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Benign Prostatic Hyperplasia, also called 'enlarged prostate' is generally
found in men over the age of 50. In fact, nearly all men over the age
of 50 have an enlarged prostate to some degree, but not all of these cases
require treatment. The prostate is located under the bladder in men and
behind the pubic bone. It partially surrounds the urethra and is responsible
for many of the lower urinary tract problems experienced in men as it
enlarges with age.
Symptoms
- Frequency of urination, nocturia (frequency at night)
- Urgency (desire to void again within a short time of urinating)
- Hesitancy (waiting some time to initiate the stream)
- Decreased force of urinary stream
- Intermittency (a stop-start pattern in urinating)
- Feeling of incomplete emptying (urine remaining in the bladder after
urinating)
Diagnosis
On occasion, patients may develop similar symptoms due to prostatitis
(inflammation of the prostate), primarily from infection that is treated
with antibiotics. To determine if these symptoms are due to BPH, patients
may be evaluated with:
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- DRE (digital rectal exam) is primarily done
to rule out abnormalities of the prostate, such as cancer or prostatitis.
- Urine studies (Urine Culture and Cytology)
are done to rule out infection, hematuria (blood in the urine),
glucosuria (sugar in the urine as can be seen in diabetics), and/or
cancer.
- Uroflow testing records the amount of urine
voided, the speed (force) with which one urinates, the time needed
to urinate, and will determine abnormalities in these areas. After
uroflow testing is done, residual urine can be determined with
a bladder scan, which is similar to an ultrasound of the bladder.
If either of the two tests is abnormal, further evaluation with
urodynamics (see below) is recommended.
- AUA Symptom Sheet is used to determine the
severity of your symptoms and to monitor treatment. This is a
list of seven questions that incorporate much of the symptoms
described above. Scored from 1-5, patients can receive a minimum
score of seven (mild symptoms) or maximum score of 35 (severe
symptoms).
- Urodynamics determines bladder function with
the aid of a computer. It is separated into 2 phases: a filling
phase, and urinating phase. In the filling phase, the bladder
is evaluated for involuntary contractions (overactive bladder),
compliance (elasticity of the bladder), incontinence (involuntary
loss of urine) and capacity (amount of fluid the bladder can comfortably
hold). During urinating, bladder pressure is recorded to determine
if it is normal, hypocontractile (weak) or obstructed (blocked).
This test is generally done in the office and can take fifteen
minutes.
- Ultrasound is used to evaluate the kidneys
for hydronephrosis (swelling) especially when there is residual
urine found in the bladder either due to a hypocontractile bladder
or obstruction from BPH. On occasion, a bladder ultrasound is
done to evaluate prostate size, amount of residual urine and/or
the presence of bladder stones.
- Cystoscopy is performed to evaluate prostate
size prior to or during treatment for BPH. This is an office procedure
done with a local anesthetic. It not only evaluates the urethra
for other causes of obstruction (i.e. strictures), it evaluates
the prostate and more importantly the bladder. Many times a camera
is placed on the cystoscope so that the patient can also see.
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Treatment
Once it is determined that your symptoms are associated with BPH, treatment
will depend on the severity of these symptoms. Treatments are either medical
(non-surgical) or surgical.
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- Medical treatments include medications categorized
as:
Alpha Blockers, i.e. Flomax®, Cardura® (Doxazosin),
and Hytrin® (Terazosin). Their action is aimed at the bladder
neck (bladder opening) and prostatic urethra (area of the urethra
surrounded by the prostate). By blocking the receptors that increase
compression and closing of these channels, they allow for dilation
and opening of the prostatic urethra and therefore a better flow
of urine. Symptoms may improve within several days of starting
the medication.
- 5 Alpha Reductase Inhibitors, i.e., Proscar®. By
blocking the 5 Alpha Reductase enzyme, the production of DHT (dihydrotestosterone)
in the prostate is inhibited, therefore slowing or stopping growth.
Many times this is used in combination with alpha blockers, and
may take 3 to 6 months before prostate volume is notably decreased.
In addition, PSA (prostate specific antigen) measured in the blood
will be decreased by 50%. Therefore, it is important to alert
your physician that you are on this medication if your PSA is
being evaluated.
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Surgical treatments for BPH vary from TURP (transurethral
resection of the prostate), to minimally invasive procedures such as TUNA
(Transurethral Needle Ablation), ILTT (Indigo Laser Thermotherapy),
Microwave Therapy, WIT, or Prostatic Stents. While TURP removes tissue,
the minimally invasive techniques employ the use of energy to heat the
prostate, and time to allow the prostatic channel to open so that urinary
flow is improved.
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- TURP (transurethral resection of the prostate)
is the ‘gold standard’ by which all other surgical
treatments of the prostate are compared to as it has had the best
results. Done in a hospital setting with anesthesia, prostate
tissue is resected (scraped) from within the urethra to create
an open channel for one to urinate through. Afterwards, patients
are placed on CBI (continuous bladder irrigation) to remove blood
and clots that can form after the procedure. Generally a ‘voiding
trial’ (removal of catheter to see if one can urinate) is
performed about 1-2 days after the procedure.
- TUNA (transurethral needle ablation) incorporates
the use of radiofrequency energy delivered through two adjacent
needles that are inserted into the prostatic tissue through the
urethra. The treatment time is short and the procedure can be
done with light sedation or local anesthesia in the office. Patients
are sent home the same day with a catheter that is generally removed
within seven days.
- ILTT (Indigo Laser Thermotherapy) uses laser
energy via a needle that is inserted into the prostatic tissue
through the urethra. Generally done in an office setting, the
procedure time is short and patients are generally sent home with
a catheter that is removed after several days.
- Microwave therapy is done either in the office
or in the hospital with sedation. Using a urethral catheter, microwave
energy is emitted to the area of the prostate over a period of
about 45 minutes. Patients are sent home with a catheter for several
days.
- WIT is an office procedure that is done with
local anesthesia. It uses the concepts of balloon dilation and
hot water to treat the prostate. A urethral catheter is placed
and a large balloon dilated in the prostatic area to push open
the prostate. Then, heated water is circulated through the balloon
to heat the prostatic tissue. Treatment time is generally 45 minutes
and patients are sent home with a catheter that is removed after
several days.
- Prostatic Stents are devices placed in the
prostatic urethra thereby compressing the obstructing prostate
and creating an open channel to urinate through. They are generally
used in patients that cannot tolerate any prolonged surgery.
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For a referral to a Beth Israel urologist in Manhattan or Brooklyn specializing in BPH-benign prostatic hyperplasia (enlarged prostate) treatment, call our Physician Referral Service at 1-877-484-3466.
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