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 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 an “enlarged prostate”. It is no more a disease than 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 the 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 Dr. Engel, or any of our providers, 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
Initial treatment for BPH in our practice will typically consist of a daily pill called an alpha-blocker. We consider this the first step and do not generally skip it in lieu of offering treatments until a patient has at least tried these medications so they know what they can and cannot do for them. 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 often men prefer to take these meds indefinitely if satisfactory results are achieved. 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 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 they tend 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.
We 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. We would be remiss if we did not mention herbal or alternative remedies here, as they are heavily advertised and often an option readily offered and available for BPH. We do not discourage their use, but it seems clear that their effects have more to do with a placebo effect that is achieved by simply believing they will work more than actual efficacy. There have been several studies, practically none well-designed, that show that such herbal formulations work better than “sugar pills”. Patients are very welcome to try them. Regardless of why they help, if they provide adequate symptom relief, they may be a reasonable solution. However, we find that once a patient is telling us that an FDA-approved medication is failing, typically this will not be a lasting solution.
BPH Procedures / Surgeries
If, after trying one or more medications or remedies, a patient gets to the point where he feels that their urinary problem is bothersome to the point that they have decided that they want the problem solved and not simply ameliorated, it is time to consider a procedure. There are many procedures to choose from, but they basically fall into two categories: Procedures designed to be done under local anesthesia in the office, that are quick, easy, and low risk, and procedures that must be done in a surgery center or hospital under anesthesia and may or may not require an overnight stay. Dr. Engel calls these either office procedures or operating room procedures. The fundamental difference between these two groups of procedural/surgical solutions is the convenience, the success rate, and the risk involved.
Some urologists will perform office procedures in their surgical center facilities, but we feel that this defeats the purpose, and negates the primary advantage of choosing this class of procedure – convenience. All of these are developed and designed to be done under simple local anesthesia in the office, typically take 15 minutes or less to perform, usually offer a 75-85% success rate, and have minimal to very low risk of complications. Today, the two most heavily marketed procedures are the Urolift and the Rezum. The predecessor to the Rezum procedure is the TUNA/Prostiva procedure which we still find very useful for some clinical situations where a less intense thermotherapy would be best applied. One may still find Cooled Thermotherapy, or Microwave procedures being performed but in large part, this is no longer offered except in the rare circumstance of an elderly patient who is catheter dependent.
Please see our procedures section for a much more detailed description of each of these, and to learn why, after personally performing all of these here at Urologic Surgeons of Washington, we have decided to use Rezum as our primary office procedure with the application of TUNA/Prostiva for certain anatomies and clinical circumstances.
If one fails a minimally invasive office procedure, has more serious medical complications of BPH necessitating a more aggressive relief of obstruction, or simply wants to skip over office therapies in favor of something with a more immediate result with a higher success rate, an operating room procedure will be offered.
Office procedures have distinct advantages. In our practice, most patients will choose these over more aggressive options as part of the step-wise approach that we employ. However, as stated, office procedures have a lower success rate of typically between 75 and 85 percent. We accept a lower success rate due to their simplicity and safety profile. In men where these fail, where a patient demands a higher success rate, or if there are anatomic considerations or medical complications of BPH that demand a more aggressive approach, there are several options in the category we call operating room procedures, These will typically offer at least a 95% success rate and durability of 7 years or more compared to the typical durability of five years of a successful office procedure. However, these will require anesthesia and the preparation that goes into that. Operating room procedures will have an approximate 1% chance of incontinence after the procedure and will almost certainly create a situation where there will be no semen with ejaculation. Other risks would include bleeding and infection. The gold standard here is called the TURP, or trans-urethral resection of the prostate. Although the instrumentation is far more advanced and safe now, the TURP has been the mainstay operation in this category for over 50 years. When the prostate is quite large, perhaps 80 grams or higher, Dr. Engel will offer his patients a Robotic Simple Prostatectomy as the safest, quickest solution. HOLEP, or Holmium laser enucleation of the prostate, is employed by a few Urologists in this same setting, but due to Dr. Engel’s skill with robotic surgery, he does not find this to be the safest solution in his hands here. Robotic Simple Prostatectomy and HOLEP are two excellent ways of treating very large prostates, both with their own pros and cons, and there is no clear winner. Both require a special skill set so typically an expert in one does not do the other, and most urologists do neither. Aquablation is a relatively new device that allows such urologists to offer a solution for very large prostates, but the bleeding risk is severe as compared to Robotic Simple Prostatectomy or HOLEP and therefore is not at all the safest approach in Dr. Engel’s hands given his vast experience with robotic surgery. Laser procedures, such as Green Light Laser, and others, are included in this category because they require anesthesia. Although marketed as minimally invasive approaches they still have all the same risks of a TURP with less efficacy and durability. Often side effects are worse than a TURP with laser procedures such as the Green Light. For this reason, we perform Green Light Laser procedures only in special circumstances, not as our mainstay operating room procedure. We usually see office procedures as better solutions in the setting of initial treatment for an average-sized prostate. Again, please go to our Procedures section of this site to learn much more.
Regardless of the procedure or operation recommended, the goal is the same – to solve a man’s annoying BPH problem in the simplest, safest way possible while still offering high success rates. All men will undergo office testing to determine the right procedure for them, and all reasonable solutions will be outlined and offered by the physicians at Urologic Surgeons of Washington.