In recent years, experts have become more convinced that mild cases of benign prostatic hyperplasia (BPH) do not require treatment. Symptoms related to such cases may clear on their own and merely require monitoring. Patients may receive evaluation forms that can help a physician determine how symptoms change over time.

Some men take herbal supplements such as saw palmetto and stinging nettle in an effort to control or prevent BPH. Some studies have found that saw palmetto, which is made from berries of a southeastern U.S. palm, might reduce symptoms of mild but not severe BPH. Side effects may include mild gastrointestinal distress. Patients are advised to consult their physician before trying any complementary or alternative therapy.

Several treatment options are available when BPH becomes a major inconvenience or a health threat. Two classes of drugs are used long term to treat BPH:

• Alpha blockers. Though a type of antihypertensive (blood pressure drug), alpha blockers are used primarily to treat BPH. They improve urine flow by relaxing the smooth muscle of the prostate and the neck of the bladder. The U.S. Food and Drug Administration (FDA) has approved four alpha blockers to treat BPH: alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax) and terazosin (Hytrin).

People having surgery for cataracts, another common condition of middle and old age, should tell their eye surgeon in advance if they have ever taken alpha blockers. These drugs can affect the iris (colored part of the eye) and may require the surgeon to use modified surgical techniques, but they are safe and effective, according to the American Urological Association and the American Academy of Ophthalmology.

Other possible side effects of alpha blockers include dizziness, runny nose, drowsiness, weakness, sleep difficulties or (rarely) sexual problems or fast heartbeat.

• 5-alpha reductase inhibitors. These drugs slow the prostate’s growth or shrink it by impeding production of a hormone called DHT. The FDA has approved two 5-alpha reductase inhibitors to treat BPH: dutasteride (Avodart) and finasteride (Proscar).

Side effects may include sexual difficulties (often lessening after the first year) and tenderness and sometimes enlargement of the breast. Women should not take or even handle 5-alpha reductase inhibitors because of the risk of a birth defect.

The Medical Therapy of Prostatic Symptoms Trial (MTOPS) found the combination of an alpha blocker and a 5-alpha reductase inhibitor more effective than either one alone.  

Various forms of minimally invasive heat therapy also are available to treat BPH. Transurethral microwave therapy (TUMT) uses computer-controlled heat in the form of microwaves to destroy excess prostate tissue. Another procedure called transurethral needle ablation (TUNA) uses low-level radiofrequency energy to remove a portion of the enlarged prostate. These procedures do not cure BPH and do not work well in men with very large prostates. But for many patients, they reduce urinary frequency, urgency, straining and intermittent flow.

Other forms of heat therapy include:

• Electrovaporization. Uses a special metal instrument that emits a high-frequency electrical current.
  
  
• Laser therapy. Uses heat-generating laser to remove excess prostate cells.
  
  
• Transurethral evaporation of prostate (TUEP). Similar to electrovaporization, except that laser energy is substituted for electrical current.
  
  
• Visual laser ablation of the prostate (VLAP). Uses laser energy to dry up and destroy excess prostate cells.
  
  
• Interstitial laser therapy. Directs laser energy inside the prostate growths instead of at the urethral surface.
  
  
• Photoselective vaporization of the prostate (PVP). Similar to transurethral resection of the prostate (TURP) (see below), except that it uses laser energy instead of an electrical current.

However, in some cases medication and heat therapy are not viable treatment options. This is especially true if the patient experiences incontinence, recurrent blood in the urine, urinary retention or recurrent urinary tract infections. In such cases, an operation may be necessary to treat BPH.

Transurethral surgery involves providing regional or local anesthesia and then inserting an instrument through the urethra (the canal that carries urine and semen out of the body) and removing enough tissue to enhance urine flow. TURP is the surgery most commonly used to treat BPH. In this procedure, obstructive tissue is removed a small piece at a time with an instrument called a resectoscope. Transurethral incision of the prostate (TUIP) is often used in men who have a relatively small or only moderately enlarged prostate. It involves widening the urethra by making small cuts in the prostate gland.

In some cases, transurethral or laser surgery is not an option. Open surgery requiring general anesthesia may be necessary to remove the prostate gland. This procedure, prostatectomy, involves making an incision in the abdomen or perineal area (between the anus and genitals). A prostatectomy is reserved for cases when the prostate is greatly enlarged, if there are other complications or if there is cancer.

Patients who undergo invasive surgeries such as TURP, a laser procedure or prostatectomy will likely require a hospital stay. Patients sometimes have to wear a catheter (flexible tube used to drain urine from the bladder) for several days following the procedure. Surgery is usually very effective, and many patients experience increased urine flow within just a few days.

During recovery, it is important for patients to drink plenty of water (e.g. at least eight glasses a day) to flush the bladder and speed the healing process. In addition, it is important to rest for several weeks after surgery. Overexertion and heavy lifting should be avoided.

Surgery can sometimes cause temporary or permanent impotence, urinary incontinence, retrograde ejaculation (a dry climax during sexual intercourse), infertility and narrowing of the urethra. Complications such as a blood clot or buildup of scar tissue in the bladder are most likely after a prostatectomy (the most invasive procedure) and least likely after TUIP (a less invasive procedure). Men often continue to experience normal sexual function after prostate surgery.

Patients are urged to call a physician right away if they pass less urine than usual following surgery. Other complications that require medical care include blood or pus in the urine, fever or chills, and pain in the abdomen, back or side.

Patients who are unable or unwilling to tolerate surgery or other treatments may have a tiny metal coil called a prostatic stent placed inside the urethra. This widens the urethra and helps keep it open. However, complications such as irritation, frequent urinary tract infections and migration (movement) of the stent have made this option less popular than it once was. 

Despite successful treatment, BPH recurs in about 10 percent of men, according to the National Institutes of Health. This is more likely to occur when BPH surgery occurs at an early age and in rare cases when scar tissue develops in the bladder after surgical treatment.