BPH is an acronym for the condition known as benign prostatic hyperplasia or what is
commonly referred to as prostate enlargement. Oftentimes, patients confuse BPH
with prostate cancer. As the name of this condition implies this is a benign condition
and is not associated with malignant or cancerous prostate conditions.
BPH is diagnosed by your physician after performing a complete history and physical
examination. The symptoms of BPH coupled with a rectal examination
demonstrating an enlarged prostate is suggestive of the condition. Your physician
might ask you to fill out a questionnaire quantifying the degree of your symptoms.
The IPSS (International Prostate Symptoms Score) is a validated questionnaire
utilized by physicians to quantify the degree of BPH symptoms. Your physician will
have to perform some tests to confirm your condition. Additional tests include: PSA and Testosterone, Urine analysis and culture to rule out urinary tract infection, Residual urine determination, Flow rate, Cystoscopy, Transrectal ultrasound, Urodynamics.
There are several medications available for the treatment of BPH. These medications
can be divided into three general categories: phytotherapy, alpha-blockers and
5-alpha reductase inhibitors.
Saw palmetto is an extract from the berry of the dwarf palm that is indigenous to the
Southeastern United States. It is a non-prescription medication available at most
drug stores and its production and distribution are not regulated by the FDA. It is
usually taken at a dose of 160 mg twice daily. Despite its popularity, the medical
literature has not shown this medication to have any benefit over placebo
medications. A recent randomized double blind placebo controlled study showed that
saw palmetto has no benefit in relieving prostate symptoms or objective parameters
of BPH compared to placebo.
(Bent S et al, N Engl J Med, February 2006)
Alpha-Blockers Alpha blocker medications are drugs that block the alpha receptors in the prostate
causing relaxation of the smooth muscle component of the prostate. This relaxation
allows the channel to open and relieves a man of his urinary symptoms. Alpha
blockers can be divided into two different categories: selective and non-selective. The
non-selective alpha blockers, as the name implies, are not specific for the prostate
and can effect other organ systems. The effects on other organ systems can cause
decreases in a man's blood pressure, dizziness, runny nose, sexual dysfunction and
erectile dysfunction. These non-selective alpha blockers also require dose titration to
prevent the most severe of these side effects. Non-selective alpha blockers include
terazosin, prazosin and doxazosin.
In contrast, the selective alpha blockers are designed to exert their effect primarily on
the prostate. Medications such as tamsulosin (Flomax) and alfuzosin (Uroxatrol) are
the two FDA approved selective alpha blockers. These medications have been shown
to be equally effective to the highest doses of the non-selective alpha blockers while
minimizing the side effects of this medication class.
5-alpha Reductase Inhibitors (5ARI) The prostate gland grows under the direct influence of testosterone. The drug class
of 5ARI's prevent the conversion of testosterone to dihydrotestosterone (DHT), the
more potent form of testosterone which has its primary effect on the prostate, liver and
scalp. By suppressing the amount of DHT, we can decrease the size of the prostate
gland by "starving" the gland.
There are two FDA approved medications in the 5ARI class: finasteride (Proscar) and
dutasteride (Avodart). The difference between the two drugs is that dutasteride
inhibits both types of 5ARI in the prostate, whereas, finasteride only inhibits one of the
isoforms. This translates to a 97% vs 70% effectiveness of inhibiting 5ARI,
respectively. Both medications are fully effective after 6 continuous months of therapy
and cause a decrease in the PSA by at least 50%.
Combination Therapy Combination therapy with an alpha blocker and 5ARI has been shown to be the most
effective medical therapy for BPH. Combination therapy is usually reserved for men
with progressive symptoms on monotherapy.
Catheterization Placement of a catheter into the bladder will temporarily drain urine. Catheters can
be placed intermittently every six to eight hoursóclean intermittent catheterizationó
or left in place for one to three months at a time (indwelling). Catheters can be
placed either through the urethra or by making a small puncture into the bladder
above the pubic bone (called a suprapubic tube). Infection is the biggest risk of
having a catheter in place for long periods, as bacteria can stick to the surface of the
catheter, making it difficult for the body's immune system or antibiotics to clear the
organisms. Another risk is that after a few years there is a higher risk of bladder
cancer due probably to the long-term irritation caused by the catheter sitting in the
bladder. Catheterization, performed by the individual or a caregiver every six to eight
hours, minimizes the risk of infection and cancer compared with an indwelling
catheter. Catheters are most useful as a treatment of choice for temporary drainage
while waiting for medication to start working, surgery to be scheduled, or clearance
of infection. They also might be the most appropriate choice for a patient with
multiple medical problems and a short life expectancy, where the risk and
discomfort of surgery outweigh the risk of infection or cancer. Catheterization is the
treatment of choice over medications or surgery for patients who have neurogenic
bladder in addition to prostatic obstruction.
Microwave Thermotherapy (TUMT) This is an office-based procedure performed with topical and oral pain medication
and does not require anesthesia. Computer-regulated microwaves are sent through
a catheter to heat portions of the prostate. A cooling system is required in some
types for better tolerance. Traditionally, the best use of this procedure has been for
patients who have too many medical problems for more invasive surgery or for
patients who truly wish to avoid any type of anesthesia. Benefits are that there is no
need for anesthesia and there is no blood loss or fluid absorption (these would be
significant benefits in a person with a weak heart). Patients usually go home the
same day. Many urologists have the technology available in their practice and results
are pretty reliable regardless of who performs the procedure. The use of TUMT has
been expanding to a broader patient population and there are several types of TUMT
TUNA The procedure involves anesthesia and medications to make the patient sleepy. The
technology involves heating of tissue using radio frequency energy transmitted by
needles inserted directly into the prostate. High frequency radiowaves heat the
prostate up 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
this procedure. Advantages in the use of TUNA include the limited anesthesia
requirement, the ability to perform the procedure in an office setting and avoidance of
serious complications sometimes associated with other procedures.
Photoselective Vaporization of the Prostate (PVP) This is fast becoming a very popular procedure performed either in a well equipped
office or as an out-patient at the hospital. It uses a high-powered laser that vaporizes
the obstructing prostate tissue with minimal bleeding or side effects. This procedure
can serve to get men off of medical therapy. It is effectively replacing more invasive
Transurethral Resection of the Prostate (TURP) Transurethral resection is the most common surgery for BPH. In the United States,
approximately 150,000 people have TURPs performed each year. This can be done
using electric current or with laser light. After the patient receives anesthesia, the
surgeon inserts an instrument called a resectoscope through the tip of the penis into
the urethra. The resectoscope contains a light, valves for controlling irrigating fluid
and an electrical loop that cuts tissue and seals blood vessels. The removed tissue
pieces are carried by the irrigating fluid into the bladder and then flushed out and
sent to a pathologist for examination under a microscope. At the end of the
procedure, a catheter is placed in the bladder through the penis. The bladder is
continuously irrigated with fluid through the catheter in order to monitor bleeding and
prevent blood from clotting and obstructing the catheter. Since there are no surgical
incisions with this procedure, patients normally stay in the hospital only one to two
days. Depending on surgeon preference, the catheter may be removed while the
patient is still in the hospital or the patient may be sent home with the catheter in
place, attached to a leg bag for convenience and removed several days later as an
Transurethral incision of the prostate (TUIP) Transurethral incision is used for men with smaller prostate glands who suffer from
significant obstructive symptoms. Instead of cutting and removing tissue to relieve
the obstructed bladder, this procedure widens the urethra by making several small
cuts in the bladder neck where the urethra joins the bladder and in the prostate itself.
This reduces the pressure of the prostate on the urethra and makes urination easier.
Patients normally stay in the hospital one to three days. A catheter is left in the
bladder for one to three days after surgery.
Open Surgery - Simple Prostatectomy
When a transurethral procedure cannot be done, open surgery may be required.
Open prostatectomy for BPH is also performed for a prostate that is too large to
remove through the penis. Other reasons for choosing an open prostatectomy
include patients with large bladder diverticula, with large bladder stones and who
cannot physically tolerate having their legs placed in stirrups for TURP/TUIP surgery.
An incision is made in the abdominal wall from below the belly button to the pubic
bone. The prostate gland can then be removed in its entirety through either an
incision in the fibrous capsule surrounding the prostate (retropubic prostatectomy) or
through an incision made in the bladder (suprapubic prostatectomy). Postoperative
pain is mild to moderate. Patients usually stay in the hospital for several days and go
home with a urinary catheter. In some cases a second catheter draining the bladder
through the lower abdominal wall is used.
Postoperatively, patients typically experience significant improvement in their
symptoms (table 1). As with any operative procedure, complications do exist. Some
occur in the early postoperative period (table 2) while others may occur many years
later (table 3).
Table 1: Overall improvement in patient symptoms
Table 2: Immediate post-operative complications
Bleeding Requiring Transfusion
Table 3: Late post-operative complications
Stricture and bladder neck contracture (scar tissue causing obstruction)
Most urologists say that even though it takes a while for sexual function to return
fully, most men are able to enjoy sex again. Most experts agree that if you were able
to maintain an erection shortly before surgery, you will probably be able to do so
after surgery. Most men find little or no difference in the sensation of orgasm
although they may find themselves suffering from retrograde ejaculation.