Benign Prostatic Hyperplasia   Frank Barnhill M.D.
 

Benign prostatic hyperplasia (BPH) is a non-cancerous (benign) overgrowth of normal prostrate tissue in males.

The reason BPH occurs is unknown, but it appears that increasing age and the male hormone testosterone must be present for it to occur. Men who were castrated prior to puberty do not develop BPH.

Other things thought to be related to BPH development and progression include:

Smoking, alcohol intake, vasectomy, race, sexual activity, diet, socioeconomic status

Further studies will be required to define exactly what aspects of each of these “suspected causes” could be responsible for BPH.

More about the disease

BPH is one of the most common disorders affecting men age 40 years and older. In the United States, about 50% of sixty year old and 90% of 85 year old males will have evidence of BPH. Approximately 40% of these men will experience lower urinary tract symptoms (LUTS) as they approach 70 years of age.

Key Point:  Symptoms of prostate enlargement (LUTS) do not correlate well with the size of a man’s prostate. I’ve seen men who had very large prostates, yet had few symptoms and conversely have examined men with very small prostates who suffered terrible symptoms!

Here are a few of the more prominent symptoms of BPH:

·       Frequent urination (often every two hours while you’re awake)

·       Straining to urinate (can progress to retention or being unable to urinate)

·       Decreased force of your urine stream

·       Urgency (feeling as if you must go soon!)

·       Hesitancy or dribbling (urine flow is hard to get started or starts and stops)

·       Feeling as if your bladder does not completely emptied

·       Frequent nighttime urination (nocturia)

Doctors often use the presence or absence of these symptoms in a scoring system, the International Prostate Symptom Score (IPSS) to help in deciding about the need for and the type of therapy best suited for this problem.

However, before starting medications or advising surgery, your doctor will:

·       Perform a digital rectal exam (DRE) to measure size and check consistency and for nodules or tenderness

·       Draw blood for PSA levels to help exclude prostate cancer (normal is less than 4 micrograms per milliliter)

·       Check a urinalysis for blood, abnormal renal cells or signs of infection

·       Perform a trans-rectal ultrasound to image tissue density and nodules not detected by DRE (this test may be optional)

If all of these tests are normal, you have isolated benign prostatic hyperplasia (BPH) and any therapy should be targeted at “improving your quality of life”.

One of my 76 year old male patients summarized his quality of life issue with these words:

“All I do all day long is run to the bathroom to pee and when I get there it’s like squeezing milk out of a cow!” “I don’t get to do much else.” “I can’t go anywhere unless there’s a bathroom and then I’d have to stop to pee every twenty miles.”

When you’re 76 years old, your quality of life is sometimes more important than anything else.

Let’s proceed to our discussion on BPH therapy…

Current non-surgical treatment options include:

·       Watchful waiting
Lifestyle changes (discussed below) are used to help men with few or no symptoms of BPH avoid future difficulties.

·       Alpha adrenergic blocking agents
Blocking agents such terazosin (Hytrin), alfuzosin (Uroxatral), tamsulosin (Flomax) and doxazosin (Cardura) help by relaxing smooth muscle in your prostate.

·       5-alpha reductase inhibitors
These agents, finasteride (Proscar) and dutasteride (Avodart) actually help your BPH by decreasing prostate volume (size) by interfering with testosterone metabolism. (Remember: no testosterone= no prostate enlargement)

·       Phytotherapy
Herbal supplements such as Saw Palmetto (serenoa repens), African plum (Pygeum africanum) and South African star grass (Cynodon nlemfuesis) may help BPH symptoms through mechanisms discussed in blocking agents and inhibitors. A word of caution: while generally considered safe, these supplements need further study to determine long term effects of their use!

If these treatment strategies fail to improve your quality of life or should physical complications such as obstruction worsen or become complete (unable to urinate), your doctor will probably advise one of the following surgical procedures.

Minimally invasive surgeries include:

·       Transurethral needle ablation (TUNA)
Using cystoscopy, low energy radiofrequency passed between two needles is used to heat your prostate tissue to 80 to 100 degrees F, creating a “necrotic (dead) area” that will shrink and scar

·       Transurethral microwave thermotherapy (TUMT)

In TUMT, a cystoscope inserted microwave unit is used to heat prostate tissue to 140 to 176 degrees F, to the same result as TUNA

·       Transurethral incision of the prostate (TUIP)
Involves using a cystoscope attached scalpel to make two or three incisions in your prostate and the surrounding tissue to “relax tight areas”

·       Laser therapy
Lasers are used to create very high pulsed (rapid) vaporization of your prostate tissue to depths between 0.4 millimeters to 4 millimeters.

·       Transurethral resection of the prostate (TURP)

Is a little more invasive than the above procedures discussed above, but is considered the “Gold Standard therapy” as it is well proven to be effective and has been around a long time.
TURP involves completely removing (resecting) the prostate through a cystoscope.

* Cystoscopy refers to the procedure in which a fiber-optic tube called a cystoscope is   inserted through the penile opening (urethra) to directly visualize things in most parts of the urinary tract.

Key Note: All of these therapies are meant to improve urine flow by relieving obstruction (decreasing prostate size or volume) and may not cure the problem forever!  In addition, most have significant side effects that you should discuss with your doctor.

Most men achieve improved urine peak flow rates of between 60 to 85% within a month of one of these procedures. I’m sure you can imagine how much this improves their quality of life.

It’s rare that these treatment modalities will fail to improve or eliminate your BPH problem.

In fact, in the last ten years, I’ve only seen one patient who failed to improve after having two of these procedures. He required complete surgical removal of his prostate (prostatectomy).

Lifestyle changes you can make to improve the health of your prostate and help BPH:

·       Avoid all tobacco products (nicotine)

·       Reduce or avoid alcohol intake

·       Decrease your caffeine intake

·       Do not routinely use antihistamines or decongestants

·       Drink plenty of water, but avoid a lot of liquids prior to bed to improve sleep

·       Eat a healthy balanced diet to obtain necessary nutrients

Before we conclude your education on prostate disease, please let me mention a few other important things about the male urinary system.

There are several other lower urinary tract symptoms (LUTS) that may indicate more serious problems:

·       Blood in your urine (hematuria)

·       Severe burning or pain while urinating (dysuria)

·       Pain in your testes or just above the bladder

·       Chronic or severe pain in the lower back

·       Thick mucus or white cloudy urine

·       Discharge from your penis

·       Bloody ejaculate during sex

All of these may mean the presence of kidney stones, kidney damage, infection, tumors, or even cancer of your urogenital organs. If you notice any of these more serious symptoms of disease, please see your doctor as soon as possible.

One of my patients once jokingly noted, “When you’re young a prostate is a wonderful thing to have.” “When you get old, it ain’t so wonderful!”

Hopefully, this information will help your prostate “remain young” well into your eighties.

Dr. Frank

Comments? drfrank@drhuggiebear.com

References:  Christensen M.D., Tyler L. and Andriole, M.D., Gerald: Benign prostatic Hyperplasia: Consultant, 49-02: 02-2009

Conn’s Current Therapy 2009

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