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II. Benign Prostatic Hyperplasia (BPH)
Benign prostatic hvperplasia (BPH) is an enlarged prostate. Benign means noncancerous and hyperplasia means excessive growth of tissue. BPH is the result of small noncancerous growths inside the prostate. It is not known what causes these growths, but they may be related to hormone changes that occur with aging. By age 60, more than half of all American men have microscopic signs of BPH, and by age 70, more than 40 percent will have enlargement that can he felt on physical examination.
The prostate normally starts out about the site of a walnut. By the time a man is age 40, the prostate may already have grown to the size of an apricot; by the age of 60, it may be as big as a lemon.
BPH, which usually does not affect sexual function, is a troublemaker because the prostate, as it enlarges, presses against the bladder and the urethra, blocking the flow of urine.
A man with BPH may find it difficult to initiate a urine than a dribble. He also may need to urinate frequently, or he may have a sudden, powerful large to urinate. Many men are forced to get up several times a night; others have an annoying feeling that the bladder is never completely empty.
Straining to empty the bladder can make matters worse; the bladder stretches, the bladder wall thickens and loses its elasticity, and the bladder muscles become less efficient. The pool of urine that collects in the bladder can foster urinary tract infections, and trying to force a urine strearn can produce backpressure that eventually damages the kidneys. The kidneys are where urine is formed, as waste products are filtered from the blood.
BPH sometimes leads to problems. For instance, a completely blocked urethra is a medical emergency requiring immediate cathetetization, a procedure in which a tube called a catheter is inserted through the penis into the bladder to allow urine to escape. Other serious potential complications of BPH include bladder stones and bleeding.
Diagnosing BPH
A detailed medical history focusing on the urinary tract - kidneys, ureters (the pair of tubes that carry urine from the kidneys to the bladder), the bladder, and the urethra - allows the doctor to identify symptoms and to evaluate the possibility of infection or other urinary problems.
The initial medical workup typically includes a physical exam called a digital rectal examination (DRE), a urinalysis to check for infection or bleeding, and a blood test to measure kidney function. Some physicians may also check the amount of prostate-specific antigen (PSA), using a PSA test (see Evaluating Prostate Health), to help rule out the likelihood of cancer. PSA is a protein that is produced by the cells of the prostate gland.
In addition, other tests may help a urologist -a doctor who specializes in disorders of the urinary tract and the male reproductive tract- to determine if BPH has affected the bladder or kidneys. These include tests that measure the speed of urine flow, pressure in the bladder during urination, and how much urine is left in the bladder after urinating.
Some other tests that are widely used, according to an expert panel sponsored by the United States Public Health Service (USPHS) practice guidelines, are expensive, sometimes risky, and, for most men, unnecessary. These include cystoscopy, in which the doctor inserts a viewing tube up the urethra to get a direct look at the bladder; an x-ray called a urogram, in which urine is made visible on an x-ray after dye is injected into a vein; and ultrasound, which obtains images of the kidneys and bladder after a probe is placed on the abdomen.
Treating BPH
About half of the men with BPH develop symptoms serious enough to warrant treatment. BPH cannot be cured, but its symptoms can be relieved by surgery or by drugs in many cases.
BPH does not necessarily grow worse. According to one review, mild to moderate symptoms worsened in only about 20 percent of the cases. They improved (without any specific treatment) in another 20 percent, and stayed about the same in the rest.
Men whose symptoms are mild often opt for an approach called watchful waiting. This means that they report for regular checkups and have further treatment only if and when their symptoms become too bothersome.
The USPHS Clinical Practice Guidelines call watchful waiting "an appropriate treatment strategy for the majority of patients." Men who choose watchful waiting should have regular, perhaps annual, checkups, including DREs and laboratory tests.
For those who choose watchful waiting, a number of simple steps may help to reduce bothersome symptoms. These include limiting fluid intake in the evening, especially beverages containing alcohol or caffeine, which can trigger the urge to urinate and can interfere with sleep; taking time to empty the bladder completely; and not allowing long intervals to pass without urinating.
Men monitoring prostate conditions should also be aware that certain medications they are taking for other ailments may make their symptoms worse. These include some over-the-counter cough and cold remedies, prescribed tranquilizers, antidepressants, and drugs to control high blood pressure. Switching to a different prescription may help.
Watchful waiting, of course, is not always enough for BPH, and surgery or drug therapy may be required. Here is a close look at both options:
BPH Surgery
Although the popularity of prostate surgery has diminished since drug therapy became available (a total of 250,000 procedures were performed in 1996, down from 400,000 in 1988), operations for BPH remain the most common surgery performed on American men.
Several types of surgery can relieve the symptoms of an enlarged prostate. They are:
Transurethral Resection of the Prostate (TURP). This procedure accounts for more than 90 percent of all BPH surgeries. TURF relieves symptoms quickly, typically doubling the urinary flow within weeks.
Here is how the surgery is done. The patient is numbed from the waist down with an anesthetic injection known as a spinal block. The surgeon then inserts a slim fiberoptic tube through the penis and up the urethra as far as the prostate. Using either a tiny blade or an electric loop, the surgeon pares away the urethras lining and bits of excess prostate tissue. Gradually the passageway is expanded.
A TURP patient is usually hospitalized for several days after surgery. During convalescence, a catheter remains in the bladder through the penis to drain out urine. By the time the patient leaves the hospital, he is usually able to urinate on his own.
The TURF procedure ordinarily does not pose the two main dangers generally linked to prostate surgery: incontinence (loss of urinary control) and problems with sexual function, especially sexual impotence (the inability to have an erection).
About 5 percent of men become partially incontinent after the TURF procedure although the incontinence sometimes clears up over time. In addition, some men develop scarring in the urethra that can block urination. As many as 10 percent will need repeat surgery because prostate tissue grows back.
About 5 percent of men become impotent after the TURF procedure. But TURF does not usually affect a man's ability to have an erection or an orgasm, since the nerves that control erection lie outside the prostate and are not touched by the operation. A more common side effect is a dry, or retrograde, ejaculation. It occurs after surgery when the neck of the bladder fails to close properly during ejaculation. The result is that semen spurts backward into the bladder rather than through the penis. Men who experience this side effect still have the sensation of an orgasm but are unable to father children.
Transurethral Incision of the Prostate (TUIP). This procedure is used on small prostate glands of 30 grams or less and is used far less frequently than TURF.
Like TURF, TUIP is performed by passing an instrument through the penis to reach the prostate. The difference is that a doctor makes only one or two small cuts to relieve pressure in the prostate rather than trimming away tissue. Like TURP, the procedure considerably increases the urine flow.
TUIP is an outpatient procedure with a low risk of side effects. Because of that, the USPHS, Clinical Practice Guidelines recommend that the technique be used more often.
Transurethral Needle Ablation (TUNA). This recently approved technique, which can be done with a local anesthetic on an outpatient basis, uses radio frequency energy delivered through needles to kill excess prostate tissue. A catheter that deploys the needles toward the obstructing prostate tissue is inserted into the urethra before the procedure begins. Some clinical studies have reported that TUNA improves the urine flow with minimal side effects when compared with other procedures.
Open Prostatectomy. The word "open" refers to the fact that a surgeon makes an incision to reach the prostate, instead of inserting an instrument through the urethra. Open prostatectomy may involve either a radical or a partial procedure. A radical prostatectomy, which removes the whole prostate, is done for cancer. The incision is made through either the lower abdomen or the perineum. Partial prostatectomy, which leaves the posterior portion of the prostate intact, is used to treat BPH. The incision for a partial prostatectomy is usually through the abdomen. Open prostatectomy once was the sole recourse for an enlarged prostate. Today it is used only on extremely large prostates, which represent about 5 percent of all cases.
BPH Drug Therapy
Millions of American men have chosen drugs over surgery since drug therapy for BPH made its debut in the early 1990s. Although regarded as less effective than surgery, drugs are also less invasive and usually free of major side effects.
There are two major classes of drugs: alpha adrenergic blockers and finasteride.
Alpha adrenergic blockers were originally used for the treatment of high blood pressure, to relax smooth muscles in blood vessel walls. In BPH, they relax the muscular portion of the prostate and the bladder neck. This allows urine to flow more freely. In the average patient, these drugs increase the rate of urine flow and reduce symptoms, often within days. Side effects include dizziness, fatigue, and headache.
Finasteride shrinks the prostate by blocking an enzyme that converts the male hormone testosterone into a more potent, growth-stimulating form. Some, but not all, studies show that taking finasteride for at least six months can increase urinary flow rate and reduce symptoms. It seems to work best for men who have greatly enlarged prostates. In a small percentage of men, the drug can affect sexual activity, decreasing a man's interest in sex, diminishing his ability to have an erection, and causing problems with ejaculation. It sometimes also reuses tenderness or swelling of the breasts. It may cause a drop in PSA levels. These side effects can be reversed by stopping the drug.
Some doctors think that combining the two types of drugs may produce better results.
Researchers are working to develop BPH treatments that are more effective and less traumatic, with fewer side effects. These include using laser surgery, powerful electric currents, and microwaves. Doctors have also tried to enlarge the urethra by inserting a balloon into it and inflating it with fluid, and by inserting a stent (a small metal coil) into the urethra to hold it open.
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Testing Drug Therapies for BPH Some 3,000 volunteers are participating in a National Institutes of Health clinical trial at 17 sites accros the country. The trial will compare finasteride with an alpha adranergic blocker and with an inactive look-alike (placebo). The goal of the trial is to see B drugs, in addition to relieving symptoms, will keep symptoms of BPH from progressing. |
Choosing a Treatment for BPH
If a man has no serious complications such as the inability to urinate, kidney damage, frequent urinary tract infections, major bleeding through the urethra, or bladder stones, the best approach for treating BPH is not clear.
The USPHS Clinical Practice Guidelines advise doctors to leave treatment decisions to the patient, after a discussion of the benefits and side effects of each treatment option.
The options selected by an individual man are tied to his own preferences. For instance, some men want immediate relief and are willing to undergo surgery or embrace a drug regimen to get that relief. Some men also are eager to take drugs even if their only symptom is an elevated PSA level. Others are reluctant, often unwilling, to undergo surgery or to take pills daily for an extended period.
"Patients ...who have the same levels of symptoms when offered treatment choices will choose quite differently. Their choices will reflect concern about sexuality and how much symptoms bother them. So this concept of the degree of `botheredness' is a new dimension in decision-making."
USPHS Clinical Practice Guidelines
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Self-Test for BPH To help patients, and their physicians, assess the severity of BPH symptoms, the American Urological Association has developed a seven-question index. Over the past month, how often have you:
Here is how to score. For the first six questions, give yourself a score of 1 for having problems less than one time in five, a score of 2 for having problems less than half the time, a score of 3 for having problems about half the time, a score of 4 for having problems more than half the time, and a score of 5 for having problems almost all the time. For the seventh question, give yourself 1 for each time you got up in the night. (If you had to get up five times or more, use 5 for scoring.) Symptoms are classified as mild if your score totals 1 to 7, moderate from 8 to 19, and severe from 20 to 35. |
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