Benign Prostatic Hyperplasia (BPH)
The prostate is a walnut-shaped glandular organ located around the neck of the urinary bladder and is only found in males. It weighs only few grams at birth, but grows significantly during puberty and reaches the adult size of about 20g by age 20. It remains relatively stable in size until the fifth decade of life when another growth spurt begins in most men.
Because of this second growth spurt, enlarged prostate is common among men over 45 years old and increases in frequency thereafter, such that by the eight decade, about 90 percent of men have enlarged prostate. The prostate gland produces about 20% of seminal fluid. It principally stores and secretes a milky alkaline fluid which contains the semen, spermatozoa and seminal fluid. The alkaline nature of the fluid helps neutralize the acidic fluid in the vaginal tract.
The prostate also contains smooth muscle. The prostate surrounds the urethra, and an enlarged prostate is the commonest cause of obstruction to outflow of urine in men. Enlarged prostate can be benign or malignant, and most of the causes can be treated without adversely affecting sexual function.
Infections, commonly called prostatitis, can also cause prostate enlargement. It is advisable that men who are age 50 and older, should have digital rectal exam and Prostate-Specific Antigen test as part of their annual physical exam, to enable early detection of enlarged prostate gland. This will increase the chances of a possible cure.
Benign Prostatic Hyperplasia Treatment
Benign prostatic hyperplasia is often loosely interchanged with benign prostatic hypertrophy ( even among urologists). BPH is the most typical cause of prostate enlargement. This condition is particularly common among men over 45 ( because of the second prostate growth spurt, which commences during the fifth decade of life). The incidence increases with age after that. Estimations show that about 90% of men have hyperplasia of the prostate by the eighth decade of life, often discovered at autopsy.
The disorder occurs in all populations, but statistically it occurs less frequently in the Oriental population. The benign prostatic hyperplasia symptoms occur earlier in blacks ( mean age = 60 years) than whites ( mean age = 65 years). This condition is the commonest cause of obstruction to urinary outflow in men. It has not yet been established whether hyperplasia predisposes to the development of prostatic cancer.
The hyperplasia begins in the prostate tissue around the urethra and then progresses to compress the remaining gland. The tissue becomes nodular, comprising of smooth muscle, stroma, and glandular epithelium. The precise reason for the proliferation of the glandular epithelium is unknown. However, the involvement of Androgen (testosterone and other male hormones) estrogens and other growth factors have been postulated. The prostate lies between the bladder ( and surrounds the urethra) and the rectum. Therefore, the enlargement can obstruct urinary outflow causing urinary retention. It can also block the rectum, causing constipation and, consequently, may be associated with abdominal pain.
Benign Prostatic Hyperplasia causes both obstructive and irritative symptoms. Obstructive symptoms are related to the mechanical obstruction of the urethra by the enlarged prostate (initially, the bladder tries to overcome the obstruction by undergoing compensatory hypertrophy). In contrast, irritative symptoms result from the contraction of the bladder detrusor muscle. Sometimes, an individual may have BPH without any symptoms.
The obstructive symptoms include:
- hesitancy ( difficulty in initiating the flow of urine);
- a diminished force of urinary stream (despite a full bladder);
- a feeling of incomplete bladder emptying ( patient feels that there is still some residual urine);
- intermittent urinary stream;
- straining to urinate;
- Post-urination urinary dribbling ( ranging from a couple of drops after urination to a continuous leak that is difficult to control);
- urinary retention ( this retention may occur suddenly or over some time).
The irritative symptoms include:
- daytime frequency;
- nocturia (awakening from sleep to pass urine at night);
- dysuria (painful or difficult urination);
- urgency (sudden, compelling urge to urinate that brooks no delay);
- overflow or urge incontinence ( an urgent need to urinate that may be associated with leakage of urine).
If the condition becomes complicated, there may be hematuria (presence of blood in the urine) due to the congestion and rupture of the prostatic urethra’s superficial veins. Straining to urinate may eventually lead to syncope (vasovagal), inguinal hernias. Other symptoms may also include abdominal discomfort and urinary retention. Urinary retention can either be chronic ( developing over time) or acute ( occurring suddenly). Infections, alcohol, anesthetics, exposure to cold, or antihistamines can cause acute urinary retention.
Management Of Benign Prostatic Hyperplasia
Diagnosis Of BPH
Diagnosis of the condition is based principally on the digital rectal examination and the patient’s symptoms. Digital rectal examination may reveal an enlarged prostate with or without a palpable bladder. The natural history of the condition is not often clear cut. The majority of men with BPH do not present with either significant obstructive or irritative symptoms. An enlargement of the prostate alone is not always a valid reason to treat the affected individual.
The attending health practitioner will take a detailed history, focusing on the urinary tract, making every effort to identify or rule out other possible causes of urinary voiding dysfunction. The practitioner may quantify the disorder ( as either mild, moderate, or severe) based on the AUA Symptom index (also used in planning treatment and patient follow-up). Prostate-specific antigen ( PSA) may be measured and used to exclude advanced cases of prostate cancer. PSA is not particularly useful in the early case of Prostate cancer.
There are other tests like uroflowmetry, postvoid residual urine volume, pressure-flow studies, urethrocystoscopy, and imaging studies such as ultrasonography and intravenous pyelography. The health practitioner will determine which is appropriate.
Treatment Of BPH
Patients who have benign prostatic hyperplasia but do not have any symptoms are generally not placed on any treatment. A variety of decision diagrams are available to assist health practitioners in making decisions as to what kind of action is applicable, but ultimately, the decision to treat and the appropriate treatment depends on the severity ( and type) of the symptoms and affected individual’s expectations and preparedness to accept the adverse consequences of treatment.
Lifestyle Modification: Doctors advise affected patients to decrease fluid intake before bedtime and reduce alcohol or caffeinated beverages.
This approach is for individuals who do not have symptoms. But these individuals must be monitored annually for evidence of disease progression.
Before engaging in any form of medical or surgical intervention for BPH, the health practitioner will perform the following: Take a complete history, perform a thorough physical examination which includes a digital rectal examination, ultrasound, routine urine analysis, electrolyte check, determination of post-void residual urine, cystoscopy and PSA determination.
Medical treatment is targeted towards relaxing the prostatic smooth muscles ( by inhibiting the alpha-adrenergic receptors) and suppressing the hormones.
A doctor may prescribe alpha-blockers if the prostate is relatively small. They tend to open up the bladder neck and the prostate and let the bladder work a little bit easier. They work very well and. These drugs don’t tend to stop the progression of the BPH. And symptoms may continue to accumulate over time.
There is a second class of drugs – Proscar (Finasteride) and Avodart. The way they work is by basically preventing the prostate from seeing the testosterone that it needs. Finasteride is the most promising of the anti-androgenic drugs that are currently in use. This drug inhibits the 5-alpha reductase enzyme and thereby blocking the conversion of testosterone to dihydrotestosterone
The prostate takes testosterone, changes it to a form that it can use, and then uses that to grow. These two drugs prevent that conversion. A prostate shrinks by about 20 to 30 percent for about six months. These drugs tend to work better for larger prostates than it does for smaller ones.
Terazosin effectively relaxes the bladder neck’s smooth muscle and increase the urinary flow rate. Not all affected people respond to medical treatment, and the drugs also have their side effects, which we will not discuss here.
TUMT (Transurethral Microwave Therapy of the Prostate)
TUMT (Transurethral Microwave Therapy of the Prostate) is a minimally invasive treatment for men who have urinary difficulties secondary to prostate enlargement. Like several minimally invasive treatments, the idea is to heat the prostate tissue to a very high temperature. This high temperature will destroy the prostate tissue, which will die off and help relieve your symptoms over the next several days and weeks.
The procedure is relatively easy to do within an office setting. A doctor inserts a catheter into the penis. Inside that catheter is the microwave instrument that will generate the energy causing the heat. Another catheter is placed inside the rectum that has a thermometer inside. That way, it’s possible to measure and monitor the amount of heat that’s getting into your body. This way, it is possible to circulate water around the catheter inside the penis to keep the temperature from getting too high. This prevents from causing damage for the body.
The procedure takes about an hour to perform. Patients generally can go home the same day. Frequently they will go home with a catheter. And one of the issues about TUMT compared to either the TERP or the green light laser is the symptoms do not often get relieved right away. A catheter may be necessary for a day or longer. And even when the catheter is removed, patients may find that their symptoms have not been completely eliminated. It takes days or weeks until that occurs.
The procedure is very safe, with a low incidence of complications. The main thing is that you may need a catheter or that you may get a urinary infection. There’s a low incidence of urinary incontinence and retrograde ejaculation.
Newer technics have been emerged, which are minimally invasive. They are less painful, have fewer complications, and are easier to perform.
Laser prostatectomy is done through a scope, which is a tube with a light and vision. It enables a doctor to see what kind of treatment he is doing.
GreenLight® is used in the early stages to prevent the prostate from further growth. Thus, the damage to the kidneys of the bladder can be avoided. The chance of bleeding after this procedure is minimal. Overall, the discomfort which the patient has is also significantly decreased compared to other invasive procedures. Patients do not have to stay in the hospital for a long time and can be back to active life very soon.
The procedure also prevents the long-term use of medications. Doctors prescribe special drugs to avoid the growth of the prostate. However, it takes a lot of time for these medications to be effective. And patients may not want to wait too long for relief.
Prostate surgery provides the best chance of improvement in symptoms, but it also comes with possible complications. In general, transurethral resection of the prostate is the most common surgical method in use. This the ideal procedure used for patients with relatively small prostates. Open prostatectomy is used on patients with a huge prostate. Open prostatectomy has high complication rates.
Other treatment methods, such as laser surgery, thermal therapy, and stents, seem very promising. But the health practitioner will decide as to which line of action is appropriate for you. Be sure to consult your doctor for clarification.