Prostate Enlargement

What is the prostate?

The prostate is part of the male reproductive system, is about the same size and shape as a walnut and weighs about an ounce. It is located below the bladder and in front of the rectum, and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce ejaculatory fluid.

What is BPH?

Benign prostatic hyperplasia (BPH), also known as lower urinary tract symptoms (LUTS), is a common urological condition caused by the non-cancerous enlargement of the prostate gland in aging men. As the prostate enlarges, it can squeeze down on the urethra. This can cause men to have trouble urinating leading to the symptoms of BPH.

What are some of the risk factors for BPH?

Risk factors for developing BPH include increasing age and a family history of BPH.

What are some of the symptoms associated with BPH?

Since the prostate surrounds the urethra just below the bladder, its enlargement can result in symptoms that irritate or obstruct the bladder. A common symptom is the need to frequently empty the bladder, sometimes as often as every one to two hours, especially at night. Other symptoms include the sensation that the bladder is not empty, even after a man is done urinating, or that a man cannot postpone urination once the urge to urinate arises. BPH can cause a weak urinary stream, dribbling of urine, or the need to stop and start urinating several times when the bladder is emptied. BPH can cause trouble in starting to urinate, often requiring a man to push or strain in order to urinate. In extreme cases, a man might not be able to urinate at all, which is an emergency that requires prompt attention.

How is BPH diagnosed?

In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. This diagnostic system includes a series of questions that ask how often the urinary symptoms identified above occur. This helps measure how severe the BPH is — ranging from mild to severe.

When a doctor evaluates someone for possible BPH, the evaluation will typically consist of a thorough medical history, a physical examination (including a digital rectal exam or DRE), and use of the AUA BPH Symptom Score Index. In addition, the doctor will generally do a urine test called a urinalysis. There are a series of other studies that may or may not be offered to a patient being evaluated for BPH depending on the clinical situation. These include:

• prostate specific antigen (PSA), a blood test to screen for prostate cancer
• urinary cytology, a urine test to screen for bladder cancer
• a measurement of post-void residual volume (PVR), the amount of urine left in the bladder after urinating
• uroflowmetry, or urine flow study, a measure of how fast urine flows when a man urinates
• cystoscopy, a direct look in the urethra and/or bladder using a small flexible scope
• urodynamic pressure-flow study that tests the pressures inside the bladder during urination
• ultrasound of the kidney or the prostate

When should I see a doctor about BPH?

A man should see a doctor if he has any of the symptoms mentioned previously that are bothersome. In addition, he should see a doctor immediately if he has blood in the urine, pain with urination, burning with urination or is unable to urinate.

Is BPH a rare condition?

No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

Does BPH lead to prostate cancer?

No, BPH is not cancer and cannot lead to cancer, although both conditions can exist together. There are usually no symptoms during the early stages of prostate cancer, and so yearly physical examinations and PSA tests are highly recommended to eliminate cancer diagnosis.

Are there risks in not seeking treatment for BPH?

In the majority of men BPH is a progressive disease. It can lead to bladder damage, infection, blood in the urine, and even kidney damage. It is therefore important for men with this condition to continue to be followed.

Which type of drugs are the best?

To date, there is not enough research data to predict who will respond to medical therapy or which drug will be better for an individual patient. There are a variety of drugs available and, in some men, a combination of drugs may work best.

How do I know if oral medications are the best treatment for me?

If you are diagnosed with BPH, you should discuss all treatment options with your urologist. Together, you can decide whether medication, minimally invasive therapy or surgical treatment is best for you.

How are the urinating symptoms secondary to BPH diagnosed?

In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. This diagnostic system includes a series of questions that target the frequency of the urinary systems identified above, and as a result, helps identify the severity of the BPH — ranging from mild to severe.

There are a number of diagnostic test procedures that can be used to confirm BPH. The tests vary from patient to patient, but the following are the most common: digital rectal examination (DRE), PSA test, transrectal ultrasound (this measures the size of the prostate), urine flow study (this measures the speed and strength of the urinary stream), measurement of how much urine is left after urinating (post-void residual urine) and cystoscopy (a fiber-optic instrument inserted into the urethra to examine both the prostate and the urinary bladder).

What are some of the medical treatments available for BPH?

Alpha blockers: These drugs, originally used to treat high blood pressure, work by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and reduce bladder outlet obstruction. Although alpha blockers may relieve the symptoms of BPH, they usually do not reduce the size of the prostate. They are usually taken orally, once or twice a day and they work almost immediately. Commonly prescribed alpha blockers include: alfuzosin, terazosin, doxazosin and tamsulosin. Side effects can include headaches, dizziness, light-headiness, fatigue and ejaculatory dysfunction.

5-alpha-reductase inhibitors: Finasteride and dutasteride are oral medications that work completely different then alpha blockers. In select men, finasteride and dutasteride can relieve BPH symptoms, increase urinary flow rate and actually shrink the prostate though it must be used indefinitely to prevent recurrence of symptoms. Studies suggest that these medications may be best suited for men with relatively large prostate glands. It may take as long as six months to a year, however, to achieve maximum benefits from this drug. These drugs reduce the risk of BPH complications such as acute urinary retention (suddenly being unable to urinate) and the eventual need for BPH surgery. Side effects can include impotence, decreased libido and reduced semen release during ejaculation.

Combination Therapy: The use of both alpha blockers and 5-alpha-reductase inhibitors result in better amelioration of symptoms and long term benefits than using only one type of drug. However, this improved benefit may be associated with more side effects (possible side effects from both medications).

Phytotherapies: These compounds, also know as herbal therapies, are very popular self treatment remedies. However their effectiveness is not really known but if they provide benefit, it is much less than other medical therapies.

When is surgical treatment suggested as a form of treatment?

When medical therapy fails, surgery is required to remove the obstructing tissue. Surgery is almost always recommended for men who are unable to urinate, have kidney damage, frequent urinary tract infections, significant bleeding or stones in the bladder.

What are the different surgical treatments available?

Removal of the prostate can be accomplished in several different ways. The location of the enlargement within the prostate and the patient’s general health will help the urologist determine which of the three following procedures to use.

Transurethral resection of the prostate (TURP): Transurethral resection is the most common surgery for BPH. In the United States, approximately 150,000 people have TURPs performed each year. This can be done using electric current or with laser light. After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the tip of the penis into the urethra. The resectoscope contains a light, valves for controlling irrigating fluid and an electrical loop that cuts tissue and seals blood vessels. The removed tissue pieces are carried by the irrigating fluid into the bladder and then flushed out and sent to a pathologist for examination under a microscope. At the end of the procedure, a catheter is placed in the bladder through the penis. The bladder is continuously irrigated with fluid through the catheter in order to monitor bleeding and prevent blood from clotting and obstructing the catheter. Since there are no surgical incisions with this procedure, patients normally stay in the hospital only one to two days. Depending on surgeon preference, the catheter may be removed while the patient is still in the hospital or the patient may be sent home with the catheter in place, attached to a leg bag for convenience and removed several days later as an outpatient procedure.

Minimally Invasive Surgical Treatments

Newer surgical modalities for the treatment of BPH have been aimed at providing a one-time minimally invasive therapy that is associated with fewer complications than TURP.

Transurethral microwave thermotherapy (TUMT): Transurethral microwave thermotherapy is a minimally invasive surgical treatment which uses a device to apply heat to the prostatic tissue causing necrosis and relief of bladder outlet obstruction. While the improvements in some outcomes following TUMT have not quite reached those associated with TURP, significant improvements in urinary symptoms have been reported for long time periods. In addition, re-treatment rate for recurrent lower urinary tract symptoms occurring secondary to BPH during a 3 year follow up period has been reported to be close to 25%. Another study reported that by two years after treatment with TUMT, 46.9% of patients were using medical therapy with an alpha-adrenergic antagonist and 17.6% of patients elected for re-treatment with TURP. Overall, it is still unclear as to the long term effectiveness in the relief of lower urinary symptoms after treatment with TUMT. One of the major advantages of TUMT is that it can be performed in a single 1-hour session as an outpatient procedure without any general or spinal anesthesia. Reports of complications vary, and range from 0 to 38%, based on the study and the investigators? criteria for complications.

Urolift Urolift is an FDA approved device that is implanted within the prostate to help relieve the symptoms of BPH. Typical symptoms include weak stream, straining to urinate, frequency, and urgency. The device itself is about 3-4 cm in size, and contains two vertical ends (made of nickel/titanium, and stainless steel) connected by a suture. The standard number of devices placed during a procedure is four, however this may depend on the prostate size.

How does Urolift work?

Urolift works by pulling apart the lobes of the prostate to allow the bladder to empty more efficiently through the prostatic urethra. Urolift is implanted into the prostate through the urethra by a device that is connected to a camera. To see this in action, click on the video link below.

See the Device in Action

Is it surgery?

Urolift may be done as an outpatient procedure in the operating room or in the clinic under mild sedation. This depends on the patient’s health status, comfort, and doctor’s preference. The actual process of implantation takes about 10 minutes; some additional time is added on for the preparation. Recovery relatively quick compared to traditional prostate surgery for BPH and does not require a catheter.

What are the side effects?

The most common side effects of Urolift are blood in the urine, burning with urination, urgency, pelvic pain, and leakage of urine.

How does Urolift compare to TURP (transurethral resection of prostate)?

TURP is always done as a surgical procedure in the operating room , under general anesthesia. It also requires a catheter afterwards for a few days. With Urolift, the patient also has much less (if any) bleeding afterwards. TURP may be done if necessary after Urolift is implanted. Urolift may not be used in patients with a median lobe (prostate grows into bladder).

View Comparison Chart

What can be expected after treatment?

Postoperatively, patients typically experience significant improvement in their symptoms (table 1). As with any operative procedure, complications do exist. Some occur in the early postoperative period (table 2) while others may occur many years later (table 3).

Table 1: Overall improvement in patient symptoms

Table 2: Immediate post-operative complications

Table 3: Late post-operative complications

Will surgery for BPH affect my ability to enjoy sex?

Most urologists say that even though it takes a while for sexual function to return fully, most men are able to enjoy sex again. Most experts agree that if you were able to maintain an erection shortly before surgery, you will probably be able to do so after surgery. Most men find little or no difference in the sensation of orgasm although they may find themselves suffering from retrograde ejaculation.

Where can I get more information?

• Benign Prostatic Hyperplasia (BPH) Treatment Choices
• AUA Guidelines: BPH: A Patient’s Guide

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