Benign Prostate Enlargement and HoLEP by Dr Daniel Cohen

Benign prostatic enlargement is the most common cause of lower urinary tract symptoms in men; one third of men over 50 years old will have bothersome symptoms.

Many men are concerned that their symptoms are a sign of prostate cancer, but this is rarely the case; most men with organ-confined prostate cancer have no symptoms that are directly attributable to cancer. Checking a PSA and rectal examination are important steps in the workup men with lower urinary tract symptoms. If suspicious, referral on a target pathway is advisable.

Lower urinary tract symptoms can be divided into storage symptoms – frequency, urgency, urge incontinence and nocturia – or voiding symptoms – poor flow, hesitancy , straining and incomplete emptying. Many men have a degree of both symptoms. Lifestyle treatments may help; for example, reduction of evening fluid intake or caffeine and alcohol. It is important to check for haematuria and refer to the haematuria pathway if positive. Assessment for Sleep Apnoea and drug reactions can also be helpful.

If lifestyle treatment is not effective, the first line medication is usually an alpha-blocker such as Tamsulosin or Alfuzosin. Doxazosin can be used for concurrent LUTS and hypertension treatment. If necessary subsequent treatment can be targeted at storage symptoms, using an anticholinergic (e.g. Tolterodine or Solifenacin) or a B3 Agonist – mirabegron. If the prostate feels large on palpation or is seen to be large on imaging, a 5 alpha reductase inhibitor such as Finasteride or Dutasteride can be added. It is important to note that Finasteride and Dutasteride halve the PSA within a few months of treatment, so PSA must be doubled in men on these medications to obtain a true reading.

For those men in whom lifestyle and medical management is not adequate to control symptoms, there a number of surgical options. We are delighted to be a regional referral centre for Holmium Laser Prostatectomy (HOLEP) at The Royal Free London. HoLEP is the gold standard treatment for durable symptom improvement and can be performed in any size prostate. HoLEP can now be performed using an en-bloc technique and new generation laser offering minimal risk of incontinence. For men with smaller prostates who have bothersome symptoms, minimally invasive surgical treatments, for example Urolift, can be offered. The advantage of a daycase procedure and less risk of side effects is countered by a higher rate of retreatment. Men with very large prostates who do not wish to undergo a HoLEP, or are perhaps not fit enough for a general anaesthetic, could consider a Prostate Artery Embolisation (PAE). PAE is carried out under local anaesthetic in the interventional radiology department as a daycase procedure. We currently offer HoLEP, PAE and bipolar TURP at The Royal Free; our Urolift service is due to begin in the near future. Although many men research potential treatments prior to a consultation, we always advise a detailed consultation with a Urologist prior to embarking on invasive treatment.

Mr Daniel Cohen is Consultant urologist at Royal Free Hospital and Hadley Wood Hospital. He was awarded a PhD from Imperial College London for his research on Simulation in Healthcare training and Health Policy and has published over 20 peer-reviewed papers and book chapters and presented his research at academic and industry conferences in the UK, Europe and United States.

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