Most men, as they get older, begin to experience urinary problems. This is due to the benign growth of the prostate as men age, also called benign prostate hyperplasia or BPH. This is a common, progressive urological condition, typically beginning around age 50 with 50% of men exhibiting some signs of BPH at age 60. By age 85, 90% of men will begin experiencing symptoms of BPH. BPH is normal prostate tissue growth which begins to obstruct the outlet of the bladder– squeezing down on the urethra. It is not a cancerous condition and does not predispose one to cancer. A man with a “large or enlarged” prostate may not have urinary issues, whereas a man with a “normal” sized prostate might. It’s more about how the tissue grows and how it obstructs vs the size of the prostate. BPH is a progressive disease and can lead to bladder damage, chronic infections, the inability to urinate, blood in the urine, and even kidney damage if left untreated.
So how do you know if you should seek out BPH treatment? The American Urological Association developed a BPH Symptom Score Index to help diagnose the severity of urinary symptoms caused by BPH. It includes a series of questions that target the frequency of the urinary issues–ranging from mild to severe BPH. If you identify with any of the questions below, you likely have BPH that’s obstructing your bladder which may be bothersome to your life, but more importantly, possibly causing permanent damage: – Do you go to the bathroom more than two times within the night even if you have restricted fluids two hours before bedtime? – Do you have difficulty maintaining a steady urinary stream? Do you feel like your bladder is never completely empty? Often having to return the bathroom just after you finished urinating? – Do you have a weak or intermittent urinary stream? – Do you have to push or strain to begin a urinary stream? – Do you have dribbling after urination? – Do you have to urinate frequently throughout the day? – Do you have urinary urgency–when you get the urge to “go” you better “go.” – Do you ever leak urine? – Do you have frequent urinary tract infections or prostate infections? – Have you ever been unable to urinate at all? – Have you ever seen blood in your urine? – Have you ever been diagnosed with bladder stones? Luckily, there are different BPH treatment options ranging from lifestyle changes to medications or surgery. All BPH treatment options have been well studied and alleviate symptoms effectively.
In order to fully diagnose BPH, a careful history including the questions above must be considered, but also some in office non-invasive tests may be required including: – Urinalysis (UA): This is a quick dip of a urine sample to ensure there is no infection present which can oftentimes mimic BPH symptoms. – Prostate Exam (DRE): This exam not only is a screening tool for prostate cancer but helps generally gauge the size of the prostate. – Post-Void Residual (PVR): This is an in-office portable ultrasound that is placed on your abdomen where your bladder is and measures the amount of urine left in the bladder after urination. Uroflow (UF): This is a simple in-office test where you urinate into a funnel. This measures how fast the urine flows and what the stream of urination looks like.
BPH Diagnosis (Invasive Methods)
Sometimes more invasive methods need to be included to better obtain the severity of BPH or to ensure the prostate size and bladder function is appropriate for surgery. These in-office tests include: – Prostate Ultrasound (TRUS): A painless procedure using an ultrasound to see an image of the prostate and gauge its size and level of obstruction very specifically. – Urodynamics (UDS): This is a flow study that is useful to rule out bladder dysfunction vs prostate obstruction and may be done if failure on medications. It may also be performed prior to surgery if any suspicion of bladder dysfunction. The bladder is a muscle and over time, if it never properly empties and stays full, its ability to work effectively becomes irreversibly damaged. In this study, very small catheters are placed in the urethra and the rectum. As you urinate into a funnel it measures the pressure inside the bladder. – Cystoscopy: A small instrument is inserted into the urethra after local anesthetization, allowing for visualization of the prostate tissue, size, obstruction, as well as, examining the health of the bladder. This is typically performed prior to some surgical options and if there have been any episodes of blood in the urine.
The simplest place to start with BPH treatment is with lifestyle changes. However, this is not effective enough if the prostate has grown large enough. Some changes that may be suggested would be: Decreasing or eliminating caffeine and alcohol intake Reducing dietary bladder irritants- spicy foods, acidic foods Abstaining from fluids 2 hours before bedtime A majority of the time medical therapy is the most effective initial treatment for BPH unless symptoms are very severe. There are two classes of medications used, with the first category being most common, but oftentimes they can be used in combination. These medications have been well studied, used for many years, are affordable and come with minimal side effects:
– Alpha Blockers: Originally, these drugs were used to treat hypertension. However, over time, research found that they were less effective for hypertension treatment and most effective for BPH. They work by attaching to receptors on the smooth muscle of the prostate and bladder neck, relaxing the muscles and allowing for more space, reducing bladder obstruction. They must be taken daily to be effective and do not “reverse” the enlargement of the prostate or prevent future growth. Most are taken one to two times a day at night and work quickly to improve urine flow. Medications like Tamsulosin/Flomax, Alfuzosin/Uroxatral, Terazosin/Hytrin, Rapaflo and Doxazosin/Cardura are commonly prescribed alpha blockers. Most common side effects with these medications include light-headedness, dizziness (with position change), slight lowering of blood pressure, nasal congestion and sometimes a slight decrease in ejaculate volume. – 5-alpha-reductase inhibitors: Finasteride/Proscar/Propecia, Avodart/Dutasteride and Jalyn (a combination of an alpha-blocker and a 5-alpha-reductase inhibitor) are BPH medications used for men that either have very large prostates, have blood in the urine due to prostate tissue that is “fragile” and easy to bleed or in combination with alpha blockers as a last resort to medical treatment prior to surgery due to progressive or severe BPH. They alleviate BPH symptoms by “shrinking” the prostate–therefore allowing an increase in urinary flow. They are typically taken daily by mouth and must be taken indefinitely to work effectively. These BPH medications may take as long as six months to a year to achieve maximum benefits. Side effects can include ED, decreased libido and a decrease in ejaculate volume.
BPH Treatment – Surgery
If medical therapy fails either due to the severity of BPH or because of progressive BPH in which medical therapy is no longer working, surgery is required to remove the obstructing prostate tissue. The prostate stays intact, just the tissue obstructing the bladder is removed. In some men, surgery is the best initial BPH treatment option depending on the severity of symptoms. Surgery has advanced in that most surgeries for BPH take less than an hour (some less than 30 minute) and are performed either in a surgery center under general anesthesia where the patient goes home once the surgery is completed or performed in the office under light sedation. Surgical complications and post-surgical concerns regarding sexual function are rarely issues. The evaluation of the patient’s medical history, age, health condition, and prostate size does factor in to which surgical option may be best suited for the patient.
– TURP (Transurethral Resection of the Prostate): A TURP is the most common surgery for BPH with approximately 150,000 performed each year in the U.S. It is a day surgery performed under general anesthesia and typically takes one hour. A resectoscope is inserted 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 prostate tissue pieces are carried by the irrigating fluid into the bladder and then flushed out. There are no surgical incisions with this procedure. Typically, you go home the day of the surgery and a catheter temporarily stays in place for a few days before being removed in the office. Typically the patient is able to resume most daily activities the next day, however, strenuous activities will be restricted for 2 weeks to prevent prostate bleeding. Dramatic changes in urination are seen about 2 weeks post surgery which continues to improve within the next 3 months. – Urolift: The UroLift® System treatment is a minimally invasive approach to treating BPH. The procedure uses a few small devices or implants that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. There is no cutting, heating or removal of prostate tissue. It is often done in the office without the need for general anesthesia, only light sedation, in less than 30 minutes with no catheter to go home with. Men begin to see results quickly within 2 weeks and results are proven to last for many years post procedure. Eligibility for this procedure is dependent on prostate size.
BPH Shouldn’t Dominate Your Life!
The prevalence of BPH is far-reaching and typically men seek out treatment long after symptoms have become bothersome and disruptive to their lives. In some cases, due to chronic untreated BPH symptoms, irreversible damage has been done to the bladder. Most often, the earlier BPH treatment is started, the better the preservation of bladder function and the less aggressive the treatment options initially need to be. For more information about BPH and BPH treatment options, contact Austin Urology Institute at (512) 694-8888 to make an appointment with a provider.