BPH/Enlarged Prostate
One of the most pervasive problems common to a majority of men over the age of fifty is an enlarged prostate. The prostate is a gland that is attached to the bottom of the bladder that makes fluid that goes into the semen. The purpose of this fluid is largely unknown, although studies have shown it plays a role in the liquification of semen.
To the right you can see a depiction of the male urinary tract from Moore's Clinically Oriented Anatomy, 3rd Ed.
The urethra passes through the prostate and the penis. [photo on page]
As men age, the prostate can harbor cancer, become inflamed or infected, or simply grow. This growth is inevitable, and is a normal part of aging. Its purpose and cause are not well understood. Since you must urinate through the center of the prostate, this growth (BPH) causes a man's bladder to become obstructed. This causes the bladder to be irritable, and the urinary stream to slow. An obstructed, unstable bladder leads to symptoms such as urinating at bedtime, urgency, a slow, intermittent stream that is hard to start, and frequent daytime urination. In the worst case, this obstruction can not only cause symptoms, but can cause dangerous medical conditions such as kidney failure, infections, bleeding, stones, or the inability to urinate at all (retention).
When a man is bothered enough to ask for help, treatment begins with an assessment of urinary symptoms in the form of a validated questionnaire. The purpose of this initial survey is to provide an objective means for assessing urinary bother. Based on the severity of symptoms, a treatment plan can be formulated. Please click here to connect to our online prostate symptom questionnaire.
BPH is generally treated medically as a first line approach. The class of drugs most commonly used is called alpha blockers, although there is renewed interest in using 5 alpha reductase inhibitors in combinations with alpha blockers. Alpha blockers generally provide limited symptomatic relief via relaxation of specific muscle fibers at the base of the bladder and within the prostate. They, as well as the 5-alpha reductase inhibitors which work via inhibiting hormone production which fuels prostate growth, do not relieve the underlying problem - obstruction. For the majority of men however, at least initially, the degree of symptom relief afforded by medicines is enough to lessen how much the man is bothered by his symptoms. Therefore, for many men, medicine remains the long term solution.
Because medicine does not "cure" obstruction and must be taken chronically, a class of minimally invasive therapies called thermotherapies have developed to offer an in-office, minor procedure that offers far better results than medicine without the risks and logistics associated with more major surgery.
Such thermotherapies involve gently heating the overgrown prostate tissue, rather than cutting it, which over time causes this tissue to wither and retract, thereby relieving obstruction. Thermotherapies offer the ability to provide far better results than medicines with a single office treatment. This avoids the need for a chronic medicine, with the goal being symptom relief and the cessation of medicine use. We prefer the TUNA/PROSTIVA thermotherapy as the one with the highest efficacy and the most long term data, although we also perform microwave procedure. Dr. Engel is the regional instructor for the TUNA and is highly experienced in this minimally invasive therapy.
In the setting of medical complications, or when a man wants the most direct, immediate and efficacious treatment, it is sometimes recommended that a man undergo a more extensive procedure called a GREENLIGHT LASER or TURP (trans-urethral resection of the prostate), or even open surgery. These procedures actually vaporize, shave out or remove the overgrown BPH tissue from the center of the prostate. The end result is a wide-open prostate that is completely unobstructed. Relief is relatively immediate and sometimes dramatic. The Greenlight Laser can usually be done on an outpatient basis. The TURP and open prostatectomy require a hospital stay. These procedures all require regional or general anesthesia, and carry with them the risks of bleeding and anesthesia complications. These procedures rarely (less than five percent) cause incontinence and impotence.
Ultimately, the patient must choose between the most minimally invasive treatment with efficacy of perhaps 80-85% but little risk versus a more invasive procedure with efficacy of perhaps 93% but more risk and time in the hospital. Many patients choose a step wise approach, thus undergoing a TUNA or microwave and moving on to a GREENLIGHT or TURP if things fail or progress.
If you currently suffer from urinary symptoms, or if you would like to schedule an initial consultation with any of our urologists, please contact the office at (202) 223-1024 for scheduling.