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Benign Prostatic Hyperplasia |
Normal prostate and enlarged prostate (prostate with benign prostatic hyperplasia). (Courtesy imedicine.com)
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Definition"The prostate is a male gland that secretes the fluid (a part of the semen) which carries sperm from the testicles during ejaculation.
The prostate is located just below the bladder and in front of the rectum. It surrounds the first inch of the urethra (the tube through which urine and sperm exit the body).
Usually, the prostate gland starts to enlarge after middle age.When the prostate becomes enlarged, the condition is called benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy.
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Description"The prostate gland undergoes two growth spurts: once during adolescence and the other around the age of 50. Though the prostate continues to grow during most of a man's life, the enlargement does not usually cause problems until late in life. About 75 percent of men over the age of 50 and 90 percent of men in their 70s and 80s have had some symptoms of BPH.
The benign growth occurs when old cells do not die (as they once did) while new cells continue to grow. This accumulation of cells thickens the prostate, which can narrow the urethra, resulting in urination problems.
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Causes"As the urethra is squeezed more tightly by the enlarged prostate, the bladder may not be able to completely empty. Rarely, this blockage may cause repeated urinary tract infections and start the process of bladder or kidney damage. It may also cause acute urinary retention (a sudden inability to urinate ) which requires a visit to the emergency room.
The cause of BPH is not well understood, but researchers theorize that BPH could be caused by:
- the aging process
- testosterone levels - As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen. Studies with animals suggest that BPH may occur when a higher amount of estrogen (in the gland) increases the activity of substances that promote cell growth.
- Dihydrotestosterone (DHT) - DHT is a substance derived from testosterone in the prostate, which may help control its growth. Most animals lose their ability to produce DHT as they age, however, some research indicates that with a drop in blood testosterone level, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage the growth of cells. Scientists have also noted that men who do not produce DHT do not develop BPH.
- cell "instructions" - Some researchers suggest that BPH may develop as a result of "instructions" given to cells early in life. According to this theory, BPH occurs because cells in one section of the gland follow these instructions and "reawaken" later in life. These "reawakened" cells then deliver signals to other cells in the gland, instructing them to grow or making them more sensitive to hormones that influence growth.
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Symptoms"The obstructive (problems with urethra and urination) symptoms of BPH are:
- difficulty initiating a urine stream
- a hesitant, interrupted and weak stream
- urgency and leaking or dribbling
- blood in the urine
As the urethra becomes narrower, the bladder wall becomes thicker and the bladder itself becomes smaller, causing:
- more frequent urination
- bladder irritability
- a sudden strong urge to urinate, especially at night
- urge incontinence - (occurs when bladder muscles are too active. People with urge incontinence lose urine as soon as they feel a strong desire to go to the bathroom.)
If a man suddenly becomes unable to pass any urine at all, this condition is called acute urinary retention.
The size of the prostate does not always determine how severe the obstruction or the symptoms will be. Some men with greatly enlarged glands have little obstruction and few symptoms, while others whose glands are less enlarged may have more blockage and greater problems.
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Diagnosis"It is possible to have prostate enlargement and prostate cancer at the same time, but it is important to remember that prostate enlargement is not prostate cancer. In addition, having BPH does not seem to increase your chances of developing prostate cancer.
To make a diagnosis, the doctor will first take a detailed medical history to determine the severity of the symptoms. The results of this questionnaire will determine the course of treatment.
Additionally, a physical exam will be performed, including a digital rectal exam (DRE). This procedure involves the doctor inserting a latex-gloved finger into the rectum and feeling the prostate for any lumps or hard spots (that may indicate prostate cancer) and checking the size of the prostate to diagnose BPH.
Based on the results of the DRE and the answers to the questionnaire, the doctor may suggest a urine flow study to measure how quickly the urine is flowing, and a prostate-specific antigen (PSA) blood test. The PSA test is approved by the FDA for the purposes of helping to detect prostate cancer in men over 50 and for monitoring prostate cancer patients after treatment.
Importantly, there are some unknowns about the interpretation of PSA levels, as well as about the test's ability to discriminate cancer from benign prostate conditions and what is the best course of action following a finding of elevated PSA.
If there is a suspicion of prostate cancer, your doctor may recommend a test with rectal ultrasound.
To evaluate BPH, physicians sometimes perform an Intravenous Pyelogram (IVP), where dye is injected into the vein and an X-ray is taken to see if there is any obstruction or blockage in the urinary tract. Another exam that may be performed to evaluate this problem is a cystoscopy in which a small, thin viewing scope is passed through the urethra into the bladder to look for blockages or other abnormalities of the inside of the prostate.
It is important to tell the doctor about any urinary problems, such as those described in the SYMPTOMS and SIGNS section. Although these symptoms suggest BPH, they can also signal more serious conditions, such as a bladder infection, bladder stones, prostate cancer, diabetes, multiple sclerosis and Parkinson's disease.
(See also Prostate Cancer Screening)
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Treatment"If the score on the Symptom Index is low, the symptoms are considered mild and the usual procedure is "watchful waiting." No pharmaceutical or surgical treatment is recommended. Continue to have an annual exam so that the doctor can monitor the growth. The doctor will suggest the following lifestyle adjustments to ease symptoms:
- Reduce the intake of coffee, tea and cola drinks.
- Eat dinner in the early evening so you have a chance to eliminate fluids.
- After 7 p.m., cut down on fluids.
- Drink 8 glasses of water per day to help prevent accumulation of bacteria.
- Avoid over-the-counter (OTC) cold remedies that contain pseudoephedrine and antihistamines.
- Avoid spicy and salty foods.
- Stay regular - constipation may aggravate the urinary tract.
- Ejaculate regularly.
- Take hot baths.
- Avoid prolonged sitting.
- Sometimes drinking cranberry juice is recommended to increase the acidity of the urinary tract.
If the score on the Symptom Index is in the mid-range, the symptoms are considered moderate and the usual procedure is pharmaceutical intervention. There are two types of prescription drugs commonly used to treat BPH; alpha-receptor blockers and 5-alpha-reductase inhibitors (or hormone suppressor).
Alpha-receptor blockers (which are also sometimes prescribed for hypertension) relax the prostatic-urethral muscle thereby improving urinary flow. The most common alpha-receptor blockers are Hytrin, Minipress, Cardura and Flomax.
5-alpha-reductase inhibitors helps shrink the prostate. The most common 5-alpha-reductase inhibitor is Proscar. Some physicians, particularly in Europe, recommend the use of (the herb) Saw Palmetto extract to reduce this level of symptoms of BPH.
If the score on the Symptom Index is high, the symptoms are considered severe and the usual procedure is the use of invasive techniques. There are two types of invasive techniques, non-surgical and surgical.
Non-Surgical Invasive Treatments
Non-surgical invasive treatments include transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA).
For the TUMT (Prostatron) procedure, a catheter is threaded through the urethra into the prostate. A computer pulses microwaves through the catheter, heating the prostate, killing prostate tissue, and clearing room for the urethra to function normally.
A similar device called the Targis System received FDA approval in September 1997. Like the Prostatron, the Targis System delivers microwaves to destroy selected portions of the prostate and uses a cooling system to protect the urethra. A heat-sensing device inserted in the rectum helps monitor the therapy.
Both of these procedures take about 1 hour and can be performed on an outpatient basis without general anesthesia. Neither procedure has been reported to lead to impotence or incontinence. Although microwave therapy does not cure BPH or and does not correct the problem of incomplete emptying of the bladder, it does reduce urinary frequency, urgency, straining, and intermittent flow,
In the TUNA procedure, a pencil-sized treatment wand is inserted into the urethra. Once in place, two small needles (from the tip of the wand) are pushed into the prostate. Radio waves from the needles heat the surrounding tissue, creating zones of dead BPH tissue that the body absorbs. The TUNA System improves urine flow and relieves symptoms with fewer side effects compared to the transurethral resection of the prostate (TURP) (below). No incontinence or impotence has been observed as a result of this procedure.
Surgical Treatments
Surgical treatments include transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), and a prostatectomy. TURP is used for 90 percent of all prostate surgeries performed for BPH.
For a TURP procedure, an instrument called a resectoscope is inserted through the penis. The resectoscope (about 12 inches long and 1/2 inch in diameter) contains a light, valves for controlling irrigating fluid and an electrical loop that cuts tissue and seals blood vessels. During the operation, the surgeon uses the wire loop of the resectoscope to remove the obstructing tissue one piece at a time. The pieces of tissue are carried by fluid into the bladder and then flushed out at the end of the operation.
A variation of TURP is a laser ablation. Laser ablation uses a high-powered laser (instead of a surgical instrument) to slice away the BPH tissue. Instead of removing tissue (as with TURP) TUIP involves making a few small cuts in the prostate gland. This reduces the pressure on the urethra and permits urine to flow more freely. A prostatectomy is the removal of the inner portion of the prostate through an open incision in the lower abdomen.
Surgery usually offers relief from BPH for at least 15 years. Surgery for BPH leaves behind a good part of the gland, so it is still possible for prostate problems, including BPH, to develop again. However, only 10 percent of the men who have surgery for BPH eventually need a second operation for enlargement. Usually these men had the first surgery at an early age.
Risks And Benefits Of Invasive Treatments,
Risks and benefits exist with all forms of treatment for BPH. They are as follows:
TUMT is considered to be less effective than surgery, particularly when obstruction is at the center of the prostate. There is a risk of impotence, incontinence and retrograde ejaculation, where the amount of ejaculate is lessened because most or all of it is retained in the bladder. Though no hospitalization is required with this procedure and relief can be experienced within in three to eight weeks, another TUMT may be necessary at a later date.
TUNA is less effective than surgery. There is the possiblity of impotence, incontinence and retrograde ejaculation. Though no hospitalization is required with this procedure and relief can be experienced within in three to eight weeks, another TUNA may be necessary in the future.
TURP presents a risk of retrograde ejaculation 80 percent of the time. There is the possiblity of impotence, incontinence, blood loss and urinary tract infection. This procedure provides instant relief of BPH and improved urination. One week of recovery time is needed. This is considered to be better than the other treatments.
TUIP surgery leaves the possibility of impotence, incontinence, blood loss, urinary tract infection and retrograde ejaculation. This procedure provides instant relief of BPH. There is the possiblity of a hospital stay with a short recovery time.
New surgical alternatives are being developed. Ask your doctor to discuss the potential risks and benefits of medication and surgery.
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Sex"Many men worry about whether surgery for BPH will affect their ability to enjoy sex. Some sources state that sexual function is rarely affected, while others claim that it can cause problems in up to 30 percent of all cases. However, most doctors say that even though it takes awhile for sexual function to return fully, with time, most men are able to enjoy sex again.
Complete recovery of sexual function may take up to 1 year, lagging behind a person's general recovery. The exact length of time depends on how long after symptoms appeared that BPH surgery was done and on the type of surgery. Following is a summary of how surgery is likely to affect the following aspects of sexual function.
Erections: Most doctors agree that if you were potent (able to maintain an erection) shortly before surgery, you will probably be able to have erections afterward. Surgery rarely causes a loss of potency. However, surgery cannot usually restore potency that was lost before the operation.
Ejaculation: Although most men are able to continue having erections after surgery, a prostatectomy frequently makes them sterile (unable to father children) by causing a condition called "retrograde ejaculation" or "dry climax."
During sexual activity, sperm from the testes enters the urethra near the opening of the bladder. Normally, a muscle blocks off the entrance to the bladder, and the semen is expelled through the penis. However, the coring action of prostate surgery cuts this muscle as it widens the neck of the bladder. Following surgery, the semen takes the path of least resistance and enters the wider opening to the bladder rather than being expelled through the penis. Later it is harmlessly flushed out with urine.
Orgasm: Most men find little or no difference in the sensation of orgasm, or sexual climax, before and after surgery. Although it may take some time to get used to retrograde ejaculation, you should eventually find sex as pleasurable after surgery as before.
Many people have found that concerns about sexual function can interfere with sex as much as the operation itself. Understanding the surgical procedure and talking over any worries with the doctor before surgery often help men regain sexual function earlier. Many men also find it helpful to talk to a counselor during the adjustment period after surgery.
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Questions to Ask Your Doctor"Would a more comprehensive exam or test be more appropriate?
Which treatment alternatives apply to this case?
Which treatment should I try first?
If treatment is not done now, will there be more serious problems in the future?
After treatment, will the problem return?
Will a change in diet, exercise, coffee or alcohol consumption, etc., make a difference?
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