Benign Prostatic Hyperplasia
Benign prostatic hyperplasia is defined as a benign growth, that is, non-cancerous, of the prostate. This growth can cause discomfort related to urination, such as having to urinate very frequently, presenting a very fine stream of urine, having to squeeze to get the urine to come out, or leaking urine, among others. Discomfort while urinating is very common among men, especially over the age of 50. It is estimated that approximately one-third of men over the age of 60 will experience urinary discomfort that requires treatment.
What is Benign Prostate Hyperplasia (BPH) or enlarged prostate?
What is BPH and when does it need treatment?
There are different reasons why a person may have bothersome symptoms related to urination. The most common in men, however, is that they are due to an obstruction of the outflow of urine from the bladder caused by a benign growth of the prostate. This growth is called Benign Prostatic Hyperplasia or BPH.
Sometimes there may be more than one cause of a patient’s discomfort, such as a narrowing of the urethra, a stone or foreign body in the urinary tract, alterations in the functioning of the bladder, or others. This is why it is very important that your doctor make a complete evaluation of the different possible causes of your symptoms.
The urethra is the tube through which urine passes from the bladder to the outside. The prostate is located below the bladder and completely surrounds the urethra, like a tire. What happens in the case of BPH is that the prostate decreases the width of the urethra. When a growth of the prostate occurs, it can partially obstruct the lumen of the urethra.
It is important to know that the size of the prostate is not always directly related to the degree of obstruction. In some cases, an insignificant prostatic growth can occur, but it greatly obstructs the urethra and causes significant discomfort when urinating. In these cases, even though the prostate is small, treatment is needed.
In other cases, even significant prostate growth does not affect the lumen. There are people who in an ultrasound detect that they have a very large prostate, but they do not report discomfort while urinating. In these cases, no matter how large the prostate is, if there are no symptoms, no treatment is necessary.
What symptoms can BPH present?
In order to understand the causes and better define the treatments, the symptoms of patients with BPH are usually classified into two groups:
- Emptying symptoms: Some symptoms are experienced during urination, such as:
- Having a weak or fine stream.
- Delay or difficulty starting urination.
- Having a broken or choppy stream.
- Having to squeeze or strain to get urine to come out.
As a general rule, these symptoms are more directly related to an obstruction in the outflow of urine from the bladder.
- Filling symptoms: They are those that are perceived during the time in which the bladder is filling, that is, between urination. The main ones are:
- Increased daytime urinary frequency, or the need to urinate more times during the day.
- Nocturia or the need to wake up at night to urinate.
- Urgency or the appearance of a need for fast and intense urine that is difficult to hold.
- Incontinence; involuntary urine leakage.
As a general rule, these symptoms are due to the bladder not functioning correctly, which could be caused by a problem directly in the bladder, or by a poor adaptation of the organ to an obstruction caused by the prostate over time.
How is BPH diagnosed?
The first thing to do is find out important data about the patient such as current known illnesses, medications that they usually take, lifestyle, as well as emotional and psychological factors that can affect how a person urinates.
There are different tests that will help clarify the origin of the patient’s problems:
- A urinalysis will help rule out medical problems such as urine infection, blood in the urine, or diabetes mellitus.
- To assess the volume of the prostate, either a digital rectal examination or an imaging test can be performed, often via ultrasound. Knowing the prostate size is important to select the appropriate treatment, both medical and surgical, as we will see in the following videos.
- A blood test is useful to assess prostate-specific antigen or PSA, which helps us assess the risk of prostate cancer, as well as the risk of prostate growth. It also allows assessing the proper functioning of the kidneys by measuring creatinine levels. This is important, as patients with BPH are at increased risk of kidney problems.
- A test that provides very useful information is flowmetry. This test consists of assessing the speed of urine flow among other parameters. Patients urinate into a device that performs the measurement.
These are the most used tests in the initial evaluation of a patient with symptoms compatible with BPH. This is not an exhaustive list of tests, and it is very important to know that none of these tests individually can conclusively diagnose BPH. The tests must be evaluated as a whole, and clinics should take into account unique characteristics of each patient.
Lifestyle changes and pharmacological treatment of BPH
Many people with BPH do not exhibit a level of discomfort that warrants treatment with prescription medicine. Your doctor should rule out possible complications of BPH, such as the risk of suddenly not being able to urinate (acute urinary retention), kidney functionality issues, bladder stones, or urine infections, among others.
Many individuals with BPH who have only mild symptoms will not need treatment for years to come. In these cases, it would be advisable to simply start monitoring or consider certain lifestyle changes such as:
- Reduce the amount of liquids that are ingested at certain times, for example, before going to sleep or before making a long trip.
- Avoid or moderate your intake of alcohol or caffeine, as they have a diuretic and irritating effect and can increase the amount of urine produced and the frequency with which you urinate.
- Review the background medication to improve the type of medications and the time of day they are taken (for example, treatment with diuretics will aggravate voiding symptoms).
- Treat constipation, as it can worsen urinary symptoms.
Applying these recommendations, alone or in addition to treatment with prescription drugs, has been shown to help ameliorate symptoms and also help prevent the progression of the disease.
In the event that the symptoms or the risk of complications cannot be controlled with changes in lifestyle, pharmacological treatment should be started, that is, prescribing medicine. The different treatments will be differentiated by the type of symptoms to be treated and their origin, as well as by the size of the prostate and the characteristics and preferences of each patient.
1. Alpha-blockers (or alpha-adrenergic blockers)
The main ones are: Alfuzosin, Doxazosin, Terazonsin, Tamsulosin, and Silodosin.
- Its function is to relax the muscles of the prostate and allow urine to flow more easily.
- They do not reduce the size of the prostate.
- They are more effective in small prostates (<40 cc).
In long-term studies, they do not reduce the risk of developing acute urinary retention, the likelihood of needing surgery later in life.
No differences in effectiveness have been observed between the different types of alpha-blockers, so it is not recommended to switch from one type to another if the first has not been effective.
The most common are dizziness, orthostatic hypotension (dizziness when standing up), and tiredness.
Normally they do not affect sexual function (erections, sexual appetite), but they do produce an alteration in ejaculation that consists of no semen coming out when ejaculating. Semen usually goes into the bladder and then comes out with urine. This is known as retrograde ejaculation.
2. 5-alpha-reductase inhibitors (5ARIs)
There are 2 types of 5ARIs: finasteride and dutasteride.
They exert their effect by reducing the size of the prostate.
5ARIs reduce the level of prostate specific antigen (PSA) in the blood by approximately 50% after 6 months of treatment. Thus, when performing a prostate cancer screening on a patient taking 5ARIs, doctors must double the recorded PSA level in the test, otherwise the results could be misleading.
Because the drug’s effects are incremental, the maximum impact on the pattern of urination will be seen after 6 months of treatment. Additionally, they are more effective in prostates of more than 40cc, and do reduce the risk of acute urinary retention and reduce the need for long-term prostate surgery.
The most common adverse effects are: decreased sexual appetite, erectile dysfunction and, to a lesser extent, ejaculation disorders.
In a few cases, swelling of the breasts (gynaecomastia) may also occur.
3. Antimuscarinics (Anticholinergics) and Beta-3 agonists
- They are medications aimed at the so-called symptoms of bladder filling, which we explained above.
- They act by controlling the contraction of the bladder, they do not act on the prostate.
- The most common side effects of antimuscarinics are dry mouth, constipation, and difficulty urinating.
- Beta3-agonists produce less dry mouth and constipation compared to patients treated with muscarinic receptor antagonists, but are contraindicated in patients with severe and poorly controlled hypertension.
4. Phosphodiesterase 5 inhibitors (IPDE5)
- The most famous of this family is Viagra, but the only one accepted, at the moment, for the treatment of lower urinary tract symptoms secondary to BPH is Tadalafil.
- They improve urinary symptoms and erectile function.
- These drugs are a good option in patients with BPH and ED, but they are more expensive and are not usually covered by social security.
- Side effects:
- The main ones are facial flushing, headache and gastric discomfort.
- They are contraindicated in patients with severe heart problems, among others.
5. Phytotherapy – Plant extracts
- Phytotherapy or herbal medicines include roots, seeds, pollen, bark, or fruits.
- The mechanism of action in the patient (in vivo) of this type of preparation is not entirely clear.
- Extracts of the same plant produced by different companies and even different batches from the same company may contain different concentrations of the active ingredient. Therefore, the effect of treatment can be difficult to predict .
- Only Serenoa repens extracted with hexane has been recommended for well-established use by the European Medicines Agency.
6. Combined treatment
Depending on the patient’s symptoms or response to initial treatment, a combination of medications may be offered. The most studied and most frequently used combinations are:
- Combination of alpha-blocker and 5ARI: has been shown to be superior to each of these drugs individually, whenever indicated.
- Combination of alpha blocker and anticholinergic: it has been shown to be effective and safe in the treatment of patients with symptoms of bladder filling and emptying, that is, who present both an obstruction to the outflow of urine caused by the prostate and an excess of bladder activity.
There are other drug combinations that do not have as much scientific evidence and their use is at the discretion of each urologist and the patient’s preferences.
7. What happens when medical treatment fails?
If medical treatment is not effective from the start, if it loses effectiveness over time, or if the side effects are not well tolerated by the patient, surgical treatment should be considered, which we will discuss in the next article.
If you have any doubts about the treatment you are following, discuss it with your doctor and NEVER make changes to your medication on your own initiative.
Surgical treatment for BPH
Surgeries for BPH, with the exception of minimally invasive treatments and transurethral prostatic incision, aim to remove the prostatic adenoma and leave the prostatic capsule intact. To better understand this concept, we can imagine that the prostate is an orange. BPH surgery consists of removing the pulp of the orange, while keeping the peel as undamaged as possible.
This makes it possible to increase the caliber of the tube through which urine leaves the bladder (the prostatic urethra) without damaging important structures around the capsule of the prostate, such as the nerves that allow erections or the muscles that prevent urine from escaping.
Various different surgical techniques may be used to achieve this goal.
Endoscopic surgery is one that is performed through natural orifices or through a small incision. In urology and in the case of prostate surgery, this term is used to refer to operating through the urethra with specially designed instruments. The most common endoscopic prostate surgery techniques are:
- Transurethral resection of the prostate (TURP): It consists of resecting or cutting small fragments of the prostate from the prostatic urethra to the prostatic capsule. The cuts are made with an electrical loop that also serves to coagulate and control bleeding.
- The main immediate complications are bleeding (which may require a blood transfusion), not being able to urinate after surgery (acute urinary retention) or having a urine infection; although these complications usually occur in less than 5% of cases.
- Possible long-term complications include narrowing of the urethra that can make urination difficult and urinary incontinence, but they occur in about 3% of cases.
- Clinical practice guidelines usually recommend performing this type of surgery when the prostate is between 30cc and 80cc in size, although this could be modified depending on the experience of the surgeon.
- Transurethral prostatic incision: This technique consists of making an incision at the neck of the bladder and prostate. In this technique, prostate tissue is NOT removed. It is indicated especially for prostates of less than 30cc and that do not have a middle lobe.
- Prostatic Vaporization: This technique uses electricity or a laser to vaporize the prostate. When comparing this technique with TURP, it has been observed that prostate vaporization presents less bleeding during surgery and shorter hospitalization time. On the other hand, it has been observed that prostate vaporization has a longer surgery time and has a higher risk of needing a new surgery in the future. Prostatic vaporization could be useful in cases where there is a high risk of bleeding since it produces better coagulation than TURP. It is indicated for prostates of <80cc.
- Prostatic Endoscopic Enucleation: This technique consists of separating the prostatic capsule from the prostatic adenoma, that is, separating the pulp of the orange from the orange peel, in 1 or 2 complete pieces, to later leave them inside the bladder and extract them with a device called morcellator that suctions and cuts the prostate tissue. It is in this technique that lasers are most used. Lasers are used to create this separation between the adenoma and the prostatic capsule. The most widely used laser for enucleation, and for which there exists more positive research, is the Holmium laser.
Endoscopic laser enucleation has some advantages over TURP. Less bleeding during surgery, less time wearing a tube after surgery, and shorter hospital stay have been observed. It also can be used for prostates larger than 80cc. No important differences have been observed in long-term complications compared to TURP, such as urethral strictures or urinary incontinence.
When comparing the results of endoscopic enucleation with open surgery (which we will see later) it is observed that they are similar in terms of results, with endoscopic surgery being less aggressive and therefore with faster recovery and less bleeding. The main drawback of endoscopic enucleation is that it is a complex and difficult technique to learn.
Laparoscopic Open Surgery
- Open Simple Prostatectomy or Adenomectomy: It is the oldest and most aggressive type of surgery, since it presents more bleeding, a larger wound and longer hospitalization time. However, it is an effective method with very good long-term results. The technique consists of making an incision in the lower part of the abdomen to access the prostate, then, through an incision in the bladder or in the prostate capsule, the prostatic adenoma is removed. It is the treatment of choice for prostates >80cc if the equipment or experience to perform endoscopic enucleation is not available.
- Simple Laparoscopic or Robotic Prostatectomy: These are relatively new techniques. The available studies show similar functional results to open prostatectomy, with the advantage of presenting less bleeding and less time in the hospital and less time wearing a bladder catheter.
Minimally invasive procedures
Minimally invasive techniques are treatments that improve urine flow with shorter and usually less aggressive interventions than conventional surgery. They present the advantages of preserving ejaculation in most cases. On the other hand, by removing less prostate tissue, minimally invasive techniques can be less effective over time.
The most used in our environment and those for which more scientific evidence is available are:
- Rezüm: Injecting steam into the prostate. The energy released by the water vapor produces a reduction in the size of the prostate. It has the advantage that it can be performed under local anesthesia, outside the operating room, and the patient goes home the same day. It has the drawback that after the procedure, it is necessary to wear a bladder catheter for 3 to 5 days.
- Prostatic urethral lift: Applying a permanent suture implant that compresses the prostatic lateral lobes. The functional results are worse than those of TURP and it is more common for the patient to require a new surgery after 5 years, but it does not affect ejaculation, and recovery after the procedure is faster.
- iTIND: Placing a device that expands inside the prostatic urethra and the neck of the bladder and applying pressure to these areas for 5 days, after which it is removed. It would seem that it is effective, but we are awaiting more robust studies to evaluate its effectiveness.
- Aquablation: It consists of applying a jet of serum at high speed that manages to destroy prostate tissue. It has the advantage of reducing surgery time and presenting greater preservation of ejaculation than TURP. However, it requires general anesthesia and presents some problems in controlling bleeding, with a greater need for transfusion than TURP in the available studies.
Whenever we talk about surgical techniques, we must remember the importance of the experience of a surgical team or a surgeon in a particular technique. The subspecialization of medicine and the development of different technologies means that more and more surgeons subspecialize in a group of surgical techniques and dedicate their medical activity to this subtype of surgery.