Benign Prostate Hypertrophy: Benign but Not Fun

With an increasing aging population, the prevalence of benign prostatic hyperplasia (BPH) is increasing. Recent data indicate that more than 80 percent of men older than 70 years have BPH. Benign prostatic hyperplasia is a disorder that affects the prostate gland. The prostate gland is located just behind the bladder and surrounds the urethra at the base of the penis. The prostate gland generally enlarges with age. As the gland gets bigger, it presses on the urethra and obstructs the urine flow. Most men who haven an enlarged prostate complain of the inability to pass urine forcefully and have a weak urinary stream. When symptoms of urinary obstruction interfere with quality of life, treatment is warranted.

Most symptoms of BPH start gradually. One early symptom is the need to get up more often at night to urinate. Another symptom is the need to empty the bladder often during the day. Other symptoms which appear later are a difficulty in starting urine flow and dribbling after urination ends. The size and strength of the urine stream may decrease in cases of moderate to severe BPH. Urgency, hesitancy, difficulty passing urine all appear during the later stages of the disorder.

These symptoms can be caused by other disorders besides BPH. These may include prostate cancer, urethral stricture, medications or prostate infection. Simple tests will reveal the cause of the urinary trouble.

Diagnosis

The diagnosis of BPH is based on the patient’s symptoms. These symptoms include urinary frequency, nocturia, urgency, hesitancy, weak or intermittent urine stream, straining to void, and sensation of incomplete voiding. It is common for an enlarged prostate to be found on rectal examination, but enlargement is not necessary for the diagnosis of BPH. In many individuals there is no correlation between the size of the prostate and the symptoms.

To allow for more accurate diagnosis and severity of BPG, various scoring systems have been developed by the American Urological Association (AUA). The system allows patients to rate various urinary symptoms on a scale of zero to five. The total point score is then matched to the point range for mild, moderate, or severe BPH. (Table 1)

A rectal exam is a must for all individuals with suspected prostate problem. The rectal exam is not painful but just uncomfortable (some men do like it). The rectal exam allows the doctor to feel the size of the prostate gland and any abnormality.           

All patients with suspected BPH should undergo urinalysis testing to screen for infection or blood, and kidney function is always assessed. In addition, prostate-specific antigen (PSA) testing may be offered to patients at risk for prostate cancer who prefer to be screened for the malignancy. The AUA recommends that PSA testing and rectal examination be offered annually to men 50 years of age and older if they are expected to live at least 10 more years. Black men and men who have a first-degree relative with prostate cancer are at high risk for prostate cancer.

Only in the very dubious cases is an ultrasound exam or a biopsy of the prostate done to help make the diagnosis of BPH. Optional radiological tests may include assessment of urinary flow rate and pressure measurements.

Treatment Options

For those individuals who have none or very mild symptoms, no treatment is indicated. For those with mild symptoms, one may also elect to observe as the condition is known to improve on its own. However, all patients with moderate to severe symptoms will require treatment.

Observation

Watchful waiting is appropriate in some individuals who have a low AUA symptom score (zero to seven). In these individuals, medications are no more effective than sugar pills, plus the medications also have side effects. However, if observation is undertaken, the individual should be regularly followed up because BPH can undergo spontaneous remission without treatment. Those with high AUA scores should be treated.

MEDICAL TREATMENTS

Drugs

Alpha blockers

Various drugs available to treat BPH. They basically reduce the tone in the prostate muscle and relax the tension on the urethra. They do work immediately and are effective for all patients with mild to moderate symptoms of BPH. At least 7-10% of patients who take these drugs complain of some type of side effects which includes dizziness, postural hypotension, fatigue, and asthenia. To limit the side effects, it is encouraged that a low dose be used and that the drug be taken just before bed time. The availability of various generic products has made this a cheaper form of therapy

5 alpha-Reductase Inhibitors.

These drugs decrease the production of testosterone and hence result in a decrease size of the prostate over time; most patients respond to the drug after about 3-6 months of treatment.

The drugs include Finasteride (brand name: Proscar) and dutasteride (brand name: Avodart). These drugs are able to block the effects of testosterone on the prostate gland and thus prevent it from enlarging. However, these drugs for some reason do not work in all patients with BPH. The drugs also have unpleasant side effects which affect sexual function and decrease libido. These sexual side effects are temporary and disappear when the drugs are stopped. However, when the drugs are stopped, the prostate will start to re enlarge again and produce the same symptoms as before. At this point an alternative treatment may be suggested.

One important point of note is that Finasteride decreases PSA levels by 40 to 50 percent. PSA levels are increased in prostate cancer and thus in patients taking Finasteride PSA levels should be doubled and then compared in the usual fashion to age-related norms. Recently, Dutasteride (Duagen) has become available for the treatment of BPH. It has also shown to be an effective drug for hair growth. This drug has a distinct mechanism of action and its sexual side effects are similar to those of Finasteride.

In general these drugs work best in men with large prostate gland, whereas the alpha blockers are effective across a wide range of prostate sizes

SURGICAL options

Surgery is considered to be the most effective treatment for BPH and is generally recommended in individuals with severe symptoms. Surgery is also the next alternative when drug therapy has failed. The surgery can also help to make a diagnosis of prostate cancer (it is present). The surgery is usually done via the urethra and there are no major surgical incisions.

Surgery is recommended for individuals who have failed drug therapy, have refractory urinary retention, require continuous bladder catheter, or have recurrent urinary tract infections, persistent blood in the urine, bladder stones or kidney failure. Surgery is also the first choice of treatment for individuals with high AUA symptom scores.

Open Prostatectomy

The oldest and most effective surgical method of relieving BPH is open prostatectomy. The surgery involves removal of the inner portion of the prostate using. This is the gold standard for treatment of BPH. It immediately relieves symptoms and maximizes urine flow. Less than 2% of individual develop recurrence.

However, open prostatectomy is the most invasive procedure for a benign disorder and has a high morbidity. The surgery is rarely done today and is a last resort treatment for patients with bulky large prostate or a structural median prostate lobe that causes obstruction of urine flow.

Transurethral Resection of the Prostate (TURP)

This is the most common surgical procedure done today in North America. The procedure relieves symptoms in about 90% of patients but is associated with a number of complications.  The most frequent complications of the procedure are inability to pass urine (soon after the procedure), blood clot retention, and secondary infection. Bleeding, the most morbid complication occurs in 1 percent of patients. Other long-term complications include retrograde ejaculation (sperm are ejected back into the testis), impotence (lack of sexual desire) and urinary incontinence (leakage of urine all the time). At least 10% of patients require repeat treatment within 5 years.

Newer Procedures.

Since many patients with BPH are elderly and have numerous medical problems, they are poor candidates for TURP; In contrast, many younger patients find the high risk of sexual dysfunction unacceptable with TURP. Thus, newer minimally invasive procedures have been devised to treat BPH. These newer procedures are in fact less expensive and have low morbidity but are not widely available everywhere.

Transurethral incision of the prostate (TUIP)

TUIP is an endoscopic procedure and requires the making one or two incisions on the prostate to reduce narrowing of the urethra without removing any of the prostate gland. The procedure can be done under local or spinal anesthesia and has a rapid recovery period. TUIP is performed as an outpatient procedure. It is generally offered as a treatment option for younger patients for whom fertility and antegrade ejaculation are important future issues. The technique also reduces operating room time and is associated with significantly less bleeding. The results are the same as TURP. Long term results are pending.

Transurethral microwave thermotherapy (TUMT)

TUMT is a minimally invasive outpatient procedure whereby a tiny microwave tube is placed through the urethra. The small probe is heated via microwave energy and this causes deep, rapid tissue heating around the urethral base. To prevent heat damage to surrounding tissues, a cooling system with circulating water is a must. The procedure can be done by infiltrating the urethra with local anesthetic but frequently some patients do require general or spinal anesthesia. The procedure takes about 45-60 mins and only one session is required for most patients. With the few limited patients, it has been shown to decrease symptoms in at least 70% of patients. Recent data indicate that at two years after undergoing TUMT, at least 10% percent of patients required retreatment.

The procedure has not been associated with any major complications. Only a few patients have had urinary incontinence and sexual dysfunction. When high temperatures are used, the incidence of symptoms such as urinary retention do tend to increase.

 Transurethral vaporization of the prostate (TUVP)

TUVP is another minimally invasive procedure which involves ablation (destroying) the prostate by heat energy generated by a laser. The initial studies were fraught with bacterial infections. However, recent advances in electrodes, lasers and physician experience has decreased this complication. TUVP or transurethral electro-vaporization of the prostate (TVP) is now performed using fancy endoscopic instruments with controlled energy release. The procedure does result in immediate decrease in urinary symptoms and is also associated with a markedly lower incidence of complications when compared to TURP. With this procedure, tissue is not excised and thus it is not possible to tell if the patient may have a concurrent prostate cancer.

Transurethral needle ablation of the prostate (TUNA)

TUNA is another minimally invasive procedure that involves the placement of radiofrequency needles in the prostate. The procedure is done under local anesthesia. The needles are then stimulated at certain frequencies and can result in the destruction of the prostate. The procedure is considered safe and is accomplished within 45-60 minutes. Early data do show promise but at 2 years at least 12-15% of patients require retreatment.

Transurethral balloon dilatation of the prostate

This is an old procedure before the development of minimally invasive techniques. Today, innovations in instruments have allowed for the dilatation of the urethra safely. In addition, stents are also available to prevent the collapse of the urethra. Early data show that this procedure still has a high failure rate with many patients requiring repeat treatments. Infections and recurrent blockages of the stent are two major complications. This procedure is at present reserved in high risk patients with a short life expectancy.

Alternative medications

Public dis-satisfaction with medicine in general has led to a renewed interest in alternative medical therapy. Numerous epidemiology studies from the Orient reveal that Asians have a lower incidence of BPH than North Americans, and this has often been linked to high content of Genistein, a major isoflavone ingredient of tofu. This substance has been observed to decrease the growth of enlarged prostate tissue. Genistein is presently sold as a non prescription agent called Trinovin. Anecdotal studies reveal that symptoms of BPH subside in 1 month. The safety, side effects and possible complications are unknown.

Saw palmetto (Serenoa repens) is a popular complementary herbal product which is known to be effective in the treatment for BPH. The mechanism of action is uncertain. In patients with BPH, saw palmetto has been shown to be as effective as Finasteride (Proscar) but not as effective as other medical treatments. It has fewer side effects and a few studies have revealed a decrease in prostate size with daily usage. It has to be taken twice a day. Its long term effects remain unknown.

The large lucrative market has allowed the mushrooming of numerous herbal medicines postulated to cure BPH. The majority of these herbal agents are unregulated, their contents remain unknown and there is no data on their safety. Other agents include African plum, South African star grass, stinging nettle, and rye pollen. As with most herbal products, buyer beware.

Conclusion

Men with mild to moderate symptoms may want a trial of alpha-blocker therapy. The patient should set his own treatment goals and weigh the benefits (ie, symptom relief) against side effects (ie, postural hypotension, dizziness, asthenia). Because all alpha-blockers have relatively short half-lives, the earliest response takes about 4-7 days. One should start on a low dose and gradually increase the dose on a weekly basis. Neither Finasteride nor dutasteride provide symptom relief for all men. Patients considering long-term drug therapy should be informed of the magnitude of potential benefits and side effects.

To date, there are no large-scale studies which have compared the results of all the treatments for BPH. Treatment costs vary widely, and the availability of less invasive surgical options also varies considerably. Although surgery is more expensive than drug therapy, it is often more effective. 

With the wide range of treatments available for BPH, the patient should play a major role in his choice of therapy. Some patients may be willing to live with minimal symptoms and side effects of a less efficacious therapy (ie drugs), whereas others may consider any residual symptom to represent treatment failure and may want more aggressive treatment like surgery. Being knowledgeable about the disease process is essential.