has information about the diagnosis
of bph, the medical
management of bph, minimally
invasive management of bph, and surgical
managment of 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
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.
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.
are the symptoms of 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:
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.
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
are the treatments for BPH?
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.
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
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
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).
alpha reductase inhibitors
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.
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
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.
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.
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.
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
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.
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:
1) Microwave thermotherapy, described on a separate
2) Radiofrequency ablation, or TUNA. This
has had limited success in the past, but new generators make this
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!
- 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.
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
These all require general or spinal anesthesia,
but result in greater improvement in urinary symptoms than office-based
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.
Copyright 2006 Napa
Valley Urology Associates