A Guide to Men's Health, Reproductive Medicine, and Microsurgery
The prostate gland is a walnut-shaped organ that is located between the bladder and base of the penis. It is part of the male reproductive system and is responsible for contributing fluid to the semen during ejaculation.
The prostate reaches normal size after puberty, but then begins to grows again when a man enters his forties. It is estimated that almost 80% of men over 70 years of age have some degree of BPH.
Although the exact cause of BPH remains a mystery, the hormone dihydrotestosterone contributes to prostatic enlargement. Cell-growth factors and genetics may also play a role, particularly in younger men who develop clinically-significant BPH.
"BPH" commonly refers to enlargement of the prostate gland that results in lower urinary tract symptoms, or "LUTS". Some men with BPH have mild urinary symptoms, while others have severe symptoms requiring medical and/or surgical treatment.
If BPH progresses to the point where it causes bladder outlet obstruction (BOO), long-term damage to the bladder may occur. If the bladder is unable to empty properly, it can lead to other problems such as urinary retention, urinary tract infection, or bladder stones. Severe problems can occur if BOO goes undiagnosed or untreated since urine can back up into the kidneys and cause kidney failure.
Urinary symptoms due to BPH can be irritative or obstructive.
Irritative symptoms include:
Obstructive symptoms include:
Hematuria (blood in the urine) may also be a sign of BPH but can also be due to many other conditions. Any significant hematuria, whether seen with the naked eye or under the microscope, should be thoroughly evaluted bby a urologist to make sure that there is not a harmful cause (i.e. cancer).
Men may also develop sexual side effects due to BPH. Specifically, ejaculatory dysfunction (decreased volume or force of ejaculate) may occur when the enlarged prostate obstructs the ejaculatory ducts from emptying. Although this is not a harmful side effect of BPH, it can be a significant bother to many men. There is no specific treatment of ejaculatory dysfunction when it is due to BPH.
Other men with BPH/LUTS may experience erectile dysfunction (ED). The exact relationship between BPH/LUTS and ED remains unclear but is an area of active research. Evidence for a common mechanism between the two conditions is that treatment of ED with oral medications in men with both ED and LUTS has been shown to improve not only their ED, but also their LUTS.
It is important to keep in mind that men, like women, can develop an overactive bladder (OAB). While it can often be determined by a careful medical history and physical examination whether or not a man has LUTS due to BPH, OAB, or both, additional studies may be necessary to help make the correct diagnosis.
A urologist may recommend some or all of the following tests to evaluate for clinically-significant BPH:
If a man experiences symptoms of BPH, he should be evaluated by his doctor, particularly to rule out any other harmful causes of his symptoms. Early diagnosis and treatment will lead to better long-term outcomes and a quicker improvement in quality of life. Every man's symptoms and underlying causes of his symptoms are different, so treatment strategies will differ from patient to patient.
A number of medical treatment options are available for lower urinary tract symptoms in men. Each treatment has its own unique mechanism of action as well as unique side effect profile.
Alpha blockers These medications work by relaxing the smooth muscles in the prostate and where the prostate attaches to the base of the bladder. Decreased muscle tone allows urine to pass through the prostate more easily. Side effect may include dizziness, nasal congestion, ejaculatory problems, and other. Common medications in this category include terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), and alfuzosin (Uroxatral).
5-alpha reductase inhibitors (5-ARI's) These medications work by reducing the amount of dihydrotestosterone inside the prostate gland, resulting in a reduction in size of the gland. After 3-6 months of therapy, the prostate should shrink by about 30%. Side effects are rare but may include gynecomastia, breast tenderness, hot flashes and decreased libido. Two 5-ARI's are available: finasteride (Proscar) and dutasteride (Avodart).
Phosphodiesterase type-5 inhibitors (PDE-5i's) These medications are better known as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). Preliminary research has shown these medications to be beneficial for some men with lower urinary tract symptoms. Currently, these medications are FDA-approved only for the treatment of ED.
Anticholinergic/antimuscarinic medications These medications are used to treat overactive bladder symptoms. In the past, it was thought that these medications should not be used in men with BPH. However, more modern studies have documented the safety and efficacy of these medications in men with BPH. Side effects can include dry mouth and constipation and should not be used in patients with narrow-angle glaucoma. Common medications in this category include oxybutynin (Ditropan), tolterodine (Detrol), solifenacin (Vesicare), trospium (Sanctura), darifenacin (Enablex), fesoterodine (Toviaz), and miabegron (Mrybetriq).
When medical therapy is ineffective in treating LUTS due to BPH, if men are having significant side-effects to medications, or if men simply would prefer not to have to take medications, then surgical therapies are recommended.
A number of surgical treatments exist for BPH. Each technique has is own sets of risks and benefits, and not all patients are candidates for every therapy.
Choosing the appropriate surgical treatment depends on a number of factors including each individual's specific situation, as well as surgeon preference and access to resources.
Transurethral Resection of the Prostate (TURP) - Obstructing tissue is resected through a cystoscope using electrocautery. A general or spinal anesthetic is required. Glycine irrigation is used. A urethral catheter and hospital stay of 24-48 hours is generally required. Risks include bleeding (rare blood transfusion), infection, absorption of glycine, TUR syndrome, incontinence, dysuria, and retrograde ejaculation.
Transurethral Incision of the Prostate (TUIP) - Rather than removing prostate tissue, the tight muscle fibers where the prostate and bladder meet are incised, and tension in this area is released. TUIP generally is perfomed on select symptomatic men, typically with smaller prostates.
Bipolar/Plasmakinetic TURP- Similar to conventional TURP, however saline is used for irrigation instead of glycine. Thus, the risks of glycine toxicity and TUR syndrome are obviated. The bipolar technology generally results in less bleeding and quicker recovery than a conventional TURP.
TURis Plasma Vaporization Electrode - Removes prostate tissue using saline for irrigation and plasmakinetic technology. The obstructing prostate tissue is vaporized in a nearly bloodless procedure that allows for shorter catheter time and hospital stay. This technology has been used in Europe for years and is now available in North America.
GreenLight Laser- Photoselective vaporization of the prostate uses laser energy to remove obstructing prostate tissue. The laser therapy works by simultaneously removing the tissue and coagulating the blood vessels within the prostate, resulting in a nearly bloodless procedure and significantly quicker recovery than TURP. The procedure is performed either as a same-day surgery or overnight stay. Less than 24 hours of catheterization is typically required.
Americal Urological Association Guidelines for the Management of Benign Prostatic Hyperplasia
AUA Guidelines for the Surgical Management of BPH
Urology Care Foundation patient information about BPH
Urology Care Foundation Prostate Health Series
GreenLight Laser Photoselective Vaporization of the Prostate
Prostatitis and the Chronic Pelvic Pain Syndrome
Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome
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