taken from Small Gland, Big Problem 4th Edition
by Professor Roger Kirby, Health Press 2011
BPH is most commonly treated with either drugs or surgery. Some men with mild symptoms opt for active surveillance, which involves monitoring their condition so that any worsening can be quickly spotted and treated. There are also several ‘minimally invasive’ alternatives.
Drug treatment may be recommended if your symptoms are moderate, though it may also be beneficial if your symptoms are severe. Certain complications of BPH, such as kidney problems, urinary retention or bladder stones, make surgery a more appropriate option.
There are two main classes of drug that are prescribed for BPH:
- 5-alpha-reductase inhibitors.
Alpha-blockers work by helping to relax the muscles at the neck of the bladder and in the prostate. By reducing the pressure on the urethra, they help to overcome the obstruction and so increase the flow of urine. Results available from studies to date indicate that up to 60% of men find that their symptoms improve significantly within the first 2–3 weeks of treatment with an alpha-blocker.
This type of drug does not cure BPH, but simply helps to alleviate some of the symptoms. You may still develop complications at a later date and you may still need surgery eventually.
The most commonly occurring side effects are tiredness, dizziness and headache, which affect around one in ten men.
5-alpha-reductase inhibitors work by blocking the conversion of testosterone to another substance, DHT (dihydrotestosterone), that is known to have a key role in prostate growth. To date, most information is available on the 5-alpha-reductase inhibitor Proscar (finasteride); a newer agent, Avodart (dutasteride) is also now available. Unlike alpha-blockers, Proscar and Avodart do appear to be able to reverse the condition to some extent, particularly if the prostate is significantly enlarged, so their use may reduce the likelihood that you will develop acute urinary retention and eventually require surgery. These drugs also seem to work better in patients with larger prostate glands, but it can take 6 months or so for them to be effective. Importantly, they do reduce the PSA value by around 50% so this should be taken into account when monitoring for prostate cancer; one way to do this is to double the PSA value obtained when a patient is taking either Avodart or Proscar.
The main side effects of these agents are a reduced sex drive and difficulty in maintaining/achieving an erection; these appear to affect around 3–5 men in every 100. There is also a small chance of about 1% or less that you might experience tenderness and swelling around the nipples. These symptoms usually disappear if treatment is stopped. Be aware that crushed or broken Proscar or Avodart tablets should not be handled by a woman who is pregnant or who is planning a pregnancy, as there is a risk that they could cause problems to a developing baby.
Combination therapy with an alpha-blocker and a 5-alpha-reductase inhibitor has been shown to be more effective than either agent used alone in preventing the worsening of the symptoms of BPH or the development of complications, such as acute retention or the need for surgery. However, the increased cost and additional side effects have to be weighed against these benefits. Patients most likely to respond to combination therapy are those with both a large prostate and severe symptoms. A combination of dutasteride and tamsulosin in one pill, known as Combodart, has recently been released, and patients often find this to be more convenient. Side effects are a combination of those seen with the individual medications.
Other medical strategies for symptom relief in BPH include anticholinergic agents like Detrusitol XL (tolterodine), Vesicare (solifenacin) and Toviaz (fesoterodine) to control urinary urgency and frequency. However, these agents carry a small risk of precipitating acute retention of urine in men with severe obstruction and may also result in a dry mouth. Botox (Botulinum toxin) has been used in a small number of men with BPH in the form of an injection into the prostate under ultrasound control. Preliminary results look encouraging, but the results of larger, longer studies are needed before it can be regarded as standard therapy.
In patients who are particularly troubled by the need to pass urine during the night (nocturia), vasopressin analogues such as Desmospray or Desmotabs (desmopressin) last thing at night, used in addition to fluid restriction in the evenings, can be quite effective. These drugs work by reducing the amount of urine produced by the kidneys for 6–8 hours.
There are a number of surgical options for BPH:
- transurethral resection of the prostate (TURP)
- transurethral incision of the prostate (TUIP)
- open prostatectomy
- laser prostatectomy.
TURP is still the ‘gold-standard’ operation for men who have not responded to medical therapy or who have developed complications such as complete retention of urine, and is usually carried out under a general anaesthetic. It involves passing an instrument up through the penis, and then using it to cut the middle out of the enlarged prostate, piecemeal (see diagram on facing page). A catheter is passed through the urethra into the bladder at the end of the operation to drain off the urine. This is left in place for a couple of days. A normal hospital stay following TURP is 3 or 4 days, but you should try to rest as much as possible for a few weeks afterwards to minimize the risk of secondary complications such as bleeding that may occur 10–12 days after the original operation.
After the operation, you may find that you experience an urgent need to urinate and/or a burning sensation when you pass urine. This should disappear within a few weeks. You may also notice some blood in your urine. This is normal, but if it is particularly heavy or persists for more than a few weeks, or if you notice some blood clots, drink extra fluids and contact your doctor.
The most common side effect is a phenomenon known as retrograde ejaculation – where semen passes into the bladder during orgasm, rather than out through the penis (see overleaf). You then pass the semen mixed with urine the next time you urinate. This is not harmful and, providing that they know about this potential side effect before undergoing the surgery, most men do not find it bothersome. However, retrograde ejaculation will almost certainly reduce your fertility, though it does not make you reliably sterile.
A few men complain of an inability to achieve or maintain an erection after the operation, though this does not seem to be a problem specifically caused by this surgical procedure. In a study that compared men with BPH who had undergone a TURP with men with BPH who had not had surgery, the proportions of men who reported erectile problems were similar. Some were even improved by surgery.
Some men notice some incontinence after a TURP – if you find that you are leaking urine slightly, talk to your doctor. This problem nearly always resolves completely with time, but if it persists further investigation may be warranted.
An operation under general anaesthetic always carries some small risks, as occasionally an individual reacts badly to anaesthesia. There is also a chance of significant blood loss and the subsequent need for a transfusion. In the postoperative period, there may be problems with catheter blockage or bleeding after the catheter has been removed. These problems are relatively unusual with a TURP, however, and the outcome is usually good. Narrowing of the urethra, a so-called ‘urethral stricture’, may also develop, but can usually be resolved with a further minor procedure.
When a TURP is performed the prostate tissue removed is sent to the pathology laboratory for analysis. In most cases the results come back confirming benign prostatic hyperplasia (BPH); however, in around one case in ten, a small amount of prostate cancer is identified. Small areas of prostate cancer may not require active treatment, but careful follow-up is indicated, with scanning and biopsy of the remaining prostate tissue, which may harbour some residual cancer tissue.
A new device has come on to the market that helps to reduce bleeding during TURP. Known as the ‘button electrode’, it vaporizes the prostate. However, this means that there is no tissue available to check for cancer.
TUIP (also known as ‘bladder neck incision’) is appropriate for the man who is experiencing obstruction problems but who has a relatively small prostate. It is quite quick to perform, taking only around 20 minutes, but you will still be given a general or spinal anaesthetic. As with a TURP, an instrument will be passed up through the penis, but rather than removing a portion of the prostate, one or two small cuts are made in the neck of the bladder and in the prostate. These have the effect of reducing the obstruction and allowing the bladder neck to spring apart. As with a TURP, you will be catheterized at the end of the operation to allow urine to drain away freely. The catheter will be removed after around 24–48 hours, and you will be able to leave hospital after a couple of days. For the next week or so, you should take things easy.
The chance that you will experience a side effect following a TUIP is lower than following a TURP. Retrograde ejaculation (see
pages 83 and 84), for example, affects a much lower proportion of men after the operation (one in ten compared with eight in ten).
There is a risk that symptoms will return after the operation (see table on page 88); if this happens, then it is likely that you will need a TURP.
Again, as the operation is performed using a general anaesthetic, there is a small risk of anaesthetic-related complications and postoperative bleeding.
Open prostatectomy is only really appropriate for the man whose prostate is very large (more than 100 grams) or who has large bladder stones. It is a more complex procedure than a TURP, and complications afterwards are somewhat more likely.
The surgeon gains access to the prostate through a horizontal incision made in the lower abdomen. Through a cut made either in the prostate or bladder, the surgeon is then able to remove the central part of the prostate. A catheter is inserted into the bladder during the operation so that urine can drain away, and this is left in place for 3 or 4 days. Because this is relatively major surgery, you will usually need to stay in hospital for 5–7 days. Even when you go home, you are advised to rest for up to 6 weeks, and you should avoid lifting anything heavy for several months. The operation will leave a scar.
An open prostatectomy can also result in retrograde ejaculation (see pages 83 and 84), with about seven in ten men being affected; some men also find it difficult to achieve/maintain an erection (around two men in ten). Other problems associated with surgery of this type are similar to those described in the section on TURP.
The long-term picture following surgery
Useful information comparing the outcomes following each surgical procedure is presented in the table on page 88.
Newer minimally invasive treatments
As has already been said, minimally invasive treatments are relatively new. While greeted with enthusiasm by some urologists – and many patients – it has to be said that, currently, some minimally invasive techniques do not always work as well (or as definitively) as the more traditional treatments. One that particularly deserves a mention is laser therapy.
Laser therapy is carried out under general anaesthetic. A laser probe is inserted up through the penis, and the laser energy it generates destroys some of the prostate tissue. The ‘GreenLight’ laser vaporizes the prostate so that no tissue is available for examination under the microscope; higher power 180 watt GreenLight lasers have recently been introduced and are becoming popular.
A new holmium laser technique – so-called holmium laser enucleation of the prostate or HoLEP – allows the prostate to be
cut away, and the pieces are then broken down into a paste and removed from the bladder by suction.
Bleeding is minimal after laser therapy, but catheterization is usually necessary for a short time afterwards. For a while, a
burning sensation may be experienced on passing urine, which may be prolonged and quite troublesome. If this persists, a urine specimen should be sent to the laboratory for culture to rule out a urinary tract infection. The laser techniques are especially suitable for patients taking anticoagulants because they generally cause virtually no bleeding; they are becoming more popular as more and more specialized laser machines become available. As with any type of surgery, experience with the technique improves the results, so you should enquire how many operations the team has performed.
Active surveillance (no immediate treatment but regular monitoring) may be recommended if your symptoms are mild or if you are not too troubled by them. Your doctor will advise you about small changes that you can make to your lifestyle that might help; for example, try not to drink large volumes of fluid in the evenings. Tea, coffee and alcohol can worsen symptoms. At regular intervals (usually yearly) you will have a check up that will include the examination and tests described on pages 19–21.
Plant extracts (phytotherapy)
There is an increasing range of plant extracts available that supposedly alleviate BPH and many claims have been made as to
their effectiveness. However, scientific data from properly conducted long-term studies to support their safety and usefulness are limited. A recent report on saw palmetto suggested that it was no more effective than inactive placebo; however, some patients swear by it. Nevertheless, phytotherapy almost certainly does no harm, it is relatively cheap and most urologists do not actively discourage its use.