Enlarged Prostate (BPH)
What is Benign Prostate Hyperplasia (BPH)?
Benign prostatic hyperplasia (BPH), also called 'enlarged prostate,' generally affects men over age 50. In fact, nearly all men over the age of 50 have an enlarged prostate to some degree and by age 85, about 90 percent of all men will report lower urinary tract symptoms, also known as LUTS. Not all cases require treatment.
The prostate is a gland located under the bladder and behind the pubic bone. Its primary role is helping in the production and secretion of semen. The prostate partially surrounds the urethra and gets larger with age. It causes many of the LUTS that men experience.
BPH occurs when noncancerous cells of the prostate divide to make more cells. While BPH is not associated with the development of cancer, the two often go together. Distinguishing between them is an important part of the diagnosis process.
Symptoms
Men with BPH experience a variety of symptoms such as:
- Needing to urinate frequently, particularly at night - also called nocturia
- Feeling an urgent need to urinate shortly after urinating
- Experiencing difficulty starting to urinate or maintaining the flow
- Decreased force of urinary stream
- Having a stop-start pattern in urinating (intermittency)
- Feeling as though there is urine left in the bladder after urinating
- Blood in the urine (called hematuria)
When symptoms become severe, you may find you cannot hold your urine long enough to find a toilet (urge incontinence) or may stop urinating entirely (urinary retention). Not urinating can sometimes lead to kidney damage.
LUTS secondary to BPH occurs because of the location of the prostate gland (a walnut-sized gland that is part of the male reproductive system) which sits under the urinary bladder. Urine must pass through the prostate on its way out of the body. BPH obstructs this flow, slowing the urine stream, making it harder to empty the bladder, and causing it to empty incompletely. If we do not treat BPH, the bladder is left constantly fighting the obstructed prostate. This can lead to worsening symptoms, urinary tract infections, and kidney problems.
BPH Treatment Options
Mount Sinai South Nassau has extensive experience in treating benign prostatic hyperplasia (BPH). Once we diagnose this condition, we determine the most appropriate treatment, depending on how severe your symptoms are.
Treatment options for lower urinary track symptoms (LUTS) include watchful waiting and progress through medical to surgical interventions. For the majority of patients their starting point on the treatment pathway will be dictated by their symptoms and degree of discomfort.
Watchful Waiting
If you are experiencing mild symptoms (IPSS ≤7) or moderate symptoms with minimal discomfort, your condition can be managed with watchful waiting. Watchful waiting includes recommendations for lifestyle changes that can help ease or circumvent symptoms. These changes include advice about the volume and timing of fluid consumption, avoidance of caffeine, abstinence of evening alcohol and regulation of bowels. Over-the-counter ‘decongestants’ should also be avoided as they can exacerbate symptoms.
Medical Therapy
The aim of medical therapy is to improve your symptoms, lower the risk of progression and improve your quality of life. There are many pharmaceutical options with guidelines and algorithms readily available to help guide your selection.
- Alpha blockers, such as Flomax®, (tamsulosin) Cardura® (Doxazosin), and Hytrin® (Terazosin), work on the bladder neck (bladder opening) and prostatic urethra (area of the urethra surrounded by the prostate). By blocking the receptors that that cause these channels to compress and close, the medications help the bladder neck and prostatic urethra to dilate and open, which improves urine flow. You will probably find that your symptoms improve after you’ve been taking the medication for a few days. This approach is most effective for people with mild to moderate symptoms.
- 5 Alpha reductase inhibitors, such as Proscar®, block your 5 alpha reductase enzyme, which stops production of dihydrotestosterone (DHT) in your prostate and slows or stops the growth of the prostate. We often use these medications together with alpha blockers. It may take three to six months before you feel any improvement. This approach is best for prostates that are significantly enlarged. Please note that these medications will also decrease your prostate specific antigen (PSA) by 50 percent, so if you are taking this medication and a doctor is monitoring your PSA, you should alert your doctor that you are taking an alpha reductase inhibitor so that we can appropriately assess your levels.
- Phosphodiesterase 5 inhibitors, such as Cialis (tadalfil) uses another pathway to reduce smooth muscle contractility. Inhibition of phosphodiesterase type 5 (PDE5) allows relaxation of smooth muscle in the bladder neck, urethra and prostate. The most effect dosing appears to be 5mg tadalafil daily, which improves erections as well as LUTS.
- Antimuscarinics are designed to reduce bladder irritability which may cause urgency and frequency. In men bothered mainly by irritable symptoms, the use of anti-cholinergic medication can provide better symptom relief. Agents include anti-muscarinics (non-selective: oxybutynin, tolterodine and selective: solifenacin) and β 3-adrenoceptor agonists (mirabegon).
Combination Therapy
Combining agents from different pathways can have a synergistic effect. The most common combination is dutasteride with tamsulosin. This combination has been shown to not only produce durable improvement in voiding symptoms but significantly reduces the risk of disease progression, and in particular, decreases the risk of retention.
The combination of tamsulosin with tadalafil has also been investigated.
Surgical Therapy
There are many surgical options available to you that can be classified into three main groups: Compressing the prostate tissue, removing some of the prostate enlargement, or removal of the entire enlargement.
UroLift: Involves the insertion of a device which compresses the prostate laterally thus widens the urethral channel. This approach is relatively new and usually reserved for men with mild to moderate symptoms or in men who are not fit for a more definitive procedure. This procedure can be done in our office. The Urolift leads to short-medium term improvements in symptoms and emptying of the urinary bladder. In addition, there may be improvement in sexual function and avoidance of retrograde ejaculation, a common side effect from other operative interventions.
ReZum: This is also known as convective radiofrequency water vapor thermal therapy, which is a minimally invasive procedure that can be performed in our outpatient facility. We use a hand-held device that passes through the urethra to reach the prostate. The energy transported by the water damages the offensive cells, which in turn causes them to die. Over time, the body absorbs the treated tissue as part of the natural healing process, and as it does, your symptoms of BPH are relieved. We have had very good results using Rezum with improvements in symptoms, as well as preservation of ejaculation.
Surgical treatments for BPH vary widely. Here are the most common procedures.
Transurethral resection of the prostate is the ‘gold standard’ against which we compare all other surgical prostate treatments, because it has historically had the best results. This hospital-based procedure, performed under anesthesia, involves scraping (resecting) prostate tissue within the urethra to create an open channel to urinate through. Afterward, we perform continuous bladder irrigation to remove any blood and clots that may form after the procedure. We usually do a ‘voiding trial’ (removing the catheter to see if you can urinate) a day or two after the procedure.
Bi-polar diathermy has the advantage of allowing resection with saline irrigation. Greenlight laser vaporisation, which also utilizes saline irrigation, has the additional advantages of being able to be performed while patients remain on anticoagulation therapy and as a 1-day procedure. Microwave treatment can also be done as a day procedure with minimal risk.
Aquablation therapy is a one-of-a-kind procedure. It is the only procedure that uses a heat-free waterjet controlled by robotic technology to remove prostate tissue and combines a camera (called a cystoscope) with ultrasound imaging, giving the surgeon the ability to see the entire prostate in real time. As a result, Aquablation therapy is precise, consistent and predictable and provides long-term relief no matter how large your prostate is, and has a very low rate of irreversible complications.
Contact Info
Mount Sinai Doctors - Rockville Centre, Urology and Urogynecology
2 Lincoln Avenue, Suite 102
Rockville Centre, NY 11570
Phone: 516-390-2850
Fax: 516-390-2855
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