Let's Put Active Surveillance for BPH in Perspective

Waking up in the middle of the night to take a leak or two.

Being unable to completely empty your bladder.

Having difficulty maintaining a urine stream.

These are all tell-tale signs of benign prostatic hyperplasia (BPH), a noncancerous condition where the prostate enlarges as men age. About half of men between the ages of 51 and 60 have BPH, according to the American Urological Association. Nearly all men older than 80 have BPH.

Treatment options for BPH can range from prescription drugs and supplements to minimally invasive procedures and open surgery. However, some men opt to do nothing and instead keep an eye on it, a process referred to as watchful waiting or active surveillance.

"Generally, BPH is a quality-of-life issue—it's not life and death," said Michael Eisenberg, M.D., associate professor of urology at Stanford University. "For most men, we talk about these symptoms and if it doesn't bother them enough that it's worth taking a pill, it's probably not worth treating."

'Generally, BPH is a quality-of-life issue—it's not life and death.'

Eisenberg provides his patients with validated questionnaires that assess the severity of their symptoms. The questionnaire includes an important query about their quality of life: If you could live the rest of your life as you are now, how would you feel about that?

"Some men are more bothered than others," he said. "Some men wake up several times at night, and that's the end of the world for some individuals. But for others, it's not that big of a deal. We just meet them wherever they are."

To intervene or not to intervene

Medications, including alpha blockers and 5-alpha reductase inhibitors, are the first-line treatments for BPH. These drugs are effective in staving off symptoms but carry side effects, so some men don't want this treatment, Eisenberg said.

As long as the man does not have more serious complications, such as kidney damage, infections, bleeding or bladder stones, there's no danger in watchful waiting, said Martin Kathrins, M.D., an assistant professor of surgery at Harvard Medical School and a urologist at Brigham and Women's Hospital in Boston.

"You may be happier if you intervened, but you don't have to," Kathrins said, adding that he usually errs on the side of watchful waiting if a patient is doing okay and doesn't have warning signs of an underlying medical condition.

About 30 percent of men will progress in their BPH symptoms over the years, either from mild to moderate or moderate to severe. That's the percentage, which has been substantiated in medical literature, that Kathrins will provide when his patients ask, "What's the danger of me waiting?"

"Another 30 percent of men may see some improvement in symptoms with doing nothing, but there's a little bit of controversy and some conflicting evidence around that," Kathrins added.

Lifestyle modifications

If a man chooses not to have any medical intervention for his BPH, lifestyle modifications may provide relief.

Certain foods and beverages irritate voiding, or urinating. Caffeine, for example, is a diuretic that causes you to create more urine, and it can also be a bladder irritant. Spicy and acidic foods, as well as orange juice and tomato juice, can have a similar effect, Eisenberg said.

Patients may be advised to keep a voiding diary—yes, a daily record of their bladder activity—where they track their fluid intake. This can be a vital tool to help urologists evaluate an overactive bladder.

"Some men are trying to dehydrate themselves to some extent before they go to bed: no fluid after 6 or 7 at night so that there's less fluid in the bladder to wake them up in the evening," Eisenberg said.

The 'active' in active surveillance

The term "active surveillance" is more often associated with cancer than BPH. Active surveillance for prostate cancer, for instance, involves keeping an eye out for symptoms, checking prostate-specific antigen (PSA) levels in the blood and visiting the doctor regularly. Prostate cancer surveillance may entail repeat biopsies and imaging studies to see if anything is progressing.

"The same rationale can apply to BPH: checking with men and seeing how their symptoms are with these validated questionnaires and seeing if there's progression," Eisenberg said.

That's in addition to obtaining objective data, such as a urine test to make sure no infections have cropped up.

"Essentially, I think 'active' is checking with your doctor on a regular basis to make sure nothing is changing or worsening," he said.

Kathrins pointed out the importance of a post-void residual (PVR) urine test, which measures the amount of urine left in the bladder. This indicates how well a man's bladder is emptying and whether he's retaining urine.

Essentially, I think 'active' is checking with your doctor on a regular basis to make sure nothing is changing or worsening.

"If that residual starts to drift up and it reaches this red zone, as a urologist, you start to pay attention," he said. "If he's bothered already, I worry about his bladder getting exhausted, and I would push him to intervention."

If the bladder is functioning well and urine is emptying, the risk of the patient progressing to needing a catheter in the future is relatively low, Kathrins added, and intervention would typically not be necessary.

"There's no doubt it's a complicated scenario," he said of BPH. "Each patient is different. It really is this sort of longitudinal relationship you develop with a urologist, which is what's so unique about the field. We follow these men for years and years and years about the decision to intervene."