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What is Benign Prostatic Hyperplasia (BPH)
Benign prostatic hyperplasia (BPH) is a non-cancerous condition that affects a substantial number of men as they age. In BPH an enlarged prostate can squeeze or partially block the urethra – the tube that carries the urine from the bladder out of the body. This can lead to bothersome urinary symptoms that may include a weak stream, trouble starting and stopping, the frequent feeling of needing to urinate, greater urgency when the feeling hits, leaking or dribbling, and the sense that the bladder isn’t empty after urination. These symptoms can be detrimental to a patient’s health and quality of life, and can easily be treated with medications and procedures.
The prostate, a walnut-sized gland within the male reproductive system, is located just beneath the bladder. The urethra passes directly through the prostate. As men age the prostate may grow and impinge on the urethra, leading to symptoms that typically begin in the 40s to 50s.
Symptoms of Benign Prostatic Hyperplasia (BPH)
BPH symptoms are familiar to a large proportion of men during middle age and beyond, and when untreated they can progressively worsen. Approximately half of men in their 50s and as many as 90 percent of men in their 70s and 80s have enlarged prostates that are often symptomatic. Typical symptoms of BPH include urinary urgency, frequency, slower stream, nocturia (waking multiple times at night to urinate), sputtering of urine stream, sensation of incomplete emptying, and the retention of urine. Symptoms of BPH are often severely detrimental to a patient’s quality of life – often due to lack of sleep, discomfort, and even embarrassment.
Many men assume that BPH is simply an inevitable part of aging, and that they must live with the symptoms. This is a mistake for two reasons: first, untreated BPH has the potential to lead to serious complications, ranging from recurrent urinary tract infections, bladder stone formation, urinary retention, and even damage to the kidneys. There are now many effective treatment options from which to choose, including new medications; lower-risk, less invasive enlarged prostate surgeries; and alternative approaches such as herbal supplements.
Diagnosis of Benign Prostatic Hyperplasia (BPH)
The symptoms of BPH often bring patients to their doctor. An enlarged prostate can be diagnosed during a routine digital rectal examination. Other common tests used to diagnose BPH include a urine flow study, which uses a device that measures the speed of the stream; a transrectal ultrasound to measure the size of the prostate gland, and a visual exam called cystoscopy, which uses a flexible camera inserted into the urethra to view the prostate and bladder.
No single prostate treatment is best for everyone. Much depends on the symptoms and individual preferences. For minor symptoms, certain lifestyle changes can help, including limiting beverages consumed in the evening, reducing alcohol and caffeine consumption, and avoiding intake of diuretics, antihistamines and decongestants.
Medications and herbal supplements for the treatment of Benign Prostatic Hyperplasia (BPH)
Medications are also an effective way to treat the symptoms associated with BPH. Alpha blockers are a class of drug that relax the muscle fibers of the bladder neck and prostate, resulting in improvement of urine flow. Common alpha blockers include tamsulosin, terazosin, alfuzosin, and doxazosin. Another class of drugs called 5-alpha-reductase inhibitors can actually shrink the prostate itself over the course of several months, leading to symptom improvement. Finasteride and dutasteride are commonly used 5-alpha-reductase inhibitors. While some patients experience side effects, they are usually mild and are reversible once the patient stops taking the drug.
For men with moderate symptoms who are looking for more “natural’ alternatives to BPH medications – either because the drugs’ side effects are intolerable or because they simply don’t like the idea of being on medication – options such as herbal prostate treatments have become more widespread. An estimated one-third of men with BPH have tried these supplements, the most common of which are saw palmetto, pygeum africanum, and beta-sitosterol. When used appropriately, herbal treatments tend to have few side effects, and many men with mild symptoms have found that they provide relief, either alone or in conjunction with FDA-approved drugs. However, in the United States, supplements do not undergo the same rigorous testing and regulation as drugs. The evidence on their efficacy is therefore less certain, and the contents of each product can vary widely.
Surgeries and minimally invasive procedures to treat Benign Prostatic Hyperplasia (BPH)
For patients with more severe symptoms and those who cannot tolerate or have failed medications, surgeries and minimally invasive procedures are excellent choices to relieve the symptoms of BPH. These options remove, destroy, or reconfigure the actual tissue of the prostate. Surgeries require a trip to the operating room, anesthesia, a night in the hospital, and often a temporary catheter to drain the urine. These have the best control of urinary symptoms but have increased risk of sexual side effects, such as retrograde ejaculation or erectile dysfunction. Minimally invasive procedures drastically reduce the risk of sexual side effects and can be done as an outpatient in the urologist’s office. However, these treatments tend not to improve BPH symptoms to the same degree as surgeries.
Surgical options to treat Benign Prostatic Hyperplasia (BPH)
Transurethral resection of the prostate (TURP) has long been the mainstay of enlarged prostate surgery. During a TURP, the obstructing portion of the enlarged prostate tissue is removed via and endoscopic device using electrocautery. Although very effective, TURP requires treatment in an operating room, catheterization and comes with risks associated with anesthesia and surgery. Patients are usually discharged home with a catheter on the same day as surgery or without a catheter one day after surgery. Risks of incontinence and/or erectile dysfunction are small. The rate of retrograde ejaculation (when fluid goes into the bladder rather than out of the penis during orgasm) following TURP is reported to range from 50-75 percent.
Photoselective Vaporization of Prostate (PVP)
An alternative to TURP is laser prostate surgery. During this surgery, a laser is used to endoscopically vaporize prostate tissue, creating a channel in the urethra through which men can urinate more freely. Thus far, almost every study has shown that when done by experienced urologists, the laser enlarged prostate surgery produces results that are equal to those with TURP. This surgery is often used in patients who need to remain on anticoagulation (“blood thinners”).
One of the newest BPH surgeries offered at UCLA is Aquablation. This procedure uses an image-guided high-pressure water jet to precisely destroy excess prostate tissue. The procedure is guided by a live ultrasound that allows real-time visualization of the prostate. The high-definition imaging allows for better preservation of the structures involved in ejaculation. Aquablation requires less time to perform than TURP, but still requires an overnight stay in the hospital. See more detailed information about Aquablation >
Holmium laser enucleation of prostate (HoLEP) is an endoscopic surgery that is ideal for patients with very enlarged prostates. During this surgery, the surgeon will use a laser to remove the majority of the interior of the prostate. Similar to TURP and PVP, patients are usually discharged home the day after surgery.
Robotic simple prostatectomy
This surgery is best suited for patients with very large prostates. During a robotic simple prostatectomy, a surgeon uses a robot to enter the pelvis through several tiny incisions. The capsule of the prostate is then opened, and the entirety of the interior of the prostate is removed.
Minimally invasive procedures to treat Benign Prostatic Hyperplasia (BPH)
The UroLift® System, approved by the U.S. Food and Drug Administration in 2013, is a minimally invasive approach to treating BPH and symptoms caused by an enlarged prostate. During this procedure, tiny anchors are placed into the prostate to pin back the obstructing tissue and reconfigure the shape of the prostatic urethra. Urolift can be done under local anesthesia in the clinic setting. The risk of sexual side effects following Urolift are virtually zero. This option is ideal for patients looking for alternatives to drugs and desire for preservation of sexual function. See more detailed information about the UroLift® System >
Rezum is a minimally invasive procedure that employs steam injected directly into the prostate to heat the prostatic tissue, ultimately leading to its destruction. This treatment takes only minutes, and is done in the office setting. Patients usually need a catheter for a few days after Rezum, and symptoms may take several weeks to months to begin to improve following treatment.