Benign Prostatic Hyperplasia

BPH is the medical term for enlargement of the prostate gland. In men over 50, this is the most common prostate condition, and it is noncancerous.

Men living with an enlarged prostate can experience slow or blocked urine flow. You may strain to go, or have stopping and starting when you urinate. You may have the urgent need to urinate, or wake up to go. You may have a weak stream, you may have to go over and over again, and you may never quite feel as if you’ve emptied.

If you have BPH, this can have upstream effects on your urinary tract, bladder and kidneys.

DiagnosisMedical TreatmentsSurgical Treatments
BPH can only be diagnosed by your physician, after a complete history and physical examination. You’ll fill out a questionnaire describing your symptoms and their severity. The physician will perform a rectal exam. Other tests could include

  • Urinalysis
  • PSA and testosterone levels
  • Urine culture
  • Flow rate
  • Cystoscopy
  • Transrectal ultrasound
  • Urodynamics
If your condition is caused by BPH, medication may be the answer. Medical treatments can be divided into three categories: Phytotherapy, alpha-blockers and 5-alpha reductase inhibitors.

Phytotherapy is treatment with saw palmetto, a name you may have seen in the vitamin supplement section of your drugstore. It is a non-prescription therapy, and its production and distribution are not regulated by the FDA. The usual dosage is 160 mg two times per day. Though saw palmetto is popular, studies have not shown it to have any benefits over placebo medications.

Alpha-blockers block the prostate’s alpha receptors, causing the smooth muscle to relax. This, in turn, allows the channel to open and relieve urinary symptoms. Alpha-blockers come in two categories: Selective and non-selective.

  • Selective alpha-blockers can focus primarily on the prostate. The two approved by the FDA are tamsulosin (Flomax) and alfuzosin (Uroxatrol). They are equally effective to non-selective alpha-blockers, while minimizing side effects.
  • Non-selective, as the name implies, aren’t specific to the prostate. Therefore, they can affect other organ systems. Side effects include changes in blood pressure, runny nose, dizziness, erectile dysfunction and sexual dysfunction. Medications include terazosin, prazosin and doxazosin.

5-Alpha reductase inhibitors (5ARI) prevents the conversion of testosterone to dihydrotestosterone (DHT)—testosterone’s more-potent form. By suppressing DHT, we effectively “starve” the prostate gland, reducing its size. Finasteride (Proscar) and dutasteride (Avodart) are the FDA-approved medications.

Combination Therapy with an alpha blocker and 5ARI has been shown to be the most effective medical therapy for BPH. Combination therapy is usually reserved for men with progressive symptoms on monotherapy.

There are many minimally invasive treatments for BPH. These are the procedures we prefer, based on the patient’s needs.

Catheterization drains urine from the bladder. Catheters can be placed in the bladder intermittently every six to eight hours (clean intermittent catheterization) or left in place for one to three months at a time (indwelling). The catheter is either placed through the urethra or by making a puncture above the pubic bone.

  • Risks include infection and a higher risk of bladder cancer over time, especially in indwelling catheters versus intermittent
  • It’s most appropriate for temporary drainage while medication starts to work, while surgery is being scheduled, or while trying to clear infection
  • Catheterization is also most appropriate (less risky) when the patient has many other health issues or a shorter life expectancy
  • It is the treatment of choice for patients with neurogenic bladder as well as BPH

Microwave therapy (transurethral microwave therapy, or TUMT) is an office-based procedure performed with topical and oral pain medication. The prostate is heated through a catheter that emits computer-regulated microwaves. There is no anesthesia, so patients usually go home the same day.

  • This is best for patients who prefer to avoid anesthesia, or those who have too many health risks to undergo more-invasive surgery
  • There is also no blood loss, no fluid absorption, and results are rather reliable

Transurethral needle ablation (TUNA) of the prostate uses needles directly inserted into the prostate to emit radio frequencies and heat the tissue. The prostate initially swells, then shrinks. The procedure itself requires anesthesia and oral medications, and the patient may require catheterization for a period of time during healing.

  • Limited anesthesia is required, so TUNA can occur in an office setting
  • Serious complications are usually not a factor

Photoselective vaporization of the prostate (PVP) is fast becoming a very popular procedure.It can be performed either in a well-equipped office or as an outpatient at a hospital or surgical center. A high-powered laser vaporizes the obstructing prostate tissue with minimal bleeding or side effects. This procedure can serve to get men off of medical therapy. It is effectively replacing more invasive surgical treatment.

Transurethral resection of the prostate (TURP) is the most common surgery for BPH. In the United States, approximately 150,000 people have TURP performed each year. This can be done using electric current or with laser light. After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the tip of the penis into the urethra. The resectoscope contains a light, valves for controlling irrigating fluid and an electrical loop that cuts tissue and seals blood vessels. The removed tissue pieces are carried by the irrigating fluid into the bladder and then flushed out and sent to a pathologist for examination under a microscope. At the end of the procedure, a catheter is placed in the bladder through the penis. The bladder is continuously irrigated with fluid through the catheter in order to monitor bleeding and prevent blood from clotting and obstructing the catheter.

  • Since there are no surgical incisions with this procedure, patients normally stay in the hospital only one to two days
  • Depending on surgeon preference, the catheter may be removed while the patient is still in the hospital or the patient may be sent home with the catheter in place, attached to a leg bag for convenience and removed several days later as an outpatient procedure

Transurethral incision of the prostate (TUIP) is used for men with smaller prostate glands who suffer from significant obstructive symptoms. Instead of cutting and removing tissue to relieve the obstructed bladder, this procedure widens the urethra by making several small cuts in the bladder neck where the urethra joins the bladder and in the prostate itself. This reduces the pressure of the prostate on the urethra and makes urination easier. Patients normally stay in the hospital one to three days. A catheter is left in the bladder for one to three days after surgery.

Rezūm – Rezūm is a minimally invasive alternative to BPH medications that relieves symptoms safely and effectively in an office or out-patient setting, with minimal side effects. The procedure is done during one visit and patients return to activities within a few days.

Rezūm uses the natural energy stored in water vapor, or steam, to treat the extra prostate tissue that is causing the BPH symptoms. The water vapor is delivered into the targeted prostate tissue and when the vapor contacts the tissue it turns back into water, releasing all the stored energy, causing the prostate cells to die.
Over time, the body’s natural healing response removes the dead cells, shrinking the prostate. With the extra tissue removed, the urethra opens, reducing BPH symptoms.

Most patients begin to experience symptom relief in as soon as two weeks and maximum benefit will occur within three months.

Open surgery – simple prostatectomy is best when a transurethral procedure cannot be done. An incision is made in the abdominal wall from below the belly button to the pubic bone. The prostate gland can then be removed in its entirety through either an incision in the fibrous capsule surrounding the prostate (retropubic prostatectomy) or through an incision made in the bladder (suprapubic prostatectomy). Postoperative pain is mild to moderate.

  • Patients usually stay in the hospital for several days and go home with a urinary catheter; in some cases a second catheter draining the bladder through the lower abdominal wall is used
  • This is recommended when confronting a prostate that is too large to remove through the penis
  • Other reasons for choosing an open prostatectomy include patients with large bladder diverticula, with large bladder stones, or those who cannot physically tolerate having their legs placed in stirrups for TURP/TUIP surgery