BENIGN PROSTATIC HYPERTROPHY

Cause
Benign prostatic hypertrophy is a condition common to men as they age. It is caused by a combination of androgens (male hormones) with a permissive effect of estrogens (female hormones). More specifically, testosterone is converted to a second hormone, dihydrotestosterone by the enzyme 5 alpha-reductase. Dihydrotestosterone is what is responsible for post-pubertal enlargement of the prostate gland.

Symptoms
The symptoms of BPH are many. Nocturia (going to the bathroom at night), urinary frequency, decreased force of urinary stream, double voiding, post-void dribbling, hesitancy of urination and intermittency of the urinary stream. An AUA symptoms score can help to quantify the severity of these symptoms.

Indications For Treatment

1. SUBJECTIVE:
The patient is symptomatic.

2. OBJECTIVE:
Recurrent urinary tract infections.
Hydronephrosis or dilation of the collecting system of the kidneys due to blockage of outflow of urine from the bladder.
Hematuria.
Bladder stones.
Urinary Retention
The indications for treatment of BPH are several. Most important is if the patient is symptomatic. The patient will require treatment if he is bothered by getting up two or three times at night to go to the bathroom. Frequent urges of urination with a significant decreased force of his urinary stream and post-void dribbling are also an indication for treatment.

Other indications for treatment include recurrent urinary tract infections, hydronephrosis or dilation of the collecting symptoms of the kidneys due to blockage of outflow of urine from the bladder, urinary retention or being unable to void without a catheter, hematuria or bloody urine, and bladder stones. It is very important to rule out other conditions that may mimic these symptoms. These conditions include prostatitis, bladder cancer, prostate cancer and urethral stricture disease.

Treatment Options
Treatment options for prostate cancer can be broken down into medical and surgical.

Medical Options
Medical options include the alpha blockers - Hytrin and Cardura. The alpha blockers relax the smooth muscle of the bladder neck and prostate gland, thereby enlarging the channel that urine has to flow through when exiting the bladder. Proscar is a 5 alpha reductase inhibitor. This decreases the available dihydrotestosterone which is the compound most responsible for post-pubertal growth of the prostate gland. Recent studies have shown that Proscar is most effective in larger (greater than forty grams) prostate glands.

Surgical Options
TURP (transurethral resection of the prostate gland). This is the gold standard for surgical therapy. Through a resectoscope sheath or telescopic-like instrument that is passed into the penis through the urethra, the prostate gland is cored out. This is typically done under a spinal anesthetic and takes less than an hour to perform. Patients are hospitalized for one to two days and go home without a catheter. Post-operative recovery usually takes one to two weeks with urinary frequency and burning of urination being the most bothersome symptoms in the post-operative period. Delayed bleeding may occur up to three weeks from the time of surgery. Approximately eight percent of patients require a repeat procedure within the first eight to ten years after their TURP.

ADVANTAGE: Provides best long-term results.

DISADVANTAGE: Retrograde ejaculation (greater than eighty percent).

POTENTIAL COMPLICATIONS: Urethral stricture, incontinence, erectile dysfunction and bleeding.

TUIP (transurethral incision of the prostate gland). Two incisions are made into the prostate gland. The incisions are performed endoscopically, as with a TURP. The incisions start just distal to the ureteral orifices and end at the verumontanum. The procedure is typically done under a spinal anesthetic. The hospital stay is up to twenty-three hours.

BENEFIT: Decreased incidence of retrograde ejaculation. Short hospital stay.

OPEN PROSTATECTOMY. Reserved for patients who have very large glands (greater than 100 grams) or who cannot be adequately positioned for a TURP (dorsal lithotomy position). The procedure includes an incision of the lower abdominal wall and dissection down to the prostate gland. The prostate is digitally enucleated. Typically, the procedure is done under general anesthesia. The patient is hospitalized for three to five days and often leaves the hospital with a catheter.

POTENTIAL COMPLICATIONS: Blood loss, stricture of prostatic fossa and incontinence.

VLAP (visual laser ablation of the prostate gland). Through a cystoscope, a laser is focused at the prostate gland. The laser heats the prostate tissue and thereby kills prostate tissue. Over the following four to six weeks, prostate tissue is sloughed when the patient urinates. Thus, the channel through which the patient urinates is enlarged. This procedure is done under general or spinal anesthesia. The patient is discharged from the hospital the same day with a catheter. The catheter typically stays in place for five to seven days.

ADVANTAGE: Short hospital stay. Minimal bleeding.

DISADVANTAGE: Post-op catheter. Results not as good as with TURP.

VAPORTRODE. A rollter ball-type instrument is attached to a resectoscope that is inserted into the penis through the urethra. The electric current through the roller ball is a very high and when it is rolled over prostate tissue, the prostate tissue is vaporized. Thus, a larger channel through which the patient urinates is created.

ADVANTAGE: Minimal bleeding. Shorter hospital stay.

DISADVANTAGE: No tissue to pathologically be checked for prostate cancer. Bleeding may still occur.

PROSTATRON. A microwave catheter is inserted into the penis and a rectal temperature probe is inserted to monitor rectal temperature. The microwave probe heats the prostate tissue which kills a portion of the prostate gland. The microwaved prostate tissue collapses outwards, thus increasing the size of the channel through which the patient urinates. It is done under local anesthesia and takes one hour to complete. The patient goes home after the procedure typically with a catheter. No bleeding occurs.

ADVANTAGE: Minimally invasive. Local anesthesia with or without oral or inramuscular Valium/Demerol. No bleeding. No retrograde ejaculation.

DISADVANTAGE: Post-procedure catheter. Results not as good as with TURP.

TUNA (transurethral needle ablation of prostate). Cystoscopically, a TUNA catheter is placed into the prostatic urethra. Two needles similar to antennae, are then released from the TUNA catheter. The needles penetrate the prostate gland. The needles are connected to a radio wave generator that heats the surrounding prostate tissue. After three to five minutes, the needles are withdrawn, re-positioned to a different portion of the prostate gland and re-inserted into the gland. The process is repeated until the entire gland is treated. The heated prostate tissue dies allowing the prostate gland to collapse outward, thus enlarging the channels through which the patient urinates. This can be done with local anesthesia and combined with oral or intramuscular pain medication either in the doctor’s office or in the hospital.

ADVANTAGE: Minimally invasive. No retrograde ejaculation. Local anestheia. No overnight hospitalization.

DISADVANTAGE: Results not as good as with TURP. May require post-procedure catheter.

INDIGO LASER. Similar to TUNA procedure except laser probes are inserted into the prostate gland to heat the surrounding tissue, typically done as an out-patient procedure in a hospital or surgery center setting.

ADVANTAGE: Minimally invasive. No retrograde ejaculation. Same-day procedure.

DISADVANTAGE: Results not as good as with TURP. May require post-procedure catheter.

AUA Symptoms Score Questionnaire

Your total symptom score equals the sum of questions one through seven.