Treatment for BPH is usually guided by the impact on the patient’s quality of life/degree of bother. Also a patient’s co-morbidities, fitness for surgery (or medical treatment) and individual preference will determine which treatment option is commenced. The treatment options for BPH include: lifestyle changes/watchful waiting, medical therapy and surgery.
Lifestyle changes/watchful waiting:
This option is usually recommended for patients with mildly bothersome voiding symptoms. This is based on the premise that most men with benign prostatic hyperplasia (BPH) do not progress. Simple options to help improve LUTS include limiting fluid intake in the evenings prior to bed, decreasing caffeine intake and bladder retraining exercises for overactive bladder symptoms, and pelvic floor relaxation techniques for pelvic floor dysfunction.
This is a good option for patients with bothersome voiding symptoms who may not require or be ready for surgery, or are not fit enough to undergo surgery. There are two classes of medication for BPH. The first is an alphablocker which causes relaxation of the smooth muscles in the prostate and bladder neck. They do not shrink the prostate however. Commonly prescribed alphablockers are: Prazosin (also known as Minipress or Pressin) and Tamsulosin (also known as Flomaxtra). Tamsulosin is more specific to the prostate, and has fewer side effects compared to Prazosin ie: light headedness and dizziness. Other side effects can include nasal congestion, drowsiness and retrograde ejaculation.
Alpha blockers tend to have an immediate effect on voiding symptoms (ie: within a few weeks of initiating treatment). If there has been no significant improvement in LUTS after one month then this medication should be ceased.
The second medication type is a 5-alpha reductase inhibitor (5-ARI). 5-ARIs prevent the formation of active testosterone in the prostate which leads to a decrease in the size of the prostate. The prostate can decrease in size by up to 30%. The symptomatic improvement often takes greater than six months to occur, and the treatment course is usually for a minimum of twelve months. The reduction in the size of the prostate leads to a decrease risk of BPH progression, acute urinary retention and surgical intervention. The two agents used in Australia include Dutasteride and Finasteride. The side effects of 5ARI’s include breast tenderness or enlargement, decreased libido, decreased erections and retrograde ejaculation. 5ARIs do not work on small prostates -ideally prostates should be larger than 40gms to receive a benefit from 5-ARIs.
There is now a combination medication (Duodart) which contains both a 5-ARI (Dutasteride) and an alphablocker (Tamsulosin). The combination therapy has a greater clinical benefit than either single drug treatment alone, but as expected, the side effect profile is greater.
There are several natural/herbal therapies available including Saw Palmetto and Trinovin. Studies have shown little or no benefit in the treatment of BPH symptoms with these therapies. They are possibly no better than placebo medication in the treatment of BPH.
Surgery for BPH:
Indications to proceed with surgery for BPH management include failure of patients to respond to medical treatment (or patients who decline medical treatment), and patients who have developed BPH complications including urinary tract infections, bladder stones, urinary retention, and renal impairment. Surgery should also be considered in patients who have elevated bladder post-void residual volumes > 250mls.
1.TransUrethral Resection of the Prostate (TURP)
The traditional operation for BPH surgery is a transurethral resection of the prostate (TURP). This is still the gold-standard which other newer surgical options are compared to. A telescope is passed through the urethra to the prostate, and segments (chips) of tissue are removed in a piecemeal fashion. The aim of surgery is to remove enough obstructing prostate tissue to improve one’s voiding symptoms. Not all of the prostate is removed via this operation. A catheter is left in the bladder after the operation and is removed the second day after the surgery. Some of the risks associated with this procedure include bleeding, infection, incontinence, impotence, retrograde ejaculation, re-operation, failure to resolve all voiding symptoms, and post-operative/anaesthetic complications.
2. Laser prostatectomy
A newer form of surgical intervention for BPH is laser surgery. There appears to be little difference in the success of a laser prostatectomy when compared with a traditional TURP. The current types of laser being used in Queensland are the Greenlight laser and the Thulium laser. The aim of laser surgery is to remove obstructing prostate tissue to allow an improvement in LUTS. In both of these operations a telescope is passed through the urethra and into the prostate, and a small laser fibre vaporises the tissue (ie: turning it from a solid to a gas) whilst at the same time cauterizing the small blood vessels. As a result there tends to be less bleeding throughout this operation, and therefore a catheter is removed at midnight the night of the surgery or alternatively the morning after the surgery. The advantages of the greenlight and thulium lasers over a traditional TURP include less bleeding at the time of the operation, less time for catheterisation, and a reduced hospitalisation period. Another advantage of the laser prostatectomy over traditional TURP is less risk of impotence, given that there is no electrical energy going through the prostate and affecting the nerves outside the prostate that supply the penis. The risks of infection, incontinence, failure to improve all voiding symptoms and the re-operation rate are similar to a TURP. Patient’s having a laser prostatectomy may experience more irritative voiding symptoms (e.g. frequency and urgency) initially after the operation which typically resolve over the first few months post-operatively. The other possible downside to this operation is that no prostate tissue is removed for histological examination.
3. Open prostatectomy
This is traditionally used for patients with very large prostates. In this operation a transverse incision is made in the lower abdomen, the prostate capsule is opened, and the prostate gland is enucleated and removed. A catheter is traditionally left in the bladder for a longer time than with a TURP (e.g. up to five days) to allow healing of the prostate capsule. Because an incision is made in the lower abdomen there is more pain associated with this approach. There is also a higher risk of wound infection and deep vein thrombosis (DVT), and the patient has a slower return to normal daily activities and work.
4. Newer treatments
Newer treatments for management of LUTS continue to evolve. Currently the Uro-lift is being offered for the treatment of younger men with moderately bothersome voiding symptoms who want to avoid the possible side effects of a TURP or laser surgery. This procedure involves the application of two to four “staples” into the prostate to try and compress the lateral lobes of the prostate tissue, resulting in a more open prostate fossa. This procedure doesn’t preclude further treatment for BPH in the future.