Benign Prostatic Hyperplasia (BPH)/ Enlarged Prostate
One of the most common causes for a visit to the Urologist is when a man notices that he is starting to urinate more frequently, with a slower stream, more urgently, and perhaps now must get up to urinate in the middle of the night. This usually begins when a man is approaching the age of fifty, and to that man, it represents a new change that can sometimes cause alarm. Most men want to make sure this is not a sign of prostate cancer, which it almost never is, or to be sure they do not have another problem such as an infection or bladder cancer. All of these things are almost always quickly ruled out during an office visit. Most of these patients are seeking reassurance and not necessarily treatment.
BPH is no more a disease than is graying hair, but in some men can gradually and eventually become a significant detractor to their quality of life. BPH can, in its most severe form, cause not only medical problems such as urinary retention, bladder stones and infections, but also life threatening kidney failure and serious infections.
The usual cause for these urinary symptoms in a man is the simple fact that, for reasons not fully elucidated, as a man ages his prostate grows. This growth is benign in nature and as stated above is not a malignant process. It is called benign prostatic hyperplasia/hypertrophy, shortened to BPH, and is commonly known as “enlarged prostate”. It is no more a disease than is graying hair, but in some men can gradually and eventually become a significant detractor to their quality of life. BPH can, in its most severe form, cause not only medical problems such as urinary retention, bladder stones and infections, but also life threatening kidney failure and serious infections called urosepsis.
If one understands that, as seen in the schematic, that one must urinate directly through the middle of the prostate, then it is simple to understand why growth of the prostate will gradually but steadily crowd out the urine channel (urethra) and make it harder and harder for the bladder to do its job and squeeze sufficiently to empty. The bladder gets overactive when it is asked to work too hard, thus leading to urgency and frequency; the enlarged prostate obstructs the bladder, and therefore blocks urine flow, slows the stream and leads to higher and higher amounts of urine left over after one is finished urinating. This leftover urine is called urinary retention. If retention gets severe enough, a man may acutely need a catheter to empty his bladder. But, except for situations where the bladder never becomes irritable called silent prostatism, a man’s symptoms usually alert him to a problem far before this occurs.
During a visit with either Dr. Engel or Losee, a man will be asked to fill out a survey called the International Prostate Symptom Score (IPSS) or the AUA Symptom Score Index. This will alert us to exactly what a patient’s complaints are but will most importantly tell us if a man is looking largely for reassurance or to be treated. If one tells us that his symptoms are bothersome enough that he would be willing to be treated with chronic medication or even a procedure, then we will start treatment. If not, we will simply follow that patient and treat them if either urinary retention or another complication occurs or progresses, or if one does become bothered enough to ask for treatment.
Medical Treatment for BPH
The initial treatment for BPH is medical, and in our practice will consist of a daily pill called an alpha blocker. These medications are usually very well tolerated. In some cases they may cause dizziness, nasal stuffiness, or decreased semen output during ejaculation. As with all medications, patients are asked to come for another consultation if problems occur and another treatment will be prescribed. Alpha blockers will not halt the progression of BPH, and will not work in all cases to a patient’s satisfaction. They do not work to the same degree as procedures, but with few exceptions they are always the first step at Urologic Surgeons of Washington. If a man is satisfied with their result, he will stay on that medication and return in a year. If not, or if he is unwilling to be on a chronic medication and would prefer a procedure as a more complete solution, he will come back to the office to discuss this after trying medication for one month.
Other medications, called 5-alpha-reductase inhibitors, are also available. They are used less frequently, as Drs. Engel and Losee find them to be less effective as alpha blockers, take 3-6 months to take full effect, and literature shows them to be useful only in the case of very large prostates. So, if a man has progressed through an alpha blocker, or wants better relief, he may be offered a second drug but will also at that point be offered a procedure.
Dr. Engel and Losee see BPH as a progressive problem, and feel that its treatment should take a similar stepwise approach. Almost always, by the time a man is seeking a procedure he has first noticed symptoms but did not seek treatment. He then started with an alpha blocker as the least invasive treatment. He may have then taken herbal supplements, none of which having been shown to be more effective than placebo in the literature, or taken a second drug. All of these are reasonable stepwise maneuvers to try.
In-Office BPH Procedures
Most patients are not seeking a big leap into the operating room to undergo an invasive procedure. For those patients, which make up a majority, we offer an in-office procedure called a TUNA/Prostiva (Trans-urethral needle ablation) procedure or a microwave (Cooled Thermotherapy) procedure. These procedures are quick, safe, simple procedures done during one office visit under local anesthesia only. They are both in the category of thermotherapies, whereby the prostate and bladder neck is heated gently. No tissue is cut, and bleeding is minimal. With both of these procedures, the patient goes home with a urinary catheter for a few days, may have some exacerbation of their symptoms for a few days, but the risk of impotence or incontinence is well less than 1%. With both procedures, decreased semen output during ejaculation is avoided in most but not all patients (20-25% of patients will report this), and a hospitalization inclusive of general anesthesia is avoided. The results are not immediate here, and the success rate in properly selected patients is approximately 75%. TUNA is offered much more commonly than is microwave in our practice, and if successful, the symptom relief achieved far exceeds the best results with medication alone, and will typically last at least five years.
If one fails a thermotherapy, has more serious medical complications of BPH necessitating a more aggressive relief of obstruction, or if one simply wants to skip over thermotherapies in favor of something with a more immediate result with a higher success rate, an operating room procedure will be offered.
Surgical Treatment of BPH
If one fails a thermotherapy, has more serious medical complications of BPH necessitating a more aggressive relief of obstruction, or if one simply wants to skip over thermotherapies in favor of something with a more immediate result with a higher success rate, an operating room procedure will be offered. One will find many procedures that have been invented to try to compete with the gold standard, called a TURP or trans-urethral resection of the prostate. One heavily marketed approach is called a Greenlight laser, although there are several other similar lasers on the market. Also popularized by some is the HOLAP, which utilizes a different type of laser called a Holmium laser. Drs. Engel and Losee are experienced in all of these approaches, but in all cases have returned to the TURP as the most effective, simplest procedure that produces the fewest side effects. One positive effect of the development of these new technologies has been the application of pressure on the companies that make TURP instruments. Now, a safer and more effective version of the TURP predominates called a bi-polar TURP. Dr. Engel and Losee favor this approach, but will also discuss the pros and cons of all approaches and let the patient ultimately decide. All operating room procedures cut out or burn out the inner part of the prostate (adenoma).
They are not to be confused with surgeries that remove the whole prostate for cancer (see Robotic Prostatectomy).
All such procedures require at least one night in the hospital, the patient will typically go home with a catheter for a few days, and as with thermotherapy there is little pain or recovery. The success rate is upwards of 95%, but the main negatives to this approach is the palpable 1% risk of incontinence, bleeding that may require re—operation, and a near 100% likelihood that one will no longer have semen present during ejaculation. These downsides often cause the patient to prefer to try a thermotherapy before proceeding to a procedure like a TURP or similar.
Please see the Common Procedures section of the site for more information on the BPH procedures we commonly perform.