Benign Prostatic Hyperplasia (BPH)
BPH is the benign enlargement of the prostate. The prostate gland is a small organ the size of a walnut that sits just below the bladder and surrounds the urethra. It produces fluid for nourishment of sperms. However, after the age of 50 years, it tends to enlarge due to hormone imbalance; the effect of this being compression of the urethra.
This causes obstruction and irritation of the bladder leading to symptoms like slow / intermittent stream, and urinary frequency both day and night. BPH is assessed from the history, physical examination, ultrasound and uroflow investigations. Left untreated, the consequences are: damage to the bladder, urine infections, bladder stones and even kidney failure. Many men mistaken the symptoms to be due to their ageing bladder, but the enlarged prostate needs to be excluded and treated before assuming that the bladder symptoms are age-related.
1.This is a questionnaire that covers the symptoms caused by the enlarging prostate. The total score gives an indication of the severity of the prostatic symptoms and how bothersome it is.
2.The abdomen is examined for any bladder distension and a rectal exam (DRE) done to feel the consistency of the prostate and estimate its size. The DRE is also important from the point of detecting prostate cancer.
Complications of BPH
Complications arise when the enlarged prostate causes retention of urine BPH can be a progressive disease. Left untreated, there is a risk of significant bladder blockage leading to high residual urine which in turn can lead to repeated urinary infection and formation of bladder stone.
When the blockage gets even worse, swelling of the kidneys (hydronephrosis) can occur due to the higher bladder pressures and ultimately, sudden inability to pass urine. In such an event, surgery using a resectoscope instrument is needed to remove as much of the enlarged prostate as possible. This surgery is called TURP (transurethral resection of the prostate).
Treatment of BPH
Medical therapy is the first-line treatment. There are 2 main groups of drugs available. The first are the alpha1-blockers, (eg. Hytrin, Xatral) which help relax the tone of the prostate and bladder neck. They are taken at bedtime, are 70% effective, but carry a 10% chance of causing giddiness in the morning due to lowering of the blood pressure. However, they do nothing to reduce the prostate size.
The second group are the 5-alpha reductase inhibitors, (eg. Proscar, Avodart) which decrease the male hormone level, dihydrotestosterone (DHT) within the prostate and thereby, decrease prostate size. They are indicated for large glands (> 30 ml size) but because the drug can take up to 3 months to sufficiently reduce the prostate size, combination with alpha1-blocker drugs is needed for the initial months.
Surgery is indicated when complications arise or when medical treatment fail. The most effective surgery is TURP, which is endoscopic resection of the obstructing prostate to recreate an open channel . It is usually done under spinal anaesthesia and takes 1 hour to do. Hospital stay is 3 to 4 days and the main complications are bleeding and retrograde (backward) ejaculation.
There are many variants to TURP, eg. TUIP, laser TURP, bipolar TURP but they are essentially different techniques or using different machines. Of recent interest is the Greenlight (PVP) laser which has the advantage of less bleeding and shorter hospital stay. However, it is slower to perform and costs more than the standard TURP. Thermotherapy (heat treatment) is also an alternative lesser-invasive option, eg. TUMT, TUNA but these do not create an immediate channel and may not have durable results. Open prostatectomy requires an incision over the pubis and is reserved for very huge BPH. It is rarely done nowadays.