Enlarged Prostate (BPH)

Benign prostatic hyperplasia, or BPH, is a condition in which the prostate enlarges as men get older. Over 70% of men in their 60s have BPH symptoms so it is very common. While BPH is a benign condition and unrelated to prostate cancer, it can greatly affect a man’s quality of life.

The prostate is a male reproductive gland, about the size of a walnut that produces fluid for semen. The prostate surrounds the urethra, which is the tube that carries urine from the bladder out of the body. As the prostate enlarges, it presses on and blocks the urethra, causing bothersome lower urinary tract symptoms (LUTS).

Risk Factors

Risk factors for developing BPH include:

• Aging is the biggest known risk factor for an enlarged prostate
• Family history of BPH
• Lack of physical activity
• Obesity and high blood sugar may also be risk factors

Symptoms

As the prostate enlarges, it presses on and blocks the urethra, causing bothersome urinary symptoms such as:

• Frequent need to urinate both day and night
• Weak or slow urinary stream
• A sense that you cannot completely empty your bladder
• Difficulty or delay in starting urination
• Urgent feeling of needing to urinate
• A urinary stream that stops and starts

Evaluation and Diagnosis

The evaluation of BPH typically consist of a thorough medical history, a physical examination (including a digital rectal exam or DRE), urinalysis, and use of the AUA Symptom Score (AUASS).

The AUASS was developed by the American Urological Association to help assess the severity of such symptoms. This diagnostic system includes a series of questions that ask how often the urinary symptoms identified above occur and the amount of bother from these symptoms. This helps measure how severe the BPH is, ranging from mild to severe.

There are a series of other studies that may or may not be offered to a patient being evaluated for BPH depending on the patient’s current medical condition. These include:

• Prostate specific antigen (PSA) — a blood test to screen for prostate cancer
• Post-void residual volume (PVR) — measures the amount of urine left in the bladder after urinating
• Urine flow study (Uroflowmetry) — measures how fast urine flows while urinating
• Cystoscopy — a small flexible scope that is passed through the penis to look in the urethra and bladder
• Urodynamic pressure/flow study — tests the pressures inside the bladder during urination
• Imaging of the prostate — to evaluate prostate size and shape and assess presence or absence of an intravesical lobe

Treatment

The treatment for BPH depends on the severity of symptoms. Mild cases of BPH may need no treatment at all. Sometimes it is as simple as making lifestyle changes. In some cases, minimally invasive procedures that do not require anesthesia are good choices. And sometimes a combination of medical treatments works best.

The main treatments for BPH are:

Behavioral Changes

The first line of treatment for BPH consists of behavioral changes, such as double voiding, timed voiding, avoidance of caffeine, alcohol and other diuretics, as well as night-time fluid restriction. This treatment option is good for patients who have mild symptoms of BPH or have moderate to severe symptoms but are not bothered by their symptoms.

Patients suffering from kidney problems as a result of BPH, urinary retention (suddenly being unable to urinate), or frequent urinary tract infections, and urinary incontinence are not good candidates for this treatment option.

Medications

Medical therapy often consists of using alpha blockers, such as Flomax, Uroxatral, Rapaflo, Cardura, or Hytrin. Originally used to treat high blood pressure, these medications relax the muscle around the prostate and bladder neck, thereby increasing urinary flow and decreasing symptoms.

Five-alpha reductase inhibitors (5ARIs), such as Proscar or Avodart, block the conversion of testosterone to dihydrotestosterone within cells of the prostate. This results in shrinkage of the prostate and a decrease in the associated blockage of urinary flow.

Often, alpha blockers and 5ARIs are used in combination to augment therapeutic effect.  Anticholinergics, medications that inhibit bladder contractions, can also be used to further improve symptom relief.

Finally, Cialis has been used to also help improve BPH-related symptoms.

Micro-Invasive Therapy

SoracteLite — is an innovative and micro-invasive treatment for BPH. It is a non- surgical procedure which, by exploiting laser energy, obtains a significant reduction in the volume of the prostate consequently freeing up the urethral channel from the compressive processes that obstruct normal urinary flow. This ensures a gradual resolution of symptoms and progressive improvement in the quality of life for the patient, who will urinate less frequently with a more powerful flow, while the number of night-time urinations is reduced or eliminated, and the risk of urinary tract infections decreases.

SoracteLite is an alternative treatment to surgery and other mini-invasive techniques that use a transurethral approach. It differs from these by the treatment methods (in-situ thermal ablation without tissue removal), absence of complications involving the urethra, reduced hospitalization (day hospital procedure), and rapid recovery of the patient (few hours after treatment).

Minimally Invasive Therapies

New treatments have been developed in recent years that can effectively reduce the size of the prostate and relieve urinary blockage but are less invasive and damaging to healthy tissue than is surgery.

Minimally invasive treatments include:

Prolieve thermodilation — The Prolieve system provides a 45-minute in-office treatment that combines microwave thermotherapy capability with balloon compression technology to both heat the prostate and dilate the prostatic urethra. The Prolieve system provides a relatively painless and effective alternative to drug therapy and certain types of surgical procedures to treat the symptoms of enlarged prostate (BPH). Clinical studies have shown that Prolieve treatment can be done with topical sedation only and does not require post-treatment cauterization in 95% of the cases. Many patients report noticeable BPH symptom improvement within 2 weeks after the treatment.

UroLift — The UroLift system treatment is a minimally invasive approach to treating BPH that lifts or holds the enlarged prostate tissue out of the way, so it no longer blocks the urethra. There is no cutting, heating or removal of prostate tissue. The UroLift System treatment is typically performed using only local anesthesia in a physician’s office. Patients experience rapid symptom relief, significant improvement in quality of life and preservation of sexual function.

Rezūm — Rezūm is a treatment for BPH that can be performed in a clinic or out-patient setting. Rezūm uses the stored thermal energy in water vapor (steam) to treat the extra prostate tissue that is causing symptoms such as frequency, urgency, irregular flow, weak stream, straining and getting up at night to urinate.

Inside a hand-held device, radiofrequency energy is applied to a few drops of water to create vapor (steam). The water vapor is injected into the prostate tissue that is blocking the flow of urine from the bladder, where it immediately turns back to water, releasing the energy stored in the vapor into the cell membranes. At this point, the cells are gently and immediately damaged, causing cell death. Over time, your body will absorb the treated tissue through its natural healing response.

Symptom improvement following the procedure is gradual and can vary.  Many patients experience significant symptom improvement within 2 weeks after the treatment.

Surgery

Surgery represents the most reliable way to relieve urinary symptoms, although it is typically reserved for patients for whom medications are not helpful, or for those unable to tolerate, or unwilling to take, medications.

Most surgeries for BPH today are endoscopic in nature and therefore do not require any incisions.  Rather, surgical instruments are passed via the urethra to the level of the prostate.

The gold standard consists of transurethral resection of the prostate (TURP), where the core of the prostate is cut into small pieces and then removed.  TURP may be performed using different types of electrosurgical as well as laser energy. Laser TURP is performed using lasers of various types and wavelengths (e.g., holmium laser, Greenlight™ laser) that carry the advantage of decreased risk of complications such as intraoperative bleeding and fluid absorption.

Newer electrosurgical technologies include the use of bipolar button or loop, which also decrease the risk of fluid absorption.

Finally, simple prostatectomy can be performed in open, laparoscopic, or robotic fashion, and is typically reserved for patients with very large prostates, where transurethral surgery would be difficult to perform safely. The prostate is accessed via incisions in the skin.