Stephan L. Werner, MD F.A.C.S.
Benign Prostatic Hypertrophy, also known as BPH, is a virtually universal overgrowth of the prostate gland in men as they age. Various factors affecting BPH are age, genetic makeup, testosterone levels, and environment. It can start in men's 20's but usually does not cause problems until middle age. It is not related to either Prostate Cancer, (PCa), or prostatitis.
What is BPH? The prostate gland lies below the bladder and surrounds the urethra, or urine tube. The prostate has little function in humans other than supporting the urethra and some of the sperm ducts.
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What are the symptoms of BPH? As the prostate enlarges it compresses the urethra causing obstruction to urine flow. The urinary stream becomes smaller, there may be difficulty in initiating the stream, (hesitancy), dribbling, intermittent flow, frequency of urination, getting up at night to void, (nocturia), inability to empty, or even inability to void at all, (retention). BPH can also be the cause of urinary tract infections.
How is BPH Evaluated? The Urologist will take a history, frequently asking the patient to fill out an AUA Symptom Score, do a physical examination including a digital rectal examination, (DRE), and then perform some of the following tests:
Urinalysis to determine the presence of infection or bleeding
PSA a blood test to help determine the need for cancer evaluation
Uroflow to measure the rate and volume of flow
Bladder residual urine by catheter or sonogram to see if the bladder empties completely.
Cystoscopy to look inside the bladder, urethra and prostate with a telescope.
How is BPH Treated? Once the diagnosis of BPH has been made, and infection or prostatitis treated, there are several options for treatment. If the symptoms are mild and there is no significant retention, the patient may be observed with reevaluation every 6 to 12 months. However, when the flow is very slow, the symptoms are great, and especially when retention reaches 100 cc, (3-4 oz.), treatment becomes necessary.
When a patient cannot void at all, acute urinary retention, a catheter is inserted for several days, treatment may be instituted, and the a trial of voiding given. If the patient is able to void, and empty well no treatment or continuing medical treatment is appropriate. When greater symptoms and/or retention exist, medical or surgical therapy is indicated. Some patients may have had blockage for so long that they have caused kidney damage, and may require a catheter for several weeks to allow the kidneys to regain whatever function remains before definitive surgical therapy.
Medical Treatment of BPH There are two forms of medical treatment for BPH: a series of drugs called alpha blockers relaxes the muscles within the prostate and bladder neck, allowing the flow of urine to improve; a second family of medication, 5-alpha reductase inhibitors, will cause some large prostates to shrink and thereby improve flow , although the action is slow and maximum response may take 6-12 months to achieve. The herbal saw palmetto is a biologic 5-alpha reductase inhibitor.
There are four drugs in the alpha blocker family: terazocin/Hytrin™, doxasacine/Cardura™ , tamulosin/Flomax™ and alfuzacin/Uroxatrol™. The first two are also antihypertensives, so they can be used to treat two conditions, they require dose titration, may take several weeks to reach maximum dose effectiveness and are available as generics. Flomax and Uroxatrol are selective, working predominantly on the prostate and bladder neck muscles, and work in several days. Side effects for all four may include dizziness, decreased erections and retrograde ejaculations, (dry orgasms). In some patients the prostate will continue to grow and some patients will require increasing doses of medication, addition of other drugs or surgical intervention over time.
Finasteride/Proscar™ and dutasteride/Avodart™ are the 5-alpha reductase inhibitors available and will slowly shrink prostates. They take about 3 to 6 weeks to begin to have an effect , and may take 3-6 months to reach maximum effect. They will only have an effect on larger prostates, and are effective in about a third of patients. The herbal, saw palmetto works in a similar fashion, but as an herbal is less well controlled. Decreased sexual functioning and increased hair growth, (Rogaine™ is finasteride), may affect a minority of patients on 5-alpha reductase inhibitors. 5-alpha reductase inhibitors artificially lowers PSA, the prostate cancer blood test. So if you are taking one of these you must let your doctors know, so that they can take it into account when doing your prostate cancer check!
Surgical Treatment of BPH There are three forms of surgical treatment for BPH: TURP/PVP Laser, minimally invasive procedures and open surgery. Over the past several years there has been a boom in treatment modalities for BPH.
TURP or transurethral resection of the prostate, (known euphemistically as "roto-rooter"), remains the gold standard for treatment of significant BPH. A specialized telescope, called a resectoscope, is inserted under anesthesia, into the urethra, and the overgrown prostate tissue is cut away from the inside using electric current. The urethral lining is removed during this process, but will regrow over several months. Results in terms of rate of urine flow, and long term effectiveness is the best of all the procedures available. It frequently requires a short hospital stay. Results are seen immediately, and complications can include bleeding, infection, incontinence, scarring and stricture and infrequently a decrease in potency. Dry ejaculations are common. It is uncommon to require a repeat TURP during ones lifetime.
The new (2003) high power Laserscope, PVP Green Light laser is very similar to a TURP, but by using laser there is virtually no bleeding and patients frequently go home the same day, most without a catheter. It is the only procedure approved for patients on anticoagulants or blood thinners. The procedure is usually not done in the doctor's office, but in the hospital outpatient department or surgicenter. Laserscope, Dr. Werner is a national instructor for the PVP laser.
Minimally invasive procedures include a family of procedures that destroy islands of tissue within the prostate using different forms of energy: laser, microwave, radio-frequency waves, or ultrasound. The procedures go under the various names of Indigo Laser, TUNA, TUMT, Prostatron, etc. An energy source is inserted through a cystoscope into the prostate, and when the energy is turned on, it coagulates an olive shaped volume of tissue. This may be done to multiple areas in the prostate. The coagulated tissue is slowly absorbed by the body, opening up the urinary channel. The procedures are usually done as outpatient procedures. A catheter must remain in for several days to a month or two, as the prostate swells up after the procedure, and the tissue is absorbed slowly. Maximum effectiveness is seen in 3 to 6 months. The improvement in flow rates is less than with TURP or PVP Laser. The durability of the results has not yet been fully determined but repeat procedures after several years are not uncommon. Bleeding, infection and scarring can occur. Dry or retrograde ejaculation or decreased potency is not common, but does occur.
A newer minimally invasive procedure, Thermodilation or Prolieve™ combines TUMT with balloon dilation of the prostate, an older technology that afforded a rapid but short lived improvement in voiding. This procedure is usually done in the urologist's office under sedation, takes about an hour. Most patients are able to void right after the procedure, though a few require a short term catheter. The long term results are equivalent to the other minimally invasive procedures. As the balloon dilation slowly fails over several months, the TUMT is improving flow, so there does not appear to be a change during the healing process. At the present time this is our preferred minimally invasive technique. Thermodilation/Prolieve
Cryotherapy or freezing is another minimally invasive procedure for obstructive BPH. Similar to the heat induced treatments, an iceball is formed within the prostate, and the destroyed tissues slowly sloughs. A catheter is frequently needed, and rates of impotence are high.
Open surgery for BPH is relatively rare but is sometimes needed for very large prostate glands. The procedure requires a hospital stay. Results are usually good an seen shortly after surgery. Complications include, bleeding, infection, scarring, retrograde ejaculation, incontinence and occasionally, impotence among others. However for most patients requiring an open prostatectomy, there is no good alternative.
Rev: 07/05 Stephan Werner, M.D., F.A.C.S.