenoma).

There are different types of surgical procedures, but all of them aim to relieve your symptoms and improve the flow of urine.

The main procedures are:

  • Transurethral resection of the prostate (TURP)
  • Transurethral incision of the prostate (TUIP)
  • Open prostatectomy
  • Laser vaporisation of the prostate
  • Laser enucleation of the prostate
  • Prostatic urethral lift

There are also some procedures which are still under investigation:

  • Aquablation of the prostate: A method used to reduce the size of the prostate using a water stream. This is done through the urethra, so no cuts are made in your belly.
  • Prostatic Artery Embolisation: A method used when there is an obstruction of the arteries that supply blood to the prostate. The procedure is done with specific tools that are introduced through an artery (blood vessel) in your arm or your leg.
  • Convective water vapour energy (WAVE) ablation, or the Rezum system: The principle of the Rezum system creates thermal energy in the form of water vapour that reduces the size of the prostate.