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BENIGN PROSTATIC HYPERPLASIA OR
BPH
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 What
is prostate gland? |
| What
is Benign prostatic hyperplasia or BPH? |
| What
are the causes? |
| What
are the symptoms? |
| How
is it diagnosed? |
| What
are the treatment options? |
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| What
is prostate gland? |
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| 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. |
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| 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. |
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| What
is Benign prostatic hyperplasia or BPH? |
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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. |
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| What
are the causes? |
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| 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. |
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| What
are the symptoms? |
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| 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. |
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| problems related with urination, like: |
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- 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
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| 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. |
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| How
is it diagnosed? |
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| 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: |
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 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:
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- 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.
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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.
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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. |
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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. |
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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. |
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| What
are the treatment options? |
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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: |
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| Medical treatment |
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| 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. |
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| Surgical treatment |
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| 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: |
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A. Conventional surgery
B. Minimally Invasive procedures
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| A. Conventional surgery |
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| The conventional surgery is also called
open surgery. In this, prostate gland is removed. So it
is also referred to as Open prostatectomy. |
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| What to expect |
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 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. |
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| Ideal candidate |
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| 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. |
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| Benefits and drawbacks |
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| 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 |
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| B. Minimally Invasive procedures |
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| 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: |
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| Transurethral resection of the
prostate (TURP) |
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| 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. |
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| What to expect |
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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. |
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| Ideal candidate |
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| 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. |
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| Benefits and drawbacks |
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| 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. |
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| Transurethral incision of the
prostate (TUIP) |
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| 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. |
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| What to expect |
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| 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. |
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| 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. |
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| Ideal candidate |
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| 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. |
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| Benefits and drawbacks |
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| 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. |
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| Laser surgery |
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 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.
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| Types of laser surgery: |
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- 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.
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| Ideal candidates |
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| The ideal candidates are those men
who have mild prostate enlargement. |
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| Benefits and drawbacks |
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| 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. |
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| Transurethral microwave procedures(TUMT) |
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| 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. |
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| Transurethral needle ablation |
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| 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). |
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| Water-induced thermotherapy |
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| 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. |
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