Ashlee Williams, MD (Host): If you're getting up two, three, even four times a night to use the bathroom, or you've noticed a weaker stream, or that frustrating feeling of not quite emptying your bladder, you might be wondering, is this just aging or is something wrong? For millions of men, the answer is an enlarged prostate or BPH. It's one of the most common changes men experience as they get older, yet many hesitate to talk about it even with their doctor.

Welcome to The Healthier You Podcast. I'm Dr. Ashlee Williams. And today, I'm talking with Dr. Kai Li, a board-certified urologist with Kaiser Permanente, about what BPH is, why it happens, the warning signs you shouldn't ignore, and how it's different from prostate cancer. More importantly, we'll talk through proven treatment options that can dramatically improve quality of life. Dr. Li, thank you so much for being here.

Kai Li, MD: My pleasure.

Host: Really excited to talk about this important topic that affects so many men. Let's just start with the basics. What is BPH and what causes it?

Kai Li, MD: So, BPH stands for benign prostatic hyperplasia, which is exactly what you mentioned, it's an enlarged prostate. It's a non-cancerous enlargement. The key is non-cancerous, because this is commonly confused with prostate cancer, which also happens in the prostate for men of similar age, which is as men age. But this is specifically benign. It's non-cancerous, and it has actually nothing to do with prostate cancer.

The prostate, as men age, usually after the age of 40, that's when we start seeing the first signs and symptoms of this, the prostate unfortunately continues to grow and it is a fact of life. It's unfortunate. But every man's prostate will grow to some extent. Some much larger than others. Some will have problems. Some others will not have problems. Because, unfortunately it is poorly understood, as with everything, it has something to do with genetics. But it's not completely correlated as in, if your father and brother have it, it doesn't necessarily mean that you will definitely have it, although you are more predisposed. Generally, I tell patients it has to do with good or bad luck.

Host: So, what are some common symptoms of BPH?

Kai Li, MD: They're all urinary symptoms. So, the prostate, it's a sex organ that sits right underneath the bladder. It actually envelops the urethra—so therein lies the problem. As the prostate gland grows, it can grow outwards, which doesn't cause any problems. But when it starts growing inwards, it can cause compression of the urethra. And that creates all the problems such as urinary frequency, urinary urgency, trouble initiating a stream, a weak or intermittent stream, dribbling at the end of urination, nocturia, which is urinary frequency at night, which disrupts sleep; incomplete emptying. And it could even cause incontinence, typically, urge incontinence where you have such a strong urge to get to the bathroom, but because you can't get there in time, because the bladder is so overactive as a result of the prostate, it can result in leakage.

Host: Got it. So, let's say you're a man and you're slowly starting to develop some of these symptoms. When would you recommend someone see a doctor and talk to them about this?

Kai Li, MD: Yeah, that's a great question. It is dependent on judgment and preference, and this has a lot of caveats. So, the thing about enlarged prostate and urinary symptoms is that they develop very gradually. It's rare that they develop really acutely. If it's something acute, we look for other things such as infection or any sort of obstruction. But this develops pretty gradually. So, it's pretty common for me to see men who have been dealing with this for years. And by the time I see them 20, 30 years later, they don't think their symptoms are that bad. But that's just because the symptoms have come on so gradually that they've learned to live with it.

So that being said, I would recommend seeing your doctor early about this because, even though they may not be such an encumbrance, the symptoms early on, they will decrease your quality of life, such as your sleep quality. Frequent trips to the bathroom slowly starts eroding away at your social interactions; you start thinking about, "Oh my gosh, where is the next bathroom? Should I be going to this event?" You know, I have to go to the bathroom every hour. If they don't have a bathroom nearby, maybe I'll just stay at home." That's really not a way that we want our patients to live. This is a very manageable disease. So when patients have symptoms early, we would prefer them to come see us early.

Host: It can have such a large impact on your quality of life. So, we talked a lot about the symptoms of BPH. How do we actually diagnose it as clinicians?

Kai Li, MD: So, it has to do with the symptoms specifically and a detailed health history and physical exam. This should include a digital rectal exam so we can have some size estimation of the prostate, but also rule out other causes such as prostatitis or prostate cancer. We may order additional tests such as a bladder scan, a bladder ultrasound, a PSA test to look for oncomitant prostate cancer.

We may want to check the kidney function with a blood test. We may want to rule out infection with another urinary test. We can also take a look inside the urethra, the prostate, and the bladder with a simple office test called cystoscopy wherein we guide a soft, flexible camera gently up the urethra. And both we as clinicians and the patients can look at the screen at the same time and have a better understanding of what the anatomy looks like.

Host: Right. And I know in primary care we have a questionnaire that we use to help gauge severity. Do you guys use that in your practice in urology?

Kai Li, MD: Yes, that is actually the most important questionnaire and most important determination of whether or not patients need intervention, whether it is medication or surgery. That questionnaire is called the IPSS or International Prostate Symptom Score.

Host: Okay. So, let's say we've diagnosed the enlarged prostate. It's really impacting someone's quality of life. What treatment options do we have available?

Kai Li, MD: Initially, we start with lifestyle modifications. Men who go to the bathroom multiple times a night, one of the first questions we ask is, "Well, tell us about your hydration status. When do you drink fluid?" And to our surprise, a lot of men drink fluid at night, even up to the point where they go to bed, sometimes they drink fluid. Even when they wake up, they keep a glass of water by their bed. It's pretty common to see. And that's like low-hanging fruit. Because if you drink fluid right before you go to bed, you're going to pee at night.

Other things that we ask for is whether or not there's caffeine or alcohol intake. Alcohol and caffeine are both diuretics, meaning that they cause the kidney to make more urine. So if that is taken, especially before bed, that can lead to increased nighttime voiding. And in additional, they're also both bladder irritants. So even if it's not taken at night, during the day, can cause daytime frequency.

So after we address those issues, then we talk about treatment. And we usually start with medications. We have two main classes of medications that we like to use for enlarged prostate. One helps immediately and the other helps gradually. The one that helps immediately is something like Flomax or tamsulosin, or doxazosin, Cardura, these are called alpha blockers. And what they do is they help relax the prostate and the internal bladder neck to help the urine pass more easily. A lot of times, these medications work really, really well. They can provide relief for many, many years, sometimes even forever depending on how bad the symptoms are.

The other class of medications are called 5‑alpha reductase inhibitors. And these work gradually, these actually work to help shrink the prostate itself. However, these medications take at least six months to start working and they don't always achieve the desired effects in every patient. These are medications that are called Proscar, or finasteride, or dutasteride. The key is that these medications do not provide immediate relief, but provide relief in the long-term.

Host: Got it. So, how do you choose the best treatment option for patients?

Kai Li, MD: We usually look at how severe the symptoms are. We always do behavioral modifications, And then, we usually start with medications. And after the medications, we've given it maybe a few weeks to a few months to work. Then, we talk about more aggressive treatment such as surgery. And I say aggressive candidly. It is certainly more aggressive than medications. But modern day surgery is very minimally invasive and it's not scary, and the risks are low, recovery is fast, and benefit is very high. So if I have a patient who comes in who has been—I wouldn't say ignoring—but has been putting off going to the doctor, because the symptoms are so gradual, and I get the symptom score on them and their score is off the charts, I kind of know that lifestyle modifications and medications are not going to solve the problem. I'm going to start with that, of course. But we're headed towards doing a minor surgery to really relieve the symptoms.

As I explain to patients, these patients in particular who have really severe symptoms, the medications are more like a Band-Aid, and the surgery is a cure. So, we are fortunate in Kaiser to have all of the cutting-edge technologies available to us. I, myself, do about nine different enlarged prostate surgeries. So, they can range from different smaller procedures that we can do in the office. These include a procedure called Rezum, which is where we go in with the scope, and a small needle pokes itself into the prostate. And then, we inject water vapor or steam into the prostate. And that causes the prostate cells to die off. And then, the body reabsorbs them, which then opens the channel.

Then, for our surgical procedures, we have multiple. We have procedures like UroLift that can staple the prostate open. We have a new procedure called iTind implantation where basically it places a nitinol cage inside the prostate, which stays in for a week, which opens up the channel.

One of the most exciting innovations that we have to this space is called Aquablation, which I brought to Kaiser about four years ago. And this is a water jet treatment—this this under general anesthesia, so it's done in the operating room—where we go in and, using an ultrasound-guided robotic system, we can use a high pressure water jet to remove the prostate tissue and ablate it to create a wide open channel. The Aquablation is unique in that it can virtually handle any size prostate. And this is important because when we talk about size of the prostate, remember in the beginning, I said that you could have the prostate grow outwards or inwards. We don't use prostate size as a determination of whether or not patients need surgery. We use symptoms and whether or not they have any complications of their prostate, such as, you know, urinary retention, or if they're having a lot of bleeding from the urethra or if they're getting bladder stones. Those are the reasons why we do surgery. It's based on the patients needs, their symptoms, signs, et cetera. We don't use the prostate size. But where the prostate size does come into play is when we determine which of the surgeries are going to be best suited for that patient.

So, Aquablation is unique in that it can pretty much handle any size prostate. A lot of the surgeries that we do for prostates can only be done up to a certain size. Aquablation can handle the sizes beyond that. And the Aquablation provides removal of the tissue at the time of operation, meaning that there's immediate benefit. And it also preserves sexual function. The reason why I mentioned this is because we have surgeries that may or may not affect the sexual function. And that plays a role when I counsel patients of which surgeries they should have, all of it comes into play.

None of the modern surgeries that I do really will affect any of the patient's erections. However, it could affect their ability to ejaculate. What does that mean? It means their ability to have a wet orgasm, okay? So, that means that at the end of sex, at climax, whether or not semen comes out. A lot of the older surgeries and a lot of the surgeries that actually remove tissue at the time of surgery, unfortunately, that is sacrificed. A lot of the newer procedures that we have, including a lot of the ones I mentioned and also the Aquablation can preserve that.

So, it really is an exciting time for me to be in this space and also a good time for patients to come see their doctors because these are some of my happiest patients where they can come to me with severe symptoms. They're getting up over five times a night. During the day, they're going to the bathroom every 30 minutes. Sometimes, these guys have to stand in front of the toilet for 10 minutes trying to squeeze the urine past. And then, some of them have to wear Depends, because they're leaking in between when they can get to the bathroom. These are some of the most severe cases. And with doing one surgery, it more or less completely gives them their life back where they can go back to normal, they don't have to go to the bathroom every three to four hours, they have a strong urine stream. And this is some of the most gratifying things that I do.

So, it's exciting for me, because we have so many options available. And also, the benefit is so high and the risk is so low, that there's no reason for patients to be scared to come to their doctor for their enlarged prostate.

Host: Yeah, that's a lot of different options that we have available. Thank you for bringing these innovative techniques to Kaiser Permanente. And it's even more amazing to know that a lot of these things can be done in the clinic as a procedure. And you mentioned a little bit about how some of these things are done surgically, but we have surgical centers within some of our medical office buildings. Are you doing a lot of these procedures in our medical office building surgical procedure suites?

Kai Li, MD: That's right. The vast majority of all our BPH operations are done in our own surgery centers here at Kaiser. I do them at the Tyson's Corner location as well as the Caton Hill location. And what that means is that it's a short surgery, less than an hour. It's a day surgery, meaning they go home the same day. And the recovery is quick and satisfaction is high.

Host: That's amazing. Can you talk a little bit more—so, we have all these options for treatment. What can we do on the front end? Is there anything that men can do to prevent an enlarged prostate?

Kai Li, MD: The short answer is no, unfortunately. And you know, I wish it wasn't the case because, here at Kaiser, we're all about preventative medicine. And nowadays, there's more and more of a push in the general community that diseases, we should try to prevent them. There's a huge market for supplements and, you know, naturopathic medicine, all of which I support. But unfortunately, there aren't really any dietary or lifestyle factors that cause your prostate to grow faster or slower.

That being said, the general recommendations is to eat a healthy, balanced diet, low in highly processed foods, sugars, high in protein, fiber, vegetables, fruit, all of those things. But there is not really any specific food that if you cut out or if you start taking the specific supplements, it's going to shrink your prostate. Unfortunately, it's not that easy.

Host: Yeah. And thank you for clarifying that. There is so much information on the internet, and we want to make sure that we're giving correct science-guided information on that. So, thank you. So with everything that's been said today, what is your biggest takeaway for men listening today?

Kai Li, MD: My biggest takeaway is that men should not suffer in silence, that the symptoms are gradual, they can be insidious. But knowing that every man is going to go through this, every man is going to have enlarged prostate should make men feel like they're not alone, and that this is kind of like an expected natural history of life, so to speak.

So when men start having symptoms, at the earliest they can, they should go see their doctor. And we have incredible treatments that are easy to get through that are relatively painless that can create a huge, huge benefit in their lives. So, this is not something that men have to suffer through.

Host: Yes. And thanks to you and your team, our members have lots of options for treatment. Thank you, Dr. Li, for walking us through what men need to know about BPH. Here are a few of the key takeaways.

BPH is non-cancerous enlargement of the prostate that becomes more common with age. Symptoms like weak stream, urgency, and nighttime urination should not be ignored. Treatments can be incredibly effective and range from lifestyle changes and medications to minimally invasive procedures like Aquablation.

New options are available that preserve sexual function and offer quicker recovery times. Talk to your doctor early, small changes can make a big difference in your comfort and health.

For more expert advice, visit kp.org/doctor and explore more episodes of Healthier You wherever you get your podcast. If you found this episode helpful, be sure to subscribe so you don't miss what's next, and leave a comment with topics you'd like for us to cover next. Thank you. And from all of us at Kaiser Permanente, be well.