BPH

Benign (non-cancerous)prostatic hypertrophy– is an enlargement or growth of the area in the prostate gland that is nearest the urethra.

This growth can block or constrict the urethra, causing urination problems.

BPH is one of the most common conditions of the aging male with an estimated one third of men older than 50 years developing symptoms from the condition and 30% of these men eventually requiring surgery to alleviate the problems.

Although BPH is a common condition, it doesn’t always result in symptoms that need treatment. LUTS (Lower Urinary Tract Symptoms) is the name given to the actual symptoms, not the condition. LUTS affects when and what treatments should be prescribed.

Treat When Bothersome

Having symptoms is one thing. Being bothered by them is another.

“The patient is the only one who can tell the severity of the symptoms by the sense of “bothersomeness,” Dr, McVary said.

For example, some men don’t mind getting up in the middle of the night to go to the bathroom. They go right back to bed. The symptom is not a problem. Others, once they wake up, can’t get back to sleep. For them, the symptom creates a major problem and they want it to be treated.

“BPH is common, but bothersome symptoms shouldn’t be accepted. Treating LUTS is one of the gratifying aspects of being a urologist. After conventional treatment, whichever option is used, patients almost always have less bothersome symptoms,” McVary said.

On the other hand, all treatments from medications to surgery have some risk and McVary doesn’t recommend men begin any treatment until their symptoms are bothersome.

Bothersome Symptoms

The following are symptoms, and their causes, which can be bothersome:

1. Need to urinate often during the day and night (called nocturia) is a first symptom.
2. A weak or interrupted urinary stream (called intermittency) results when the prostate obstructs the urethra, causing the bladder to work harder to increase the pressure.
3. Eventually, the bladder, as a pump, starts to weaken and symptoms increase as the pump increasingly fails.
4. Even when the bladder feels full, it’s difficult to start the urine flow. The weak bladder needs more time to build up strength to pump out the urine.
5. Feeling the bladder isn’t completely empty is also caused by a weakened bladder functioning as a less effective pump.

Symptoms Mandating Treatment

Some symptoms are more than bothersome and men should know the important or cardinal signs that mandate treatment:

1. Recurrent infection of the urinary tract that relates to the blockage
2. Bladder stones that develop because the urine stays in the bladder too long, resulting in urine salts accumulating and forming bladder stones.
3. An increasing post void residual, which causes the urine left behind to make the bladder floppy. A urologist will be able to diagnose this condition.
4. Recurrent blood in the urine
5. Renal, or kidney, deterioration because of increased bladder pressure

“With any of the above symptoms, a urologist would be telling you, ‘It’s time to get treatment now,’” McVary said.

Treatments

Treatments vary from prescription drugs, minimally invasive therapy, and conventional surgical treatment.

In terms of selecting treatments, Dr. McVary suggests the patient begin by going to an experienced urologist who prescribes and performs a variety of treatments. If a patient goes to a urologist who specializes in one treatment, the others often aren’t given as options.

Treatment choice is usually left up to the patient, except when acute urinary retention dictates surgery.

Drug Treatment

“Although surgery has the best outcomes, patients often choose to start treatment with drugs or minimally invasive procedures. When patients have the option of choosing less risk, knowing it’s also with less benefit, they seem first to choose the treatment with the least risk,” McVary said.

Usually that means starting with drugs.

“What seems to be the most effective drug treatment now is a combination therapy of both alpha blockers (Hytrin, Cardura, Flomax or Uroxiatral), which relax the smooth muscle of the prostate and bladder neck, and finisteride (Proscar) or Avodart, which can stop growth of the prostate or possibly shrink it,” he said.

(Dr. Catalona informs patients that taking Proscar has the potential of masking prostate cancer symptoms by affecting PSA levels.)

Minimally Invasive Therapies

Minimally invasive therapies (microwave, electrovaporization, laser-resection) need to be tailored to the individual patient.

Dr. McVary said that in 50% of his patients, he would not recommend these minimally invasive alternatives.

He explained, for example, that if the prostate gland is too small, the procedures are not safe because they could cause damage in areas beyond the prostate.

In glands that are too big, the procedures can’t take out the necessary amount without causing other problems, such as swelling.

“These minimally invasive therapies can be effective but only for certain patients,” McVary said.

An enlarged prostate and prostate cancer have no apparent connection, but men having symptoms associated with an enlarged prostate should always check with a doctor to rule out prostate cancer before concluding they have BPH.

Surgical Therapy

In terms of surgery, the most common operation is TURP (transurethral resection of the prostate) where parts of the enlarged tissue are peeled off. If drugs can’t prevent acute urinary retention, TURP is often the only treatment choice.

But even without acute urinary retention, TURP is the choice with potentially the best results for alleviating symptoms from an enlarged prostate.

Some men worry about the risks of impotency and incontinence with TURP. In some studies, the surgery has been linked to erectile dysfunction in 14% of men treated and urinary incontinence in 5%, but these outcomes have not been linked directly to the operation and possibly would occur in this percentage of men without the surgery.

“With an experienced urologist, TURP is an excellent and usually most effective treatment choice,” McVary said.

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