Benign prostatic hyperplasia ( BPH) is one of the most common diseases to affect men beyond middle age. It becomes more likely as men get older. Since the number of men reaching a mature age is increasing, so are the number of cases of BPH. Today, only 20% of patients with BPH receive surgery to treat their problem. The remainder are often managed by "Watchful Waiting." The majority of these "watchful waiting" patients will require medication in the future as their condition worsens.
BPH is rarely life-threatening. The symptoms of BPH are: frequency (the need to urinate often), urgency (the need to urinate immediately), nocturia (night-time urination), and incomplete bladder emptying. These can be very bothersome. These symptoms occur slowly and serious health risks are uncommon. These often impact a patient's quality of life.
Growth and development of the prostate is affected by the male hormone testosterone. BPH is usually a slowly developing condition. This is not, however, always accompanied by a worsening of symptoms. As BPH progresses, the normal prostatic tissue is compressed more and more by the surrounding tissue. This then pinches the urethra. The prostatic urethra becomes less flexible, causing progressive obstruction of urine flow. Patients complain of hesitancy and a reduced stream. If bladder emptying becomes too difficult, the patient may develop urinary retention (urine cannot drain from the bladder). This intense stretching and strain on the bladder may make recovery of bladder function difficult, if not impossible.
History and Symptom Assessment
BPH is characterized by many obstructive and irritating symptoms, often referred to as lower urinary tract symptoms (LUTS). Symptoms include:
- Hesitancy (stop-and-go stream)
- Weak stream
- Straining to pass urine
- Prolonged urination
- Feeling of incomplete bladder emptying
- cute urinary retention (urine is trapped in the bladder)
- Urge incontinence
Symptoms can be assessed by means of the IPSS, (International Prostate Symptoms Score) or the AUA (American Urologic Association) symptoms score index. The physical examination is done by a digital rectal examination (DRE) on patients with BPH. DRE provides useful information about the size, consistency, and limits of the prostate. An analysis of the urine is done, either by dipstick or microscopic examination. A serum creatinine ( blood test) is used to assess kidney function. All patients below 75 years of age should also have their Prostatic Specific Antigen (PSA) levels checked. These tests are useful in helping to identify patients with prostate cancer.
Patients with low symptom scores and a normal PSA and DRE can be considered for watchful waiting. These patients are seen on a yearly basis. Symptom scores are checked over time. Patients with increasing symptom scores will progress to other treatments.
Medical treatment of BPH should be regarded as an option in its own right, rather than as merely an interim measure in patients waiting for surgery. Drugs such as Cardura, Hytrin, and Flomax have all been shown to increase urine flow rates and improve symptoms in about 60% of patients with BPH within 4 weeks of treatment. These drugs work by relaxing the smooth muscle in the prostate. This reduces obstruction to urine flow without affecting the bladder's ability to contract. These drugs are given once a day. Most patients start with a small dose, and gradually increase the dose to improve their symptoms. Side effects from these drugs are tiredness, dizziness, and headache, which occur in about 10% of patients. Decreased blood pressure occurs in only 2-5% of patients and this can be minimized by lowering the drug dosage.
Other drugs like Proscar act by shrinking the prostate. Proscar reduces the volume of the prostate by 20-30% in two-thirds of patients. This results in improvements in both symptoms score and flow rates, and usually takes about 3-6 months.
Surgical Management of BPH
Surgical treatment is usually indicated for patients who have complications of BPH, those who have symptoms that are not adequately controlled by medical therapy or who elect to forego an attempt at medication for more definitive treatment. These standard surgical operations are available:
- Transurethral resection of the prostate (TURP)
- Transurethral incision of the prostate (TUIP)
- Open prostatectomy
In general, surgical treatments produce the best improvement in urinary symptoms and urine flow. If compared with medical therapy, there are more complications with this type of treatment. About 95% of prostatectomies are currently carried out by the TURP procedure. With this procedure, a scope with a surgical loop is introduced through the urethra and chips of prostate tissue are cut and removed through the scope's sheath. The operation can be performed under spinal, epidural or light general anesthesia. A catheter is left in place for 36-48 hours after surgery. Symptoms and urine flow rates are improved in about 70-90% of patients. Complications include infection, bleeding, incontinence, retrograde ejaculation, and erectile dysfunction, although these are rare.
Even though BPH is almost never life-threatening, its symptoms can have a significant effect on the patient's well-being. There are many ways to treat BPH and with successful treatment, an improvement in the patient's quality of life can be achieved.