BPH is not necessarily progressive. Patients may present with varying degrees of irritative symptoms or in urinary retention.
Medical Treatment for Irritative Symptoms
1. Alpha-1 blockers
These medications, such as Hytrin, Cardura, and Flomax, relax the smooth muscle in the prostate, allowing the bladder to empty better. In addition, these medications may also lower the serum cholesterol and triglycerides. However, in some men, they may affect ejaculation by allowing retrograde ejaculation to occur.
Finasteride (Proscar) is an anti-androgen that blocks the conversion of testosterone to dihydrotestosterone. The conversion to DHT is through the enzyme 5-alpha reductase and Proscar blocks this enzyme.
Phytotherapeutic agents (herbs)
The most common over-the-counter agent available for the treatment of BPH is saw palmetto berry extract. This berry comes from the saw palmetto palm plant. Although the clinical usefulness of saw palmetto and many other agents is still unproven, a number of patients believe their symptoms are improved on this agent alone or further improved after they add saw palmetto to an alpha-1 blocker such as Hytrin, Cardura or Flomax. Also, it is not known to what degree the placebo effect plays a role.
Surgical Treatment of BPH
1. Minimally Invasive Procedures for the Treatment of BPH.
Voiding symptoms of BPH or LUTS (lower urinary tract symptoms)
- straining to void
- weak flow
- post void dribbling
- feeling of incomplete emptying
It is very important to note that some of these symptoms may not be significant in the face of too much water drinking. There is absolutely no scientific evidence for loading up on an extra 6 to 8 glasses of water a day and urinary frequency in the face of this fluid loading is simply the body telling you this amount of fluid is not needed. The body’s thirst mechanisms are smart enough to tell you when to take in extra fluids.
The procedure for laser prostate ablation is normally done under an anesthetic in an outpatient setting but small prostates can now be ablated in the urologists office under sedation,local anesthetic and a periprostatic nerve block.
A cystoscope is advanced down the urethra and a side firing laser fiber introduced down the working channel of the cystoscope and under camera control,the lobes of the prostate are vaporized. The patient goes home with a catheter for 24 hours.
A big advantage of the laser prostate ablation/vaporization procedures are:
- usually done as an outpatient
- can vaporize a large amount of prostate
- relatively bloodless
- catheter is usually only left overnight
- short recovery time
- quick return to normal daily activities
- definitive and long lasting relief of voiding symptoms
- men can usually dispense with the taking of further prostate medications
Some men may notice some burning and urgency after catheter removal. If the urgency is severe it may be treated with a bladder antispasmodic but this issue will resolve with time and the healing of the wound within the prostate.
Because the bladder neck is also vaporized and removed (as it is in all surgeries to the prostate) a man can notice retrograde ejaculation (dry orgasm). Impotence and strictures (scarring of the bladder neck and or urethra) are rare. Also,men who have previously had treatment of their prostate cancer with radiation or cryoablation and have obstructive voiding symptoms may have a better response to conventional TURP rather than the laser form as their prostate tissue does not vaporize as well after radiation or cryo.
A. Vaporization Procedures
Transurethral laser-induced prostatectomy (TULIP) has fallen out of favor due to irritative voiding problems postoperatively. Visual laser ablation of the prostate (VLAP) has similar problems to TULIP. Holmium:YAG laser resection. Interstitial laser coagulation (Indigo). The Greenlight PVP (photoselective vaporization of the prostate) and Evolve laser PVP procedure laser procedure may be performed as an outpatient.The Greenlight PVP laser procedure of the prostate may be performed as an outpatient through a virtually blood free treatment under regional anesthesia and with restoration of urinary flow. (See Laserscope)
1. The PlasmaButton vaporization procedure vaporizes away obstructing prostate tissue for immediate relief of poor flow and dribbling. It is performed as an outpatient under anesthetic with minimal discomfort with removal of the catheter the following day. This procedure is an advance over laser procedures for BPH as there are far fewer frequency and urgency symptoms after surgery.
2. GreenLight Laser and Transurethral resection of the prostate (TURP).
The Greenlight and Evolve lasers are ideal for TURP’s (transurethral prostatectomy) and very effective at removing prostate tissue and relieving a mans urinary symptoms. If a man has failed all conservative means of treating his BPH (benign prostatic hypertrophy) and normalizing his voiding habit or he has gone into urinary retention and failed several voiding trials,then an outpatient laser ablation of the obstructing prostate lobes is an ideal procedure to resolve his voiding issues. The reason a man can develop worsening symptoms of urination with age is that the prostate sits at the base of the bladder and surrounds the prostatic urethra and this has the ability to choke off the urinary channel. However,his urinary symptoms are not totally related to the size of his prostate as some men with small prostates can have significant voiding issues while some men with large prostates can have minimal symptoms.
- Transurethral incision (TUIP). This procedure is indicated in patients with obstructive symptoms from normal-sized or very small prostates, where resection would be considered excessive.
- Transurethral vaporization (Vaportrode or Rollerball)
Dry electroresection-TUNA. Transurethral needle ablation (TUNA) delivers radio-frequency energy to the prostate. A temperature probe is placed in the rectum, the TUNA catheter is placed into the urethra, and two specialized needles (which act as radiofrequency antennae) are passed through the catheter into the enlarged prostate. Radiofrequency energy is then transmitted via the needles into the tissues and the needles repeatedly replaced, with each treatment section lasting for about 5 minutes. This procedure takes about an hour and is done as an outpatient using local anesthesia. (See TUNA Therapy)
Transurethral microwave therapy (low or high energy). This procedure (TUMP) damages the muscular components of the prostate tissue, bringing about their relaxation and therefore improvement in urinary symptoms. The procedure is done as an outpatient, and the patient reclines on a specially designed couch with a temperature probe in the rectum. A small catheter containing the microwave antenna is then positioned in the urethra adjacent to the prostate. The treatment usually lasts for an hour. (See Thermatrix)
Prostatic stents. Permanent spiral metal stents have been used in certain situations to keep the prostate open but have the complications of encrustation, obstruction with inflammatory granulation tissue, and migration. Some stents have also been made with a shape memory alloy with thermal expansion of the stent taking place after the positioning catheter is removed. Bioabsorbable and biodegradable urologic stents are also being evaluated.
Balloon dilatation. The prostate is dilated with a special balloon catheter under an outpatient anesthetic. The effects on the prostate are usually transitory.
Injectables. Alcohol and Botox injections into the prostate are being investigated and evaluated.
2. Open Prostatectomy
In those with very large prostates or associated bladder stones or other bladder pathology, a small suprapubic incision is made to enucleate the prostate. Recovery may take 2 or 3 days extra than that needed for the transurethral resection but more importantly offers definitive treatment so the patient has an excellent chance of normalizing his lifestyle once more.