What Is BPH?
BPH stands for benign prostatic hyperplasia, the medical term for an enlarged prostate. It involves prostate tissue response to testosterone and occurs normally in all men after age 40. All men with BPH do not require therapy.
Symptoms of benign prostatic hyperplasia vary from person to person, and can include one or many of the following:
- Difficulty starting urination (urinary hesitancy)
- Slow urinary flow
- Intermittent urinary flow
- Sense of incomplete bladder emptying
- Urinary frequency
- Nocturia (nighttime urinary frequency interrupting sleep)
- Urinary urgency
- Urinary incontinence (leakage of urine)
If left untreated, BPH can lead to bladder dysfunction, bladder stones, recurrent urinary tract infections, and even obstruction of the kidneys and subsequent kidney failure.
A proper diagnosis is essential to developing the optimal treatment plan for each patient with BPH. It is important to first begin with a thorough history. Men can complain of a multitude of symptoms, and therefore it is essential that a treatment plan is based upon how BPH is specifically affecting each of their lives. Your doctor may ask you to fill out an AUA Symptom Score to better assess the impact of your symptoms on your quality of life.
Physical Examination – A thorough physical examination is paramount in the diagnosis of BPH. Specifically, the digital rectal examination is performed by inserting a gloved finger into the rectum in order to help determine if the prostate gland is enlarged or feels abnormal and possibly suspicious for prostate cancer.
Other tests to assist in the diagnosis and subsequent treatment of BPH include:
- Urinalysis – An evaluation of the urine can help detect abnormalities such as inflammation or infection, and blood in the urine requiring additional evaluation.
- Uroflow – This test is performed in order to evaluate objectively the flow rate of the urine stream.
- Post Void Residual – Often used to detect how much urine is left over in the bladder after voiding. This is performed with a noninvasive ultrasound of the bladder ("bladder scan")
- Prostate Specific Antigen (PSA) Test – PSA is sometimes elevated with BPH, cancer, and infection. If elevated, it may be a sign of prostate cancer which would require additional information.
- Ultrasound –Ultrasound can also help determine the effects of BPH on parts of the urinary tract (bladder or kidneys).
- Cystoscopy – A thin tube with a lens and camera attached, called a cystoscope can be inserted into the urethra to help visualize the internal urethra and bladder. This scope, which is smaller than a standard urinary catheter, can help evaluate compression from the enlarged prostate gland, anatomic configuration of the prostate which could affect treatment choice, and other bladder abnormalities often associated with prostate enlargement (stones, bladder wall thickening, and diverticulae or pockets in the bladder wall that can cause problems).
- Urodynamic Studies – This specialized study precisely characterizes pressures within the urinary tract, and helps characterize the bladder’s response to filling and ability to empty with normal contraction. This test is often required in men with BPH and other conditions that can affect bladder function (neurologic diseases, diabetes, extremely poor bladder emptying) to be more certain regarding treatment alternatives.
How is BPH treated?
There is no cure for BPH, but once treatment is started, growth is generally halted. Due to different ways BPH affects the individual, there are multiple types of treatment. Frequently, less invasive treatments will suffice.
- Medical Treatments
Alpha-adrenergic receptor blockers: these drugs have been used for many years to treat the symptoms of BPH. Over the years, newer more selective types of alpha blockers have become available with better efficacy and fewer sider effects. Examples are Hytrin®, Cardura®, Flomax®, Uroxatrol® and Rapaflo®. Side effects may include dizziness, fatigue and headaches. Most also cause decreased or absent ejaculation.
- 5-alpha reductase inhibitors: these drug prevent the conversion of testosterone to dihydrotestosterone. This causes the prostate to shrink in size in about 30-40% of patients, thus reducing the BPH symptoms and increasing urinary flow rates. It is also very useful in patients who have bleeding from the prostate. Your doctor may prescribe this medication for you if surgery is planned as it may reduce bleeding during and after the procedure. Examples are Proscar® (finasteride) and Avodart® (dutesteride).Side effects may include impotence (ED), decreased libido and decreased volume of ejaculate.
- PDE-5 Inhibitors: Cialis® has recently been approved for daily use in the treatment of men with BPH and/or ED
- Herbal medications: Many patients seek out non pharmacological remedies. The most commonly used of these is Saw palmetto. Since this is an anti-inflammatory, it reduces the swelling of the prostate. Limited studies have been performed to test its effectiveness.
- Surgical Options
All surgical approach work on the premise that they enlarge the prostate urethra (urinary channel) by removing tissue.
This is considered the "gold standard" surgical treatment because of its durability and efficacy as a procedure. By using an endoscopic camera, your doctor can shave away the prostatic blockage and seal blood vessels with an electrical loop until a larger urinary channel is created. No incision is made on the skin. This is done using general or spinal anesthetic and commonly requires staying in the hospital overnight. A urinary catheter is left to drain the bladder until the channel is healed (usually 3-5 days). Upon catheter removal, in most cases, the improvement in urinary symptoms is dramatic. Constipation, sexual activity and strenuous activity should be avoided for at least six weeks following the procedure. Side effects may include incontinence, problems with sexual performance and bleeding and scar tissue. The long term outcomes remain excellent.
GreenLight™ Laser Therapy is a BPH treatment option that combines the effectiveness of TURP with fewer side effects. The procedure evaporates the prostatic tissue blocking the outlet of the bladder. GreenLight is generally performed under anesthesia as an outpatient procedure.
During the procedure, a telescope is inserted into the urethra up to the prostate. A laser fiber is then guided through the scope, gently vaporizing the prostate tissue.
GreenLight is known for providing impressive improvements in urine flow and a speedy return to normal activities. Side effects may include retrograde ejaculation, impotence, incontinence and scar tissue in the urethra.
There are numerous other minimally invasive surgical treatments for BPH. Your doctor can discuss these with you in greater detail.