BPH

Urologyhealth.org has information about the diagnosis of bph, the medical management of bph, minimally invasive management of bph, and surgical managment of bph.

BPH, or benign prostatic hyperplasia, is an extremely common condition that affects up to half of all men at some point and over 70 percent of men aged 80 or more. The reason for this is that all men (except for the rare ones who congenitally do not have one) have prostates, and the prostate tends to grow as men age. It does so under the influence of testosterone.

From puberty on, the testicles produce testosterone, giving men their male characteristics such as increased muscle mass, facial hair, deepening of the voice, a volatile temper for some, etc. One of the unwanted affects of testosterone in the healthy male is that it causes the prostate to grow. This would not be a problem were it not for the fact that the urinary channel from the bladder to the outside world, known as the urethra, passes right through the middle of the prostate. This is illustrated well in this video from another website.

It is not the absolute size of the prostate that causes difficulty with urination. Some people have large prostates but have minimal or no symptoms. Some men have small prostates and have marked symptoms. The reason for this disparity is that it is only the internal growth of the prostate that causes symptoms. If the growth occurs so that the urethra is narrowed then symptoms usually will become manifest. This narrowing or blockage of the urethra is termed bladder outlet obstruction or BOO.

As the urethra is narrowed by the benign growth of the prostrate and BOO occurs, the bladder gets stressed. Under normal conditions the bladder squeezes during urination as the prostatic urethra and urinary sphincter relax and open. The bladder is a muscle that functions very well. As BOO occurs, the bladder needs to squeeze harder in order to get the urine out. As a muscle, the bladder is able to compensate initially by growing bigger and getting stronger, similar to the bicep after doing arm curls for a few weeks. This compensation works well for some time, but as the bladder gets more muscular it becomes less compliant or strechable, so that it can no longer hold as much urine as it could before. This is when symptoms usually start to occur.

After years of working harder to empty itself of urine, the bladder will begin to decompensate if BPH is not treated. This decompensation occurs as the bladder becomes both more rigid and weaker, so that it is unable to hold much urine and does not have enough strength to empty it. Once this occurs, then it is too late to be able to reverse the detrimental affects of BPH. It is very important for men to get their BPH treated before this occurs.

What are the symptoms of BPH?

BPH causes problems that are categorized as irritative or obstructive. Irritative symptoms are caused by the stress affects on the bladder having to work harder against the obstructing prostate and include:

1) Urgency
2) Frequency
3) Nocturia (waking up at night to urinate)

Obstructive symptoms are those caused directly by the narrowing of the urethra by the prostate and include:

1) Decreased force of the urinary stream
2) Hesitancy (takes time to get stream started)
3) Intermittancy (the urine stream starts and stops alot)
4) Incomplete emptying
5) Stranguria (having to push urinate).

These symptoms are most often assesed by urologists by a questionnaire known as the AUA (American Urological Association) symptom score (AUA SS). This questionnaire assesses each one of the symptoms listed above and is very accurate at diagnosing BPH. It is the most validated questionnaire in all of medicine. The symptom score gives a number value between 0 and 35. The higher the number, the more severe the symptoms are. This questionnaire can be found here.

The severity of symptoms is characterized as mild, moderate, or severe by the number value one gets on the symptom score.

Mild = 0 to 7
Moderate = 8 to 19
Severe = 20 to 35.

Mild symptoms can safely be monitored without treatment. Moderate to severe symptoms should be treated to prevent possible later complications of BPH which include renal failure, urinary retention requiring a catheter, recurrent bladder infections, or chronic problems urinating that will not improve with any type of therapy.

What are the treatments for BPH?

There are both medical and surgical treatments for BPH. It is recommended that any patient with moderate to severe symptoms, as defined above, be given a trial of a medication. There are both standard medications than can help as well as some complimentary medicines (CAM) which may be of benefit. We will review those drugs used the most and supported by the literature.

Alpha blockers

There are alpha receptors in the prostate that, upon stimulation, cause constriction or tightening of the prostatic urethra. Alpha blockers block these receptors, causing the prostatic urethra to relax and open up more during urination, often times dramatically improving urinary symptoms.

The urethra is constricted here by the prostate.

Alpha blockers help ease the constriction caused by the prostate on the urethra.

There are non-selective and selective alpha blockers that can be used. The non-selective medications, such as hytrin (terazosin) and cardura (doxazosin), also block alpha receptors in the blood vessels. As a result, they can lower blood pressure and need to be titrated up slowly to prevent light-headedness or syncope (passing out). These work well as a combination for both high blood pressure and BPH, and are available in generic form as well.

The selective alpha blockers do not affect the blood vessels, so that changes in blood pressure are much less common and the medications do not need to be titrated up. These include Flomax (tamsulosin) and Uroxatrol (alfuzosin). These are more expensive than the non-selective medications but have much lower rates of side effects and are covered by most insurances. Retrograde ejaculation can be a problem with Flomax in 5 percent of cases, while it is less common with Uroxatrol.

In patients who have a large prostate with BPH, studies recently have shown that combination therapy with an alpha blocker as well as a 5 alpha reductase inhibitor works better than an alpha blocker alone. This is recommended for patients who have a prostate larger than 40 grams (20 grams is normal).

5 alpha reductase inhibitors

As was mentioned earlier, the prostate grows under the influence of testosterone. More specifically, it is the more active form of testosterone, dihydrotestosterone, that causes the prostate to grow. 5 alpha reductase is the enzyme that actively converts testosterone to dihydrotestosterone. By blocking the receptor to this enzyme, dihydrotesterone levels are lowered and the prostate will actually shrink.

Proscar (finasteride) was the first 5 alpha reductase to get FDA approval and has been around long enough that it will be available in generic form by the end of 2006. This medication causes the prostate to shrink by 30 to 50 percent and will lower the psa level by 1/2. It takes 4-6 months for these effects to occur. This medication has been shown to decrease the chance of having urinary retention when the prostate is 40 grams or larger. A large trial also showed that daily proscar can reduce the risk of prostate cancer, although the risk of getting high-grade prostate cancer was increased, so it is recommened not to use this for prostate cancer prevention at this time until more studies are done.

Avodart (dutasteride) is another 5 alpha reductase inhibitor that has been shown to shrink the prostate in 4 to 6 months. Some data suggests that it shrinks the prostate a little bit faster than Proscar, but there has not been any randomized trial showing this or showing whether there is any added benefit to patients when compared to Proscar. Like Proscar, a patient on this medication should have their PSA doubled to get the true PSA value, as it will decrease by 1/2 with this therapy.

Combination Therapy

There is data recently that suggests that men with larger prostates benefit from taking both an alpha blocker and a 5 alpha reductase inhibitor. If patients elect to go this route, what can often times be done is the alpha blocker can be stopped after six months. Alpha blockers work much quicker than the 5 alpha reductase inhibitors, so they can help with the initial relief of symptoms until the 5 alpha reductase inhibitor kicks in.

Continued monitoring

Regardless of which type of medicine a patient takes, it is important that they continue to visit a urologist to ensure that there symptoms are responding appropriately. Typically we have patients come back to see us after trying the medications for a month or so. At that time another AUA symptom score is done. If there is a dramatic improvement in the symptom score, then we typically will see the patient every six months after that.

We expect the AUA symptom score to improve enough to put them in the mild symptomatic category, or at least the lower end of the moderate symptom category. If not, then the medicine is not working well enough to prevent complications of BPH, so more invasive therapy is then recommended.

Surgical Therapy

If medications do not improve symptoms from BPH, then it is recommended that more invasive treatments be undertaken to prevent complications of BPH. Men are generally afraid of having any surgical therapy done. However, there are a number of minimally invasive procedures that are very safe and effective at dramatically improving symptoms from BPH.

Prior to having any procedure done to improve symptoms from BPH, additional tests are usually performed. This can include a transrectal ultrasound, wherein an ultrasound probe about the size of a human thumb is inserted into the rectum to accurately measure the size of the prostate.

Transrectal ultrasound visualizing the prostate. This is the most accurate method to determine the size of the prostate, which is important in planning therapy.

Another common procedure is cystoscopy, where a small flexible scope the size of a small catheter is inserted under local anesthesia in order to visualize the prostate to get a better idea of the anatomy. A bladder scan may be done to check to see if the bladder is emptying completely. Finally, a PSA, a prostate cancer screening test, is generally performed, as well as a digital rectal exam, to rule-out the possibility of prostate cancer.

Once these tests are done, recommendations can be made as to options for surgical therapy. All of these procedures involve passing an instrument through the penis to the prostate and using some sort of energy to ablate or remove the obstructing prostate tissue. These options include:

Office-based procedures:

1) Microwave thermotherapy, described on a separate page.

2) Radiofrequency ablation, or TUNA. This has had limited success in the past, but new generators make this more promising.

These can be done with a local anesthetic with little discomfort with generally 70 percent effectiveness.

3) In-Office Biolitec diode laser prostatectomy:
This is an exciting option that we are now using that effectively removes the obstructing prostate tissue utilizing this exciting laser in the office. We have seen dramatic results that are equally effective to the green light laser, but can safely be done in the hospital with local anesthesia with minimal to no discomfort. Dr. Hendricks does feel there is even less bleeding utilizing this laser than there is with the green light laser.
Please go to http://www.drjhendricks.com/OfficeBPH.htm to hear more about this exciting new option!

Hospital-based procedures:

Green light laser prostatectomy, or photoselective vaporization of the prostate (PVP). The new gold standard described on a separate page. Patients go home the same day of the procedure.
Holmium laser enucleation of the prostate. This works well, but results ? as good as PVP.
TURP - transurethral resection of the prostate. The old gold standard that involves cutting out the prostate through the urethra with excellent long term results. Usually requires a 2 day or more hospital stay due to more bleeding than 1 or 2 above. This is usually recommended for larger glands.

TURP: An instrument passed through the penis is used with a loop attached to a cutting current to cut the obstructing prostate out, making the urine channel much wider.

4. Open simple prostatectomy. If the prostate is very large, generally more than 100 grams, then an open procedure is recommended as it would take much longer to remove enough prostate to improve symptoms with TURP or laser therapy. This requires 3-5 days in the hospital, but is much safer if the prostate is large.

These all require general or spinal anesthesia, but result in greater improvement in urinary symptoms than office-based procedures.

Dr. Hendricks has a large experience using all of these treatments for BPH. He tailors treatment to the individual. Recommended treatments depend on the individual patients medical history and their particular anatomy. He will discuss all the important issues regarding treatment and give you all the information you need to make an informed decision on how to be treated.

See the separate pages using the links to Green light laser prostatectomy and microwave thermotherapy.

Contact us at (707)224-7944 if you would like an appointment to discuss management of symptoms of bph.