Fuelling two birds with one pill

Dear Dr G,

I am emailing you for a strange problem that is happening to me as I get older.

I am generally healthy as I exercise and watch my diet regularly.

Sadly, I noticed a strange phenomenon as I age, and the symptoms are more obvious.

I started waking up at night to urinate and struggle with the stream.

I noticed I needed to strain a little and this causes the urine to spray on the toilet seat, clearly not pleasing the wife.

Besides, I am also struggling with my erection, as I can no longer maintain firm erections during sex, and the morning wood is getting less and less frequent.

My wife asked me to pay the doctor a visit, and was told that the problem is caused by prostate enlargement, apparently the same issue that resulted in my father needing an operation.

The urologist reckoned I have the ageing-related problem of Benign Prostatic Hyperplasia (BPH).

Although the doctor said he could not think of any association between my two problems, he did say it was common for the two conditions to coexist.

I am really struggling to come to terms with silent nights and no more morning glory due to BPH.

He suggested I should try tadalafil, which will kill two birds with one stone.

Before killing any bird with any stone, I am curious to put Dr G on the spot.

First of all, what causes the prostate to enlarge? Is this cancerous?

What are the causes of BPH? Is it genetic?

How does prostate enlargement cause poor urinary stream and erectile dysfunction (ED)?

Is there a correlation or is it pure coincidence?

My father needed an operation as he ended up unable to urinate but is this inevitable for me as well?

Yours truly,

Prostate Peter

Benign Prostate Hyperplasia (BPH) is a common condition that affects many men with advancing age. The gradual overgrowth results in the compression of the urethra, leading to various urinary symptoms including poor flow, hesitancy in initiation, dribbling and straining during urination.

In addition, the post-void residual urine can also result in day and night time frequency of urination. When the symptoms become worse, it can also cause urgency and urge incontinence.

Such a collection of urinary symptoms are known as Lower Urinary Tract Symptoms (LUTS), which inevitably affect all ageing men.

One of the most bothersome symptoms experienced by individuals with BPH is night-time urination, also referred to as nocturia.

Nocturia is a common symptom experienced by individuals with BPH. The mechanism behind this correlation is believed to be influenced by pressure on the urethra, restricting the flow of urine.

The constant pressure exerted by an enlarged prostate on the bladder may also lead to decreased bladder capacity. This means that the bladder fills up faster, requiring individuals to wake up and urinate during the night. This results in incomplete emptying of the bladder during daytime voiding.

Nocturia is the most bothersome symptom caused by prostate enlargement, having significant impact on the quality of life for men affected.

While BPH itself does not directly cause erectile dysfunction (ED), its presence and associated symptoms can indirectly contribute to the development of this condition. The night time visit to the bathroom can also adversely affect partners and sexual relationships.

ED, on the other hand, is the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.

Apart from the association of ED with men with hypertension, dyslipidaemia, obesity and diabetes, poor erection is also commonly linked to BPH.

Although the exact pathophysiology is unknown, it is stipulated when men experience prostate enlargement, the pressure exerted on the urethra can disrupt normal blood flow. The blood vessels responsible for engorging the penis during sexual arousal are impeded, leading to difficulties in achieving and maintaining an erection. Besides, the prostate gland surrounds the urethra, which is responsible for transporting both urine and semen.

The frustration and anxiety caused by the urinary symptoms associated with BPH can also negatively impact a man's sexual confidence and performance. Such psychological stress can further contribute to erectile difficulties.

Both ED and BPH are an age-related phenomena commonly affecting men above fifty. The correlation with the changes in hormones is also widely speculated.

As men age, hormonal changes due to the increase in dihydrotestosterone (DHT) can lead to the proliferation of prostate gland cells. Several factors have been identified as potential contributors to BPH. These include hormonal imbalance, particularly the increased conversion of testosterone to DHT, considered a significant factor in the development of BPH.

Genetic factors also play a role in predisposing certain individuals to BPH. Lastly, lifestyle choices, such as a sedentary lifestyle, obesity, smoking, and excessive alcohol consumption have been associated with an increased risk of BPH.

Various treatment options are available to address both prostate enlargement and erectile dysfunction. Lifestyle modifications, medication, or surgical procedures may be recommended depending on the severity of symptoms. In fact, oral medications such as long-acting Phosphodiesterase 5 Inhibitors (PDE5-I) are the common medications that can resolve both issues at the same time, effectively killing two birds with one stone.

A small daily dose of tadalafil is recognised to enhance blood circulation to the penis resulting in improvement of erection. At the same time, the relaxation of the smooth muscle is also known to improve LUTS, predominantly frequency and urgency of urination.

Therefore, for patients with both issues, it is effectively solving both problems at the same time!

The diva Celine Dion once said, “There is no such thing as ageing, but maturing and knowledge.”

BPH, nocturnal urination and ED can significantly impact the quality of life for ageing men.

While prostate enlargement and erectile dysfunction may seem like separate concerns, the link between these two conditions goes beyond being mere coincidence.

Having knowledge of effective treatment strategies allowing men to take proactive steps to maintain overall health and enjoying a fulfilling sex life is often the key. When men facing experiencing problems of ED with BPH put Dr G on the spot for a solution, his view is: “There is definitely such a phenomenon as ageing BPH, while a maturing prostate may inevitably cause silent nights and no more morning wood, knowledge of the treatment strategies can potentially fuel two birds with one pill”.