Benign prostatic hyperplasia (BPH), a term used to describe non-cancerous enlargement of the prostate, is one of the most commonly encountered urologic problems in the aging male. Generally starting in the 4th and 5th decade of life, hormonal changes produce not only external enlargement of the prostate, but more importantly, internal blockage of a tube-like structure which passes through the prostate called the urethra. The urethra carries urine from the bladder to the tip of the penis. Over time, this internal obstruction can produce both urinary irritation and symptoms of urinary retention.
Unfortunately, the symptoms of BPH tend to worsen over time. Additionally, severe BPH can result in multiple serious conditions including urinary retention (an inability to urinate), bleeding, infections, stones and even kidney failure.
ANATOMY AND FUNCTION
The prostate is a walnut-sized gland responsible for the production of ejaculatory fluids. These fluids are rich in nutrients and enzymes responsible for improving the survival of sperm. The prostate is located at the base of the bladder. As previously mentioned, the urethra travels from the bladder to the tip of the penis. Shortly after the urine leaves the bladder, the urine is carried through the prostate. As the prostate enlarges, the inner passage commonly narrows resulting in bothersome urinary symptoms.
As the prostate enlarges, a number of bothersome urinary symptoms can occur. Most are described as either irritative or obstructive in nature. A valuable screening tool called the International Prostate Survey Score (IPSS) is commonly used by urologists to determine the severity of lower urinary tract symptoms (LUTS). A score between 0-35 is obtained. Although this survey can quantify the severity of BPH, many other urologic conditions including infections, urethral stricture, etc. can produce a high score as well. Interestingly, women could be asked the same survey and obtain a score despite the fact that they do not have a prostate! The most important factor that determines whether treatment is necessary relates to the amount of bother patients experience.
1. Over the past month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
2. Over the past month or so, how often have you had to urinate again less than two hours after you finished urinating?
3. Over the past month or so, how often have you found you stopped and started again several times when you urinated?
4. Over the past month or so, how often have you found it difficult to postpone urination?
5. Over the past month or so, how often have you had a weak urinary stream?
6. Over the past month or so, how often have you had to push or strain to begin urination?
7. Over the last month, how many times did you usually get up to urinate from the time you went to bed at night until the time you got up in the morning? Never 1 time 2 times 3 times 4 times 5 times or more
A supportive history, a digital rectal examination (DRE) demonstrating an enlarged prostate and a high IPSS score often suggest a diagnosis of BPH. However, additional testing is often necessary to not only confirm this diagnosis, but also to be certain that other urologic problems are not the cause of the urinary symptoms. These tests include:
Urinalysis: A rapid urine test to check for infection.
Urine Culture: A more comprehensive urine test that not only checks for infection but also identifies the bacteria responsible for infection. Sensitivity to specific antibiotics can also be performed.
Urine Cytology: A microscopic study of the urine used to detect bladder cancer.
Prostate Specific Antigen (PSA): A blood test used for the screening of prostate cancer.
Uroflow: An office test used to measure of the volume and rate of urination.
Post-Void Residual: A measure of the amount of urine remaining in the bladder after urinating.
Urodynamics: A more comprehensive urine study that evaluates the mechanics of urine storage and emptying.
Cystoscopy: A small fiberoptic scope that is used to evaluate the prostate and bladder area. An excellent way of evaluating the internal obstruction of the prostate. Also provides valuable information regarding the bladder.
Prostate Ultrasound: A rectally-placed ultrasound probe that is used to measure the size of the prostate and length of the urethra. As well, a prostate biopsy looking for prostate cancer can be performed with the assistance of a prostate ultrasound.
Kidney and Bladder Ultrasound: An ultrasound study used to evaluate for tumors, blockage or stones of the kidneys and bladder.
There are many different treatment options for BPH. Urinary bother as well as BPH-related complications such as bleeding from the prostate, kidney damage from obstruction or recurring urinary infections are common reasons to pursue treatment. There are far more treatments available than those mentioned in this section. However, the most commonly used and accepted treatment options are listed below.
Interestingly, watchful waiting, or avoidance of any therapy, is a very popular approach among many patients. This is an excellent option for patients who wish to avoid the cost and adverse affects of medications or surgery. This option is most appropriate for patients with mild urinary symptoms without a history of urinary bleeding, recurring infections, or other serious prostate-related problems.
Herbal supplements are a commonly sought treatment option for patients experiencing urinary bother. Although formal clinical studies of herbal supplements have been mixed regarding improvement of urinary symptoms, their popularity attests to the fact that many patients do find them to be helpful. Popular herbals commonly used for urinary bother include saw palmetto, Pygeum africanum and beta-Bitosterol. We encourage our patients to inform their doctors about herbal supplements that they are taking.
Although each physician may have their biases regarding the value of such supplements, two facts remain consistent:
1) the herbal supplement market, unlike prescribed medications, remain completely unregulated. As a result, great variations in the actual active ingredients can vary from brand to brand, bottle to bottle and even pill to pill. As well, when a manufacturer makes a claim of having the highest concentration of a specific herbal supplement, the manufacturer is in no way obligated to prove this claim.
2) all medications and herbal treatments have side-effects. Some herbal remedies can even have far more serious side effects than prescription medications. Again, because the herbal market is unregulated, they are by no means obligated to inform patients of all potential side effects.
Alpha Blockers: This class of medications remains the mainstay of BPH therapy. Common brand names in the class of medications include: Tamsulosin (FLOMAX), Alfusosin (UROXATROL), Doxazosin (CARDURA), and Terazosin (HYTRIN). As the prostate grows, the muscular tone of the prostate increases. This class of medications works by relaxing the muscular tone of both the prostate and bladder neck. As a result, there is less resistance to the flow of urine.
Improvements in urinary symptoms, improved emptying and fewer night time voids are commonly seen shortly after starting these medications. The main side effects include headache, dizziness, nasal congestion, harmless changes in ejaculation, as well as respiratory infections.
5-Alpha Reductase Inhibitors: This class of medications, which includes Finasteride (PROSCAR) and Dutasteride (AVODART), is responsible for physically shrinking the prostate. By decreasing the size of the prostate, this not only improves the urination seen similarly with alpha blockers, but there is also the potential benefit of delaying the need for prostate surgery for BPH.
Unlike alpha blockers, this class of medications requires at least 6months to a year to achieve maximum benefit. For this reason, combined treatment with both alpha blockers and 5-alpha reductase inhibitors is a common practice. Additionally, patients who benefit the most from 5-alpha reductase inhibitor are those patients with larger prostates.
Side effects can include impotence, decreased libido and reduced semen release during ejaculation.
Surgery is often recommended for patients who do not respond well to medications or for patients with complications due to the severity of their BPH, such as urinary retention (an inability to urinate). Over the past few decades, many new “minimally-invasive” procedures have been developed to minimize the risks of surgery for the treatment of BPH. Throughout much of the ‘70s and ‘80s, transurethral resection of the prostate (TURP), also commonly known as the “rotorooter” in layman’s terms, was the most commonly performed procedure for BPH. Interestingly, it remains the “gold standard” procedure for the degree of improvement in urinary symptoms as well as the duration of benefit following surgery. However, newer approaches have been developed that have fewer side-effects and risks in comparison to TURP.
Although there are many more procedures than listed below to surgically treat BPH, the Urology Center feels that these are the best options presently available to patients. All of the mentioned options are offered at the Urology Center.
Transurethral Resection of the Prostate (TURP): Transurethral resection of the prostate refers to a surgical procedure where a highly specialized lighted scope is placed into the tip of the penis to carefully remove tissue blocking the prostate area. This procedure is performed in an operating room and does require either spinal or general anesthesia. In addition, patients are generally admitted overnight following surgery. Complications of this procedure include bleeding, infection, mineral abnormalities, erectile and ejaculatory disturbances, urinary leakage, as well as scar tissue following surgery. TURP remains the “gold standard” procedure regarding both the degree of improvement in urinary symptoms as well as the duration that the surgery benefits the patient.
Transurethral Microwave Thermotherapy of the Prostate (TUMT): Transurethral Microwave Thermotherapy of the Prostate refers to an in-office procedure in which a catheter with a microwave component is temporarily placed to heat and destroy prostate tissue that is blocking the outflow of urine. In addition, the Urology Center uses the latest technology, referred to as “thermodilation”, which not only has a microwave component but also has a balloon dilating system which stretches the prostate area and can provide immediate improvement in urination.
This procedure is performed in the office with oral and topical pain medications. The actual procedure takes approximately 1 hour with most patients being sent home without a catheter. The complications of TUMT are quite similar to TURP but occur with much less frequency. Unlike a TURP, urinary benefit is gradual and often requires 3 to 6 months before maximum benefit is noticed.
TUMT is not indicated for all patients but is an excellent treatment option. Additionally, TUMT can be particularly well-suited for more elderly patients, surgical high-risk patients and those patients who prefer a procedure with fewer side-effects.
GreenLight PVP: The GreenLight PVP refers to a procedure that is performed through the urethra with the use of a very powerful side-firing laser that vaporizes (dries out and destroys) prostate tissue that is blocking the outflow or urine. Like a TURP, this procedure is performed in the operating room with either spinal or general anesthesia. Unlike a TURP, most patients can go home the same day as surgery. The complications of GreenLight PVP are similar to TURP but occur with slightly less frequency.
GreenLight PVP is not indicated for all patients but is an excellent treatment option. Additionally, GreenLight PVP is particularly well-suited for more elderly patients, patients who must remain on aspirin or blood thinners and those patients who prefer a procedure with fewer side-effects.
Open Prostatectomy: Open prostatectomy refers to BPH surgery performed through a low abdominal incision to remove portions of the prostate responsible for blocking the flow of urine. Unlike a radical prostatectomy done for cancer, the entire prostate is NOT removed.
This procedure is indicated when the prostate is too large and obstructed to be surgically repaired by other less invasive means such as a TUMT or TURP. As well, open surgery is well-suited for patients who require surgery to fix other problems associated with BPH including large bladder stones or pouching of the bladder. Complications of an open prostatectomy include bleeding, infection, hernias, erectile and ejaculatory disturbances, urinary leakage, as well as scar tissue following surgery.
BPH is a commonly treated problem in aging males generally starting in the 4th and 5th decades of life. Patients often experience varying degrees of irritative and obstructive urinary symptoms. Unfortunately, BPH is progressive and can lead to serious medical conditions. Treatment with medications remains the mainstay of BPH therapy. Newer minimally-invasive treatments are currently available with fewer side effects and risks than more traditional transurethral resection of the prostate (TURP). Although there are many different options to manage BPH, ultimately, the best treatment option is individual to each patient. We strongly encourage our patients to inquire about various treatment options for BPH.