Benign Prostatic Hyperplasia

What is benign prostatic hyperplasia (BPH)?

Benign prostatic hyperplasia (BPH) is the term used to describe a non-malignant growth of the prostate gland; one that is responsible for blocking the flow of urine out of the urinary bladder. It is more commonly known as enlarged prostate.

Normal Prostate

Enlarged Prostate

What causes BPH?

As a male matures, the prostate goes through two main periods of growth. The first occurs early in puberty, when the prostate doubles in size. At around age 25, the gland begins to grow again. It is this second growth phase that often results years later in BPH.

As the prostate enlarges, the surrounding capsule stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. Because of this, the bladder wall becomes thicker and irritable and begins to contract even when it contains small amounts of urine. This causes more frequent urination. As the bladder weakens, it loses the ability to empty itself, and urine remains behind. This narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH.

When do symptoms of BPH usually start to appear?

Although the prostate continues to grow during most of a man's life, the enlargement doesn't usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and as many as 90 percent in their seventies and eighties have some symptoms of BPH.

What are the Symptoms of BPH?

Some men with BPH or an enlarged prostate have no symptoms at all. Those who do have symptoms can complain of waiting a long time for urination to start, a slow stream of urine, and a feeling that the bladder does not empty completely. They may also complain of frequent urination, an urgent need to urinate immediately, or getting up frequently at night to void.

What are the treatment options for BPH?

Medical treatments for prostate disease have gone in multiple directions over the last few years. There are two major thrusts -- reducing prostate size, and relaxing the muscles surrounding the prostate to allow flow through the urinary channel. The following are some of the treatments used:

Hormone suppression

The drug Avodart (Dutesteride) and Proscar (finesteride) suppresses the action of the hormone testosterone in the prostate cells. This allows men to have normal libido, but at the same time the prostate responds as if there is very little testosterone present. Current studies suggest that 50-70 percent of properly selected patients experience a reduction in prostate volume and enlarged prostate symptoms over a four to 12-month period. Proscar has been shown to be very safe with very few minor side effects. The only commonly seen side effect is a 3 percent (three out of 100 men) incidence of loss of sexual potency. Proscar works best in men whose prostate glands are larger than normal size. It has less effect on men whose prostate size is small and where the urinary blockage is based on increased muscle tone.

Medication that relaxes the muscles that surround the prostate channel

The anatomy of the bladder and prostate is such that a special muscle surrounds the urinary channel in its course from the bladder into the prostate. In many men, increased tone of this muscle occurs with aging and can be a cause of significant blockage of urinary flow without significant prostate growth. This muscle that runs around the prostate channel can be relaxed by taking specific medications. Most of these drugs are blood pressure medications, including Hytrin or Cardura and Flomax (terazosin and doxasin). The smooth muscles around the neck of the bladder and prostate are relaxed by these medications, and many men have both subjective and objective improvement of their urinary flow. These improvements usually occur within the first few weeks of taking the medication. These seem to work best in patients with smaller prostates, but work in larger glands as well.

Transurethral resection of the prostate (TURP)

Transurethral resection of the prostate (TURP) has been the primary choice of treatment for the past 50 years for BPH that causes obstruction of the bladder outlet. TURP is a safe procedure with four out of five patients experiencing resolution of their voiding symptoms with improvement of all of their urinary flow measurements. Essentially, TURP is the removal of the obstructing portions of the prostate with a telescopic electric knife. The TURP requires an anesthetic and takes from 30 to 60 minutes to perform. A tube (catheter) is inserted into the bladder and is left in place for 24 to 48 hours. The hospitalization lasts from one to three days and requires two weeks of severe activity restrictions and another two weeks of modest restrictions. Complete recovery may take as long as 12 weeks in some individuals. No treatment to date has bettered the long-term effectiveness of TURP in alleviating obstruction caused by benign prostatic hyperplasia.

Because TURP is a surgical procedure with some risks, and because of the monetary cost and necessary time off work, other methods of therapy are being intensively looked at by the medical community. These include medical treatments and alternative surgical treatments which are less complicated than transurethral resection of the prostate.

The illustration below is a representation of the prostate gland after TURP (transurethral resection of prostate), open prostatectomy, transurethral laser removal of prostate, and transurethral vaporization of prostate.

Transurethral incision of the prostate (TUIP)

A transurethral incision of the prostate (TUIP) is the alternative to TURP that comes closest to matching its results in both symptom relief and improvement in flow rates. The basic goal of the procedure is to remove just a minimum of prostate tissue to allow adequate flow through the prostate. This is done by making a simple cut (incision) along the entire length of the prostate. Because of the circular muscle fibers running around the prostate, the TUIP allows the bladder neck to spring open and allow free urinary flow. TUIP is particularly beneficial for smaller prostates and has a lower incidence of ejaculation disturbances. The success rate for TUIP is about the same as transurethral resection of the prostate, but only in those patients who are carefully selected (those with a smaller prostate). Hospital stays and recovery times are much shorter.

Open prostatectomy

Open prostatectomy refers to a major surgical procedure for removal of the obstructing portion of the prostate. Open prostatectomy involves an incision on the lower abdomen. The prostate can be approached either through the bladder (suprapubic) or directly through the capsule of the prostate (retropubic). In either case, the blocking or obstructing portion of the prostate is shelled out from the prostate capsule in one piece. The end result is similar to the TURP, in which the obstructing portion of the prostate is removed, leaving the prostate capsule behind. Performing an "open" prostatectomy is based on the size of the prostate. The telescopic approaches (TURP, TUIP, laser, hyperthermia and balloons) are ineffective or impossible with prostate glands that are in the upper five to 10 percent of size (usually greater than 75 to 100 grams). Open prostatectomy requires an anesthetic (general or spinal) and usually three to five days of hospitalization. Some prostates are large enough that open prostatectomy is the only treatment option. Open prostatectomy, also called "simple" or "subtotal" prostatectomy, should not be confused with "radical" prostatectomy, an operation done for prostate cancer in which the entire prostate, including capsule, is removed.

Transurethral laser removal of prostate

This procedure consists of passing a laser into the prostatic channel under telescopic guidance. The laser is then used to destroy or heat up the obstructing portions of the prostate. Compared to transurethral resection, the advantages of the laser-assisted procedure are a shorter hospitalization, reduced operating time, an apparent decreased incidence of postoperative scarring, decreased incidence of lack of ejaculation, and no significant bleeding. The laser-assisted prostatectomy is not optimum in the treatment of the very large prostate yet because of the necessity for multiple treatments. Another concern is that no prostate tissue is removed so we cannot be certain that cancer does not exist. Given the excellent diagnostic techniques available today with PSA and ultrasound, the lack of tissue does not seem to be very important. There is also a fair amount of swelling of the prostate channel initially (three to 10 days) which

may require catheter drainage (a tube through the penis into the bladder). A couple weeks of frequency and irritation of urination occurs while the prostatic channel is healing. The biggest advantages are that it is usually an outpatient procedure and there is ordinarily little bleeding.

Transurethral vaporization of the prostate

"Vaporization" of the prostate is the newest treatment option for prostate enlargement. The vaporizer uses a high-energy electric source similar to the electrical source used for transurethral resection or incision of the prostate mentioned above. The difference is the amount of electrical current used (all are safe) and the type of contact made with the instrument. For transurethral resection the electric current is passed through a small wire. This allows cutting of the prostate tissue to remove it, but if the current is turned to a higher setting and a blunt roller ball is used (about the size of a BB), the tissue actually melts or vaporizes.

Essentially, the procedure consists of passing an electrode into the prostatic channel under telescopic guidance. The electrode is then used to vaporize the obstructing portions of the prostate. Compared to transurethral resection, the advantages of the vaporization procedure are that there is a shorter hospitalization and no significant bleeding. The vaporization prostatectomy is not optimum in the treatment of the very large prostate yet because of the necessity for multiple treatments. Another concern is that no prostate tissue is removed so we cannot be certain that cancer does not exist. Transurethral resection for biopsy purposes initially followed by vaporization may solve this dilemma. The biggest advantages are that it is usually an outpatient procedure and there is ordinarily little bleeding. This technology is new and long-term results and side effects are not yet known, although in theory it is very promising.

Transurethral microwave therapy of the prostate (TUMT)

In concept, TUMT is similar to the transurethral laser procedure. TUMT is done on an outpatient basis with local anesthesia and mild sedation. The procedure involves the use of a special catheter that houses a microwave source at its tip. This catheter is placed through the penis so that the microwave source is placed into the prostatic channel. The prostate is heated to temperatures above 105 degrees Fahrenheit. This causes destruction to the prostate tissue and shrinkage of the gland, and also may act to relax the channel through the prostate by affecting prostatic nerves. Again, no prostate tissue is removed for pathologic diagnosis. One of the newer techniques uses a catheter that cools the lining of the prostate while the prostate tissue deep inside is heated, and this allows for a faster recovery time. Some testing of hyperthermia has been done in the USA with reasonably good results -- about 50 percent of patients benefited. Patients with very large prostates or enlargement of the middle lobe of the prostate are not good candidates for TUMT. Because the prostate is likely to swell initially, most patients are discharged with a catheter in the bladder for a few days to allow drainage until the prostatic swelling subsides. Sexual functioning is not usually affected by TUMT. The FDA approved the use of microwave hyperthermia in September 1995. Experience in the United States, however, is still limited.

Transurethral needle ablation of the prostate (TUNA)

Transurethral needle ablation of the prostate is similar to laser ablation of the prostate. In this procedure, a telescope is placed into the prostatic channel. Special needles are placed deep through the telescope into the prostate tissue. High frequency radio waves are emitted from the end of the needles, which are similar to radio antennas, and the prostate is heated to very high temperatures. The heated prostate tissue is destroyed and initially swells but then shrinks. Most men require a catheter for a period of time after the TUNA procedure until the swelling subsides. As with the laser procedure, no prostate tissue is removed for pathologic diagnosis. The FDA has recently approved the use of the TUNA procedure in the United States. Experience in the United States is still limited.

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