Joey Wahler (Host): They're frustrating and often embarrassing conditions for men. So, we're discussing benign prostatic hyperplasia, also known as BPH, and urinary incontinence. Our guest, Dr. Stanley Swierzewski. He's a urology specialist for Harrington HealthCare System.

This is Healthy Takeout, a podcast from Harrington HealthCare System. Thanks for joining us. I'm Joey Wahler. Well, I know you prefer to be called Dr. Stan, so I'll say hi, Dr. Stan. Thanks for joining us.

Stanley Swierzewski, MD: Hey, it's my pleasure. I'm looking forward to this.

Host: Same here. So first, what are the signs that a man is suffering either from BPH, as it's sometimes known, or urinary incontinence.

Stanley Swierzewski, MD: Well, urinary incontinence is easy because you're actually leaking urine and wetting your pants. So, that's pretty straightforward as far as realizing there's an issue. As far as enlarged prostate, that has to do with frequency of urination, urge to the bathroom. The fact that you know where every bathroom is in a 10-mile radius around your house is a good tip-off. If you get up at night or if you have a slow stream, all those things are most likely related to BPH or benign prostatic hypertrophy of the prostate. On occasion, it may be related to prostate cancer.., but predominantly, it would be benign enlargement, meaning non-cancerous enlargement of the prostate.

Host: But even in its most benign form, am I right, it's an enlarged prostate that can cause incontinence?

Stanley Swierzewski, MD: It can cause urgency and urge incontinence, meaning that you can't get to the bathroom on time. So, incontinence can be broken down into two categories. One would be stress incontinence, where you cough and leak or you have some sort of stress in your pelvis that causes you to leak. Mostly, that's primarily a problem for women. Men can have urge incontinence. Once again, that's just urgency. You can't shut it down. Your basically brain and bladder are not connected anymore and it's going to go whenever it wants to and usually at the most inappropriate time for you. That's caused by BPH.

Host: Gotcha. So, other than that one form of incontinence, if one has an enlarged prostate, what are some of the issues that it brings about?

Stanley Swierzewski, MD: It can lead to socialized isolation if people feel like they have to find a bathroom all the time and that's really an important one to realize. But it's causing a problem with the bladder. So, your bladder has two functions. Your bladder needs to store urine, it needs to empty urine, and it's got to be approximately a 50/50 ratio. If you add an obstruction like a prostate, and if you think about the prostate, it's basically like a donut, and the urine goes through the donut hole. As your prostate enlarges, the donor hole gets smaller and smaller. The bladder has to work harder and harder to push the urine out through that donut hole. So, that's very much like if I started lifting weights from my biceps, and the more resistance I put on, the bigger my biceps get. So, the more resistance that the bladder sees from the prostate, then it becomes thicker. And the thicker it gets, it's not compliant. So, it gets very good at expelling urine, but not so good at storing urine.

So, that's the dilemma. How do we open up the prostate either by drugs or by procedures to allow for the urine to come out easier, which in turn decreases the fibrosis and the muscle layer inside the bladder so after a few months, things get back to normal again? The problem here is it's much like congestive heart failure, which can be caused by hypertension. And basically, your heart stops working. Both of the heart and the bladder are similar muscles, so they both have to pump. And you can get bladder failure as well as heart failure if you're left untreated. So, that's one of the bigger issues in regards to bladder outlet obstruction caused by an enlarged prostate.

Host: Interesting, doc. I've never heard anyone compare the bladder and the heart before.

Stanley Swierzewski, MD: They're simply pumps. Both of them are pumps. The heart has four chambers, the bladder only has one chamber. But when you look into the bladder for somebody that's had a long-standing resistance, you'll find what we call trabeculations, highly thickened muscle fibers, and you'll see what we call cellular formations, which basically are, if you had a bunch of muscles shaped in a ball, the pressure gets high enough that the lining of the bladder gets pushed through the muscle fibers. So, that leads to high-pressure voiding, that leads to backflow on your kidneys, and potentially renal failure over long term. It also means that you're probably not emptying very well, and that can lead to urinary tract infections. So, the only time a man gets a urinary tract infection is going to be with an enlarged prostate. So, that's another tip off that you have an issue. It doesn't have to happen all the time. If it happens one time, you should be aware that you have a prostate issue. Because some people in the ERs and that, when they see this, they don't make the connection. They just tell you to take some antibiotics, you'll be fine, which is true, but there's a bigger issue going on behind the scenes.

Host: Gotcha. So at what age might a man start experiencing an enlarged prostate typically?

Stanley Swierzewski, MD: Every man is different, but typically you're looking at about 50 would be the majority of cases, 50 and beyond. You've seen patients in the low 40s that have had an issue. But generally in the 30s and that, that's not going to be an issue for anybody. Prostates grow at their own speed, at their own pace. But generally speaking, if you live long enough, you will need to be treated for an outlet obstruction due to your prostate.

Host: That being said, is there anything men can do lifestyle-wise to help prevent or at least delay an enlarged prostate from coming about?

Stanley Swierzewski, MD: Lifestyle, there aren't any specific foods. I mean, I guess if you ate a lot of soy, you might have some benefit. Anything that would decrease testosterone, increase estrogens, would be helpful. But generally speaking, I mean, you have all those tablets out there that you can buy online, Prostate Super Beta X, and all these things, most of them have saw palmetto in them. Saw palmetto is a herb, and it was the original thing that we only had to treat enlarged prostate besides surgery. So, a lot of people got that, gosh, 30 years ago. That's been shown through multiple tests that it is not effective at all in helping people.

The natural course to enlargement of the prostate is it's cyclic. So, you go through lows and highs. So, sometimes your symptoms are going to be crazy bad, then they're going to get better. And so, you get lulled into this idea that, "Okay. Well, something must have been happening. Maybe I ate something wrong or something, and everything got bad. Now, it's all better. I'm feeling pretty good." Then, it's going to happen again. You're going to go back into that upswing where you're going to have more symptoms. So when you take these pills that are shown on TV and on the internet, what generally happens is that they may provide a small amount of benefit by increasing your estrogens, which you don't necessarily want to do cause that's going to also lead to issues with ED. But do you usually take advantage of the fact that this is a cyclic disease? So if you start them and all of a sudden you're on the downswing from having a problem, you think this is the greatest pill ever. Everything went fine. Then, you're sort of locked on to the fact that, "Well, it's getting a little bit worse, but I'll keep taking these pills. Oh, they got better again." So, there really isn't a good non-pharmacological agent to treat enlargement of the prostate.

Host: Understood. And then, getting back to incontinence for a moment. So, besides enlarged prostate, what are some of the other common causes of having urinary issues?

Stanley Swierzewski, MD: That's a broad question. You can have urinary tract infections, you can have urgency, frequency. We talked about urge incontinence. You can have retention, which means that you actually have to go to the ER or to a doctor's office to have a catheter put in because you can't void any longer. Those would be the main ones that I would think of for that question.

Host: Okay. And so, with an enlarged prostate, what are the most commonly used treatment options?

Stanley Swierzewski, MD: Well, the gold standard is what's called a TURP or a transurethral resection of the prostate. But that is a very bloody operation and that's been refined over the years. So, there are multiple modalities available. I've done pretty much all of them. But right now, main focus would probably be what's called UroLift. That's where you actually use a stapler, if you will, if the patient's asleep. You look in with a telescope. The telescope is actually a stapler and it staples back the prostate tissue. That's been around for approximately 10 years now. Using it on the right size prostate, the right anatomy, it works very well. It also doesn't cause what's called retrograde ejaculation. When you open up the prostate, you have to realize that when you ejaculate, the prostate also has to close to force the semen out through the tip of your penis. Some of the procedures that are done, that mechanism doesn't work very well after the procedure, so you can have what's called retrograde ejaculation. You ejaculate, the semen goes into your bladder, which is not a problem unless you're trying to have kids, but it doesn't come out the tip of your penis. It doesn't change your erections, and it doesn't change your orgasm, but it's concerning for some men when that happens to them. That's one option.

Another option is steam. It's called Rezūm. Basically, you puncture the prostate with a needle, and you send steam directly into the prostate to try to necrose it. That's available. I don't personally think that's a great option, and I don't offer it to my patients.

The other option is called Aquablation. And if you want to think about that, it's basically using a pressure washer, watch under an ultrasound through a robot. And basically, using that pressurized fluid, it removes the tissue, and that takes approximately 10 minutes to do. And then, some patients go home, some patients stay overnight just to make sure that there's no bleeding. That's very effective, especially for people that have large prostates. You can see prostates the size of a golf ball, all the way up to a large grapefruit. So when you get to those larger sizes, Aquablation is a great procedure.

You also can use lasers. There's green light lasers, there's diode lasers, all have their advantages and disadvantages. But they basically vaporize the tissue and it's gone, which is nice because, as opposed to Rezūm, which is steam-based, which continues to have prostate tissue until necrosis with a laser, you actually get rid of the tissue, so you don't have that waiting period for everything to get better.

Those are primarily the ones that we use. The TURP, as I mentioned, is electrosurgical. And those are pretty much it.

Host: And so generally speaking, with regard to those treatments for enlarged prostate, what would you say about what patients can expect result-wise? Does it significantly improve it? Because it doesn't actually cure it or completely remove the issue, right?

Stanley Swierzewski, MD: Once again, depending on which one you use, some of them completely remove the issue. Most of them do. Definitely improvement. We have a scoring system that looks at how much urgency, frequency and nocturia as you rate the patients ahead of time and then after their treatments. And you can get a 50 to 60% improvement and patients that have that improvement are ecstatic because, especially if you use something called the Urolift, they're in and out of the hospital the same day. It takes 15 minutes to do the procedure. They don't necessarily have to have a catheter when they go home. And they notice a significant improvement where they've gone from five or six times getting up at night, maybe to one time at night, maybe to no times at night; having no urgency and frequency and no incontinence. So, it makes a huge difference in lifestyle for men and ability to do social things.

Host: Okay. Great. And then getting back for a moment to incontinence, in terms of treatment there, I suppose it depends largely on what the cause is.

Stanley Swierzewski, MD: But in a male, I mean, if you had a radical prostatectomy for prostate cancer, there's a high chance that you're going to have what's called stress urinary incontinence. That can be treated by a few different methods. There's what's called a sling procedure, where you actually put a piece of surgical mesh in that tightens up the bladder neck so that it doesn't leak so much. There's also something called an artificial sphincter, which is also an implantable device, which has a cuff on it and the cuff actually goes around the urethra and fills with water and clamps off the urethra so that you don't leak. And then when you want to urinate, there's a little pump in your scrotum and you push on that and that allows you to void and then it tightens back up again and keeps you continent. Those would be the primary ones for stress urinary incontinence.

Host: Gotcha. Well, folks, we trust you're now more familiar with enlarged prostate, also known as BPH and urinary incontinence. Dr. Stan, great to meet you. Thanks so much again.

Stanley Swierzewski, MD: Thank you so much for having me. I really appreciate it.

Host: And for more information, please visit harringtonhospital.org/urology. Again, harringtonhospital.org/urology. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler. Thanks again for listening to Healthy Takeout, a podcast from Harrington Healthcare System.