Men's Health
BPH
Benign prostatic hyperplasia (BPH) also known as nodular hyperplasia, benign prostatic hypertrophy (technically a misnomer) or benign enlargement of the prostate (BEP) refers to the increase in size of the prostate in middle-age and elderly men. To be accurate, the process is one of hyperplasia rather than hypertrophy, but the nomenclature is often interchangeable, even amongst urologists. It is characterized by hyperplasia of prostatic stromal and epithelial cells, resulting in the formation of large, fairly discrete nodules in the periurethral region of the prostate. When sufficiently large, the nodules compress the urethral canal to cause partial, or sometimes virtually complete, obstruction of the urethra, which interferes the normal flow of urine. It leads to symptoms of urinary hesitancy, frequent urination, dysuria (painful urination), increased risk of urinary tract infections, and urinary retention. Although prostate specific antigen levels may be elevated in these patients because of increased organ volume and inflammation due to urinary tract infections, BPH is not considered to be a premalignant lesion.
Adenomatous prostatic growth is believed to begin at approximately age 30 years. An estimated 50% of men have histologic evidence of BPH by age 50 years and 75% by age 80 years. In 40-50% of these patients, BPH becomes clinically significant.
Symptoms
Benign prostatic hyperplasia symptoms are classified as storage or voiding.
Storage symptoms include urinary frequency, urgency (compelling need to void that cannot be deferred), urgency incontinence, and voiding at night (nocturia).
Voiding symptoms include weak urinary stream, hesitancy (needing to wait for the stream to begin), intermittency (when the stream starts and stops intermittently), straining to void, and dribbling. Pain and dysuria (burning sensation in the urethra) are usually not present. These storage and voiding symptoms are evaluated using the International Prostate Symptom Score (IPSS) questionnaire, designed to assess the severity of BPH.
BPH can be a progressive disease, especially if left untreated. Incomplete voiding results in stasis of bacteria in the bladder residue and an increased risk of urinary tract infections. Urinary bladder stones are formed from the crystallisation of salts in the residual urine. Urinary retention, termed acute or chronic, is another form of progression. Acute urinary retention is the inability to void, while in chronic urinary retention the residual urinary volume gradually increases, and the bladder distends.
Some patients that suffer from chronic urinary retention may eventually progress to renal failure, a condition termed obstructive uropathy.
Treatment
Lifestyle
Patients should decrease fluid intake before bedtime, moderate the consumption of alcohol and caffeine-containing products, and follow timed voiding schedules.
Medications
The two main medications for management of BPH are alpha blockers and 5α-reductase inhibitors. Alpha blockers (technically α1-adrenergic receptor antagonists) are the most common choice for initial therapy in the USA and Europe. Alpha blockers used for BPH include doxazosin, terazosin, alfuzosin, tamsulosin, and silodosin. All five are equally effective but have slightly different side effect profiles. The older drugs phenoxybenzamine and prazosin are not recommended. Alpha blockers relax smooth muscle in the prostate and the bladder neck, thus decreasing the blockage of urine flow. Common side effects of alpha blockers include orthostatic hypotension, ejaculation changes, nasal congestion, and asthenia.
The 5α-reductase inhibitors finasteride and dutasteride are another treatment option. These medications inhibit 5a-reductase, which in turn inhibits production of DHT, a hormone responsible for enlarging the prostate. Effects may take longer to appear than alpha blockers, but they persist for many years. When used together with alpha blockers, a reduction of BPH progression to acute urinary retention and surgery has been noted in patients with larger prostates. Side effects include decreased libido and ejaculatory or erectile dysfunction.
Antimuscarinics such as tolterodine may also be used, especially in combination with alpha blockers. They act by decreasing acetylcholine effects on the smooth muscle of the bladder, thus helping control symptoms of an overactive bladder.
Sildenafil shows some symptomatic relief, suggesting a possible common etiology with erectile dysfunction.
Herbal remedies
People commonly seek herbal remedies for BPH. Several are approved in European countries, but none in the USA. Saw palmetto extract from Serenoa repens is one of the most extensively studied. It showed promise in early studies, though later trials of higher methodological quality indicated no difference from placebo.
Other herbal medicines that have research support in systematic reviews include beta-sitosterol from Hypoxis rooperi (African star grass) and pygeum (extracted from the bark of Prunus africana), while there is less substantial support for the efficacy of pumpkin seed (Cucurbita pepo) and stinging nettle (Urtica dioica) root.
Cernilton, from rye grass pollen (Secale cereale) has also shown symptomatic relief.
Minimally invasive therapies
While medication is often prescribed as the first treatment option, there are many patients who do not achieve success with this line of treatment. For many patients, medication is a good option; however, patients may not respond to medical management, they may not achieve sustained improvement in symptoms or they may stop taking the medication because of side-effects. There are options for treatment in an urologist's office before proceeding to surgery. The two most common types of office-based therapies are Transurethral microwave thermotherapy (TUMT) and TransUrethral Needle Ablation (TUNA). Both of these procedures rely on delivering enough energy to create sufficient heat to cause cell death (necrosis) in the prostate. The goal of the therapies is to cause enough necrosis so that, when the dead tissue is reabsorbed by the body, the prostate shrinks, relieving the obstruction of the urethra. These procedures are typically performed with local anesthesia, and the patient returns home the same day. Some urologists have studied and published long-term data on the outcomes of these procedures, with data out to five years. The most recent American Urological Association (AUA) Guidelines for the Treatment of BPH in 2003 lists minimally invasive therapies including TUMT and TUNA as acceptable alternatives for certain patients with BPH.
Transuretheral microwave therapy (TUMT) was originally approved by the FDA in 1996, with the first generation system by EDAP Technomed. Since 1996, other companies have received FDA approval for TUMT devices, including Urologix, Dornier, Thermatrix, Celsion, and Prostalund. Multiple clinical studies have been published on TUMT. The general principle underlying all the devices is that a microwave antenna that resides in a urethral catheter is placed in the intraprostatic area of the urethra. The catheter is connected to a control box outside of the patient's body and is energized to emit microwave radiation into the prostate to heat the tissue and cause necrosis. It is a one-time treatment that takes approximately 30 minutes to 1 hour, depending on the system used. It takes approximately 4 to 6 weeks for the damaged tissue to be reabsorbed into the patient's body. Some of the devices incorporate circulating coolant through the treatment area with the intent of preserving the urethra while the microwave energy heats the prostatic tissue surrounding the urethra.
Transuretheral needle ablation (TUNA) operates with a different type of energy, radio frequency (RF) energy, but is designed along the same premise as TUMT devices, that the heat the device generates will cause necrosis of the prostatic tissue and shrink the prostate. The TUNA device is inserted into the urethra using a rigid scope much like a cystoscope. The energy is delivered into the prostate using two needles that emerge from the sides of the device, through the urethral wall and into the prostate. The needle-based ablation devices are very effective at heating a localized area to a high enough temperature to cause necrosis. The treatment is typically performed in one session, but may require multiple sticks of the needles depending on the size of the prostate.
Surgery
If medical treatment fails, and the patient elects not to try office-based therapies or the physician determines the patient is a better candidate for surgery transurethral resection of prostate (TURP), surgery may need to be performed.
