Benign Prostatic Hyperplasia Treatment | Endourology | Aastha Healthcare | Super Speciality Center Hospital | Mulund | Mumbai | India

What is prostate gland?

The prostate is a glandular organ, about size of a walnut, present in males. The prostate is normally about 3 cm long and it lies at the neck of the bladder and in front of the rectum. The prostate gland produces fluid that makes up part of the semen.

You will be surprised to know that Urinary obstruction from prostatic hypertrophy has been described for many centuries, starting with the ancient Egyptians in the 15th century BC. The word "prostate" comes from the Greek prostat, which means "one who stands before or in front of", which, in this case, means in front of the bladder.

What is Benign prostatic hyperplasia or BPH?

Benign prostate hyperplasia (BPH) is a condition that affects the prostate gland of the male reproductive system. The prostate gland enlarges in size though this may not cause problems until late in life. It is estimated that about 90% of men in the age group of 70-85 years have BPH. It is one of the most common problems experienced by men during the old age. As the name suggests, there is hyperplasia or overgrowth of the prostatic tissue. This leads to enlargement of the prostate gland. Now since prostate surrounds the urethra. So any enlargement will definitely cause constriction of the urethra. So in BPH, the flow of urine is also reduced, making it increasingly difficult to empty the bladder. Similar symptoms may also be present when a person has prostate cancer. So it is very important for the physician to carefully rule out the possibility of the latter. To know more about prostate cancer, click here.

What are the causes?

For centuries, BPH has been associated with older men. The cause of BPH is not well understood. There have been various theories which have been put forward for the same. One suggests that men produce two hormones through out their life- oestrogen (small quantity) and testosterone (high proportion). As aging occurs, the amount of testosterone decreases, leaving a higher proportion of oestrogen. Studies done on animals have suggested that BPH may occur because the higher amount of oestrogen increases the activity of substances that promote cell growth. One more theory says that BPH is a result of lack of DHT, a substance which is derived from testosterone. DHT helps in controlling the growth of prostate gland. But due to aging, most animals lose their ability to produce DHT and this may cause BPH.

What are the symptoms?

A person having BPH may remain asymptomatic for quite some time. Infact he may just come to know about it during a clinical examination. Sometimes a person may suddenly start experiencing urination problems. So it is always advised to go for a routine health check up. AASTHA offers various Health Packages for different age groups to ensure proper assessment of health.

problems related with urination, like:

incomplete emptying of the bladder difficulty in starting to pass urine, weak stream, need to strain to pass urine, need to pass urine urgently, urgency and leaking or dribbling Feeling a burning sensation or pain when passing urine. Frequent urinary tract infection as incomplete voiding leads to stasis of bacteria in the bladder

In case the prostate is much enlarged, then there may be severe urine blockage problems. In urinary retention, the urine does not flow out of the bladder leading to accumulation of bacteria and distension of bladder. Untreated, this leads to a decrease in renal function and hydronephrosis (obstructive uropathy). Besides this, due to accumulation of urine in bladder, it can lead to formation of stones. So bladder stones, and incontinence-the inability to control urination may be present. This in the long run may lead to bladder or kidney damage, So it is very important to diagnose BPH at early stage to ensure that it does not lead to complications.

How is it diagnosed?

The patient may either report with some problem or the doctor may diagnose during a routine checkup. If BPH is suspected, you will be attended by a urologist. An urologist may do any or all of the following test to determine the level of enlargement:

Digital Rectal Examination (DRE) This examination is usually the first test done. In this, the doctor inserts the finger in the rectum and tries to palpate the prostate gland. He gets a general idea about the size and density of the gland. Prostate-Specific Antigen (PSA) Blood Test This test measures the level of PSA in the blood. PSA, a protein produced by prostate cells. PSA levels are very high in men who have prostate cancer. So this test is conjugated along with other test to rule out prostate cancer. Biopsy If the urologist suspects prostate cancer, he may advice for a biopsy. This involves removal of cells or tissues so they can be viewed under a microscope by a pathologist. The pathologist will examine the biopsy sample to check for cancer cells and determine the Gleason score. The Gleason score ranges from 2-10 and describes how likely it is that a tumour will spread. The lower the number, the less likely the tumour is to spread. There are 2 types of biopsy procedures used to diagnose prostate cancer:

Transrectal biopsy: The removal of tissue from the prostate by inserting a thin needle through the rectum and into the prostate. This procedure is usually done using transrectal ultrasound to help guide the needle. A pathologist views the tissue under a microscope to look for cancer cells. Transperineal biopsy: The removal of tissue from the prostate by inserting a thin needle through the skin between the scrotum and rectum and into the prostate. A pathologist views the tissue under a microscope to look for cancer cells.

Transrectal ultrasound If there is a suspicion of prostate cancer, your doctor may recommend a test with rectal ultrasound. In this procedure, a probe is inserted in the rectum. The probe is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. To determine whether an abnormal-looking area is indeed a tumor, the doctor can use the probe and the ultrasound images to guide a biopsy needle to the suspected tumor.

Urine Flow Study Your doctor may ask you to urinate into a special device that measures how quickly the urine is flowing. A reduced flow often suggests BPH.

Cystoscopy In cystoscopy, a small tube (called cystoscope) is inserted through the opening of the urethra in the penis. The cystocope contains a lens and a light system that help the doctor see the inside of the urethra and the bladder. This test allows the doctor to determine the size of the gland and identify the location and degree of the obstruction.

Other tests Some other blood tests may be recommended (include kidney function tests and test for diabetes). Both of these problems can also cause urinary symptoms. Abdominal ultrasound may be necessary to check for bladder stones.

What are the treatment options?

One very interesting fact is that the earliest useful therapy for urinary obstruction from prostatic enlargement was a catheter, which was first used by the Romans Celsus and Galen in the first century AD! They made catheter out of wood, leaves, rubber etc. Today, advancement in medical science has provided many new ways to treat the cases of BPH. Men who have this problem usually need some kind of treatment at some time. In case the person presents with a mild and asymptomatic case of BPH, the physician may closely monitor the patient and give the treatment only if the symptoms deteriorate. But if a person comes with symptomatic picture of BPH, there are two ways to treat it. They are:

Medical treatment

There are two main classes of drugs that are prescribed for BPH: alpha-blockers and 5-alpha-reductase inhibitors. Alpha-blockers relax the bladder muscles and prostate gland. This increases the urine output. They do not cure BPH but help to alleviate some of the symptoms. 5-alpha-reductase inhibitors, as the name suggests, inhibits the production of DHT. This drug can reverse BPH to some extent and so may delay the need for surgery.

Surgical treatment

Most doctors recommend removal of the enlarged part of the prostate as the best long-term solution for patients with BPH. With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed; the rest of the inside tissue and the outside capsule are left intact. Surgery usually relieves the obstruction and incomplete emptying caused by BPH. There are two main options for BPH:

A. Conventional surgery B. Minimally Invasive procedures

A. Conventional surgery

The conventional surgery is also called open surgery. In this, prostate gland is removed. So it is also referred to as Open prostatectomy.

What to expect

It is a major operation and carried out under a general anaesthesia. An incision is made in the lower abdomen between the umbilicus (belly-button) and the penis through which the prostate gland is removed. Usually Foley catheter is used but occasionally, a suprapubic catheter may also be inserted in the abdominal wall to help drain the bladder. Foley catheter is an artificial tube to remove urine from the body. This is a much more involved procedure and usually requires a longer hospitalization and recovery period. It may take a couple of weeks to several months to recover from surgery, depending on the exact surgical approach. Most men can return to sedentary work in two or three weeks and vigorous physical labour and sexual activity in about six weeks.

Ideal candidate

Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired.

Benefits and drawbacks

Nearly all men who have this procedure experience significant symptom relief. Side effects are as common as those with TURP. Urinary incontinence, erection problems and retrograde ejaculation occur in some men. In retrograde ejaculation, the semen passes into the bladder during orgasm instead of out of the penis

B. Minimally Invasive procedures

Minimally invasive procedures are gaining popularity these days. It has become the gold standard for treatment because it ensures less tissue damage and thereby speedy recovery of the patients. AASTHA specializes in the minimally invasive procedures and these kinds of surgeries are routinely carried out. The procedures have been discussed below:

Transurethral resection of the prostate (TURP)

Transurethral resection of the prostate (TURP) is the most common operation for BPH and over 90% of men report an improvement after the operation. This procedure is preferred because it is less traumatic than open forms of surgery and requires a shorter recovery period.

What to expect

The procedure always begins with a careful cystoscopic inspection of the anterior urethra, external urinary sphincter, prostatic urethra, and bladder. This inspection is important not only to verify the absence of associated pathologies but also to give the surgeon an idea of the anatomical relations inside. The procedure is usually done under a general anaesthesia. There is a long thin instrument called resectoscope, which is passed into the urethra. The resectoscope, which is about 12 inches long and 1/2 inch in diameter, contains light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels. It has a lens so it allows the surgeon to view the prostate either directly or on a video screen. A precisely controlled electric current, applied by a loop of wire at the end of the resectoscope, is used to shave off sections of the enlarged prostate. The surgeon uses the resectoscope's wire loop to remove the obstructing tissue one piece at a time. This creates a sort of cavity inside the gland. The pieces of tissue are carried by the fluid into the bladder and then flushed out at the end of the operation. Foley catheter is an artificial tube to remove urine from the body. This is placed to help drain the bladder after surgery. The patient is supposed to stay in the hospital for 1-2 days. One can expect some blood or small blood clots in the urine afterward for sometimes.one may experience some pain while micturition for first few days after the surgery.

Ideal candidate

TURP greatly relieves lower urinary tract symptoms in nearly all men. It is a very commonly performed procedure and is best for men who have highly enlarged prostate with a troublesome picture. Even men with severe bladder damage caused by BPH often improve after TURP.

Benefits and drawbacks

TURP relieves symptoms quickly and is not very hard on patients. The hospital stay is shorter. Most men experience a stronger urine flow within a few days. TURP is an effective procedure but with any surgical procedure there is always risk of side-effects and complications. A common side-effect of this procedure is retrograde ejaculation - where semen passes into the bladder during orgasm instead of out of the penis. This is sometimes called a "dry orgasm". Retrograde ejaculation is usually not a problem, although it may reduce fertility. Complications of the operation can include urinary incontinence or damage to the urethra, resulting in a "stricture" that can itself cause difficulty passing urine.

Transurethral incision of the prostate (TUIP)

This procedure is quite similar to TURP but is carried out on men who have less enlarged prostate. It also differs in the way that TUIP involves no removal of the prostate tissue. This procedure is usually performed on an outpatient basis and usually does not require a hospital stay.

What to expect

In this, an instrument is passed through the urethra under general or spinal anaesthesia. A small incision is made in the prostatic tissue to enlarge the lumen (opening) of the urethra and bladder outlet. But instead of removing a portion of the prostate, small cuts are made in the neck of the bladder and the prostate. This reduces the obstruction of the flow of urine thus improving the urine flow rate and reducing the symptoms of BPH.

After the surgery, Foley catheter may be placed to help drain the bladder after surgery. The catheter will usually remain in place for a few days after surgery. Another key advantage to the TUIP is the preservation of normal ejaculation.

Ideal candidate

Transurethral incision of the prostate (TUIP) may be appropriate for men who have a less enlarged prostate. Unfortunately, many patients are not candidates for this surgery due to configuration of their prostates.

Benefits and drawbacks

TUIP is slower to provide symptom relief than is TURP. Sometimes the procedure needs to be repeated. Although Retrograde ejaculation after TUIP is less common and less severe than it is after TURP. In Retrograde ejaculation, semen passes into the bladder during orgasm instead of out of the penis. Some men who have TUIP will notice some decrease in the amount of semen when they ejaculate. Erection problems also may occur.

Laser surgery

Laser surgery uses a high-energy laser to destroy overgrown prostate tissue. In March 1996, the FDA approved a surgical procedure that employs side-firing laser fibers and Nd: YAG lasers o vaporize obstructing prostate tissue. What to expect The doctor passes the laser fiber through the urethra into the prostate using a cystoscope and then delivers several bursts of energy lasting 30 to 60 seconds. The laser energy destroys prostate tissue and causes shrinkage. As with TURP, laser surgery requires anesthesia and a hospital stay. One advantage of laser surgery over TURP is that laser surgery causes little blood loss. Laser surgery also allows for a quicker recovery time. But laser surgery may not be effective on larger prostates. The long-term effectiveness of laser surgery is not known.

Types of laser surgery :

Photoselective vaporization of the prostate (PVP) PVP uses a high-energy potassium-titanyl-phosphate (KTP) laser, also called the "greenlight" laser to destroy prostate tissue and seal the treated area. KTP laser energy at 532 nm penetrates 1-2 mm deep into the prostatic tissue, making it theoretically superior to other types of prostatic laser vaporization procedures. The results are almost similar to TURP. In general, PVP is better for smaller prostates and may result in less bleeding and a shorter recovery time than with TURP. Transurethral evaporation of the prostate (TUEP) In this procedure, prostate tissue is destroyed with laser energy instead of electrical current. This is quite a safe procedure and not much bleeding is caused. The patient also improves and recovers very fast. But with the evolution of laser technology, this procedure has largely been replaced by new laser treatments such as PVP and HoLEP. Visual laser ablation of the prostate (VLAP). In this procesure, enough laser energy is applied to dry up and destroy excess prostate cells. Because of swelling and prolonged sloughing off of the dead tissue, one is likely to retain urine for several days and will need to wear a catheter. There may also be burning sensation during urination for days to weeks. This procedure also is often replaced by newer laser treatments such as PVP and HoLEP. Holmium laser enucleation of the prostate (HoLEP) This is the latest laser procedure which has got popular. This is used for men with urinary retention due to enlarged prostate. This is very similar to PVP. This procedure also has similar results like TURP but with less chance of bleeding and a shorter recovery time.

Ideal candidates

The ideal candidates are those men who have mild prostate enlargement.

Benefits and drawbacks

Laser surgery often provides immediate symptom relief, but one may experience painful urination for days to weeks. Compared with TURP, laser surgery causes little blood loss and one recovers more quickly. Unlike TURP, laser procedures can be used for men using blood thinners. Compared to URP, they have lesser side effects. But laser treatment mauy cause more painful urination lasting for days. Retrograde ejaculation is also a common side effect of laser surgeries. In Retrograde ejaculation, semen passes into the bladder during orgasm instead of out of the penis.

Transurethral microwave procedures(TUMT)

In 1996, the FDA approved a device that uses microwaves to heat and destroy excess prostate tissue. In the procedure called transurethral microwave thermotherapy (TUMT), the device sends computer-regulated microwaves through a catheter to heat selected portions of the prostate to at least 111 degrees Fahrenheit. A cooling system protects the urinary tract during the procedure. The procedure takes about 1 hour and can be performed on an outpatient basis without general anesthesia. Although microwave therapy does not cure BPH, it reduces urinary frequency, urgency, straining, and intermittent flow. It does not correct the problem of incomplete emptying of the bladder.

Transurethral needle ablation

Also in 1996, the FDA approved the minimally invasive transurethral needle ablation (TUNA) system for the treatment of BPH. The TUNA system delivers low-level radiofrequency energy through twin needles to burn away a well-defined region of the enlarged prostate. Shields protect the urethra from heat damage. The TUNA system improves urine flow and relieves symptoms with fewer side effects when compared with transurethral resection of the prostate (TURP).

Water-induced thermotherapy

This therapy uses heated water to destroy excess tissue in the prostate. A catheter containing multiple shafts is positioned in the urethra so that a treatment balloon rests in the middle of the prostate. A computer controls the temperature of the water, which flows into the balloon and heats the surrounding prostate tissue. The system focuses the heat in a precise region of the prostate. Surrounding tissues in the urethra and bladder are protected. Destroyed tissue either escapes with urine through the urethra or is reabsorbed by the body. For more information, kindly visit : http://www.aasthahealthcare.com/Benign-Prostatic-Hyperplasia-Treatment.htm ------------------------------------