Dr. Peter Loisides
SPECIAL TO THE MIRROR
Benign prostatic hyperplasia (BPH) is one of the most common diseases of aging men. It is frequently associated with bothersome lower urinary tract symptoms (LUTS) that affect quality of life by interfering with normal daily activities and sleep patterns. By 60 years of age, BPH affects greater than 50 percent of men, and up to 90 percent of men by age 85. In the past decade, there have been significant changes in the available treatment options for BPH. New forms of medical and minimally invasive treatments have been approved by the United States Food and Drug Administration.
Typical symptoms of a man with BPH are usually bothersome LUTS including: urinary frequency, urgency, nighttime urination, decreased and intermittent force of the urinary stream, and the sensation of incomplete bladder emptying. Not all men with BPH and LUTS will have prostate enlargement and, surprisingly, prostate enlargement may exist in the absence of LUTS.
Evaluation
Following the initial evaluation of the patient with a history and physical exam, urinary flow-rate assessment and measurement of post-void residual urine (PVR) may be appropriate. In some men, blood tests may be performed to rule out prostate cancer risk (serum PSA).
Management
Management of men with mildly bothersome symptoms may include watchful waiting, with or without phytotherapy (plant based supplements) like beta-sitosterol and bee pollen. Watchful waiting is a management strategy in which the patient is monitored by his physician but receives no active intervention for BPH or the related LUTS. Watchful-waiting patients are usually re-examined yearly.
Management of men with moderately to severely bothersome symptoms of BPH includes: watchful waiting, as well as medications, minimally invasive, or surgical therapies.
Additional diagnostic tests, such as pressure-flow Urodynamics studies (to assess bladder function), Cystoscopy and Trans-rectal Ultrasound (for anatomical and prostate volume assessments) are optional in men choosing the more invasive therapies.
Medical therapies for BPH include drugs that can relax the prostate’s muscles (alpha blockers), including Flomax, Uroxatral and Rapaflo, and drugs that can shrink the prostate (5-alpha-reductase inhibitors) such as Avodart and Proscar. Medical therapies are not as effective as surgical therapies but may provide satisfactory symptom relief with fewer and less serious adverse effects.
Thermal-based therapies such as Trans-Urethral Microwave Thermal Therapy (TUMT) and Trans-Urethral Needle Ablation (TUNA) use targeted high temperatures to induce physical changes of the prostate tissue resulting in volume reduction. The size and shape of the prostate are of particular importance in properly selecting patients for minimally invasive thermal therapies. These are typically in-office procedures performed using local anesthesia.
Transurethral Resection of the Prostate (TURP) involves the surgical removal of the prostate’s inner portion via an endoscopic approach through the urethral channel, with no external skin incision. An electrified loop or various forms of laser are used to remove the prostatic tissue. These procedures are performed in the operating room under regional or general anesthesia.
Lastly, open prostatectomy involves the surgical removal of the inner portion of the prostate via an incision in the lower abdominal or suprapubic area. This procedure is rarely performed but is necessary in men with prostate volumes greater than 100 cc.
In summary, although a large number of men may be affected by BPH and the associated adverse symptoms, effective treatment strategies are available to afford great improvement of a man’s health and quality of life.
Dr. Peter Loisides is Chairman of Urology at Saint John’s Health Center in Santa Monica. He has been an instructor and lecturer, and has published various articles addressing different areas of Urology. He is currently in private practice in Santa Monica.
