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BENIGN PROSTATIC HYPERPLASIA (BPH)
Benign Prostatic Hyperplasia, also called 'enlarged prostate' is generally found in men over the age of 50. In fact, nearly all men over the age of 50 have an enlarged prostate to some degree, but not all of these cases require treatment. The prostate is located under the bladder in men and behind the pubic bone. It partially surrounds the urethra and is responsible for many of the lower urinary tract problems experienced in men as it enlarges with age.

Symptoms

  • Frequency of urination, nocturia (frequency at night)
  • Urgency (desire to void again within a short time of urinating)
  • Hesitancy (waiting some time to initiate the stream)
  • Decreased force of urinary stream
  • Intermittency (a stop-start pattern in urinating)
  • Feeling of incomplete emptying (urine remaining in the bladder after urinating)

Diagnosis
On occasion, patients may develop similar symptoms due to prostatitis (inflammation of the prostate), primarily from infection that is treated with antibiotics. To determine if these symptoms are due to BPH, patients may be evaluated with:

 
  • DRE (digital rectal exam) is primarily done to rule out abnormalities of the prostate, such as cancer or prostatitis.
  • Urine studies (Urine Culture and Cytology) are done to rule out infection, hematuria (blood in the urine), glucosuria (sugar in the urine as can be seen in diabetics), and/or cancer.
  • Uroflow testing records the amount of urine voided, the speed (force) with which one urinates, the time needed to urinate, and will determine abnormalities in these areas. After uroflow testing is done, residual urine can be determined with a bladder scan, which is similar to an ultrasound of the bladder. If either of the two tests is abnormal, further evaluation with urodynamics (see below) is recommended.
  • AUA Symptom Sheet is used to determine the severity of your symptoms and to monitor treatment. This is a list of seven questions that incorporate much of the symptoms described above. Scored from 1-5, patients can receive a minimum score of seven (mild symptoms) or maximum score of 35 (severe symptoms).
  • Urodynamics determines bladder function with the aid of a computer. It is separated into 2 phases: a filling phase, and urinating phase. In the filling phase, the bladder is evaluated for involuntary contractions (overactive bladder), compliance (elasticity of the bladder), incontinence (involuntary loss of urine) and capacity (amount of fluid the bladder can comfortably hold). During urinating, bladder pressure is recorded to determine if it is normal, hypocontractile (weak) or obstructed (blocked). This test is generally done in the office and can take fifteen minutes.
  • Ultrasound is used to evaluate the kidneys for hydronephrosis (swelling) especially when there is residual urine found in the bladder either due to a hypocontractile bladder or obstruction from BPH. On occasion, a bladder ultrasound is done to evaluate prostate size, amount of residual urine and/or the presence of bladder stones.
  • Cystoscopy is performed to evaluate prostate size prior to or during treatment for BPH. This is an office procedure done with a local anesthetic. It not only evaluates the urethra for other causes of obstruction (i.e. strictures), it evaluates the prostate and more importantly the bladder. Many times a camera is placed on the cystoscope so that the patient can also see.

Treatment
Once it is determined that your symptoms are associated with BPH, treatment will depend on the severity of these symptoms. Treatments are either medical (non-surgical) or surgical.

 
  • Medical treatments include medications categorized as:
    Alpha Blockers, i.e. Flomax®, Cardura® (Doxazosin), and Hytrin® (Terazosin). Their action is aimed at the bladder neck (bladder opening) and prostatic urethra (area of the urethra surrounded by the prostate). By blocking the receptors that increase compression and closing of these channels, they allow for dilation and opening of the prostatic urethra and therefore a better flow of urine. Symptoms may improve within several days of starting the medication.

  • 5 Alpha Reductase Inhibitors, i.e., Proscar®. By blocking the 5 Alpha Reductase enzyme, the production of DHT (dihydrotestosterone) in the prostate is inhibited, therefore slowing or stopping growth. Many times this is used in combination with alpha blockers, and may take 3 to 6 months before prostate volume is notably decreased. In addition, PSA (prostate specific antigen) measured in the blood will be decreased by 50%. Therefore, it is important to alert your physician that you are on this medication if your PSA is being evaluated.

Surgical treatments for BPH vary from TURP (transurethral resection of the prostate), to minimally invasive procedures such as TUNA (Transurethral Needle Ablation), ILTT (Indigo Laser Thermotherapy), Microwave Therapy, WIT, or Prostatic Stents. While TURP removes tissue, the minimally invasive techniques employ the use of energy to heat the prostate, and time to allow the prostatic channel to open so that urinary flow is improved.

 
  • TURP (transurethral resection of the prostate) is the ‘gold standard’ by which all other surgical treatments of the prostate are compared to as it has had the best results. Done in a hospital setting with anesthesia, prostate tissue is resected (scraped) from within the urethra to create an open channel for one to urinate through. Afterwards, patients are placed on CBI (continuous bladder irrigation) to remove blood and clots that can form after the procedure. Generally a ‘voiding trial’ (removal of catheter to see if one can urinate) is performed about 1-2 days after the procedure.
  • TUNA (transurethral needle ablation) incorporates the use of radiofrequency energy delivered through two adjacent needles that are inserted into the prostatic tissue through the urethra. The treatment time is short and the procedure can be done with light sedation or local anesthesia in the office. Patients are sent home the same day with a catheter that is generally removed within seven days.
  • ILTT (Indigo Laser Thermotherapy) uses laser energy via a needle that is inserted into the prostatic tissue through the urethra. Generally done in an office setting, the procedure time is short and patients are generally sent home with a catheter that is removed after several days.
  • Microwave therapy is done either in the office or in the hospital with sedation. Using a urethral catheter, microwave energy is emitted to the area of the prostate over a period of about 45 minutes. Patients are sent home with a catheter for several days.
  • WIT is an office procedure that is done with local anesthesia. It uses the concepts of balloon dilation and hot water to treat the prostate. A urethral catheter is placed and a large balloon dilated in the prostatic area to push open the prostate. Then, heated water is circulated through the balloon to heat the prostatic tissue. Treatment time is generally 45 minutes and patients are sent home with a catheter that is removed after several days.
  • Prostatic Stents are devices placed in the prostatic urethra thereby compressing the obstructing prostate and creating an open channel to urinate through. They are generally used in patients that cannot tolerate any prolonged surgery.

For a referral to a Beth Israel urologist in Manhattan or Brooklyn specializing in BPH-benign prostatic hyperplasia (enlarged prostate) treatment, call our Physician Referral Service at 1-877-484-3466.

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