Benign Prostatic Hyperplasia (BPH)

Considerations for treatment will depend upon other health problems, as well as the specific size and architectural pattern of your prostate gland. Tests may be suggested to gather this needed information. A PSA test, a cystoscopy, and a prostate ultrasound are routine. It is very important for the PSA blood test to be done before any treatment for BPH is begun. Abnormal PSA results raise the question of prostate cancer, and must be further evaluated. If prostate cancer is found, cancer treatment becomes the priority and is completely different than BPH treatment. Cystoscopy identifies the extent of blockage by the prostate as well as other anatomic details of the urinary tract that might complicate matters. Cystoscopy involves using a lighted flexible scope to look in thru the tip of the penis to the bladder. Performed in the office, there is minimal discomfort as we use numbing jelly or mild sedation. In some cases, additional testing on the bladder is required. Urodynamics is a test that tells us about the function of the bladder, and it can help differentiate bladder problems from true prostate problems. Finally, the prostate’s exact size and architecture can be measured by transrectal ultrasound imaging. This is critical as the safety and effectiveness of these newer technologies require that the heat energy be delivered to prostate tissue and not beyond. Not all prostate glands are the same size or shape, and only with accurate information can we generate a proper treatment plan.

For those who have a significant amount of bother from their BPH symptoms, initial therapy usually involves medication. Two classes of medication are commonly used. Alpha- blocker medications (Flomax, Tamsulosin, Uroxatral, Rapaflo, and Doxazocin) relax the muscle tone of the prostate, opening the channel and relieving the blockage of BPH. 5-alpha-reductase inhibitors (Proscar, Finasteride, Avodart, and Dutasteride) can physically shrink the prostate and halt its growth, thus helping to reduce obstruction of urine flow. Other medications, like Cialis, have also been shown to improve the symptoms of BPH. All of these medications can be used alone or in combination. Not all urinary problems in men are prostate related. Many men, like women, may have overactive bladder (OAB). OAB symptoms of frequent and urgent urination are nearly identical to BPH symptoms, but are caused by a hyperactive bladder as opposed to a blocking prostate. These bladder symptoms are often controlled with medications like Detrol, Vesicare, oxybutynin or Myrbetriq. Sometimes, the blocking prostate can be the cause of overactive bladder.

In some cases, BPH can outgrow what medications can control. For patients who have progression of urinary difficulties or for those who get to the point of not being able to urinate at all, more aggressive management with surgery is often required. Transurethral resection of the prostate, or TURP, has long been the standard surgical treatment for BPH. A scope is inserted thru the penis and guided to the level of the prostate gland where the blocking portion of the prostate gland is trimmed out to open the water channel. Patients commonly refer to this process as a “ream job” or “roto-rooter.” For many years, this was the only real option for patients with severe BPH problems. Criticisms of TURP in years past centered on risks of heavy bleeding and the need for full general anesthesia in a hospital setting.

In recent years, technological advances have introduced many new, less invasive options for patients that can open the blocking prostate with safer, simpler approaches. Several options use “controlled heat” in the form of lasers, microwave energy, or steam to treat the enlarged prostate. Other new innovations can open the urinary pathway with sutures to tent open the blocking prostate tissue without even having to destroy tissue at all. While all patients with BPH are potential candidates for any of these types of therapy, minimally invasive therapies are most commonly used in patients who progress despite medications or prefer not to remain on medications as long-term therapy. In some instances, medical management is working but may cause undesirable side effects. In other cases, medication is working, but patients either do not like to take it or it costs too much. In any event, minimally invasive technology is very appealing to many BPH patients.

On the cutting edge of today’s BPH therapy are Rezum Prostate Therapy and Urolift. Presently, Rezum offers the benefit of being able to be performed in the office with local anesthesia. After numbing the prostate and urethra in the office, Rezum uses a scope inserted thru the penis that delivers a steam injection to the overgrown prostate. The steam permeates the prostate tissue in that area and remains confined in the prostate, limited by the gland’s capsule. The heat from the steam causes the prostate tissue to wither away thereby relieving blockage. A foley catheter is left in place following the procedure for 2 days and then removed in the office. Patients often experience improved flow within just a few weeks, but the prostate continues to shrink for several months after the procedure so that the maximum benefit is apparent after 3-4 months. The side effects include mild blood in the urine and some irritative voiding for 1-2 weeks. Insurances have specific approval criteria related to prostate size for Rezum that your urologist can assess.

The Urolift procedure “tacks” the prostate lobes open to relieve blockage, a concept similar to pulling back the drapes of a window to open the view. During the procedure, the Urolift instrument is inserted thru the penis and positioned at the level of the blocking prostate tissue. A suture is then accurately fired into the prostate tissue. Tension tightening of the suture retracts the lobe of the prostate and opens the water channel. Multiple sutures can be used as needed depending on the size of the prostate gland. In many cases, no catheter is needed at all following the procedure. Because this procedure does not actually destroy prostate tissue (the sutures just “tent” it open) it has very few side effects, in particular no changes in ejaculatory function. Patients may see mild blood in the urine for several days following the procedure. Urolift is usually performed in an outpatient surgery center under general anesthesia.

Each of these procedures is considered low risk and has an excellent track record for medium to large sized prostate glands. Safe and simple, they represent state- of-the-art minimally invasive prostate therapies. These therapies are not designed for prostate cancer treatment, and huge prostate glands may need a more robust option. It is very simple for your urologist to determine if you are a good candidate. If not, many other technologies are available, including LASER (Evolve laser, Green Light Laser), Vaporization (“Button” TURP), and TUMT (transurethral microwave thermotherapy).

Minimally invasive procedures represent true advancements in the treatment of BPH, but clearly they are not for everyone. BPH is not the only cause of urinary difficulties, and careful evaluation by your doctor can determine whether your symptoms are caused by BPH or something else. Once the diagnosis of BPH has been made, physicians at the Conrad Pearson Clinic will decide which treatment options are best for you.