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BPH Relief That Preserves Sexual Function
Contributing Author: Kevin C. Zorn, MD, FRCSC, FACS
BPHCanada – Canadian Prostate Surgical Institute, Montreal, Canada
Men diagnosed with benign prostatic hyperplasia (BPH), otherwise known as an enlarged prostate, are all too familiar with the condition’s associated side effects such as the urgent need to urinate, nocturia (nighttime urination), daytime frequency, urinary tract infections, blood in the urine, bladder stones, incontinence and more. Their quality of life has likely been significantly impacted, and their symptoms may even be worsening over time with advancing prostate growth. Historically, after talking to their urologist and doing research of their own, many patients aren’t satisfied with the current mainline treatment options available to them. Whether it’s a lifetime of taking medication or undergoing surgery that has the potential of impacting their sexual function, many men opt to just continue to deal with their symptoms.
This article will examine the technological and surgical advances that are making it possible for what is increasingly being considered the true meaning of BPH treatment success, with a focus on the emergence of minimally invasive surgical BPH treatment options (MISTs) that are providing symptom relief while also preserving male ejaculatory function.
“I’ll take BPH symptom relief, please, without the side effects”
Over the past century, there have been extraordinary advancements in science and surgical techniques and as a result, today there are a multitude of personalized BPH treatment approaches available to physicians and their patients. Furthermore, there has been a recent renewed focus on providing treatment from a holistic perspective – meaning, not just looking for an improvement in urinary symptoms, but a minimization of side effects as well. For many men, at the top of this side effects list is any negative impact on sexual function. In fact, maintaining ejaculatory function is a priority for most men suffering from BPH who are opting for surgical therapy.
Historically, once diagnosed with BPH before men are presented with surgical options, medication is typically offered as an initial treatment method. These medications will fall into one of the following categories: a1-blockers, 5-alpha reductase inhibitors, phosphodiesterase-5 inhibitors, Beta-3 agonists, Muscarinic receptor antagonists (MRAs) and combination therapy. However, many men prescribed these medications don’t find optimal relief, aren’t compliant with taking a lifelong, daily medication and sometimes they find themselves experiencing new side effects – from the medications themselves. These classes of medications have been associated with a number of serious side effects like cardiovascular events (postural hypotension, asthenia and dizziness), gynecomastia, acute urinary retention, urinary tract infection, hypertension, headache, constipation and nasopharyngitis (Frontiers in Pharmacology, 2020). They also are associated with a host of side effects related to sexual function, including ejaculatory dysfunction, decreased libido and erectile dysfunction. Furthermore, they don’t address the underlying cause of the issue – bladder obstruction.
Patient demand has skyrocketed over the past number of years for BPH treatments that not only provide symptom relief but also lack negative side effects. Not surprisingly, this demand has led to the development of treatment options outside of medication management, including MISTs that don’t require men to take pills for the rest of their lives and also address the actual bladder obstruction issue. But even among the new MIST options, some continued to have associated side effects – especially related to sexual function.
Thankfully, in the years since MISTs came on the scene, we’ve seen a continued evolution of technological advances resulting in treatment options that are even less invasive and at the end of the day, preserve ejaculatory function.
Because of that, today we are seeing MISTs increasingly being considered as a first-line treatment option. Many of the options available today have a low side effect risk profile, are done in an outpatient setting with patients seeing quick recovery times and are safe and effective. MIST options that are cleared by the U.S. Food and Drug Administration to be safe and effective include treatments such as the Optilume BPH Catheter System, prostatic urethral lift (PUL), Rezum, Aquablation, and temporarily implanted nitinol devices.
With these new approaches, the goal continues to be to advance toward achieving the ideal BPH treatment trifecta, which means symptom relief that lasts while also preserving urinary continence and sexual function.
New technologies, advanced techniques and a way of thinking
Today, more than ever before, urologists have a diverse toolkit to meet patients’ needs and desires. Patients with varying prostate sizes, ages, comorbidities and individual values have personalized BPH treatment options available to them. But the dawn of these new technologies has also played a key role in empowering urologists to safeguard ejaculatory outcomes, as well as their understanding of the key anatomic landmarks essential for sexual preservation. Recent pelvic imaging research during ejaculation has caused a shift from surgical emphasis being on bladder neck closure to preserve male ejaculatory function, and instead, the importance of conserving the pericollicular tissue surrounding the verumontanum. Furthermore, studies have shown that preservation of the ejaculatory ducts can be achieved with approximately 90% accuracy if up to 10 mm proximal to the verumontanum during transurethral resection of the prostate (TURP), coupled with a block of tissue 7.5 mm from the midline of either side of the verumontanum is preserved.
In addition to these technological and surgical advancements, there’s also been a shift in thinking around the need to remove prostate tissue to successfully treat BPH. Traditional methods of treating BPH have involved cutting, steaming or burning off excess prostate tissue, but even within the past few years, new options have become available that require no removal of prostate tissue, and no implants left behind. This is important because when BPH treatments are associated with erectile or ejaculatory dysfunction or retrograde ejaculation, it’s typically because of factors such as impact on the bladder neck, indirect thermal injury to the erectile nerves, injury to the internal urinary sphincter, neurovascular bundle damage, etc. When treatment options aim to preserve these anatomical structures, the risk of impact on sexual function is decreased.
Conclusion
We’ve seen an evolution in the world of BPH management over time to a patient-centered, option-rich approach, where true success in treatment means relieving urinary symptoms as well as preserving ejaculatory function and satisfaction. Today’s urologists are utilizing cutting-edge imaging technologies, employing the use of advanced precision surgical techniques and staying on top of the robust, ongoing research and available technologies that take into account anatomical considerations to be able to give their patients what they really want – freedom from BPH symptoms – without giving up sexual function – and ultimately a better quality of life.
About the Author: Dr. Zorn
Kevin C. Zorn, MD, FACS, FRCSC, is the founder of the BPHCanada Canadian Prostate Surgical Institute, a personalized, private, prostate solution center founded in 2023 to offer all approved BPH therapies to Canadian men, and director of Robotic & MIS BPH Prostate Surgery, Mont-Royal Surgical Center. Dr. Zorn is a former associate professor of urology at the University of Montreal (CHUM) and the University of Chicago, sub-specializing in robotic surgery and benign prostatic hyperplasia (BPH) surgical care.
Dr. Zorn attended McGill University for his pre-med program, his medical degree, and his residency in urological surgery. He became a fellow of the Royal College of Physicians and Surgeons of Canada (FRCSC) in 2005. Dr. Zorn also completed a two-year fellowship in oncology and endourology at the University of Chicago. In 2007, he became American Board of Urology certified in urology and a fellow of the American College of Surgeons.
Research and innovation have been the hallmarks of Dr. Zorn’s career. Among his many firsts, he was the first in Canada and Québec to use many new BPH technologies, including Greenlight XPS, Rezum, iTind, Optilume, Aquablation and Zenflow.
Dr. Zorn is the senior author of the male lower urinary tract symptoms (LUTS)/BPH guidelines for the 2018 and 2022 Canadian Urological Association (CUA) and consulted on the American Urological Association BPH guidelines. Dr. Zorn has authored 400 peer-reviewed publications and 12 book chapters on BPH and minimally invasive surgical care. With such accolades, Dr. Zorn has become a sought-after speaker, teacher and researcher. He has traveled to lecture, teach, and proctor surgery around the world, and is intimately involved with the development of several pioneering BPH technologies. In 2024, Dr. Zorn retired from his position at the University of Montreal to dedicate his full clinical practice to BPH Canada.
The opinions in this blog do not necessarily reflect the views and opinions of Men’s Health Network.
