Benign Prostatic Hyperplasia

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Benign Prostatic Hyperplasia

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WHAT IS BENIGN PROSTATIC HYPERPLASIA?

Definition of Benign Prostatic Hyperplasia

Hyperplasia is a general medical term referring to excess cell replication. Benign prostatic hyperplasia (BPH) is noncancerous growth of the prostate gland [ see Box ]. It is the most common noncancerous form of cell growth in men and usually begins with microscopic nodules in younger men. It should be noted that BPH is not a precancerous condition. Prostate cancer usually occurs in the outer area of the prostate, called the peripheral zone.

As BPH progresses, overgrowth occurs in the central area of the prostate called the transition zone, which wraps around the urethra (the tube that carries urine through the penis). This pressure on the urethra can cause lower urinary symptoms that have been the basis for diagnosing BPH. [ See What Are Lower Urinary Tract Symptoms? Below. ] In 2000, an expert committee suggested that the impact of such symptoms on quality of life, including sexual activity, is also important in assessment of the disease.

The Prostate Gland

Description of the Prostate Gland. The prostate gland is located between the bladder and the rectum and wraps around the urethra (the tube that carries urine through the penis) . It is basically composed of three different cell types:

Smooth muscle cells, which contract during sex and squeeze the fluid from the glandular cells into the urethra, where it mixes with sperm and other fluids to make semen.
Glandular cells, which produce a milky fluid that liquefies semen.
Stromal cells (which form the structure of the prostate).

The central area of the prostate that wraps around the urethra is called the transition zone. The entire prostate gland is surrounded by a dense, fibrous capsule.

Functions of the Prostate Gland. The prostate gland provides the following functions:

The glandular cells produce a milky fluid, and during sex the smooth muscles contract and squeeze this fluid into the urethra. Here, it mixes with sperm and other fluids to make semen.
The prostate gland also contains an enzyme called 5 alpha-reductase that converts testosterone to dihydrotestosterone, another male hormone that has a major impact on the prostate.

Changes During the Lifespan. The prostate gland undergoes many changes during the course of a man's life. At birth, the prostate is about the size of a pea. It grows only slightly until puberty, when it begins to enlarge rapidly, attaining normal adult size and shape, about that of a walnut, when a man reaches his early 20s. The gland generally remains stable until about the mid-forties, when, in most men, the prostate begins to enlarge again through a process of cell multiplication.

WHAT ARE LOWER URINARY TRACT SYMPTOMS?

The symptoms commonly associated with BPH are collectively called lower urinary tract symptoms (LUTS). It should be noted that BPH is not always the cause of these symptoms. An enlarged prostate may be accompanied by few symptoms, while severe LUTS may be present with normal or even small prostates and are most likely due to other conditions. LUTS are now being categorized by many experts as either voiding or storage symptoms to help define the source of the problem. [ See Box The Process of Urination.]

Voiding (Obstructive) Symptoms

Voiding symptoms, also sometimes referred to as obstructive symptoms, can be caused by an obstruction in the urinary tract. They are often, but not always, due to BPH. Obstruction is the most serious complication of BPH and requires medical attention. Voiding symptoms include:

Weak or intermittent urinary stream.
Straining when urinating.
A hesitation before urine flow starts.
A sense that the bladder has not emptied completely.
Dribbling at the end of urination or leakage afterward.
Painful urination.
Hematuria (blood in the urine).

Storage (Irritative) Symptoms

Storage symptoms, also sometimes referred to as irritative symptoms, include:

An increased frequency of urination, particularly at night.

An urgent need to urinate.

Bladder pain or irritation when urinating.

The Process of Urination

The process of urination is more complicated than it appears:

It begins when waste fluids flow out of the kidneys into two long tubes called ureters:
The ureters empty into the bladder, which rests on top of the pelvic floor, a muscular structure similar to a sling running between the pubic bone and the base of the spine.
As the bladder fills to its capacity of 8 to 16 oz of fluid, its nerves send signals of fullness to the spinal cord and the brain.
The brain regulates the muscles in the urinary tract partly by means of a pathway of nerve cells and neurotransmitters (chemical messengers) called the cholinergic system .
While the bladder is filling, the brain signals the bladder to relax.
As the bladder swells, the individual senses this, and the brain voluntarily contracts the muscles to prevent urination.

At the time of urination, the spinal cord initiates the voiding reflex . This is an automatic process. The detrusor muscles (which surround the bladder) contract, while the internal sphincter (a strong muscle encircling the neck of the bladder) relaxes. The detrusor and internal sphincter muscles are involuntary; that is, they require no conscious effort for contraction or relaxation.

When the internal sphincter is open, urine flows out of the bladder into the urethra (the tube that carries urine from the bladder out through the penis.)

WHAT CAUSES CELL GROWTH LEADING TO BENIGN PROSTATIC HYPERPLASIA?

The causes of benign prostatic hyperplasia are not fully known. A number of theories have been proposed to explain benign cell growth in the older man.

Male Hormones

Androgens (male hormones) most likely play a role in prostate growth. The most important androgen is testosterone, which is produced throughout a man's lifetime. The prostate converts testosterone to a more powerful androgen, dihydrotestosterone ( DHT). DHT hormone stimulates cell growth in the tissue that lines the prostate gland (the glandular epithelium) and is the major cause of the rapid prostate enlargement that occurs between puberty and young adulthood. DHT is a prime suspect in prostate enlargement in later adulthood.

Estrogen

Some authorities believe that the female hormone estrogen may also play a role in BPH; some estrogen is always present in men. As men age, testosterone levels drop and the proportion of estrogen increases, possibly triggering prostate growth.

Late Activation of Cell Growth

Another theory focuses on cells in a certain section of the gland that may become active late in life, signaling other prostate cells to replicate or causing them to be sensitive to growth-stimulating hormones.

Defective Cell Death

Yet another theory suggests that a process known as apoptosis, in which cells naturally self-destruct, goes awry and results in cell proliferation.

WHAT CAUSES LOWER URINARY TRACT SYMPTOMS?

A number of structural or medical conditions, either independently or in conjunction with BPH, can cause lower urinary tract symptoms. Prostate growth, in fact, does not always explain symptoms normally attributed to BPH. Men with large prostates do not always have symptoms, and men with small or normal-sized prostates sometimes have symptoms that are more severe than in those with enlarged glands. [ See Box The Process of Urination.]

Abnormalities in the Urinary Tract

Abnormalities in the urinary tract can cause BPH-like symptoms in men with or without enlarged prostate glands. Such conditions can produce obstruction, impair or weaken the detrusor muscles surrounding the bladder, or cause other damage that impacts the urinary tract. They include the following:

Muscle contractions in the area where the bladder and urethra meet.
A narrowing of the urethra.
A weakened bladder.
Over-activity in prostate muscles.

Aging

The process of aging weakens the detrusor muscles that surround the bladder, which causes the bladder to become unstable and lose capacity. Unstable detrusor muscles may also impair bladder storage capacity, which then produce irritative or storage symptoms. Studies are also indicating that as men get older they may produce more urine at night, although the total daily output of urine is similar to that in middle-aged men. It is not fully known why this occurs.

Prostatitis

Prostatitis is an inflammation of the prostate gland. It can be caused by bacterial infection, which is the easiest cause to diagnose. However, the most common form of prostatitis is nonbacterial.

Bacterial Prostatitis. A prostatitis infection can be acute (occurring abruptly) or chronic (long term). Chronic bacterial prostatitis (CBP) is often subtle and may persist for weeks or months with low-grade symptoms, including an urgent need to urinate, frequent urination, and the need to urinate at night. Pain may occur in the lower back or rectum, or it may develop after ejaculation. Because the prostate isn't swollen, physicians may mistake chronic prostatitis for BPH. A urine culture should always be taken, which, in the case of both acute and chronic bacterial prostatitis, will reveal bacteria and confirm a diagnosis. Antibiotics are required to treat CBP; fluoroquinolones and trimethoprim-sulfamethoxazole (Bactrim, Septra) are particularly effective, but prolonged treatment may be necessary.

Nonbacterial Prostatitis. In nonbacterial prostatitis, inflammation occurs but no bacteria are present. It is eight times more common than bacterial prostatitis. The causes of nonbacterial prostatitis have not been determined. The routine use of drug therapy (antibiotics, anti-inflammatory drugs, or agents used in BPH) does not seem to be beneficial for treating this condition. More research is needed.

Prostatodynia. Although it is considered a form of prostatitis, prostatodynia is a noninflammatory disorder characterized by prostate pain but neither inflammation nor bacteria are present. The causes of prostatodynia are unknown.

Interstitial Cystitis

Interstitial cystitis is an inflammation of the bladder that may be associated with allergic or autoimmune response. Some physicians believe this is a psychologic condition but there is a significant amount of evidence that it represents a physical problem. It is occurs much more frequently in women but some experts believe it is more common in men than many physicians believe and may be misdiagnosed as prostatitis or BHP.

Congestion of the Prostate (Prostatosis)

Congestion of the prostate, sometimes called prostatosis, is a benign condition in which the prostate seems to be swollen by excess fluid. It can cause frequent, slow, or uncomfortable urination, but it responds well to a program of frequent ejaculation and sitz baths.

Cancer

On occasion, prostate cancer can mimic BPH, since both conditions may cause obstruction of the urethra. Bladder cancer can sometimes cause urinary bleeding, frequency of urination, or a sense of urgency, also symptoms of BPH.

Other Conditions Affecting the Urinary Tract

A number of other conditions can impair the lower urinary tract, including tumors, reactions to medications, and spinal cord injuries. Diseases that affect the nervous system, such as diabetes, multiple sclerosis, and shingles, can desensitize the nerves so that they fail to sense fullness and do not trigger the contraction of the bladder.

WHO GETS BENIGN PROSTATIC HYPERPLASIA?

Aging

About 5.5 million American men have benign prostatic hyperplasia (BPH) that could warrant medical attention. Age is the major risk factor. According to a British study, only 3.5% of men in their late 40s have signs of BPH, but by age 80, 35% of men have the BPH with lower urinary tract symptoms. And, according to another study, as many as 80% of men have at least some signs of BPH. Research into possible risk factors is ongoing. The problem appears to be more prevalent in the US and Europe, and may be more common in married men than single men.

Ethnic Groups

Although some studies have suggested that African American men are at higher risk and Asian men at lower risk for BPH than Caucasians, a 2000 study found no greater risk for African Americans and only a slightly lower risk for Asians. Among Caucasians in the study, men of southern European heritage were at greater risk while men of Scandinavian ancestry had a lower chance of developing BPH. (The study reported no differences in male hormones among the Caucasian groups.)

Family History

A family history of BPH appears to increase a man's chance of developing the condition. One study reported that men with BPH who had three or more family members with the condition had much larger prostate glands than men with BPH without such a family history.

Diabetes

According to a 2000 study, diabetes worsens urinary tract symptoms in men with BPH. In the study, flow rates were adversely affected by diabetes, although residual urine volumes were not significantly greater.

HOW SERIOUS ARE BENIGN PROSTATIC HYPERPLASIA AND LOWER URINARY TRACT SYMPTOMS?

Reduced Quality of Life

Problems with urination can be very distressing and severely affect quality of life, although individual response to these symptoms varies widely. Some men can tolerate very uncomfortable sensations of abnormal urination, while other men seek relief from mild symptoms. BPH does not appear to impair sexual function.

Bladder Obstruction

Men are more apt to tolerate voiding symptoms (intermittent flow, hesitancy before urinating) and seek help for storage symptoms (urgency, frequency, urination at night). Voiding symptoms, however, may indicate an obstruction blocking the bladder, which if extensive can severely reduce urine flow and cause other complications, some serious.

Acute Urinary Retention. Sometimes a man is unaware of an obstruction until he suddenly cannot urinate at all. This condition is called acute urinary retention. It is a dangerous complication that can damage the kidneys and may require emergency surgery. In general, BPH progresses very slowly and acute urinary retention is very uncommon. Men with BPH at highest risk for this complication tend to be elderly and to have moderate to severe lower voiding symptoms. Taking anti-hypertensive drugs (except for diuretics) or antiarrhythmic drugs may also increase the risk.

Other Complications. Bladder obstruction can also cause bladder stones, blood in the urine, urinary tract infection, and incontinence. Unfortunately, no current tests can accurately predict which men are at higher risk for complications, although men with a weak urine stream and larger prostates are at higher risk for urinary retention.

Prostate Cancer

BPH and prostate cancer occur in men in the same age groups and BPH causes prostate enlargement. Many men are concerned, therefore, that BPH may be related to prostate cancer. Fortunately, current evidence indicates that there is no link. The two conditions develop in different parts of the prostate: BPH occurs in the inner transition zone, while cancer tends to develop in the peripheral outer zone. A ten-year study found no higher risk for prostate cancer in men with BPH. Unsuspected prostate cancer is detected during surgery in about 15% of BPH patients, but the risk of this slow-growing cancer is high in all older men. Some estimates suggest that up to one-third of all men over age 50 have at least microscopic prostate cancer. Still, screening tests for prostate cancer (digital rectal exam and a PSA test) are often recommended for men who have lower urinary-tract symptoms.

WHAT TESTS ARE USED TO EVALUATE LOWER URINARY TRACT SYMPTOMS?

International Prostate Symptoms Score

An indexing tool called the International Prostate Symptoms Score (IPSS) [ see Table below ] can help evaluate the key lower urinary tract symptoms. As opposed to laboratory tests or other objective tests, this scoring system measures the patient's own experience. The higher the score, the more severe the conditions. It is useful for many reasons:

The patient's score on this test gives a highly accurate assessment of the effect of lower urinary tract symptoms on the quality of a man's life.
It is a reasonable basis from which the patient and physician can discuss treatment options.
The index is also often used to gauge treatment outcomes and may be a better indicator of success than objective tests, such as the measurement of the prostate gland or the rate of urine flow.

Limitations. It should be noted that the IPSS is useful only as a gauge of symptom severity, and has the following limitations:

Other conditions can produce similar scores, so the test is not used as a diagnostic tool for BPH.
The index does not include other urinary symptoms, such as dribbling and incontinence or sexual health, that are important for quality of life. At the very least, the patient should have a frank discussion with his physician if such symptoms are present and affect his life.
It also does not reflect regional or ethnic differences that can vary the responses to these symptoms.

International Prostate Symptoms Score (IPSS)

Circle appropriate number. Totals of: 7 or less = mild symptoms; 8-19 = moderate; 20-35 = severe.

Symptoms over past month	Never	Less than 1 time in 5	Less than half the time	About half the time	More than half	Almost always
Sensation that the bladder is not empty after urinating	0	1	2	3	4	5
Need to urinate within two hours of a previous urination	0	1	2	3	4	5
Need to stop and start again several times while urinating	0	1	2	3	4	5
Have a weak urinary stream	0	1	2	3	4	5
Need to strain to urinate	0	1	2	3	4	5
	None	One time	Twice	3 times	4 times	5 times or more
Number of times during the night awakened by the need to urinate	0	1	2	3	4	5

Other Indexing Systems

Other indexing systems, such as Symptom Problem Index (SPI) and the BPH Impact Index (BII), which gauge different quality-of-life and disease issues, are being used in addition to the IPSS to help assess the patient.

Physical Examination

Digital Rectal Exam. The digital rectal exam is used to detect an enlarged prostate. The doctor inserts a gloved and lubricated finger into the patient's rectum and feels the prostate to estimate its size and to detect nodules or tenderness. The exam is quick and painless, but embarrassing for some, and far from infallible. The test helps rule out prostate cancer or problems with the muscles in the rectum that might be causing symptoms, but it generally underestimates the prostate's size. It is not accurate for diagnosing prostate cancer, and is never the primary diagnostic tool for either BPH or cancer.

Other Physical Examinations. The physician will usually press on and manipulate (palpate) the abdomen and sides to detect signs of kidney or bladder abnormalities. The physician will also check for signs of anemia or swelling in the legs and arms. Certain procedures that test reflexes, sensations, and motor response may be performed in the lower extremities to rule out possible neurologic causes of bladder dysfunction.

Uroflowmetry

To determine whether the bladder is obstructed, the speed of urine flow is measured electronically using a test called uroflowmetry. The test cannot determine the cause of obstruction, which can be due not only to BPH, but possibly also to abnormalities in the urethra, weak bladder muscles, or other causes.

The patient is instructed not to urinate for several hours before the test and to drink plenty of fluids so he has a full bladder and a strong urge to urinate.
To perform this test, a patient urinates into a special toilet equipped with a uroflowmeter.
It is important that the patient remains still while urinating to help ensure accuracy, and that he urinates normally and does not exert strain to empty his bladder or attempt to retard his urine flow.
Many factors can affect urine flow (such as straining or holding back because of self-consciousness) so experts recommend then that the test be repeated at least twice.

Q[max]. The rate of urine flow is calculated as milliliters of urine passed per second (mL/s). At its peak, the flow rate measurement is recorded and referred to as the Q[max]. The higher the Q[max], the better the patient's flow rate. Men with a Q[max] of less than 12 mL/s have four times the risk for urinary retention than men with a stronger urinary flow.

The Q[max] measurement is sometimes used as the basis for determining the severity of obstruction and for judging the success of treatments. It is not very accurate, however, for a number of reasons:

Urine flow varies widely among individuals as well as from test to test.
The patient's age must be considered. Flow rate normally decreases as men age, so the Q[max] typically ranges from more than 25 mL/s in young men to less than 10 mL/s in elderly men.
The Q[max] level does not necessarily coincide with a patient's perceptions of the severity of his own symptoms.

Urinalysis

A urinalysis may be performed to detect signs of bleeding or infection. A urinalysis involves a physical and chemical examination of urine. In addition, the urine is spun in a centrifuge to allow sediments containing blood cells, bacteria, and other particles to collect. This sediment is then examined under a microscope. Although urinary infection is uncommon in younger men, it occurs more frequently in older men, particularly those with BPH. A urinalysis also helps rule out bladder cancer.

Pre and Post Massage Test (PPMT)

To rule out prostatitis a simple test called the Pre and Post Massage Test (PPMT) is about 90% accurate. This test requires two cultures and microscopic examinations of urine samples taken before and after massage of the prostate gland. To massage the prostate the doctor simply inserts a gloved finger into the rectum and presses several times on the prostate. The following results are indicated by findings on cultures after massage:

Category II prostatitis (Chronic bacterial). Bacteria are found on post-massage.
Category IIIA prostatitis (Inflammatory chronic pelvic pain syndrome). Leukocytes or other cells are found that indication inflammation.
Category IIIB prostatitis (Noninflammatory chronic pelvic pain syndrome). No signs of inflammation or bacteria.

Serum Creatinine

In men with symptoms, blood tests are performed to measure a substance called serum creatinine, which is a marker for kidney trouble. Kidney problems exist in an average of 13.6% of BPH patients. Studies have reported rates as high as 30% and as low as 0.3%.

PSA Test for BPH and Prostate Cancer

A PSA test measures the level of prostate-specific antigen (PSA) in the patient's blood. It is the standard screening test for prostate cancer. A PSA is recommended annually for all men over 50 years old and for men over 40 who are at high risk for prostate cancer.

BPH itself can also raise PSA levels, but the test has generally been optional for men with suspected BPH. One 2000 study indicated that PSA levels may be good predictors of future prostate growth in men with BPH. In the study, men with the lowest PSA level groups (0.2 to 1.3 ng/mL) had prostate growth rates of only 0.7 mL per year while those in the high PSA groups (3.3 to 9.9) had growth rates of 3.3. mL per year. Other research has detected a specific molecular form of PSA, which has been termed BPSA because it may be a specific marker for BPH. Such findings could eventually lead to a shift from focusing on symptoms and flow rates for diagnosis to a more specific and possibly preventive approach.

Certain treatments for BPH, including the drug finasteride (Proscar) and the surgical procedure transurethral resection of the prostate (TURP), can reduce PSA levels and possibly mask the existence of prostate cancer.

A more recent test identifies so-called free PSA, which is found in lower levels when prostate cancer is present and in higher levels with benign prostate hyperplasia. This may be more accurate than total PSA, regardless of whether a man is taking finasteride or not.

Postvoid Residual Urine

One of the important goals of tests for urinary incontinence is the postvoid residual urine volume (PVR), the amount of urine left after urination. Normally, about 50 mL or less of urine is left; more than 200 mL is a definite sign of abnormalities. Measurements in between require further tests. The most common method for measuring PVR is with a catheter, a soft tube, which is inserted into the urethra within a few minutes of urination. PVR can also be measured using transabdominal ultrasonography [ see below ].

Ultrasound

Ultrasound of the prostate does not require a catheter and gives an accurate picture of the size and shape of the prostate gland. Ultrasound is very beneficial when planning surgery and determining treatment options and gauging their effectiveness. Ultrasound may also be used for detecting kidney damage, tumors, and bladder stones. Ultrasound tests of the prostate generally use one of two methods:

Transrectal ultrasonography (TRUS) uses a rectal probe for assessing the prostate. TRUS is significantly the more accurate method for determining prostate volume. It can sometimes detect cancer.
Transabdominal ultrasonography uses a device placed over the abdomen. It can give an accurate measure of postvoid residual urine and is less invasive and expensive than TRUS.

Filling Cystometry

Filling cystometry, also called cystometography, is usually used for patients who cannot urinate and in whom nerve damage or injury of the bladder is suspected. The test is used to determine the absence or presence of a condition called uninhibited detrusor contractions (UDC), which often occurs in men with storage urinary tract symptoms. The detrusor is the group of muscle fibers that cover the outside of the bladder. The test does not add much information to results from less invasive tests and is not used routinely.

Procedure

The patient is usually lying down and is told to remain as relaxed as possible.
Sterile water (usually at body temperature) is instilled into the bladder and the pressure in the bladder is continuously measured.
The patient informs the physician about sensations experienced, and when the urge to urinate is strong, this portion of the test is stopped.
A fluid-inflatable balloon is inserted into the rectum for a second measurement. This reflects abdominal pressure.
A calculation is then made using the measurements of abdominal and bladder pressures. The result provides an accurate assessment of detrusor contractions.
If results are uncertain, the test may be repeated to provoke bladder response by having the patient stand, by increasing the speed of the filling time, or by using ice-cold water.

Urethrocystoscopy

A urethrocystoscopy, also called cystourethroscopy, may be performed in men diagnosed with BPH, particularly if they are surgical candidates or if other urinary tract problems are suspected. Such problems include blood in the urine, infection, interstitial cystitis, bladder cancer, or prior surgery or injury. The physician can determine the presence of a number of structural problems, including enlargement of the prostate, obstruction of the urethra or neck of the bladder, anatomical abnormalities, or the presence of stones.

Procedure. In this procedure, a flexible or rigid fiberoptic tube (an endoscope) is inserted into the urethra to allow doctors to view the lower urinary tract.

Complication. The procedure is not without risks. Complications are uncommon but can include allergic response to the anesthetic, urinary tract infection, bleeding, and urine retention.

Intravenous Excretory Urography

An x-ray called an intravenous excretory urography (IVU) is an invasive test that is used only when complications in the upper urinary tract, particularly in the kidney, are suspected. Abdominal ultrasound plus a normal x-ray may be as useful as IVU for most patients with suspected upper urinary tract problems.

Complications and Side Effects. If there is any danger of kidney failure, the test should not be performed, since it can exacerbate the condition. Severe side effects of the test occur in 0.1% of patients.

Differentiating between BHP and Interstitial Cystitis (IC)

Some physicians believe that a number of men may be incorrectly diagnosed with BPH when they have interstitial cystitis (an inflammation of the bladder that may be associated with allergic or autoimmune response). The potassium sensitivity test is sometimes used to diagnose IC. Some experts believe this test missed too many IC patients, although a 2001 study concluded that a combination of potassium sensitivity and urodynamic tests is useful in distinguishing between BPH and interstitial cystitis.

WHAT ARE THE GUIDELINES FOR TREATING BENIGN PROSTATIC HYPERPLASIA?

Because BPH rarely causes serious complications, men usually have a choice between treating it or opting for "watchful waiting":

Watchful Waiting. Watchful waiting involves lifestyle changes and an annual examination. It should be noted that even when choosing watchful waiting, an initial examination is critical to rule out other disorders.
Treatment Options. The primary goals of treatment for BPH are to improve urinary flow and to reduce symptoms. Many options are available. They include drug therapies, minimally invasive procedures, and major surgery.

Choosing Between Treatment and Watchful Waiting

The choice between watchful waiting and treatment usually depends on a number of factors, such as urine flow rates, prostate size, and PSA levels. Men with BPH who develop symptoms at around age 50 are more likely to need treatment within their lifetimes than older men. Unfortunately, there is no way at present to determine who specifically might be at risk for serious problems and need early treatment.

The evaluation of symptoms has been made somewhat easier by the development of the International Prostate Symptoms Score (IPPS). [ See table above. ] This scoring service serves as a benchmark for determining severity. To treat or not to treat is typically based on the guidelines described below, but the ultimate choice is often guided primarily by a man's perception of his own symptoms.

Mild or No Symptoms. Men with mild or no symptoms (IPPS scores of 7 or below) usually choose watchful waiting even if their prostates are enlarged. BPH eventually progresses to the point of needing treatment in about 15% of men with mild symptoms who wait. (It should be noted, however, that urinary tract obstructions may be present in men with enlarged prostates even if they have no symptoms, so there is some risk with this choice, although it is small.)

Moderate Symptoms. The choice is most difficult for men with moderate symptoms (scores between 8 and 19) and may simply depend on a man's ability to tolerate them. In one comparative study of such patients, after five years, only 10% of surgical patients had worse or recurrent symptoms compared to 21% of watchful waiting patients. (None of these men were taking medications, however, so it is not known how treatment with medication would compare with surgery.) Other studies have reported that up to 40% of those with moderate symptoms eventually need treatment. In a small percentage of patients, symptoms improve.

Severe Symptoms. Men with severe symptoms (scores over 20) nearly always choose treatment, although if their prostate glands are small or normal-sized, symptoms may improve.

Choosing Treatment and then Deciding Between Surgery and Medication

If a man opts for treatment, there are a number of choices. Most experts recommend a staged approach as follows:

Medications are the best choice for patients with mild symptoms who decide to have their condition treated. Such men have the same risks for surgical complications as patients with more severe symptoms, but they usually experience only a slight benefit. The major drug groups are alpha-blockers (which are usually the better choice) and anti-androgens (nearly always finasteride).
Men with moderate to severe symptoms still have good choices among drugs and surgeries. If a man chooses surgery, there are many choices. Transurethral resection of the prostate (TURP) is the standard procedure but less invasive procedures, particularly those using heat to destroy prostate tissue, are gaining prominence.

Drugs versus Surgery. Recent developments in drug therapy have reduced the number of surgical procedures needed and delayed their use. In men with severe symptoms, however, surgery is often needed eventually. For example, in men with small prostates and severe symptoms, alpha-blocking agents work more quickly than microwave treatment,, a minimally invasive procedure that uses heat to destroy prostate tissue. The microwave procedure, however, has a greater rate of success.

The most common reason for choosing surgery is obstruction of the bladder outlet, which causes urinary retention. Surgery is also typically a reasonable option when BPH is clearly related to one or more of the following conditions:

Recurrent urinary tract infection.
Hematuria (blood in the urine). Studies have suggested that left untreated, two-thirds of patients continue to bleed and one third require surgery. A 2000 study suggested, however, that the agent finasteride may prove to be a possible alternative to surgery for patients with recurrent hematuria. Further research is required.
Bladder stones.
Kidney problems.
Some experts believe that surgery might benefit patients in whom an early diagnosis of prostate cancer is important. Unsuspected prostate cancer is detected during surgery in about 15% of cases.

The greatest improvements resulting from surgery are usually increased urinary flow and reduced urine retention. One study reported that men who chose surgery reported more worry and depression before the procedure, but afterward they had less depression and anxiety than those who had chosen medication. In many cases, the benefits of surgery are not permanent, however.

WHAT ARE LIFESTYLE MEASURES FOR MANAGING BENIGN PROSTATIC HYPERPLASIA?

Daily Activities

Certain lifestyle changes can help relieve symptoms and are particularly important for men who choose to avoid surgery or drug therapy. Men should take the time to urinate when it is convenient even if there is no urge. They should take aisle seats in theaters and when traveling. Cold weather and immobility may increase the risk for urine retention. Keeping warm and exercising [ see below ] may be useful. Stress reduction techniques may also help.

Dietary Factors

Some small studies have suggested the following:

Avoiding alcohol, coffee, and other fluids after the evening meal is helpful.
There is some indication that drinking green tea, which contains plant chemicals called flavonoids, may benefit the prostate.
Genistein, a chemical found in soy, reduced the growth of BPH tissue in the laboratory. Although Asians have a low incidence of BPH and prostate cancer and also have diets rich in soy, it is not yet known if eating soy products will reduce the risk of BPH or improve any symptoms.
One recent well-publicized study found an association between a lower risk for BPH and high intake of fruits and a higher risk for BPH with a high intake of butter and margarine.
Zinc is of interest because it accumulates to the highest levels in a man's body in either a normal prostate or one enlarged from benign prostate hyperplasia. It may have some protective properties against prostate cancer.

Avoiding Medications that Aggravate Symptoms

Decongestants and Antihistamines. Men with BPH should avoid, if possible, the many medications for colds and allergy that contain decongestants, such as pseudoephedrine (Sudafed). Such drugs, known as adrenergics, can exacerbate urinary symptoms by preventing muscles in the prostate and bladder neck from relaxing to allow urine to flow freely. Antihistamines, such as diphenhydramine (Benadryl), can also slow urine flow in some men with BPH.

Diuretics. Men who are taking diuretics, which increase urination, may discuss reducing the dosage or switching to another drug. These are important drugs for many people with high blood pressure, with a proven track record for saving lives; no one should go off these medications without medical supervision.

Other Drugs. Other drugs that may exacerbate symptoms are certain antidepressants and drugs used to treat spasticity.

Exercise

A recent study reported that even moderate exercise can reduce urinary tract problems associated with BPH. According to a 2001 study, physical activity does not seem to protect against developing BPH.

Kegel Exercises

Kegel (pelvic floor muscle) exercises, which were first developed to assist women with childbirth, are also useful for men in helping to prevent urine leakage. They strengthen the muscles of the pelvic floor that both support the bladder and close the sphincter.

Performing the Exercises. Since the muscle is internal and is sometimes difficult to isolate, doctors often recommend practicing while urinating:

The patient is asked to contract the muscle until the flow of urine is slowed or stopped. He attempts to hold each contraction for ten seconds.
He then releases it.
In general, patients should perform five to 15 contractions, three to five times daily.
Kegel exercises should not be regularly performed while urinating; this practice may eventually weaken the muscles.

WHAT DRUGS ARE USED FOR BENIGN PROSTATIC HYPERPLASIA?

Primary Drug Classes

The two primary drug classes used for BPH are the following:

Alpha-blockers. These drugs relax smooth muscles, especially in the urinary tract and prostate. They include terazosin, doxazosin, tamsulosin, and alfuzosin (Xatral). Alpha-blockers are more likely to reduce symptoms of BPH and are generally the first choice, particularly in men with smaller prostates.
5-alpha-reductate inhibitors. These are a group of anti-androgens. In other words, they block male hormones, particularly dihydrotestosterone. The standard agent is finasteride (Proscar.) Anti-androgens may help men with significantly enlarged prostates.

Because the two drug classes have different mechanisms, combinations of the two are being investigated for selected candidates. For example, studies in 2001 used a combination of an alpha-blocker (to speed up symptoms relief) and finasteride (for ongoing maintenance) in men with moderately large prostates and bladder outlet obstruction. The alpha-blocker was discontinued in nine months without significant return of symptoms in many patients.

Alpha-Blockers

Alpha-blockers are drugs that relax smooth muscles. Many specifically affect muscles in the urinary tract and prostate.

Candidates for Alpha-Blockers. Alpha-blockers are prescribed for most men with BPH symptoms whose prostates are not significantly enlarged. Because they work fairly quickly, have no effect on sexual drive, and are the least expensive BPH treatment, even men with moderately enlarged prostates might try them before undertaking more intense treatments. Some experts now recommend alpha-blockers as first-line treatment for patients with moderate to severe symptoms.

Benefits of Alpha-Blockers. By relaxing the muscles in and around the prostate, alpha-blockers increase urinary flow and improve symptoms, sometimes significantly. Improvement occurs within days to weeks. Because these drugs are short acting, symptoms return very quickly once a man stops taking the medication. They do not affect PSA levels. Research also indicates that they may even promote a natural process called apoptosis, in which cells in the prostate gland self-destruct.

Alpha-Blocker Forms. Alpha-blockers are referred to as one of the following:

Nonselective. They include terazosin (Hytrin) and doxazosin (Cardura).
Selective. They include tamsulosin (Flomax) and alfuzosin (Xatral).

Both are effective in reducing symptoms and improving urinary flow, but there are differences. Patients should discuss the appropriate alpha-blocker for their individual condition with their doctors.

Nonselective Alpha-Blockers.

Brands or Forms. Brands or forms of nonselective alpha-blockers include terazosin (Hytrin) and doxazosin (Cardura). Doxazosin is available in a delayed release version of doxazosin (GITS) that requires less dosage adjustment that is as effective as n standard doxazosin.
Specific Actions and Benefits. Nonselective alpha-blockers (also referred to as alpha-specific antagonists) are referred to because they can relax all smooth muscles, not only in the prostate but also those that surround blood vessels. These agents work within four to six weeks, are inexpensive, and produce long-lasting benefits, particularly in men with smaller prostates. A 2001 study in Japan reported that terazosin was more objectively effective than a selective alpha-blocker in improving symptoms, although men subjectively reported that both were effective. Terazosin had added benefits of reducing blood pressure in men with hypertension and cholesterol levels in men with unhealthy levels. Of interest are studies suggesting that doxazosin may have some effect against prostate cancer cells.
Side Effects. Nonselective alpha-blockers can reduce blood pressure, which may cause dizziness, headache, rapid heart beat, and fatigue. Orthostatic hypotension, a sudden drop in blood pressure when standing, can occur and increases the risk of falling. Taking the medication close to bedtime can help reduce these side effects. Alpha-blockers can also cause headache, sore throat, and weakness. Nasal congestion occurs in about 2% of cases. Men may also experience a decreased ejaculate. (Impotence is not a common side effect of alpha-blockers as it is with finasteride.)
Best Candidates. Nonselective alpha-blockers may be a better choice for men with hypertension, high cholesterol levels, or both, or for those with severe urinary problems as shown by objective test results. Nonselective alpha-blockers may help boost the effects of other anti-hypertensive agents although there is also the concern that they may interfere with other medications taken by men who are being treated for hypertension. One large study using terazosin reported no danger from adding this drug to antihypertensive regimen. Its greatest additive impact was with diuretics, but there was little difference in blood pressure related side effects between men who took terazosin with other anti-hypertensive drugs and those who took the alpha-blocker alone. A 2001 study of combining doxazosin with an antihypertensive drug found it was safe and effective.

Selective Alpha-Blockers.

Brands or Forms. They include tamsulosin (Flomax) and alfuzosin (Xatral). Alfuzosin was recently approved in the US and both are available in once-a-day formulations.
Specific Actions and Benefits. Selective alpha-blockers (sometimes called alpha1A-urospecific antagonists) target only the smooth muscle of the prostate connective tissue. Tamsulosin appears to have a more rapid effect. Both drugs increase urinary flow rate and may even prevent acute urinary retention. Tamsulosin, the more studied drug in the US, has also been shown to improve quality of life and reduce the number of surgical procedures. In an another study the drug was more effective than finasteride or herbal drugs (beta-sitosterol) and had fewer side effects than finasteride. [ See also 5-Alpha-Reductase Inhibitors or Alternative Medicines below.]
Side Effects. Selective alpha-blockers appear to be very safe even over the long term (at least a year). Side effects are minimal. Most common ones are nasal congestion and dizziness. They have very little effect on blood pressure but there is some risk, particularly with alfuzosin. (Alfuzosin's once a day formulation may reduce this side effect.) They may pose a higher risk for problems in ejaculation than nonselective alpha-blockers, but do not appear to cause impotence or reduce sexual drive as finasteride does. These agents can interact with certain medications, including calcium channel blockers (particularly verapamil).
Best Candidates. Selective alpha-blockers may be useful for men who have trouble complying with drug regimens or who have severe subjective complaints but do not have serious urinary conditions.

5-Alpha-Reductase Inhibitors (Finasteride)

The prostate gland contains an enzyme called 5 alpha-reductase that converts testosterone to another androgen called dihydrotestosterone. Anti-androgens have been used to reduce the size of the prostate. Those most often prescribed for BPH are 5-alpha-reductase inhibitors. The standard drug of this class is finasteride (Proscar).

Specific Actions and Benefits . One important two-year study compared finasteride with a placebo (pills containing no medication). Finasteride reduced prostate size by 21% while the prostate became enlarged in those taking the placebo. However, urinary flow improved in 50% of those on placebo compared to 30% of those taking finasteride. About 15% of men on placebo remained trouble-free for two years, mostly those with smaller prostates. Men with larger prostates had the most benefits from finasteride. A side benefit of finasteride is prevention of hair loss related to male hormones and in some cases hair growth in men with mild to moderate male pattern baldness.

Candidates for Finasteride (Proscar). Experts now believe that finasteride is most useful for men who have all three of the following conditions:

Very large prostates (40 mL or larger).
Low urinary flow rates.
Prostate enlargement related primarily to hormone-stimulated overgrowth of glandular tissue.

It is effective in men of any age who are appropriate candidates. Finasteride is also proving to be very effective for patients who have hematuria (blood in the urine) related to BPH. The drug has little or no benefit for men with normal or moderately enlarged prostate glands and whose BPH symptoms are caused primarily by muscle-cell overgrowth.

Administering Finasteride (Proscar). Finasteride is taken once a day. It may take as long as six months for a man to notice a change in symptoms.

Effects on PSA. Finasteride reduces levels of a factor called prostate-specific antigen (PSA) levels, which is measured for screening prostate cancer. Lower PSA levels then may mask the presence of the cancer. [ See Box Finasteride and Prostate Cancer.] A more recent test that measures so-called free PSA may be accurate, regardless of whether men are taking finasteride or not.

Side Effects. Finasteride has been associated with:

Sexual dysfunction, including low sexual drive and impotence, in about 6% to 19% of patients.
Reductions in energy.
Breast tenderness.

Animal studies have reported that the drug enters semen and may cause fetal abnormalities, but studies on humans have not reported such effects.

Other Anti-Androgens

Other anti-androgens, including drugs known as gonadotropin-releasing hormone agonists, are effective against BPH, but can reduce sexual drive and are much more likely to cause impotence. Flutamide is an anti-androgen that may be an alternative to surgery in certain patients with BPH who have physical or mental disorders.

Finasteride and Prostate Cancer.

Because finasteride lowers PSA levels, a major trial is underway to determine if the drug may protect against prostate cancer. Of concern, however, is a 1998 study reporting that men taking finasteride had a higher incidence of prostate cancer after one year than those not taking the drug. Some researchers believe that finasteride may increase testosterone levels within the prostate gland, which could stimulate cancerous changes. Results from the trial may clarify these issues.

Alternative Medicines

Patients with chronic conditions are often tempted to try alternative treatments, including herbs and other nontraditional therapies. It is certainly possible that some herbal medicines may be helpful, but no one should take any herbal medication or attempt to treat BPH without first consulting a physician. [See Warning Box.]

Saw Palmetto. Saw Palmetto is derived from the berry of the plant Serenoa repens . As with all herbal remedies, saw palmetto is not regulated. A private testing group reported that saw palmetto products sold in major drugstore and health food chains (CVS, GNC, Centrum, Celestial Seasonings, Natrol, Nature's Way, Bayer, Walmart, Walgreen's, Amway, and others) met quality requirements.

Actions and Benefits. Saw palmetto may have actions that are similar to finasteride (Proscar). Some studies, in fact, have reported that it is effective and equal to finasteride in reducing symptoms and increasing urinary flow. (Alpha-blockers are more effective than saw palmetto, however.)
Side Effects. Saw palmetto does not cause impotence, which occurs in some men taking finasteride. There have been reports of increased bleeding during surgery with the use of this herb. Gastrointestinal problems have been reported and the herb may aggravate chronic gastrointestinal diseases, such as peptic ulcers, gastroesophageal reflux, and ulcerative colitis. Some experts suggest it be taken with food.
Candidates. Some experts believe that saw palmetto, purchased from a reliable store, is a safe and possibly effective option for men with moderate symptoms from BPH who are seeking a natural product with no known major side effects to date.

Other Herbal Remedies. Other herbal medications being investigated for BPH include the following:

Prostane is an herbal formulation that has shown some benefits in small clinical trials.
Bowman-Birk inhibitor, a soybean-derived protease inhibitor with anti-inflammatory and anticarcinogenic properties. A 2001 trial of a concentrated form found it provided a significant decrease in serum PSA levels, in serum triglyceride levels, and in prostate volume.
Pygeum (Tadenan), an extract from the bark of the African plum ( Pygeum africanum ). In a European study, men treated for two months reported reduction in nighttime urination and improved quality of life. Other studies comparing this remedy to placebo have reported less favorable results.
Pumpkin seeds and their extracts.
Beta-sitosterol (Harzol) has shown modest benefits in one study.

To date none of these agents have undergone rigorous testing and none are recommended.

Warnings on Alternative and So-Called Natural Remedies

It should be strongly noted that alternative or natural remedies are not regulated and their quality is not publicly controlled. In addition, any substance that can affect the body's chemistry can, like any drug, produce side effects that may be harmful. Even if studies report positive benefits from herbal remedies, the compounds used in such studies are, in most cases, not what are being marketed to the public.

There have been a number of reported cases of serious and even lethal side effects from herbal products. In addition, some so-called natural remedies were found to contain standard prescription medication. Of specific concern are studies suggesting that up to 30% of herbal patent remedies imported from China having been laced with potent pharmaceuticals such as phenacetin and steroids. Most problems reported occur in herbal remedies imported from Asia, with one study reporting a significant percentage of such remedies containing toxic metals.

The following warning is of particular importance for people with benign prostatic hyperplasia:

Extracts of stinging nettle roots (Urtica) appears to have binding effects on hormones in the prostate, but urtica poisoning has been reported.

The following website is building a database of natural remedy brands that it tests and rates. Not all are available yet. http://www.ConsumerLab.com/

The Food and Drug Administration has a program called MEDWATCH for people to report adverse reactions to untested substances, such as herbal remedies and vitamins (call 800-332-1088).

WHAT ARE THE SURGICAL AND OTHER PROCEDURES FOR BENIGN PROSTATIC HYPERPLASIA?

Surgical Options

A number of surgical approaches are now available.

Invasive Procedures. The most effective surgical procedures, transurethral resection of the prostate (TURP) and open prostatectomy, are also the most invasive. [For a description of all these procedures, see below. ] They carry the highest risks for significant complications, including impotence and incontinence. Greater experience with TURP, however, has reduced complications and hospital stays. It also is still more effective than the less invasive procedures, so it remains for many physicians the procedure of choice. When considering invasive surgery, the patient should be sure his surgeon performs at least 50 of these procedures each year. The complication rates of the surgeon should be no higher than 1% for incontinence and 4% for impotence.

Less Invasive Procedures. Transurethral incision of the prostate (TUIP), transurethral needle ablation (TUNA), and thermotherapy procedures, such as transurethral microwave thermotherapy (TUMT) and transurethral electrovaporization (TUEVP), are less invasive. [For a description of all these procedures, see below. ] Although to date, none have proved superior to TURP, at this time, good candidates for the minimally invasive surgical procedures may be the following:

Younger men.
Debilitated elderly patients.
Patients with severe medical conditions, including uncontrolled diabetes, cirrhosis, active alcoholism, psychosis, and serious lung, kidney, or heart disease.

Transurethral Resection of the Prostate (TURP)

Transurethral resection of the prostate (TURP) involves surgical removal of the inner portion of the prostate where BPH develops. It is the most common surgical procedure for BPH, although the number of procedures has dropped significantly over the past decades because of the availability of effective medications.

Procedure. TURP usually requires a one- to three-day hospital stay. The surgeon inserts a fiberoptic endoscope, which is a thin tube, into the urethra. No incision is needed. The surgeon uses the endoscope to cut away excess prostatic tissue, and water solutions are used to flush away the excised matter.

Risk of Water Intoxication. If the fluids used during TURP build up, water intoxication can develop, which can be serious. Symptoms include abdominal cramps, nausea, vomiting, lethargy, and dizziness and are referred to as TURP syndrome. Patients who undergo TURP for longer than one hour and those with larger prostate glands, seem to be at greater risk for this complication. An irrigation system that uses a mechanical valve can reduce the risk.

Postoperative Catheterization. A Foley catheter generally remains in place for three to five days after surgery to allow urination. This device is a tube inserted through the opening of the penis to drain the urine into a bag. The catheter can cause bladder spasms that can be painful, but they eventually cease.

Some studies have suggested that in selected patients the catheter can safely be removed within 24 to 48 hours, allowing patients to go home earlier. Early catheter removal is not appropriate for patients with intense urine retention, signs of infection, bleeding, or other complications.

Recuperation. Urine flow is stronger almost immediately after most TURP procedures. After the catheter is removed, patients often experience some pain or sense of urgency as the urine passes over the surgical wound. These sensations gradually subside. Complete healing takes about two months. The following are some tips for hastening recovery and avoiding complications:

During recuperation at home, the patient should avoid driving, operating heavy equipment, lifting, sudden movements, and straining of the muscles in the lower tracts, such as during a bowel movement.
Drinking eight glasses of water a day after surgery is important to flush the bladder and help healing.
Foods that help prevent constipation, such as fruits and vegetables, are important. A laxative may be needed if constipation occurs.
Kegel exercises [ see above ] can help reduce incontinence. Daily performance of three to four sets of 30 contractions each is recommended. In one study, improvement from Kegel exercises was significant within a month after surgery.

Postoperative Complications. Complications after TURP can be high, depending on the skill of the surgeon and other factors, but their incidence has decreased considerably over the past decades because of advances in surgical technique and more widespread expertise.

Bleeding. Some blood and small clots appear in the urine after surgery, and if the bladder is flushed with water, the urine may turn red. Such bleeding is normal. Occasionally, the scab on the surgical wound loosens, causing a sudden appearance of blood in the urine that can be alarming. Usually this stops after a rest, but the patient should notify the physician at once if he is concerned about abnormal bleeding or clotting or has unusual feelings of discomfort. Rarely, hemorrhage may occur, requiring a transfusion.
Infection. Urinary tract infections occur in 5% to 10% of TURP patients. The risk is particularly high if a catheter is required. Antibiotics may be given to prevent infections, although often a physician will choose to monitor a patient and administer antibiotics only if an infection is evident.
Incontinence. Temporary stress incontinence (urine leakage after activities such as sneezing, coughing, or lifting) occurs in most surgical patients. Urge incontinence is the involuntary loss of urine following an uncontrollable urge to urinate. About 2.1% of TURP patient's experience stress incontinence, and nearly 2% have urge incontinence. Total incontinence, which is the complete loss of the ability to control urination, occurs in 1% of patients. [ See also Report # 50, Urinary Incontinence. ]
Sexual Dysfunction. Some men report certain sexual differences after the procedure, particularly low volume of fluid at ejaculation. The risk for impotence is not high. For most men who report this complication, sexual function returns in short order, but it may take up to a year for complete recovery. If potency was diminished before the operation, the procedure will not restore it. [See also Report # 15, Impotence (Erectile Dysfunction). ]
Retrograde Ejaculation and Low Semen. Many TURP patients report a lower volume of semen after the procedure. Between 66% and 75% of these patients experience retrograde ejaculation, in which semen is forced backward into the bladder instead of forward out of the urethra during orgasm. During most invasive procedures, the muscle that blocks off the bladder may be cut in order to widen the outlet. In such cases, the semen flows back through the wider opening rather than out of the penis. This condition can impair fertility and is of particular concern in younger men. Neither retrograde ejaculation nor the operation itself typically affects orgasm, although it takes many men some time to emotionally adjust to these conditions.
Low PSA Levels. PSA levels may be lowered after TURP, which might cause a physician to miss a diagnosis of prostate cancer during routine screening.

Repeat Operations. Symptomatic relief is usually maintained for at least 15 years after surgery, but BPH may return or patients may need a second operation for other reasons. Up to 10% of TURP patients require a repeat operation within 10 years. In some cases, scarring in the bladder severe enough to cause obstruction occurs within a year of the procedure and may require transurethral incision (TUIP) [ see below ]. More often, the urethra is scarred and narrows, but usually this condition can be corrected by a simple stretching procedure performed in the doctor's office.

Transurethral Incision of the Prostate (TUIP)

In transurethral incision of the prostate (TUIP), the surgeon makes only one or two incisions in the prostate, causing the bladder neck and the prostate to spring open and reduce pressure on the urethra.

Candidates. TUIP is generally used only for men with minimally enlarged prostates (30 grams or less) who have obstruction of the neck of the bladder. Some experts believe TUIP is not performed enough and could benefit many patients, particularly those with severe medical conditions who are not good candidates for more invasive surgeries and men who want to lessen their risk for sterility.

Postoperative Complications. TUIP is less invasive than TURP [ see above ], has a lower rate of the same complications, particularly retrograde ejaculation, and usually does not require a hospital stay.

Laser Surgery

Procedures. Laser technology is used for removal of prostate tissue. Laser procedures can usually be done as an outpatient procedure, often performed in 20 minutes or less, and there is no risk for bleeding. Different procedures are used to provide different degrees of thermal cell destruction that range from coagulation to complete vaporization:

The neodymium:YAG (Nd:YAG) laser or small Diode lasers use a coagulation technique that seals off blood and lymph vessels, causing the excess tissue to die. It can take weeks to months for the dead tissue to slough off and for maximum improvement in symptoms to occur.
More recent laser procedures, such as those that use KTP or holmium lasers, can actually cut and vaporize the tissue. Vaporization is effective right away. Vaporization also may pose lower risks for prolonged urinary retention and reoperation rates than coagulation. (Holmium lasers are also being investigated for treatment of severely large prostate glands, which otherwise may require removal with open prostatectomy, a major operation.)

Comparisons with TURP. Important studies are now reporting that while laser surgery is not as effective as TURP, hospital stays are shorter and complication rates are lower, particularly in men with chronic urinary retention. And, laser surgery is still beneficial. A US study comparing TURP to laser reported the following results after twelve months:

Peak flow rate increased by 107.8% in laser patients, and by 150.7% in TURP patients.
Symptom scores declined by 69.5% for laser patients, and by 80.9% for TURP patients.

It should be noted that the Nd:YAG is usually the one used in comparative studies. Newer lasers may help improve outcome. For example, the Holmium laser is showing very good results with low complication rates in small studies.

Candidates. Laser therapy can be performed on nearly all patients. Because laser surgery yields fewer postoperative complications than TURP in men with chronic urinary retention, it may be preferable for such patients who are willing to accept lower effectiveness in return for lower complication rates and shorter hospital stays. The procedure may also be a good choice for men with small-sized BPH and certain high-risk medical conditions, such as heart disease. The laser procedure results in minimal blood loss and excellent control of bleeding, and so may be particularly advantageous for men who require anticoagulation therapy.

Complications. Studies have been mixed on whether laser surgery poses any risk for sexual dysfunction. In one study, TURP had a lower risk for sexual dysfunction, although the risk from either procedure was very low and it wasn't clear that lasers had even been responsible for this complication. Temporary incontinence and retrograde ejaculation [ see above ] are still common in this procedure. After laser procedures, and especially after coagulation, the prostate often temporarily enlarged and caused obstruction and irritation. Sometimes these symptoms were severe. Most men require a temporary catheter to drain urine after laser procedures.

Thermotherapy and Other Less Invasive Procedures Used to Destroy Prostate Tissue

Thermotherapy uses microwaves and other techniques to destroy excess prostate tissue by heating it to high temperatures. The higher the temperature, the more effective the procedure, but also the more likely are complications. Other less invasive procedures, such as those that use radio waves or ultrasound to destroy prostate tissue, are showing promise. According to one 2000 study, however, more men (about 25%) require a follow-up operation after such less invasive treatments than after TURP (about 4%).

Transurethral Microwave Thermotherapy (TUMT). Transurethral microwave thermotherapy (TUMT) delivers heat using microwave pulses to destroy prostate tissue. Studies have found that between 60% and 80% of men respond favorably to the treatment and the benefits seem to last. A 2001 study reported that it remained effective for at least 18 months and was superior over the long term than the alpha-blocker drug terazosin. Improvement is not as complete as with TURP, but TUMT has fewer complications.

Candidates. TUMT may be beneficial for men with larger prostates and moderate to severe bladder obstruction, including those who require indwelling catheters. A 2000 study, for example, concluded that is was a safe and effective therapy for treatment of urinary retention. In general, the procedure should not be performed on men who have pacemakers, defibrillators, or any metal implants. One possible exception, the Targis System, was approved for use for patients with hip or penile implants that are located at least 1.5 inches from the urethra. Men who have had previous radiation therapy to the pelvic area are at higher risk for injuries from this procedure.
Procedure. A microwave antenna is inserted through the urethra with ultrasound used to position it accurately. The antenna is enclosed in a cooling tube to protect the lining of the urethra. Computer-generated microwave pulses through the antenna to heat and destroy prostate tissue. When the temperature becomes too high, the computer shuts down the heat and resumes treatment when a safe level has been reached. The procedure takes 30 minutes to two hours, and the patient can go home immediately afterward. About 30% of patients experience some pain during the procedure. The patient should report any pain that appears to be unusually severe, however, since this could indicate improper application.
Complications. Swelling in the urinary tract often occurs later, which prevents urination and requires the use of a temporary catheter for about three days until the swelling subsides. There have also been reports of serious injuries to the penis and urethra from overheating due to improper application. It is important to note that TUMT does not significantly affect sexuality or cause incontinence or retrograde ejaculation, which are risks with some other prostate procedures [ see above ].

Transurethral Needle Ablation. Transurethral needle ablation (TUNA) is a simple, safe, and relatively inexpensive procedure using needles to deliver high-frequency radio waves that heat and destroy prostate tissue. The procedure usually requires only a local anesthetic. One study reported that improvement was maintained in most patients after two years, although older men (over 70) had slightly worse symptoms and quality-of-life scores. Although small clinical studies have reported that TUNA is as effective as TURP, some experts believe that in actual medical practice TURP is more effective.

Some studies have reported urinary retention, blood in the urine, retrograde ejaculation, and painful urination after the procedure, although in general TUNA has few or none of TURP's severe side effects. TUNA, for example, poses a very low to no risk for incontinence and impotence.

Transurethral Electrovaporization. Transurethral electrovaporization (TUEVP) uses high voltage to combine vaporization of prostate tissue and coagulation that seals the blood and lymph vessels around the area. Deprived of blood, the excess tissue dies and is sloughed off over time. One study reported that patients who had TUEVP were able to have their catheter removed 14 to 16 hours after the procedure compared to normal removal time of 3 to 5 days after TURP. The average hospital stay was only 19 to 36 hours. Postoperative results were similar to those of TURP.

Ultrasound. High-intensity focus ultrasound (HIFU) is a heat procedure under investigation that uses ultrasound to destroy specific prostate tissue. The principles are similar to transurethral microwave thermotherapy [ see above ], but ultrasound techniques may destroy excess tissue without damaging other parts of the urethra.

Hot Water Therapy. A device called Thermoflex, which circulates heated water through a catheter to destroy prostatic tissue, has been approved for treating BPH. Another technique uses a balloon filled with hot water to destroy tissue around the urethra. It does not require anesthesia and can be completed during a single outpatient visit.

Transurethral Rotoresection. Transurethral rotoresection combines mechanical and electric vaporization of prostate tissue. Tissue is removed using a rotoresectoscope, which produces a high-frequency rotation of a rotor tip, and by electrovaporization. Studies are promising but more research is needed.

Open Prostatectomy

In open prostatectomy the enlarged prostate is removed through an open incision in the abdomen using standard surgical techniques. This is major surgery and requires a hospital stay of several days. Open prostatectomy is used only for severe cases, about 2% to 3% of BPH patients, when the prostate is severely enlarged, the bladder is damaged, or other serious problems exist. Up to 14% of patients require a second operation because of scarring. In making a decision about prostatectomy, it is essential that the physician explains the consequences of a diminished sexual capacity that occurs after this procedure. When the situation of the patient does not constitute an emergency, prostatectomy should be considered a last resort if the patient still has an active sex life. Other complications are similar to TURP's.

Prostatic Stents

Prostatic stents used for BPH are tubes that are inserted into the urethra and made of special alloys that do not cause reactions in the body. Typically, the procedure takes only 15 minutes and requires only regional anesthetic and mild sedation. It usually requires minimal recuperation and no overnight hospital stay. Those being tested with early success include the following:

The UroLume is a mesh-like, flexible tube that is inserted into the urethra where it expands and eases urine flow.
The Intra-Prostatic Stent is made from titanium and, unlike the UroLume, is not flexible or expandable. Once implanted, it provides enough force against the urethral walls to allow increased urine flow.
The Trestle.

Complications. Between 8% and 37% of the stents need to be removed later because of poor placement or complications, including irritation when urinating, urinary tract infections, and treatment failure. They seem to be best suited for high-risk surgical patients and those with a limited life expectancy.

Balloon Dilation

Balloon dilation involves insertion of a balloon into the urethra; the balloon is inflated so that urine can flow more easily. It is safer than surgery, but it is not commonly used because it does not eliminate excess prostate tissue and has a high risk for failure after two years.

WHERE ELSE CAN HELP BE OBTAINED FOR BENIGN PROSTATIC HYPERPLASIA?

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Office of Communications and Public Liaison, NIDDK, NIH, Building 31, Room 9A04, 31 Center Drive, MSC 2560, Bethesda, MD 20892-2560. Call (800) 891-5388 or on the Internet (http://www.niddk.nih.gov)
Provides information from a number of government sources and patient information.

American Foundation for Urologic Disease, 1128 North Charles Street, Baltimore, MD 21201. Call (410) 468-1800 or on the Internet (http://www.afud.org)

American Urological Association (AUA), Office of Education, 2425 West Loop South, Suite 333, Houston TX 77027-4207. Call (800) 282-7077 or (713) 622-2700 or on the Internet (http://www.auanet.org)

The Prostatitis Foundation, 1063 30th Street Box 8, Smithshire, Illinois 61478. Call (888) 891-4200 or on the Internet (http://www.prostate.org)
This is a self-help organization for men with prostatitis, but it also offers support for those with BPH.

Digital Urology Journal, 300 Longwood Avenue, Hunnewell 3, Boston, Massachusetts 02115 or on the Internet (http://www.duj.com)
An online journal with research articles on urologic problems.

An analysis of commercial saw palmetto-based products is available on the ConsumberLab.com web site at http://www.ConsumerLab.com/results/sawpalmetto.html). Requires a subscription.