Prostate Enlargement - BPH
What is BPH?
Benign prostatic hypertrophy describes a common condition of the aging male whereby the prostate increases in size and may compress the urethra as it leaves the bladder. This ‘squeezing of the water pipe’ produces numerous urinary symptoms.
Benign prostatic hyperplasia (BPH) with associated lower urinary tract symptoms (LUTS) is a common medical condition in the aging male. The incidence has been estimated to increase from 50% among men between the ages of 50 and 60 years, to 90% for men older than 80 years of age.
In 2016, it is estimated that up to 3 million men in the UK have lower urinary tract symptoms suggestive of BPH. Traditionally the options for treatment begin with making life-style changes for mild symptoms as well as medication.
Lower Urinary Tract Symptoms (LUTS) link
This term is used to describe any symptom or set of symptoms arising from the lower urinary tract.
There are two sets of symptoms arising from the lower urinary tract:
1. STORAGE symptoms
– which are caused by the bladder not acting as an adequate storage organ and include: increased urinary frequency, urgency, nocturia ( getting up at night) and rarely urge incontinence ( or leaking before reaching the toilet),There are three main problems that affect the prostate, prostate enlargement (benign prostatic hyperplasia, BPH), prostate cancer and prostatitis.
2. VOIDING symptoms
– these are caused by a blockage on the way out – slow stream, hesitancy in starting urination, terminal dribble and feeling of incomplete evacuation.
You may have varying degrees of combination of these two sets of symtoms.
A symptom score helps evaluate the severity of your symptoms when due to the benign enlargement of the prostate and quantify how much bother it causes.
The IPSS (International Prostate Symptom Score) is the name for one of these download the questionaire here
The symptoms are graded as:
• Mild: score 1 to 8
• Moderate: score 9 to 19
• Severe: score 20 to 35
Mild and non bothersome urinary symptoms
If your urinary symptoms are mild (ie IPSS less than or equal to 7 out of 35) and do not cause bother (bother score less than 3 out of 6), then only changes in lifestyle are usually all that is necessary especially if the prostate is small, the PSA is less than 1.5 ng/ml and the bladder empties efficiently. If necessary medication such as an alpha blocker may be given to reduce symptoms. A 5 alpha reductase inhibitor may shrink the prostate over time and reduce the chance of significant problems in the future. Surgery is not usually suggested if the symptoms are mild and respond well to alpha blockers.
If biopsies of the prostate have been taken and inflammation of the prostate was found, there is a greater chance that there may be more problems with either a complete blockage (acute urinary retention) or that surgery may be needed in the future. As such, it is probably sensible to take a 5 alpha reductase inhibitor (e.g. finasteride or dutasteride) as these can reduce the probability of these undesirable outcomes.
Moderate and bothersome urinary symptoms
If the symptoms are more moderate (IPSS between 8 and 19 out of 35) and bothersome (bother score 4 or more out of 6), then treatment by either drugs (alpha blockers), or otherwise surgical options will need to be considered. If alpha blockers have not worked well or the bladder is emptying less well over time, then surgery is recommended.
What do I do about having to get up at night?
Getting up at night and passing urine becomes more common as one gets older. Surgery on the prostate may help if the bladder is not emptying completely because of obstruction. However, the prostate is not always the cause of getting up at night. Usually, urine production stops at night, but this may not occur resulting in excess urine production at night. To detect this, keep a record of the total amount of urine passed during the day and night. If the amount of urine made at night is more than 25% of the total daily amount, then the following can help, but discuss with your doctor before adopting the advice below:
• Stop drinking 4 or more hours before going to bed
• Take a nap in the afternoon making sure the legs are elevated and the body is horizontal if possible.
• Wear tight compression leg stockings during the day
Your doctor should advise you further.
Drugs such as alpha blockers (eg tamsulosin or alfuzosin) can also be of benefit. These measures can be combined with a tablet to help encourage more urine production in the afternoon (a diuretic) and something to stop urine production at night (DDAVP).
In some cases, the urgent need to pass urine occurs during the day and night. This problem may be due to overactivity of the bladder muscle and can be helped by avoiding caffeine and taking medicines. These medicines include solifenacin (Vesicare), tolterodine (Detrusitol) and oxybutynin (Lyrinel).
When you go to see a specialist ( Urologist), a detailed history will be taken by the doctor including the IPSS score. Examination of the prostate will be carried outy to assess the size and whether it is benign or cancerous.
Following this a series of tests will be recommended.
What tests are there to help decide what treatment is necessary and appropriate?
These tests include the following, but do not necessarily have to be performed always:
• Urinary symptoms (IPSS) questionnaire: This quantifies the severity of the symptoms and how much bother they cause.
• Blood test: for kidney function and to estimate the size of the prostate, and risk of prostate cancer (PSA)
• Urine Chemical Analysis: to determine the presence of blood or evidence of infection
• Urine Flow Rate: you will be asked to pass urine into a special machine that measures the speed of your urine flow as well as the volume of urine expelled. This test helps in evaluating the function of your bladder and the degree of prostatic obstruction.
• Measurement of the urine left in the bladder after passing urine (postvoid residual): The volume of urine in the bladder after it has been emptied can be measured by an ultrasound scan. If this is increasing over time, then surgery is probably a good idea
• Transrectal ultrasound measure of prostate volume: A probe is inserted in the back passage (rectum) and the size of the prostate is accurately measured. The larger the prostate, the greater the chance of problems in the future.
• Urodynamics: Measuring pressure in the bladder during urination can determine how strongly the bladder contracts, the extent of obstruction by the prostate, and whether the bladder contracts inappropriately when it is filling with urine. This test also is done by placing a small catheter in the bladder and rectum.
• Cystoscopy: To look at the configuration of the prostate and changes in the bladder that may be responsible for urinary symptoms.
Are there any medicines that can help symptoms due to an enlarged prostate?
Rather than an operation, drugs, such as alpha blockers (e.g. Tamsulosin, Flomax, Omnic, Alfuzosin, Xatral, Cardura), relieve prostate symptoms by relaxing the muscle of the bladder neck and prostate and are useful in some patients with BPH — typically younger men with milder symptoms. The drugs reduce symptoms by about 25% or 4 to 6 points out of a total of 35 (see IPSS questionnaire) in more than half of men who take the drug. Symptoms are reduced within a few days. Side effects include drowsiness and headache in about 15% of men, reduced semen volume, and nasal congestion.
Finasteride or Dutasteride can reduce the size of the prostate by about 20%, and improve symptoms in about 30 percent of patients who take it. Symptom scores improve by about 4 or 5 points out of 25. For example, if your symptom score was 16, then the symptom score would be about 11 or 12 out of 35 after 6 months or more of treatment. The chance of needing surgery for the prostate or being completely unable to pass urine ('acute urinary retention') is reduced by about 50%. To remain effective, the drugs need to be taken for the rest of your life. The side effects of finasteride include reduced volume of semen and altered semen quality, impaired erections, reduced libido, and occasional growth of the breast tissue.
Using finasteride and an alpha-blocker together is more effective than either drug alone to relieve symptoms and prevents BPH getting worse. The two-drug regimen reduced the risk of BPH progression in two out of three patients, compared to one-in three for an alpha-blocker alone and one in three for finasteride alone.
Drugs or medicines may not be enough, and more effective treatments such as a TURP or the HOLEP, may be more suitable.
Should I have an operation?
At one time, BPH was invariably thought to be a progressive disease. That is no longer the case. Only about 40 to 50 percent of all men with BPH actually develop any symptoms due to this condition, and of that number, only a proportion will need prostate surgery.
BPH requires treatment only if the symptoms are severe enough to disrupt your life or threaten your health.
If, during your prostate examination, your doctor finds that you have significant symptoms and that your prostate gland is enlarged, you may start a program of medication and changes in life style to improve your symptoms. During this time, your doctor may examine you periodically and ask you to complete questionnaires (e.g. IPSS).
If your urination problems are not adequately relieved by medication or the side effects of the drug are excessive, you might then consider a TURP or laser prostatectomy (HOLEP). TURP removes the prostate via a key hole surgery and HOLEP utilises a laser to remove prostate tissue. Removal of the enlarged part of the prostate is the best long-term solution for patients with BPH. Surgery usually relieves the obstruction and incomplete emptying caused by BPH more than any other treatment.
For certain patients with particular signs and symptoms, a TURP or laser prostatectomy is almost always recommended. These signs and symptoms include:
Total inability to urinate
Profuse bleeding through the urethra due to prostatic enlargement
Difficulty emptying the bladder because of prostatic obstruction, which can lead to progressive kidney failure
Recurrent urine infections
If you decide to have a prostatectomy for reasons of comfort or for a more severe indication, you should know that an operation offers the greatest chance of getting rid of your symptoms.
Are there any alternatives to TURP or laser prostatectomy for BPH?
Rezum utilises steam for ablating the tissue. Urolift is another less invasive procedure( which essentially is placing staples in the prostate) and another alternative is prostate artery embolization (PAE) which utilises the principle of placing coil in the blood vessels supplying prostate which shrinks the prostate
What are the risks/benefits of surgery?
Although there are nonsurgical treatments available to treat BPH, an operation offers the highest chance of alleviating prostate problems. However, it also can result in problems either during or after surgery.
After a TURP or laser prostatectomy, some men will find that semen does not go out of the penis during orgasm. Instead, it passes into the bladder and is passed with the urine next time. The feeling of orgasm stays the same. This backwards ejaculation is a problem for couples who want to have a baby.
Some conditions after TURP or laser prostatectomy may require additional treatment including:
impotence (small risk)
uncontrolled urine leakage i.e. incontinence (very small risk)
a constriction of the urethra (stricture); or the necessity of a second operation later, in some patients (10%)
These risks and benefits must be considered by anyone considering a prostate operation, and your doctor can help you make your decision.
How do I decide what treatment is necessary?
You can predict your chance of being completely unable to pass urine or needing surgery over 6 years by going to the following website (www.oncovance.com). If you register, you then need to know your age, IPSS score (also known as AUA SI) and PSA. Further information can be entered, if you have it, to improve the accuracy.
When drugs are used, it's better to use a combination of alpha blockers with finasteride or dutasteride especially when the prostate is large or the PSA is greater than 1.5 ng/ml.
The HOLEP laser prostatectomy and TURP are more effective than drugs. In general, HOLEP laser prostatectomy and TURP are most likely to be effective if the prostate is causing obstruction of the bladder. This can be determined by the tests listed above.
Severe and bothersome urinary symptoms
For severe urinary symptoms (IPSS 20 or more) that are bothersome (4 or more out of 6), it is important to look in the bladder to make sure there are no other problems. Further tests to determine whether urinary symptoms are due to obstruction by the prostate will often be necessary, especially if a TURP or other surgical procedure is being considered.
The biggest improvement in symptoms and quality of life occurs with the HOLEP or TURP, but not everyone wants these procedures. Medicines such as alpha blockers or finasteride/dutasteride also relieve symptoms, but not as much. If drugs are used alone, further treatment is necessary. A poor response to alpha blockers and increasing residual urine or symptoms mean that surgery is almost always necessary
In addition, if surgery is delayed when the bladder is obstructed by the prostate, the benefit of surgical procedures may be less than when surgery is performed early. This is possibly because the bladder may undergo irreversible changes if it is blocked for a long period of time. With less invasive treatments available now (eg Rezum, Aquablation, PAE and Urolift), it may be better to opt for one of these earlier than later.
How do I decide between drugs or surgery?
Conservative treatments and drugs such as alpha blockers work best when symptoms are mild or moderate. If symptoms are severe and the prostate is causing a blockage, then HOLEP or TURP surgery is more effective and lasts longer than drugs.
The severity of symptoms is judged best by assessing the symptom score (IPSS). If the symptom score is 20 or more and the symptoms are bothersome (4 or more). A test called urodynamics can determine if there is a blockage or not, and can also tell if the bladder contracts at the wrong time.
Sometimes, urinary symptoms such as getting up at night or having to rush urgently to pass urine are not due to the prostate; these symptoms may be due to the bladder contracting inappropriately. Urodynamics can help predict if the HOLEP or TURP may help.
The HOLEP or TURP is most effective when there is obstruction present and this is usually proven by urodynamic testing.
Other factors are also important such as general fitness. It may not be safe to have an anaesthetic, which is necessary for a TURP or HOLEP. Drugs may be the only treatment possible. Occasionally, other procedures are also possible such as 'stents'.
What about Saw Palmetto?
Saw palmetto (Serenoa repens) is a type of palm tree, also known as the dwarf palm. Its primary medicinal value lies in the oily compounds found in its berries. Most dietary supplements are composed of an extract from the berries or a berry powder.
Saw palmetto dietary supplements improve urinary flow, and reduce the frequency and urgency of urination in men with prostate enlargement. Saw palmetto is believed to inhibit the actions of testosterone in the prostate that cause prostate enlargement and interference with urinary flow.
Fatty acids and sterols found in Saw palmetto inhibit testosterone in the prostate. Sterols are also present in other herbs (such as pygeum bark, stinging nettle root, and pumpkin seed extract) used in treating symptoms of prostate enlargement.
Saw palmetto is commonly used in Germany and other parts of Europe and the United States, but less commonly in England. There have been concerns about the quantity of active agent in various preparations of Saw palmetto.
Catheter treatment from an Italian medical picture book by Henricus Kullmaurer and Albert Meher, 1510