Aquablation

Overview

Aquablation is a hospital procedure used to treat an enlarged prostate. The prostate is a small gland that sits under the bladder and wraps around the tube that carries urine out of the body (the urethra). As men get older, the prostate often grows bigger. This is called benign prostatic hyperplasia, or BPH — 'benign' means not cancer, and 'hyperplasia' means extra cells have grown. When the prostate gets bigger it can squeeze the urethra, making it harder to pass urine. Aquablation uses a thin instrument with a tiny, very precise jet of high-pressure water to remove the extra prostate tissue that is causing the blockage. A surgeon controls the water jet using a robotic arm, guided by live pictures from a small camera. The word 'aqua' means water and 'ablation' means removing tissue. It is done in an operating theatre, usually under a general anaesthetic (you are asleep) or a spinal anaesthetic (you are numb from the waist down). It is not cancer treatment.

An enlarged prostate is extremely common — most men will have some prostate growth as they get older, and many will notice urinary symptoms. Aquablation itself is a newer treatment. It is not available in every hospital, and it is usually offered by specialist urology centres. Older, well-established treatments such as medicines or other types of prostate surgery are still much more widely used. Your doctor can tell you what is available where you live.

Aquablation is for men with urinary symptoms caused by an enlarged prostate, usually men over about 45 to 50. It is generally considered for prostates within a certain size range and for men whose symptoms are not controlled well enough by lifestyle changes or medicines. It is not used in children, and it is not a treatment for prostate cancer.

Symptoms

Common symptoms

• A weak or slow urine stream
• Needing to push or strain to start urinating
• Stopping and starting while urinating
• Dribbling at the end of urination
• Needing to urinate often during the day
• Getting up several times at night to urinate (this is called nocturia)
• A sudden, urgent need to urinate that is hard to hold
• A feeling that the bladder has not fully emptied
• Having to wait a while before urine starts to flow

Symptoms in children

• Not applicable — aquablation is not used in children. Prostate enlargement does not happen in children. If a child has pain when passing urine, a weak stream, bedwetting that starts again after being dry, or blood in the urine, they should be checked by a doctor, because children can have other urinary problems that need care.

Symptoms in older adults

• Urinary symptoms become more likely with age, and older men often have other health conditions too, such as heart or kidney problems, diabetes, or reduced mobility.
• Getting up at night is more common and can increase the risk of falls, so it is worth discussing with your doctor.
• Older men are more likely to take several medicines, and some of these can affect urination — a pharmacist or doctor can review them.
• Some men cannot empty their bladder at all. This is called urinary retention and needs urgent medical help.

Causes

Main causes

• Prostate enlargement (BPH) is the usual reason urinary symptoms develop in older men. The exact cause is not fully understood, but it is linked to changes in hormone levels as men age, including testosterone and its breakdown products.
• As the prostate grows, it presses on the urethra and makes it harder for the bladder to push urine out. Over time the bladder muscle can become thicker and more sensitive, which adds to the urgency and frequency.
• Aquablation is a treatment, not a cause. It is used to relieve the blockage caused by the extra prostate tissue.

Risk factors

• Getting older — prostate growth is very common from midlife onwards
• A family history of prostate problems
• Having a larger prostate gland
• Being overweight or obese
• Not being physically active
• Diabetes and heart and circulation problems have been linked to more urinary symptoms
• Some medicines, such as certain cold and allergy remedies and some antidepressants, can make urination harder — check with your pharmacist

When to see a doctor

See a doctor urgently if:

• You suddenly cannot pass urine at all
• You have blood in your urine for the first time
• You have a fever with pain in your side or back, or burning when you pass urine
• Your symptoms get much worse over a few days

Book a routine appointment if:

• Urinary symptoms are affecting your sleep, work, or daily life
• You are getting up two or more times a night to urinate
• Medicines or lifestyle changes are not helping enough
• You want to talk about treatment options, including newer procedures such as aquablation
• You have a weak stream, dribbling, or a feeling of not emptying your bladder

Diagnosis

Your doctor will first talk to you about your symptoms and how much they affect your life, often using a short questionnaire called a symptom score. They will ask about your medical history and medicines, and may ask you to keep a diary of how often and how much you drink and urinate. A physical examination usually includes feeling your abdomen and a rectal examination, where a doctor gently feels the prostate through the back passage with a gloved finger. This is quick and helps assess the size and feel of the prostate. Blood and urine tests and a urine flow test help build the picture. If a procedure such as aquablation is being considered, you will usually see a urologist, who may arrange scans or a camera test to look at the prostate and plan the treatment.

Tests that may be done

• Symptom questionnaire and a bladder diary (a record of drinks, visits to the toilet, and how much you pass)
• Urine test to look for infection or blood
• Blood test for kidney function, and a PSA test — PSA is a protein made by the prostate; a raised level can have several causes and does not mean cancer on its own
• Rectal examination to feel the size and shape of the prostate
• Urine flow test — you urinate into a special machine that measures speed and pattern
• Ultrasound scan of the bladder to see how much urine is left after you go, and sometimes of the kidneys
• Ultrasound or other imaging of the prostate to measure its size and shape, which helps plan aquablation
• Cystoscopy — a thin tube with a camera passed gently into the urethra to look at the prostate and bladder, usually with some numbing gel
• Pre-operative checks such as blood pressure, heart tracing, and sometimes a chest X-ray or breathing test before an anaesthetic

What to expect at your appointment

The assessment is usually done over one or two clinic visits and is not painful, although the rectal examination and cystoscopy can feel a little uncomfortable. You will be told what each test is for and can ask questions at any point. If aquablation is an option, your urologist will explain how it is done, what the likely benefits are, what the risks are, and how it compares with medicines and other procedures. You do not have to decide straight away, and it is very reasonable to take time, ask for written information, or bring someone with you to the appointment.

Treatment

Treatment for an enlarged prostate depends on how much your symptoms bother you, the size of your prostate, your other health conditions, and what matters most to you — for example, how you feel about the risk of changes to ejaculation. Options range from watching and waiting with lifestyle changes, through medicines, to procedures that remove or shrink prostate tissue. Aquablation is one of those procedures. Others use heat, laser energy, or electrical cutting, or hold the prostate open with small implants. Each has different advantages, recovery times, and risks, and none is best for everyone. Your doctor should help you compare them honestly.

Self-care at home

• Cut down on caffeine and alcohol in the evening if getting up at night is a problem
• Drink enough fluid during the day, but reduce how much you drink in the two to three hours before bed
• Empty your bladder fully — try sitting down to urinate, and wait a moment and try again
• Keep warm; cold can make urgency worse
• Avoid constipation by eating fibre and drinking water, as a full bowel presses on the bladder
• Stay physically active — regular walking and other exercise can ease symptoms
• Ask your pharmacist to check whether any of your medicines, including cold and allergy remedies, could be making urination harder
• After aquablation: drink plenty of water, follow your discharge instructions, avoid heavy lifting and straining for the time your team advises, and take the pain relief you were given as directed

Medical treatments

Medicines can help many men. Some work by relaxing the muscle of the prostate and bladder neck so urine flows more easily, and they often start working within days to weeks. Others work more slowly by shrinking the prostate over months, and these are usually used for larger prostates. Each type has possible side effects, including dizziness, a drop in blood pressure, reduced sex drive, or effects on ejaculation. Your doctor or pharmacist can explain the options and check whether they are safe with your other medicines. If medicines do not help enough, or side effects are troublesome, procedures such as aquablation may be considered. Aquablation is carried out under anaesthetic in an operating theatre. The surgeon passes a thin instrument through the urethra, so there are no cuts on the outside of the body. A camera shows the prostate on a screen, and the surgeon marks the area to be treated while protecting the parts that control urine and erections. A robotic-controlled jet of water then removes the extra tissue, and the loosened pieces are washed out. A catheter (a soft tube) is left in place for a short time to drain urine while things heal, and most men go home within a day or two. Your hospital team will give you clear instructions about recovery, when to return to work, and when it is safe to drive, lift, or have sex again.

When is surgery considered?

A procedure such as aquablation may be suggested when urinary symptoms are bothersome and medicines have not helped enough or caused side effects, when you would rather avoid long-term medicines, when the prostate is enlarged and the bladder is not emptying properly, or when complications have occurred such as repeated urine infections, bladder stones, blood in the urine, or a build-up of pressure affecting the kidneys. It may also be considered when you cannot pass urine and need a catheter. Not everyone is suitable — for example, prostate size, other health problems, and anaesthetic risk all matter. Your urologist will discuss whether aquablation or another procedure is the safer and better choice for you.

Living with this condition

Most men recover well after aquablation. For the first few days you may feel tired and have some burning when you pass urine. You will usually go home with a catheter, or have it removed before you leave — your team will tell you which applies to you. It is normal to see pink or slightly bloody urine on and off for a few weeks, and to pass small clots. Urgency and getting up at night often improve over the first few weeks to months, but full improvement can take longer. Many men notice a much stronger stream within days. Follow your hospital's advice about returning to work, exercise, and sex, and keep your follow-up appointments.

Lifestyle tips

• Build gentle activity back in gradually, starting with short walks, and follow your team's advice before returning to gym work, cycling, or heavy lifting
• Keep drinking water regularly in the weeks after the procedure — this helps flush the bladder
• Avoid straining on the toilet; treat constipation early with fibre, fluid, and advice from your pharmacist
• Pace yourself in the first couple of weeks and accept offers of help
• Keep a note of your symptoms so you can tell your doctor what has changed at follow-up

Diet and exercise

A balanced diet with plenty of vegetables, fruit, whole grains, and water supports recovery and good bladder habits. If you are overweight, gradual weight loss can reduce urinary symptoms over time. Regular moderate exercise — walking, swimming, cycling on a comfortable seat once healed — is good for your heart, weight, and bladder. Limit caffeine and alcohol, especially in the evening, if frequency and night-time waking are problems. There is no special 'prostate diet' that replaces treatment, but healthy habits help you feel better overall.

Mental health and emotional wellbeing

Urinary symptoms and the thought of prostate surgery can cause real worry. Many men feel embarrassed about getting up often, leaking, or needing the toilet urgently, and some avoid social events, long journeys, or intimacy. Poor sleep from night-time trips to the toilet can affect mood and energy. These feelings are common and nothing to be ashamed of. Talking to your doctor, a nurse, or someone you trust often helps, and symptoms usually improve with treatment. If low mood, anxiety, or worry about your health is lasting more than a couple of weeks or affecting your daily life, please tell your doctor — effective help is available. If you ever have thoughts of harming yourself, contact your local emergency number or a crisis line in your country straight away.

Prevention

Prostate enlargement cannot be reliably prevented — it is a normal part of ageing for many men. However, some healthy habits may reduce how much it affects you: staying physically active, keeping to a healthy weight, eating a balanced diet, not smoking, and managing diabetes and blood pressure. Getting symptoms checked early means simpler options can be tried first, and problems such as urinary retention or kidney strain can be picked up before they become serious.

Screening programmes

There is no screening programme specifically for prostate enlargement. If you have urinary symptoms, ask your doctor for an assessment. Separately, some countries offer prostate cancer testing (often a PSA blood test) for men in certain age groups after a discussion of the pros and cons — ask your doctor what applies where you live. Aquablation does not lower your risk of prostate cancer, so keep having any tests your doctor recommends.

Complications

If left untreated

• Symptoms may gradually worsen, affecting sleep, work, travel, and social life
• Sudden inability to pass urine (urinary retention), which is painful and needs a catheter straight away
• Repeated urine infections
• Bladder stones and bladder muscle damage
• Blood in the urine
• Back-pressure on the kidneys, which can, over a long time, reduce kidney function
• Weakening of the bladder muscle, which can cause ongoing leakage or poor emptying even after treatment

Long-term outlook

Most men do well after treatment for an enlarged prostate, and many notice a stronger stream and fewer night-time trips. Aquablation has been shown in studies to relieve symptoms well, with a low chance of serious complications, and it is designed to preserve ejaculation in most men — though not everyone, and your surgeon will tell you the realistic chances for you. As with any prostate procedure, some men notice changes in ejaculation (often semen going into the bladder instead of coming out, which is harmless), and a small number have ongoing urinary urgency, infection, or narrowing of the urine tube that can be treated. Symptoms can sometimes return years later and need further treatment. Going into it with clear information, realistic expectations, and a good follow-up plan gives you the best chance of a smooth recovery.

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