Introduction

Despite benign prostatic hyperplasia (BPH) being a common condition encountered during my training, I’ve found it to be one of the more challenging conditions to evaluate and treat early on in my urology career. During my urology residency, BPH seemed simple as I generally encountered patients once they had already been scheduled for a bladder outlet reduction procedure and my role was to help my attending physician perform whatever prostate intervention he or she routinely offered. Once I completed training and was seeing patients in clinic, I had to take a step back – I realized that not all patients presenting to me with a chief complaint of BPH had a problematic prostate.

My vocabulary changed – “BPH” became “bothersome lower urinary tract symptoms” and my first task was to determine if the prostate was indeed to blame.

How I Approach Lower Urinary Tract Symptoms (LUTS)

I start by obtaining a detailed history, which we all know is critical to any patient encounter (and always the right answer to any oral board question), but much easier said than done when in the midst of a busy surgical clinic. Despite evaluating many patients previously seen by other healthcare providers for their LUTS, I had to take a step back – I realized that not all patients have been asked detailed questions regarding their fluid intake, bowel habits, comorbid conditions, and medications and, therefore, oftentimes do not understand how each of these may be contributing to their bothersome symptoms.

My history taking changed – I went back to the basics of obtaining a detailed history of present illness for all patients new to me even if previously seen by other healthcare providers and/or urologist(s).

How I Evaluate the Prostate

I reached out to a well-known urologist specializing in BPH very early on in my career. This five-minute conversation built the foundation for how I would approach prostate evaluation ever since. His message was clear, “We don’t need to guess. When a man presents with symptoms that may be due to BPH, offer him prostate measurement and cystoscopy so you have much of the information that will direct future evaluation and management.” For more complex patients, I also recommend urodynamic testing. Even when an enlarged prostate seemed like the most likely culprit, I had to take a step back – I realized that many patients did not understand the basics of prostate size or anatomy and the implications on their symptoms. Therefore, measuring and visualizing the prostate has been beneficial for both patient understanding and my ability to guide patients along the decision-making process.

My evaluation changed – I started offering a more thorough prostate evaluation prior to initiation of any therapy, even pharmacologic intervention.

How I Counsel Patients on Treatment of BPH

I don’t sugarcoat anything. I use the same counselling approach for BPH as I do for all other male-specific health concerns I treat. I follow the mantra, “When there are several options for a disease process, there is no perfect option. If a perfect option did exist, it would be the only one.” I find it to be a great advantage to have expertise in multiple BPH treatment modalities. Understanding pros and cons of several BPH treatment options allows me to have honest conversations with my patients. A beautiful thing in medicine happens when we combine the evidence, guidelines, our patients' goals and experiences, and our own experiences as healthcare providers in the decision-making process.

Prior to offering Rezūm™ Water Vapor Therapy, I heard divergent feedback on this technology. I was concerned about the potential passage of debris and three months of bothersome irritative symptoms during the post-procedure healing process, though my patients and I have been pleasantly surprised by the mild degree of both. The procedure uses natural energy stored in water vapor to treat the cause of BPH, the prostate tissue, and over time, the body’s natural healing response absorbs the treated tissue resulting in a reduction of the prostate volume. During the healing phase, small pieces of coagulated tissue may slough off and be expelled via urination and this sloughing process may continue for a few months post-procedure depending on the rate of healing. Although, in my experience, tissue sloughing has not been significant. In addition, patients may experience a continued or worsening of LUTS during the healing phase, which may require the use of a catheter for several days. Any significant worsening of irritative symptoms prompts urine testing.

Prior to offering or taking care of anyone who had undergone Rezūm Therapy, I had to take a step back – I realized I needed to reach out to as many healthcare providers and patients as possible to learn more about this treatment option, so I could accurately talk about it to patients. My colleagues Drs. Bilal Chughtai and Dean Elterman have a great article that explores top considerations for BPH treatment options.

My counselling changed – I asked as many people (patients and providers) as possible about the pros and cons of all BPH treatments. For Rezūm Therapy, specifically, I asked for advice on ideal and inappropriate candidates for this procedure, tips for managing patient expectations, and asked my patients detailed questions about their experiences during the procedure and throughout their recovery. I provide all of this feedback to my patients. If, at the end of a conversation about treatment options, my patient doesn’t know how he’d like to proceed, I know I didn’t describe the similarities and differences between the various treatment options clearly enough, so, what do I do? You got it – I take another step back.

And preparing patients for what to expect following the Rezūm Therapy procedure is just as important. My patients sometimes come in with questions about catheterization and fears of discomfort. A lack of information shouldn’t be a barrier to BPH treatment. I set clear expectations with my patients and explain why catheterization is necessary for the body to heal after treatment. When we take time to demystify our patients’ fears, they’re grateful for the information, and better understand the benefits of Rezūm Therapy.¹

How I Develop the Infrastructure to Offer a New Therapy for BPH

Interest in offering a novel therapy and obtaining the equipment are not enough to offer Rezūm Therapy – I realized that particular focus on building the infrastructure and educating all involved staff members was critical to successfully treating patients. This is not something routinely taught in training and certainly something I took for granted until I was trying to introduce a new technology into our large academic practice. I met with various team members, explained how this new technology compared to existing technology, with particular focus on pre-, intra- and post-operative differences, as well as expectations for outcomes. I also keep my team members updated on our actual outcomes so they have context for how our mutual patients are doing with this new therapy.

My expectations changed – I no longer take anything for granted (I try not to, at least). Introducing new technology, even for procedures that literally take just a handful of minutes, can be disastrous if all team members lack the necessary expertise in the treatment modality. I can only expect our team members to understand the technology if I provide them the necessary education. In order to move forward with innovative technologies like Rezūm Therapy, all of us must understand the “why” and “when” in addition to the “how.”

By making some simple changes to my vocabulary, history taking, evaluation, counselling and most importantly, my expectations, I have enhanced my ability to provide safe, efficient and effective care for my patients.