What is BPH?
Benign prostatic hypertrophy is a non-cancerous, natural occurring growth of the prostatic tissue. This occurs in nearly 50% of all men from their 50-60’s and by their 80’s, BPH affects up to 90% of men. Many men suffer with the various symptoms associated with BPH thinking it is part of the “ageing process”, however, there are many treatment options available and it is estimated that anywhere from 20-30% of men require some type of treatment for symptomatic BPH in their lifetime.
At present there are no known risk factors for BPH other than age and the presence of testes. This includes race, nationality, sexual history, diet, or other conditions or medications.
A prostate normally weighs approximately 20 grams at age 20-30. From around the age of 40, the prostate often increases in size, to an average of 40-50 grams at age 80.
Patient with BPH can experience a wide range of symptoms varying in severity. These symptoms are commonly referred to as LUTS (Lower Urinary Tract Symptoms) and include:
- Urinary frequency
- Urinary urgency
- Nocturia (having to pass urine throughout the night)
- Poor urine flow
– This can include difficulty starting the urine flow, maintaining the urine stream while passing urine, and/or stop/start patterns of the urine flow
- Abdominal Straining while urinating
- Pain with urination
- Inability to fully empty the bladder
- Post void dribbling (may be noticeable in underpants or on/around toilet)
BPH can affect bladder function, giving rise to trabeculation (a thickened bladder wall), and bladder instability (involuntary bladder contractions, causing urgency or urge incontinence). If there is a large amount of residual urine left in the bladder due to BPH, bladder stones can occur. Patients with large residual urine volumes are also at risk of urinary tract infections and in very severe cases can result in full urinary retention (the inability to pass urine).
Either microscopic (not visible) or macroscopic (visible) “haematuria” (blood in the urine) can occur with an enlarged, vascular prostate, but other causes for bleeding need to be excluded.
In order to diagnose BPH, your doctor/Urologist will need to perform some or all of the following test to rule out other urological condition.
- Physical examination (i.e. digital rectal examination) may reveal an enlarged prostate, however, the size of enlargement is not always proportional to the severity of symptoms or the degree of obstruction (i.e. Some men with extremely large prostates may have little to no symptoms, whereas men with minor enlargement may have severe symptoms).
- Urine Flow Test
– Your Urologist may ask you to attend your appointment with a full bladder and perform this test. This involves emptying your bladder into a machine that will show any restriction of flow, abdominal straining, stop/start flow profile, speed of flow etc.
- Transabdominal or Transrectal Ultrasound
– This is useful in detecting the amount of residual urine and detecting other anatomical abnormalities of the urinary tract.
- Flexible Cystoscopy
– Occasionally, cystourethroscopy (looking into the bladder with a telescope) may be important, particularly to rule out other causes of obstruction such as urethral strictures etc.
There are generally 3 major treatment options.
These include “wait and watch”, medical treatment, or surgical treatment. Before deciding on treatment it is important to understand the “natural history” of BPH.
Many patients have fluctuating symptoms, and in nearly half of patient’s symptoms remain stable for many years. Over half of patients will experience a gradual worsening in their symptoms.
There are various prescription medications that can be offered to attempt to help reduce the severity of BPH symptoms. Alpha-blockers can be used to relax the smooth muscle within the prostate, thereby making it easier to push the prostatic urethra open –thus in theory, allowing the urine to pass more freely. The most common ones used are:
These medications are all similar in their effectiveness, with a modest improvement in symptoms experienced in nearly half of patients, and a mild improvement in flow-rate experienced in approximately 1/3 of patients. They need to be taken daily and the beneficial effect occurs only during the time the patients are on the medication.
Potential side-effects, experienced in 10-20% of patients are fatigue, dizziness, nasal stuffiness, and a small percentage of patients experience postural hypotension (lowering of blood pressure noticed when changing from a lying to standing position).
Another drug treatment is alpha reductase alpha inhibitors: “Finasteride” – this medication does reduce prostate volume by about 20% over one year. However, there are generally only modest improvements in symptoms and flow rates, experienced by only about 50% of patients. Side-effects are rare, with a 3% incidence of erectile dysfunction. The overall results have been disappointing, but Finasteride is more likely to be of benefit in men with particularly large prostates.
Surgical treatment – Prostatectomy
Indications for surgical treatment:
Historically, there have been certain absolute indications for surgery which have included acute urinary retention, renal failure secondary to BPH, recurrent gross haematuria, recurrent bladder stones, a large residual urine, overflow incontinence and recurrent urinary tract infections.
In patients who do not have absolute indications, but symptoms are bothersome, disruptive and do not resolve with medical treatment, we can offer the minimally-invasive Laser Enucleation of the Prostate
Usually in these situations where medical treatment is not effective, surgery is usually performed.
Holmium or Thulium laser resection of the prostate:
This procedure is performed under general anaesthesia and is performed endoscopically with a cystoscope being passed through the urethra into the prostate allowing a fibre optic laser to be passed and used to enucleate the tissue . The advantage of this technique is, the bleeding is significantly minor in comparison to the original TURP procedure, most patients only require a catheter overnight, and can get back to normal activities more quickly than TURP, with less chance of re-bleeding.