10 THINGS YOU

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Treating Enlarged Prostate (BPH)

Until recently, the main goal of BPH treatment was to reduce bothersome lower urinary tract symptoms that had become intolerable.2 However, newer data suggest that another legitimate goal of BPH therapy is the reduction in the risk of future health-related complications.2 For complications, click here.

  • If the goal is to reduce bothersome symptoms, your doctor may make a treatment recommendation based on the frequency, severity, and degree of bothersomeness associated with your lower urinary tract symptoms2
  • If the goal is to reduce the risk of future complications, it is important to assess the size of the prostate gland, because prostate size can be a predictor of future risks2

Treatment Options for BPH

WATCHFUL WAITING

 In general, no treatment is needed for men who have only a few symptoms and are not bothered by them.1 In these cases, when enlarged prostate symptoms are mild to moderate, doctors may recommend a "watch and wait" approach, often asking patients to track BPH symptoms before pursuing other courses of treatment. It is appropriate for patients with moderate symptoms and bother to choose watchful waiting if they feel that the benefits outweigh the risks of an active therapy.3

MEDICATIONS

 Physicians will often prescribe medications to manage enlarged prostate symptoms. These medications include:
  • Alpha blockers, which relax the muscles around the neck of the bladder, making it easier to urinate. Common side effects include reduced semen released during ejaculation, low blood pressure, dizziness, headache, stomach or intestinal irritation, and a stuffy or runny nose.4 There is also a risk of floppy iris in the event of cataract surgery in anyone who has ever taken an alpha blocker5
  • Alpha-reductase inhibitors, which are intended to help shrink the prostate gland. Common side effects include erectile dysfunction, decreased libido, and reduced semen during ejaculation4
  • A combination of the two

INVASIVE SURGERY

 Surgical treatment becomes a viable option when symptoms have not responded to medication and are bothersome enough to diminish quality of life. In addition, surgery is generally required in the following situations1:
  • Kidney damage due to inadequate bladder emptying
  • Complete inability to urinate after treatment of acute urinary retention
  • Incontinence due to overfilling or increased bladder sensitivity
  • Recurrent blood in the urine despite treatment with medication
Transurethral Resection of the Prostate (TURP)
Though there are a number of invasive options, the surgical mainstay for BPH treatment is called transurethral resection of the prostate (TURP). This surgical procedure has demonstrated long-lasting symptom relief, which is significantly better than what can be achieved with medication.1 However, there are always risks associated with surgery, and there are documented prolonged side effects, including retrograde ejaculation, erection problems, painful urination, recurring UTI, bladder neck narrowing, excessive bleeding, and blood in the urine.1 Also, TURP requires a 2- to 3-day hospital stay, and most patients must wear a catheter for approximately 2 days after the procedure.6-8

MINIMALLY INVASIVE SURGICAL ALTERNATIVES

 Despite the clinical successes of TURP, the degree and severity of complications have driven the development of alternative, minimally invasive surgical tools for BPH.6 Most urologists position these therapies somewhere between medical treatment and surgical treatment.7
Although numerous medical and surgical treatment options exist, there is a continuous drive to develop less-invasive, efficacious, and cost-effective treatment options.9 This has led to an influx of minimally invasive surgical alternatives that relieve lower urinary tract symptoms without hospitalization and with fewer side effects, like the following:11
  • Transurethral needle ablation (TUNA) uses radio frequency needles placed directly into the prostate to generate heat and cause coagulation. Side effects can include blood in the urine, discomfort, and urinary tract infection
  • Transurethral water-induced thermotherapy (WIT) uses heated water circulated through a catheter system and pressure from a balloon to destroy the excess prostatic tissue. A common side effect is blood in the urine
While these treatments produce an initial level of symptomatic relief, it is important to note that the long-term effectiveness of these procedures still remains unclear.

Laser Therapies
With documented case studies, laser therapies have become a viable alternative to TURP. Laser options remove enlarged prostate tissue through the use of high-energy lasers. Currently, there are two front-running laser therapies: holmium laser enucleation (HoLEP) and photoselective vaporization (PVP) of the prostate.7

  • HoLEP is a complicated procedure with a steep learning curve7 that involves a resectoscope inserted through the penis into the urethra. The prostate tissue is vaporized by the holmium laser. Typically, the patient has a catheter removed the next day and stays 1 night in the hospital7
  • PVP, also referred to as the GreenLight™ Laser Procedure, is associated with treatment outcomes similar to TURP with a more favorable risk profile.6 It consists of a high-powered laser inserted through the urethra, which immediately vaporizes and precisely removes enlarged prostate tissue. Most patients return home a few hours after the procedure, usually without the need for a catheter, and can return to normal, non-strenuous activities within days6-8

PROSTATIC STENTS

 This option is reserved for those patients who are severely obstructed and otherwise unable to undergo surgery.

The choice of a treatment is based on the severity of your symptoms, the extent to which they affect your daily life, and the presence of any other medical conditions.10 The treatment recommendation should be made by your physician.

REFERENCES:

  1. Carter HB. Prostate Disorders: The Johns Hopkins White Papers. Baltimore, MD: Johns Hopkins Medicine; 2010:1-24.
  2. McNaughton-Collins M, Barry MJ. Managing patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Am J Med. 2005;118:1331-1339.
  3. American Urological Association. Research and future directions. In: AUA Guideline on the Management of Benign Prostatic Hyperplasia. Linthicum, MD: American Urological Association Education and Research, Inc.; 2003;1:1-7.
  4. Prostate gland enlargement. MayoClinic.com tools for healthier lives. Original Article: www.mayoclinic.com/health/prostate-gland-enlargement/DS00027/DSECTION=2. Accessed March 11, 2008.
  5. Flomax (tamsulosin hydrochloride) prescribing information, Boehringer Ingelheim Pharmaceuticals.
  6. Clinical outcome comparison of GreenLight KTP-532 laser (80 W) prostatectomy versus transurethral resection of the prostate (TURP). AMS whitepaper, 2008.
  7. Van Hest P, D’Ancona F. The management of benign prostatic hyperplasia: update in minimal invasive therapy in benign prostatic hyperplasia. Minerva Urol Nefrol. 2009;61:257-268.
  8. Barry M, Roehrnorn C. Management of benign prostatic hyperplasia. Annu Rev Med. 1997;48:177-189.
  9. Armstrong N, Vale L, Deverill M, et al. Surgical treatments for men with benign prostatic enlargement: cost effectiveness study. BMJ. 2009;338:1-13.
  10. Enlarged prostate. US National Library of Medicine, National Institute of Health. http://www.nlm.nih.gov/medlineplus/ency/article/000381.htm. Accessed Sept. 27, 2010.
  11. Prostate enlargement: benign prostatic hyperplasia. National Kidney and Urologic Diseases Information Clearinghouse. National Institute of Health. http://kidney.niddk.nih.gov/kudiseases/pubs/prostateenlargement/. Accessed Oct. 27, 2010.