Medical, surgical or no treatment. Please help me decide.

Men's health
1

I have written before and had helpful advise but am no further on in spite of seeing another urologist.

I suffer from difficulty starting to urinate and poor flow/stream.  I never need to go during the night and usually go 6 hours or so between visits to the toilet.  I feel fairly confident that I do not have any urine retained.

1st Urologist did ultrasound scan of my prostate, DRE and flow test.  After a very brief discussion told me I would have to have TURPS.  Booked me in for cystoscopy to be followed by the operation.  I was unhappy about the operation and managed to speak to him a couple of days before and he agreed to cancel and told me to seek drug advise from my GP about suitable treatment to be followed by another appointment with him to have further stream test.

After several letters and telephone calls to the urologist my GP could get no report of my condition or results of the cystoscopy.

He finally referred me to another (also private) urologist.  This one just did a DRE, told me I had a medium sized prostate and that the only options were Tamsulosin, Finesteride or TURPS.  He discounted GL treatment saying that TURPS was the only sure treatment. I mentioned to him that my stream was not consistently poor and varied, especially with improvement after sex and is very poor when sitting on the toilet.  He said this would not happen and that it would be consistently poor.  He offered no explanation for the variation and said it could not be anything other than enlarged prostate causing my problems.  He prescibed Tamsulosin and booked me in for a consultation in 4 weeks. (I was a bit bothered that he took 3 phone calls during my consultation which I thought unprofessional).

Neither consultant gave me a measurement for my prostate or suggested that retained urine should be measured.

Having read about Tamsulosin, I am concerned about the side effects.  Specifically I do not want to stop running as it keeps my weight down and fitness up but there are warnings about vigorous excercise and sweating.  I also have a slow heart rate (40bpm) at rest but normal blood pressure.  Do people think that I ought to try the drug or is there a serious health risk with my running, especially in warm weather?  Also, do the side effects or RE and reduced sex drive stop when I stop the drug?  It is very difficult to find information about these things and the urologist didn't mention the serious side effects and only commented (after me asking him) that I shouldn't have eye surgery whilst taking it and should stop just for the surgery.  I don't need surgery at the moment but fully expect to as eye problems run in my family.  

Finally the second urologist said that I shouldn't have regular PSA tests or DRE as they lead to false positives.  When I asked if he thought it could be cancerous he just said he couldn't be sure but didn't think so.

I would be very grateful for any comments from anyone out there.

Sorry for the lengthy post.

Thank you for taking time to read it.

Richard.

2

Hi, My only experience with Tamsulosin has been reasonably positive, and unless you are very unlucky, I would not fear experimenting with it if I were in your place with the recommendations you have had. I don't take it now, but while I did I din't notice anything amiss day-to-day except postural low blood pressure, which was fine as I learned to lift up from my Yoga Down Dog posture slowly and held on to the wall while the slight dizziness subsided. Driving was never a concern. Also, although intercourse felt the same, ejaculation was dry when masturbating, which made it less pleasurable. Now I'm off the Tamsulosin everything is back to my normal. I haven't heard any risks of any permanent changes from taking this drug.

3

I took Tamsulosin for many months at a time, over the years, and apart from occasional slight dizziness on getting up from heads-down Yoga postures, and dry ejaculation, only noticeable if masturbating rather than penetrative sex, there were no problems. Everything has returned to normal quickly on cessation of the medication.

4

Sorry for repetition, but my first reply appeared to 'not take'!

5

I too use running as my primary cardio. I have tried 3 different alpha-blockers and had the same side effects with them all. Dizziness, severe nasal congestion when trying to sleep, retrograde ejaculation and lower energy levels. Running at first was very difficult, but can be managed by the time of day you take the pill (after running). While I could not run as well while taking this drug, it was possible. However, long hikes and runs >10km were not possible - I simply did not have the energy. The nasal congestion was the primary reason I stopped taking them as it impacted my sleep, running was a close second.

Over the course of several months, I modified the time and dosage and the net result for me was the benefits were marginal and did not offset the side effects, so I stopped taking them, though everyone is different. Within 72 hours of stopping the drug, all side effects were gone. 

You may want to look at your diet for possible aggravating factors. For some, caffeine and alcohol can be irritants that cause urinary issues, in addtion to being diuretics. When I cut those two items from my diet, my symptoms improved, but I still have the issue of slow start after sleep. Still working on that one.

Good luck!

6

I'm shaking my head, after reading of your experience, and what the doctors you're seeing are saying!  And I applaud your decision to refuse the TURP!

Please read up on alternatives to TURP; that procedure is NO LONGER "the Gold Standard" that so many urologists claim it is, and it is SO fraught with potential side effects and quality-of-life issues.  If you check the topics on this site, you should find plenty of reasons to hold TURP as your LAST resort!

Urolift and "green light surgery" and other treatments have been discussed here at length; others will recommend their favorite solutions that don't involve TURP.  

Retention IS a potential issue, and you will want to have that test done, to see if your BLADDER is functioning correctly and is able to empty itself fully.

Prostate size and configuration is important to know! For example, Urolift can be done on prostates between 40 and 80 grams, and only if there is no medial lobe.

I favor Urolift, partly because it is the ONLY treatment that is reversible.  That said, others have argued convincingly for other options, and I trust they will in response to your situation.

I too took Tamsulosin, when first diagnosed.  It did nothing much for my situation, affected, yes, my sex drive, and also caused dizziness.  My yoga practice was not affected as much as Pepesan's was  :-)  but I was working on ladders doing construction work for my wife's church, and was simply careful and aware that I was compromised.  Driving was never a problem for me, either.

READ! READ! READ!  Learn as much as you can before you face another doctor, and know what your options are!

 

7

have you considered PAE...Prostate Artery Embolization. I notice on this forum a lot of discussion about its non invasive benefits compared with TURP. see

 https://patient.info/forums/discuss/personal-pae-at-unc-experience-529461

8

I was ~42yo when put on Tamsulosin. My daily run was 9 miles at 9mph, so running is very doable. I did not have RE while on Tamsulosin. Keep in mind, side effects may vary.

Usual workflow for diagnosis would include cystoscopy, just to see what the heck is happening at your bladder neck. You might have constricture of urethra messing with your flow.

Treatments - TURP has stopped being Gold Standard in countries were HoLEP is available. HoLEP will very likely result in RE.

PAE seems to be minimally invasive treatment, someone posted a link to it.

Urolift, ITIND will not stop your prostate from growing, you will need some other treatments down the line.

Rezum, injecting steam into prostate, is likely to reduce growth for some time.

Green Laser ( PVP), burns off parts of prostate, some folks need repeat treatments.

9

You should not consider TURP. Its a last resort only - and maybe not even that. There are three, non invasive procedures with few if any side effects and very quick recoveries. They are PAE, REzum and Urolift. PAE and Rezum kill prostate tissue - PAE by cutting off the blood supply done thru the veins by an Interventional radioligist (for that reason no urologist will suggest it), Rezum does it by spraying steam directly on the prostate. Urolift essentially holds down the prostate bulges with small bands. None carry much in the way of long term problems - the most you risk is the cost and inconvenience.

If you can, find a urologist who is familiar with and performs these procedures. Not everyone is a urolift candidate but if your prostate is "medium sized" you are almost surely one for REzum and PAE. 

Your situation isn't dire and I recommend these non surgical procedure before even something like Holep which is a srugery and will leave you with rE premanently. You can always do that if one of the less invasive things doesn't do the trick - but from your description, they probably will.

10

Yes, to what Old Buzzard just posted!  As for quick recovery times, yes indeed!  I had the Urolift in December, in Utah.  One hard day of recovery, on pain meds, but peeing immediately, no catheter.  Next day I flew home to Pennsylvania, and on the third day, I stacked half a cord of firewood, with no problems!  Your mileage may vary, of course!  :-)             

I will add that the prostate, even when held back by implants, will continue to grow.  I will be having a second session for more implants next month.  But again, little pain and the procedure is REVERSIBLE, e.g., if other surgery is needed...

11

I’ve been following this blog for about 7 months and have heard a lot about cathing, drugs, and the various BPH procedures including PAE, Rezum, Urolift, TURP, Green Light Laser and HoLEP.  The following summarizes what I’ve read as best I can.

 

Bottom line:  drugs may work for a while (for me it was about 3 years), but they are not a long term solution and can also result in damage the bladder from constantly being over extended/full.  Some procedures seem to work for some but not all.  Worse yet, some have reported total incontinence after their surgical procedures.  It’s hard to tell if it was a botched job or not.

 

The real answer imho is surgery, specifically HoLEP.  I did the research on all the procedures (except PAE….had not heard of it), and chose HoLEP.  It is the best surgical procedure because; 1) less time in the hospital and a on catheter (less than 24 hours), 2) less bleeding, 3) very small chance of needing a repeat procedure, and 4) they remove prostate tissue (instead of burning or otherwise destroying it), so they can biopsy it for cancer.  I have heard no reports of anyone having HoLEP and needing a second procedure or experiencing incontinence or needing to continue cathing.  I’ve heard way too many horror stories on this blog about TURP & GL.  My uro explained that they both burn the tissue out, and therefore leave scar tissue.  That tends to shrink over time, and hence the need for a repeat procedure. With HoLEP, they cut the tissue away, grind it up with a ‘morcellator’, push it into the bladder, and then wash it out.

 

Yes, you the have retro ejac, but sex drive returns, and since I don’t plan to have any more children (age 68), it’s not a problem for me.  I was retaining close to 800ml, and my prostate was 85 grams, PSA 3.8.  After it was 46 grams, PSA 0.2.  I had my surgery in January, and after two to three months had no problems at all.  I did have leakage for 3 or 4 weeks.  Some in the UK report they were told to do Kegel exercises for a few months before surgery to avoid this.

 

I have heard some good reports on PAE which is done by interventional radiologists.  It is an outpatient procedure and far less invasive.  If I had it to do over again, I might do that first.

 

Lastly, the experience & ability of the doc is critical, and often difficult to determine.  Hospital ratings for various specialties can be found in the US News & World Report evaluations.  Bios for docs may or may not be available.  For example, the Mayo Clinic was rated best in the nation, and they have the education and publications of their docs listed…… very helpful. Best of luck!

12

I’ve been following this blog for about 7 months and have heard a lot about cathing, drugs, and the various BPH procedures including PAE, Rezum, Urolift, TURP, Green Light Laser and HoLEP.  The following summarizes what I’ve read as best I can.

 

Bottom line:  drugs may work for a while (for me it was about 3 years), but they are not a long term solution and can also result in damage the bladder from constantly being over extended/full.  Some procedures seem to work for some but not all.  Worse yet, some have reported total incontinence after their surgical procedures.  It’s hard to tell if it was a botched job or not.

 

The real answer imho is surgery, specifically HoLEP.  I did the research on all the procedures (except PAE….had not heard of it), and chose HoLEP.  It is the best surgical procedure because; 1) less time in the hospital and a on catheter (less than 24 hours), 2) less bleeding, 3) very small chance of needing a repeat procedure, and 4) they remove prostate tissue (instead of burning or otherwise destroying it), so they can biopsy it for cancer.  I have heard no reports of anyone having HoLEP and needing a second procedure or experiencing incontinence or needing to continue cathing.  I’ve heard way too many horror stories on this blog about TURP & GL.  My uro explained that they both burn the tissue out, and therefore leave scar tissue.  That tends to shrink over time, and hence the need for a repeat procedure. With HoLEP, they cut the tissue away, grind it up with a ‘morcellator’, push it into the bladder, and then wash it out.

 

Yes, you the have retro ejac, but sex drive returns, and since I don’t plan to have any more children (age 68), it’s not a problem for me.  I was retaining close to 800ml, and my prostate was 85 grams, PSA 3.8.  After it was 46 grams, PSA 0.2.  I had my surgery in January, and after two to three months had no problems at all.  I did have leakage for 3 or 4 weeks.  Some in the UK report they were told to do Kegel exercises for a few months before surgery to avoid this.

 

I have heard some good reports on PAE which is done by interventional radiologists.  It is an outpatient procedure and far less invasive.  If I had it to do over again, I might do that first.

 

Lastly, the experience & ability of the doc is critical, and often difficult to determine.  Hospital ratings for various specialties can be found in the US News & World Report evaluations.  Bios for docs may or may not be available.  For example, the Mayo Clinic was rated best in the nation, and they have the education and publications of their docs listed…… very helpful. Best of luck!

13

Richard, If you can I would suggest doing the Holep, if not do the turp. I have been having prostate problems for around 12 years.  At first, I didn't want to do surgery, so I did all the alternative methods, herbs, diet etc. Finally, I did take medication doxasosin and avodart. It helps a little but not as dramatically as the turp.  I thought to myself, I should have done the turp, the first time around and not bother with the medication etc.  I believe I would have been better off. Right now I am wearing a catheter, because I can't urinate on my own.  I see my uro on Aug. 25, and hopefully I'll  be able to void, after the catheter is removed.  I know you must feel a little scared about doing surgery, but if the uro does a decent job, you should be fine.  Good luck!

14

Hi Dennis!

Sorry to read of your 12-year struggle!  Mine has been going on for only 2 years.  HoLEP, PAE and Urolift are all pretty new, recent developments.  For me, I've read so much about problems with TURP, that I will avoid it until I run out of other choices.  Men have written here about successes with TURP. but many more have reported in with serious quality-of-life problems, post-op.  Thigns like gross incontinence and loss of "erectibility," and other problems.  The "cure" has for many been far worse than the problem.

My stretched-out bladder (2.5 liters full when my prostate shut down my bladder 2 years ago!) remains an issue for me, and thus I continue cathing sometimes.  For me, wearing a bag was so horrible and limiting (I was working construction when the trouble started.), that I put up with it for 1 week, then insisted on intermittent self-cathing.  I've done that over 2,000 times since, with only the occasional UTI to deal with. (and those were mostly my fault!  :-) &#160

Twelve years is a long time ago, in the world of BPH; things are vastly different, and more and more uro-docs are coming to let go of that old "TURP is the gold standard" line!  

Just thoughts for your eyes only; I didn't want to start a "p*ssing match" about whose approach will have a better outcome!

If you go ahead with a TURP, please let me know how it works out!

15

First, it seems like you should find still another urologist.  It seems life threatening to not have regular PSA (and free-PSA) tests and also DRE.  It’s a ridiculous argument that there may be false positives.  Are you supposed to wait until you have symptoms of metastatic prostate cancer before you take action?  More information is always better than less information.  You just need to do some research to know what to do with the information.  Or find a urologist who doesn’t treat you like an idiot who needs someone else to make your decisions for you.  And an answer like: "couldn't be sure but didn't think so" is useless and unprofessional.

There is a great article regarding TURP and all other forms of “reaming” the prostate on the PubMed website.  Just search for the article’s title and it should come up:  “HoLEP: the gold standard for the surgical management of BPH in the 12st Century”, by John Michalak, et al., pub. April 30, 2015

 I’m 74 y.o. and my prostate is 70cc, about twice the normal volume.  During the day I have no problem urinating if I urinate when the urge strikes, although the rate of flow is widely variable.  If I have a strong urge and hold it in because, say, I’m driving, building up pressure, the stream typically begins with a low flow rate and gradually increases in flow rate.

At night, I do awaken about every 3 hours while asleep to urinate, and have a similar problem when beginning to urinate; but, none of this bothers me.

I would not want to take any medication unless absolutely essential.  The side effects are often worse than what's being fixed.  It does not bother me that sometimes my urine stream is slow or very slow, or it’s sometimes difficult to begin urinating.  That’s hardly life threatening.  It’s not a problem that demands fixing unless you can’t urinate at all.  And that’s something I sometimes think is happening when it takes a particularly long time to begin urinating.  So, if that should happen, I know where the nearest emergency room is.  No big deal.

16

Rick, my advice, get a 3T (tesla) MRI using a pelvic coil or if you can't find a pelvic coil a transrectal coil. The pelvic lays across the pelvic area. The rectal coil is inserted in the rectum for the MRI. With this test, you will detrimine several facts that you need to know. This is quick and painless and much more informative than a DRE and a biopsy. 1) you will finally know you volume (size of prostate)  2) you will know if you have cancer lesions. 3) you will know your mass density of you prostate. A radiologist is who does this. Not a urologist. That is why even though I is better and painless, they will not tell you about this. If you have cancer then, focal laser abalation is the way to go as it targets the specific tumor and has not side effects. If you only have BPH, then PAE is the best choice in my opinion. Also, to be full informed abou your situation, I would recommend a PSA and a Free PSA blood test as baseline number to use to watch. Then you will know where you are and can proceed with a active surveillance program while watching you symptoms. Lots of things are coming down the road soon in this area. Good luck.

17

Thank you for all the detailed comments and the message.  A lot of food for thought.  I will read them all thoroughly and will make a decision then.

I am so grateful for this forum where so many people take the time to be so supportive.  It is so difficult when you just have to rely on doctors and consultants who don't seem to want to explain anything, just follow their own agenda (at least that is how it seems sometimes). 

I will keep you posted about how I proceed. 

Thank you very much,

Richard.

18

I did  the turp on July 12, 2016. So it's been slightly over a month since the surgery. The uro, said he made a nice clearing for urine to pass through the urethra, but my problem is I can't void on my own. Like you I hate wearing this bag. When I go in to see him on the follow up, which is on Aug. 25, a few days from now, and if I still can't urinate on my own.  I am going to try and do what yo are doing, the self-catherizing.  Is it hard to do, and is there any pain while doing it?  How often do you have to do it daily?  Much Mahalo,for your comments.

19

SOrry to read, that you went through the TURP, but that is, as they say, urine over the dam.  :-P    The dam, in this case, is a mystery, as the TURP is supposed to remove enough prostatic tissue to allow the flow of urine in a natural fashion.  I hope that gets resolved!

As for self-cathing, I was taught in the uro-office.  What they told me was complicated and time-consuming, even though easy to learn.  It involved holding the catheter's insert-end with one hand, while feeding it into the penis.  To me, that was invitation to infection.  I have been cathing now, on and off, for 2 years.  I have a method, also practiced by others on this forum, that instead involves holding the head straight UP, and LOWERING THE CATHETER INTO THE OPENING.  This way, there is no chance of contamination, the usual cause of UTIs (urinary tract infections, the only side effect I have expereinced.  The UTIs I've gotten were due to "operator error." 

No pain, only very minor discomfort at times.  At present I cath right before bedtime, and enjoy full nights of sleep, 99% of the time!!!  I also cath mid-day.  

In your case, I'd suggest cathing more often, first thing, midday, after lunch, late afternoon...to determine how much fluid is being retained.  You should be emptying about 300cc or so.  If you have a stretched bladder, it's likely you will hold more (or much more) without discomfort, but it's not advised.

ALSO: VERY IMPORTANT!!!  We cathers stay away from those antiquated red rubber catheters that uro-nurses will sometimes pull out; they are cheap, but can irritate your insides, and require washing/sterilizing, lubing, etc.  Accept only self-lubing one-time use models.  I've used SpeedyCath and Magic-3s successfully, but recommend the SpeediCaths as the most reliable and easy-to-use.   

I've cathed over two thousand times, and hardly think about it now, just do it!  :-)

If you have more questions, please ask. 

20

I would be most concerned about your heartbeat. 40bpm is bradycardia. Are you sure? Either you are a confirmed athlete than maybe, ok, but still it is low.

The use of betablockers doesn't do anything to your sex life, although I found some of thenm (alfuzosin) more inocuous than others. All side effects are temporary. It will lower your blood pressure, but nothing dramatic. Only this bradycardia????