Benign Prostatic Hypertrophy (BPH)

The Most Common Cause of Difficulty Urinating in Aging Men.

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More information about BPH available here.

Dr. Herb Riemenschneider at the 10/10/02

Riverside Urology Prostate Cancer Support Group

The prostate is part of the urinary tract and the reproductive system. It is a walnut sized gland located at the opening of the bladder and anatomically is just below the bladder above the muscular floor of the pelvis. It has an intimate involvement with the sphincter mechanism, a group of muscles that shut of the urine flow, these are located at the bladder neck within the prostate and in the membranous urethra which is part of the pelvic floor. The urethra is a tube that runs through the prostate and the penis and is the path that urine exits from the bladder.

There are three common conditions that can affect the prostate:

1) Benign prostatic enlargement (BPH)

2) Infection (Prostatitis)

3) Cancer

BPH Prostatitis Cancer

BPH affects half of the men over 50 years of age. It is probably caused by exposure of the prostate to testosterone.

The AUA symptom score index for BPH is a method of classifying the difficulties in urinating related to prostatic enlargement. A symptom score of 1-7 is mild, 8-19 is moderate, and 20-35 is severe.

When the prostate gland enlarges, this is referred to as BPH, it restricts the flow of urine from the bladder by compressing the urethra.

Symptoms may include difficulty starting the urinary stream, the urgent need to void, frequent urination, and the need to interrupt either daily activities or sleep to urinate.The most severe for of BPH causes complete blockage of urine the result is that the bladder cannot empty. This is known as retention.

The diagnosis of BPH is made by:

1) Rectal examination
2) The AUA Symptom Score index
3) A urine flow rate
4) A PSA level

Prostate Specific Antigen (PSA), is a glycoprotein that can be measured by sampling the blood. This test can tell us whether the prostate is healthy or not. A PSA level reflects a condition of the prostate, for example it could be elevated in prostatitis, prostatic enlargement, or prostate cancer. Benign prostatic hypertrophy (BPH) is associated with no or minimal elevation of PSA.

In brief summary, it is a very efficient diagnostic test, low levels of PSA usually indicate the prostate is healthy or has benign enlargment, very high levels can be associated with prostate cancer.

Drug Therapy for BPH

Once the diagnosis of BPH is made, Urological decisions must follow. Minor symptoms usually do not require treatment. Moderate to severe symptoms do.

Medical management consists of:

1) Alpha blocking agent, ie. Flomax.
2) Testosterone blocking agent, ie. Proscar.

The alpha blocker, Flomax, is the most frequently used medical treatment of BPH because it has few side effects. The dosage may be 1 or 2 capsules day.

Proscar, a tablet, is taken once a day and requires a number of months before improvement in voiding symptoms are noticed.

Herbal preparations are used to treat BPH in many countries of the world. In Germany, up to 90% of patients who have symptoms of BPH are started on Sau Palmetto. Herbal medication treatment results are questioned by many because only a limited number of scientific trials have been done. Physicians in the United States did not use these medications nearly to the extent that they are used elsewhere in the world.

Overactive Bladder, a condition commonly referred to when describing symptoms that include an urgent need to urinate can be associated with BPH. It is very important to understand that an enlarged prostate is the cause of this particular type of overactive bladder. Two drugs are currently quite popular for treatment of Overactive Bladder, Detrol L.A. or Ditropan XL. One of these drugs, under a physicians directions can sometimes be combined with an Alpha blocking agent such as Flomax to control the symptoms of early BPH.

Surgical Treatment for BPH

When the prostate is benign and very large, treatment by incisional surgery is considered. A suprapubic incision is made and the inner portion of the prostate can be surgically removed. The resistance to flow of urine is reduced and the efficiency of bladder emptying is restored.

Prostatectomy

Transurethral resection of prostate(TURP) is a procedure where a scope is passed through the urethra into the area of the prostate. A using a cutting cautery current is used through this scope and portions of the prostate may be trimmed away thereby relieving obstruction from BPH. This procedure has been a standard for treatment of BPH since the early 1900’s. In recent years, this procedure has been refined to the point that it can be used as an outpatient treatment and not associated with hospitalization. TURP does require a general anesthetic and when the patient is discharged to home, a catheter is in place, and drains to a leg bag for a few days.

TURP

Minimally Invasive Treatments

Minimally invasive treatments can be done as an outpatient with minimal sedation and local anesthesia. These treatments include:

1) Interstitial Laser Coagulation (ILC) or otherwise known as Indigo

2) Transurethral Needle Ablation (TUNA)

The Indigo Laser

introduces heat into the prostate through a laser fiber and it is well suited to treat the moderate sized enlarged prostate.

Transurethral Needle Ablation (TUNA)

is a minimally invasive treatment that allows most patients to return to normal activities within 24 hours. It has minimal side effects, virtually no associated sexual dysfunction and 5-year clinical data that indicates safety and effectiveness.

TUNA delivers low-level radio frequency energy into the prostate gland and relieves obstruction without causing damage to the urethra. It can be performed with local anesthesia. The procedure takes less than 1 hour and catheterization is usually less than 1 day.

The treatment console is a computer that provides a great deal of information about the heating process, as it is ongoing within the prostate.

The delivery system includes a cystoscope, an irrigation system, and a cartridge that contains the radio frequency delivery system.

The radiofrequency is transmitted to the prostate through two small antennae that are actually needles that are placed into the prostatic tissue. The scope is introduced through the penis .

These small needles are deployed into the prostate and radio frequency energizes them producing heat that creates change in the prostate .

The heating process is done throughout the length of the prostate.

When these heat altered areas heal, they occupy less volume and decrease the resistance of flow of urine through the prostatic urethra and increase the efficiency of voiding. The net result is a decrease in the AUA symptom score

and increases in the maximum flow rate indicating improved emptying of the bladder.

The TUNA system is minimally invasive, done with sedation either oral or intravenous and local anesthesia. It is not associated with a hospital stay, and allows most patients to return to normal activities in 24hours.

In summary, the problem of BPH causing difficult voiding in men has been discussed. The mechanism by which the enlarged prostate obstructs urine by compressing the urethra and increasing bladder emptying difficulty is shown. It is important to differentiate benign prostatic enlargement from the other problems that can occur in the prostate such as prostatitis or Cancer. The medical treatment options are reviewed. The traditional surgical procedures and new minimally invasive treatment methods were outlined and an overview demonstrated.

BPH is a very common problem. It affects millions of men and approximately 80% of those men experience life-disrupting symptoms from prostatic enlargement.

The information in this summary gives you the opportunity to understand the problem of BPH and it’s current treatment.

For further information, contact Riverside Urology at (614) 442-3000.

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