- Overview of BPH
Benign Prostatic Hyperplasia is a condition in which the
prostate becomes enlarged as part of the aging process.
Generally, prostate growth is negligible between puberty and
middle age. When a man reaches about 40 years of age, however, hormonal changes may cause
the prostate to begin growing again. This noncancerous (benign) growth is called
"hyperplasia."
Not all men experience this enlargement; in those who do, the
condition is not always progressive. Studies have found enlarged prostates in about 40% of
men over age 55, rising to 70% in men over 70, and to 80% over age 80 and beyond.
When the prostate enlarges, the surrounding tissue prevents
it from expanding. This squeezes the gland inward, causing it to pinch the urethra and
restrict the flow of urine from the bladder. The more the prostate grows, the more the
urethra is constricted and the harder the bladder muscles must squeeze to force urine out.
This can cause the muscles of the bladder wall to grow thicker, stronger and more
irritable, creating a need to urinate frequently, even when the bladder contains only a
small amount of urine.
Over time, this can cause urinary tract infections (UTI's),
difficulty in starting or sustaining urination or an inability to empty the bladder
completely (urinary retention). Occasionally, a complete blockage of the urethra results,
causing a serious condition called acute urinary retention.
- What are the causes
and risks of the condition?
- Scientists have several theories about what causes BPH.
Men produce both the male hormone testosterone and, in small
amounts, the female hormone estrogen throughout their lives. One theory suggests that
because testosterone production decreases with age, the greater proportion of estrogen in
the blood may promote cell growth in the prostate.
Another theory holds that high levels of dihydrotestosterone
(DHT), a testosterone derivative thought to control prostate growth, may accumulate in the
prostate in some men as they age, causing hyperplasia.
What are the
signs and symptoms of the condition?
- Difficulty in urinating is the most common symptom of BPH. It
can occur in different ways:
- A hesitant, interrupted or weak urine stream
- A feeling that the bladder has not emptied completely after
urinating
- The need to push or strain to begin urinating
- A recurrent, sudden, urgent need to urinate
- Involuntary leaking or dribbling of urine
- The need to urinate frequently, particularly at night
- Obstruction;
Acute Urinary Retention
- The degree of prostate enlargement does not always determine
how severe the symptoms of BPH will be. Some men with greatly enlarged prostates
experience little obstruction of the urethra and few symptoms. Others men who have
comparatively little enlargement suffer great discomfort and urinary difficulty.
Sometimes a man will be unaware he has a problem until he
suddenly finds himself completely unable to urinate. This condition, known as acute
urinary retention, can be brought on by alcohol consumption, a long period of inactivity
or cold temperatures. More commonly, it is triggered by the use of allergy or cold
medications containing decongestants or antihistamines, which may produce a side effect
that prevents the bladder opening from relaxing. Inability to pass urine results in severe
pain. The insertion of a small tube called a catheter through the penis and urethra into
the bladder may be necessary to relieve this condition.
These symptoms, however slight or severe, indicate the
likelihood of a problem requiring medical attention. Anyone experiencing them should
consult a urologist promptly for testing and appropriate treatment.
How is this condition diagnosed?
- To determine if you have BPH, your doctor may recommend one or
more of the following tests:
- Uroflow
- Usually performed in your doctor's office, the uroflow test
determines how quickly and completely you can empty your bladder. With a full bladder, you
will be asked to urinate into a special measuring device. A reduced flow may indicate BPH.
- Pressure Flow Study
- This test measures pressure in your bladder as you urinate and
can determine how much urine is blocked. It requires the insertion of a catheter through
the penis and into the bladder. While the catheter is uncomfortable and may occasionally
cause a urinary tract infection, many doctors recommend the pressure flow study because
they feel it is the most accurate means of determining the extent of urinary blockage.
- Post-void Residual
(PVR)
- PVR tests measure how much urine is left in the bladder after
you urinate, and can help the doctor determine how greatly BPH has affected your bladder.
These tests can be performed in various noninvasive ways. Patients with large residual
urine volumes are more likely to require immediate medical or surgical treatment.
- AUA
(American Urological Association) Score
- The AUA Score or Symptom Index is a self-administered
questionnaire used to establish how severe a patient's BPH symptoms may be. It asks seven
questions related to common symptoms of BPH and asks the patient to rate the degree of
frequency or severity for each on a scale of 1 to 5. A total AUA Score of 0 to 7 is
considered mild; 8 to 19 is rated moderate, and 20 to 35, severe.
- What are the
treatments?
- Men with only mild symptoms of BPH may require
no treatment at all. If the condition progresses, however, your doctor may recommend
several alternative courses of treatment. These include, medical, surgical and nonsurgical
procedures, including catheterization for acute urinary retention.
For more information about treatments for
BPH, select from the list below.
Medical Treatment
Watchful Waiting
Surgical Treatments
Microwave Therapy
- TUNA
Water-Induced Thermotherapy (WIT)
Medical Treatment
Two types of drugs have proven successful in treating BPH.
These are finasteride (marketed under the name Proscar™) and the so-called alpha
blockers.
Finasteride/Proscar™
This drug, take orally once a day, limits the production of dihydrotestosterone
(DHT), the hormone many experts believe controls prostate growth and contributes to
prostate enlargement. A 6 month course of treatment with Proscar has been found to shrink
the prostate, and many men find their urinary problems improve or disappear. Patients
taking this drug should see their doctors regularly.
Side effects of Proscar include reduced interest in sex,
difficulty achieving an erection and a decrease in sperm. Because Proscar is a relatively
new drug, its long-term risks and benefits have not been fully documented.
Alpha blockers
Alpha blockers are a family of drugs that cause the muscles of the bladder neck
and prostate to relax, producing a slight increase in urinary flow and improvement in BPH
symptoms. They are not considered a cure for BPH complications however, and will not
eliminate the need for surgery in patients with progressive BPH. Alpha blockers typically
are taken orally once or twice a day. If your doctor prescribes alpha blocker treatment,
you may need to return for regular checkups during the first 3 or 4 weeks so your symptoms
can be evaluated and your dosage adjusted, if necessary.
Alpha blockers can have side effects, including headaches,
dizziness, light-headedness, low blood pressure, fatigue and a sense of difficulty in
breathing. Some of these appear to be related to dosage levels. Because they are a
relatively new form of treatment, their long-term risks and benefits are not fully known.
The following are among the most commonly prescribed
alpha blockers:
Prazosin/Minipres™
Prazosin, marketed under the brand name Minipres, relaxes the smooth muscles of
the urethra and prostrate, and improves the flow of urine.
Doxazosin /Cardura™
Doxazosin, marketed under the brand name Cardura, improves symptoms and increases
the flow of urine, often within the first week of taking it.
Terazosin/Hytrin™
Terazosin, marketed under the brand name Hytrin, causes the smooth muscle of the
prostate and bladder neck to relax, reducing obstruction of the urethra and improving
urine flow.
Tamulosin Hydrochloride/Flowmax™
One of the newest alpha blockers, Flowmax improves symptoms and typically
produces few of the most commonly reported side effects. Many patients report an increase
their flow of urine within 4 to 8 hours after the first dose, and an improvement in other
BPH symptoms within the first week of taking it. In several clinical studies, 8% of the
subjects experienced a mild side effect called retrograde ejaculation or "dry
climax," a condition in which semen enters the bladder rather than being expelled
through the penis. Although this is later harmlessly flushed out with urine, men with
retrograde ejaculation may be sterile (unable to father children).
- Watchful Waiting
- This is not an actual treatment, but a process that involves
having periodic examinations-about once a year-to see if your symptoms are causing you
problems or becoming worse. The doctor may order tests to determine if BPH is harming your
kidneys or bladder. Patients often are advised not to drink liquids before bedtime and to
avoid over-the-counter cold or allergy medications, which contain decongestants that may
make your symptoms worse.
In most cases, the risks associated with "watchful
waiting" are small. Sometimes a patient's symptoms will worsen during this process.
Instances of a complete inability to urinate (acute urinary retention), bleeding,
infections or damage to the kidneys or bladder have occurred during "watchful
waiting." For the most part, however, progressive BPH is a gradual process, and
patients usually will report a worsening of their symptoms or have them detected during a
periodic examination before such dramatic problems result.
- Surgical
Treatments
- When the health problems associated with BPH become serious,
urologists often recommend surgery. Conditions indicating a need for surgery include:
- Inability to urinate
- Damage to the kidneys caused by urine backing up into them
- Frequent urinary tract infections
- Major bleeding through the urethra as a result of BPH, and
- Stones in the bladder
Surgery involves removing the enlarged part of the prostate
that is pressing against the urethra. This relieves the obstruction and inability to empty
the bladder completely. The following are the most common types of surgery for BPH.
- TURP
- About 90% of all surgeries for BPH involve transurethral
resection of the prostate (TURP). This procedure requires no external incision and takes
about 90 minutes.
After giving anesthesia, the doctor inserts an instrument
called a resectoscope into the penis through the urethra. The resectoscope is about 12
inches long and half an inch in diameter. It contains a light, valves for controlling
irrigating fluid and an electrical loop to cut tissue and seal blood vessels. The doctor
uses this loop to remove the enlarged tissue one piece at a time. The irrigating fluids
carry this tissue to the bladder where they are flushed out after the operation.
Patients usually must remain in the hospital for about 3 days
after TURP surgery, during which a catheter must be used to drain their urine. After that,
recovery usually is quick. Most men find their BPH symptoms improve rapidly and are able
to return to work within a month. During the recovery period, doctors generally advise you
to:
- Drink plenty of water to flush the bladder
- Eat a balanced diet and use a laxative if necessary to prevent
constipation and straining when moving the bowels
- Avoid heavy lifting, driving or operating machinery
- TUIP
- Your doctor may recommend transurethral incision of the
prostate (TUIP) if your prostate requires surgery, but isn't greatly enlarged. This
procedure widens the urethra by making several small cuts in the neck of the bladder, the
point where the urethra joins the bladder, and in the prostate itself. This reduces the
prostate's pressure on the urethra and makes urination easier. Some experts believe TUIP
gives relief with fewer side effects than TURP, particularly a lower incidence of
retrograde ejaculation. However, others say its long-term benefits and risks have yet to
be established conclusively.
- Lasers
- In recent years, science has adapted the use of high-energy
light beams called lasers to a variety of surgical applications. Prostate surgery
involving the use of lasers is becoming increasingly common. Some studies suggest it
offers advantages over conventional prostate surgery, particularly in men with smaller
prostates, for whom such procedures as TURP might be considered unsuitable. The following
are the main laser treatments.
- TULIP
- Transurethral ultrasound-guided laser incision of the prostate
(TULIP) is a new procedure that is similar to TUIP, except that the cuts are made with a
laser.
-
Interstitial Laser Coagulation
- This new procedure uses a device called a cystoscope in the
urethra to introduce a special fiberoptic probe directly into the prostate. The probe
focuses a beam of low-power laser energy to vaporize a controlled amount of obstructing
prostate tissue, resulting in prostate shrinkage and improvement of BPH symptoms. The
process is repeated as needed, and takes about 30 to 60 minutes to perform on an
out-patient basis.
- Vaportrode
- Transurethral vaporization of the prostate (TUVP), also known
as vaportrode, is a new technique that involves direct application of high heat (less than
100 degrees) to the prostate tissue by means of a grooved roller-bar that vaporizes tissue
instead of burning it with a laser. The immediate tissue loss leads to quick improvement
in BPH symptoms and urinary flow, comparable to TURP. The procedure takes from 20 to 65
minutes. Most patients can have their catheters removed within 24 hours and can go home on
the second day after treatment.
- Prostatic Stents
- A prostatic stent is a tiny, spring like device inserted into
the urethra. When expanded, it pushes back the surrounding tissue and widens the urethra
to permit an increased flow of urine. Prostatic stents are most often used for patients
who have other medical problems that prohibit medication or surgery. Prostatic stents have
several advantages:
- They can be placed in less than 15 minutes under regional
anesthesia.
- Bleeding during and after surgery is minimal.
- The patient can be discharged the same day or next morning.
The disadvantages of stents are:
- Prepositioning them can be difficult.
- They may cause irritation and frequent urination.
- They may move and cause pain or incontinence.
- Removing them-necessary in one-third of patients-can be
difficult.
- Open Prostatectomy
- If the prostate is greatly enlarged, if the bladder has been
damaged and must be repaired, or if the patient has other complications prohibiting
transurethral surgery, an open surgical procedure called a prostatectomy (removal of the
prostate) may be necessary.
With this procedure, the patient is anesthetized and the
surgeon makes an external incision, either in the lower abdomen or in the perineum (the
area between the rectum and the scrotum), depending upon the location of the enlarged
portion of the prostate. The surgeon then removes the enlarged prostate tissue from inside
the gland. An open prostatectomy in which the surgeon accesses the prostate from the
abdomen is called suprapubic (surgery from on top or above); surgery through the perineum
is called retropubic (surgery from the back or from behind).
Microwave
Therapy
- Prostatron
- Transurethral microwave thermotherapy (TUMT) does not cure
BPH; it reduces its symptoms. TUMT uses a special catheter with a tip containing an
antenna-called a Prostatron-to deliver high-temperature (41°- 44°C) microwave energy to
the prostate without affecting adjacent structures. Depending on the elasticity of the
urethra, the therapeutic deep heat will improve urine flow. A fiberoptic thermosensor
monitors temperatures throughout the procedure, and a cooling system circulates water
within the catheter applicator to protect the urinary tract. The procedure takes about an
hour and is performed on an outpatient basis without anesthetic.
Prostatron therapy does not solve the problem of incomplete
emptying of the bladder, but its benefits are achieved without causing incontinence or
impotence. Most patients resume normal activity immediately after treatment.
- Targis
- The TargisTM System is an advanced form of microwave therapy.
It uses advanced microwave technology to deliver energy through a flexible catheter.
TargisTM therapy destroys the diseased tissue, while protecting the pain-sensitive,
healthy urethral tissue. The procedure is anesthesia-free, with no need for IV sedation,
spinal or general anesthesia. Most patients can return home the same day as the treatment
and quickly resume everyday activities.
- The catheter (also known as the Microwave Delivery System) is
inserted into the urethra. The balloon, located at the very end of the catheter, is
inflated to position the microwave antenna in the prostate.
- Chilled water is circulated through the catheter to protect
healthy urethral tissue.
- While the chilled water is being circulated, the microwave
power is started and the diseased tissue in the prostate is heated.
- Heating is continued for one hour in order to destroy the
diseased tissue.
- After one hour, the microwave energy is turned off, while the
chilled water continues to circulate to protect the healthy urethral tissue from any
residual heat.
- At the completion of cooling, the procedure is finished and
the catheter is removed.
- TUNA
- Transurethral needle ablation of the prostate (TUNA),
procedure delivers low level radio frequency (RF) energy to the prostate, relieving
obstruction without causing damage to the urethra. A small probe is inserted through the
urethra and into the prostate. Two small electrodes are deployed into the prostate and a
low level of radio frequency energy is applied. The energy heats the prostate tissue and
shrinks it, relieving the obstruction while protecting the urethra and surrounding areas.
The TUNA procedure can be performed in an office or hospital
outpatient center in less than 1 hour using minimal anesthesia. Clinical studies have
demonstrated that TUNA provides significant improvements in urine flow and other symptoms
of BPH. Its long-term side effects are minor compared with those of such conventional
procedures as TURP. Most patients are able to return to their normal activities within 24
hours.
- Water-Induced Thermotherapy (WIT)
- Water-induced thermotherapy (WIT) is the most recent
development in the treatment of noncancerous, enlarged prostate. This innovative procedure
was developed during the 1990s and received FDA approval in 1999. WIT is a minimally
invasive outpatient procedure that is less complicated than other treatments for BPH.
WIT effectively destroys excess prostatic tissue, which
presses on the urethra and compromises urinary flow, and thus reopens the urethra. WIT has
its advantages: it can be performed in ambulatory surgery, outpatient surgery, or a
physician's office; it takes only 45 minutes and does not require general anesthesia, and
therefore does not carry the risks associated with inpatient surgery; and it does not
produce incontinence or impotence, common effects of surgical treatments for BPH.
The Procedure
Before the day of the procedure, the urologist measures the size of patient's
prostate in order to select the size of the catheter. The catheter is made up of four
contiguous sections: the urinary drainage lumen, the positioning balloon, the treatment
balloon, and the insulated shaft.
On the day of the procedure, the urologist inserts Lidocaine
gel, an anesthetic, into the urethra to control pain. Next, the computer console, to which
the catheter is attached, heats the water to 60° C (140° F). The urologist inserts the
catheter through the urethra, through the center of the prostate, and into the bladder.
Once the urinary drainage lumen and the positioning balloon reach the bladder, the
positioning balloon inflates, thereby securing the catheter. Urine is allowed to pass by
means of the urinary drainage lumen for the duration of the procedure.
The treatment balloon, resting in the prostatic urethra
(located directly below the bladder), inflates and then fills with water, during which
time the patient will likely feel some pressure. The temperature-controlled water then
circulates through the insulated shaft into the treatment balloon. The catheter conducts
heat through the insulated shaft to the prostate gland, raises the temperature of the
gland, and then destroys the obstructive tissue to a depth of approximately 11 mm.
Throughout the procedure, the computer console precisely
maintains the temperature of the water at 60° C. After 45 minutes of treatment, the
catheter is removed. Over the next few weeks, the body either sloughs off or absorbs the
destroyed tissues.
Following the procedure, the patient will likely experience
swelling. A urethral catheter will ease the constricted flow of urine caused by the
swelling. The catheter will remain in place for approximately 4 to 17 days, or until the
swelling is reduced and normal urinary flow is restored. Patients also experience
transient hematuria, or temporary blood in the urine, after the procedure. Studies
indicate that some patients experienced treatable urinary tract infection or urinary
urgency after the procedure.
Common
Recovery Complications
- Bleeding: Blood or
clots in the urine are common after surgery for BPH and should clear up by the time you
are discharged. Bleeding also may result from straining or activity that disturbs the scab
which forms during healing. Any significant postsurgical bleeding should be reported to
your urologist immediately.
- Urinary Discomfort
or
Incontinence: While BPH patients usually note an improvement in their ability to
urinate shortly after surgery, some may have some initial discomfort, a sense of urgency
to urinate, or short-term difficulty in controlling urination. These conditions usually
improve as recovery progresses, but it is important to remember that the longer the
urinary problems existed before surgery, the longer it will take to regain full and normal
bladder function afterward.
- Sexual Function:
Most experts agree that surgery usually does not cause IMPOTENCE, and will not restore
potency to men who were unable to achieve or maintain an erection before prostate surgery.
However, many authorities assert that up to 30% of men who undergo BPH surgery experience
sexual function problems. It is generally agreed that complete recovery of sexual function
may take up to a year after surgery, depending upon how long the patient's problems
existed before the operation. The most common, unavoidable, long-term side effect of
prostate surgery is retrograde ejaculation ("dry climax"), which results when
the muscle that usually blocks off the bladder during ejaculation is cut or cored away.
Semen then enters the wider opening to the bladder instead of being expelled through the
penis. Apart from an inability to father children (sterility), men with this condition
suffer no other complications.
|
