BPH - Whats My Treatment?

As inevitable as gray hair, the prostate enlarges in all men, and causes urinary bother (see the details in the Benign Prostatic Hyperplasia – BPH newsletter)

At The Urology Group, we have an organized, systematic approach to treating men with BPH. At the initial visit, we check the following:

First Visit

• Symptom sheet – patient questionnaire about voiding symptoms; allows assessment of the severity of symptoms and provides tool for tracking progress over time
• Urinalysis (UA) – check for urinary infection, sugar in urine (may be seen in diabetes), blood in urine (known as hematuria)
• PSA – blood test which may help determine if prostate cancer may be present
• Bladder scan (PVR) – ultrasound to look at bladder to see how much urine is left behind after voiding
• Digital rectal exam (DRE) – manual exam of the prostate by the healthcare provider
• Voiding diary – patient records fluid intake, and time and amount of voids for 2- 3 days

Indications for initial treatment of voiding bother associated with BPH include:

• Bothersome urinary symptoms like slow stream, frequent urination, difficulty starting to urinate, need to get up at night to urinate
• Recurrent urinary tract infection
• Blood in the urine (hematuria)
• Bladder does not empty well (high post void residual)
• Bladder stones
• Urinary retention (unable to void at all)
• Kidney damage from back pressure caused by retaining large amounts of urine in the bladder

Initial treatment starts with:

• Behavioral modification – dietary changes to avoid bladder irritants, strategies to decrease nighttime urination (link to nocturia handout)
• Start treatment with an alpha blocker medication that works by relaxing the muscle in the prostate: Flomax (tamsulosin), Uroxatral (alfuzosin), Rapaflo (silodosin), Hytrin (terazosin), Cardura (doxazosin)

Follow up Visit

• After one to two months, the patient returns for reevaluation. Assessment at the follow-up visit includes:
• Symptom sheet
• Review of voiding diary
• Urinary flow study – patient voids into device that measures force of urinary flow (provides information about degree of blockage)
• Bladder scan (PVR) - ultrasound to look at bladder to see how much urine is left behind after voiding

Additional studies may include:

• Prostate Ultrasound – measure prostate size which can help make subsequent treatment decisions
• Cystoscopy – a scope test to visualize the bladder, prostate and urethra (the urinary pathway where urine flows out from the bladder); can determine nature of prostate obstruction, whether it is lateral lobe (side to side) and if there is middle lobe, which is projection of the prostate into the bladder; can assess the status of the bladder, and determine if there is a decline in bladder health with loss of bladder elasticity

At the follow up visit, the following treatment decisions may be made:

• Findings consistent with BPH
• Voiding improved, continue alpha blocker, increase dose if needed
• Voiding not improved

Consider additional medication:

• Tadalafil – a medication commonly used for the treatment of erectile dysfunction that may also improve urinary symptoms associated with BPH
• For large prostates (size greater than 40 cc), start Proscar (finasteride) or Avodart (dutasteride). Work by decreasing production of the hormone dihydrotestosterone (DHT), which fuels the growth of the prostate.
• Consider urodynamic studies (more detailed studies of bladder)

If patient does not want to use drug therapy, consider minimally invasive surgical technique -Urolfit or Rezum

If findings consistent with increased urinary output, and not BPH, take measures to decrease nighttime urinary output (see Nocturia newsletter)

Ongoing Followup

Patients reevaluated again at six months, or sooner if symptoms warrant.

Treatments Beyond Drug therapy

If patients do not respond to treatments with pills, then consideration is given to surgical intervention –

• Urolift – A minimally invasive procedure that uses tiny implants to pull apart the enlarged prostate lobes and widen the urinary channel.
• Rezum – A minimally invasive procedure where steam vapor is injected into the prostate which kills prostate cells to shrink the prostate.
• Transurethral resection of prostate (TURP) – shaves away prostate tissue with cautery.
• Greenlight laser – photo vaporizes (melts away) prostate tissue with a laser.
• Holmium laser enucleation of the prostate (HoLEP) – laser surgery that cuts and removes prostate tissue, typically used for large prostates.
• Simple prostatectomy – a surgery, usually performed as a minimally invasive procedure with robotic assistance, to remove the part of the prostate that causes urinary blockage. Typically reserved for very large prostates.

This orderly approach, which uses the concept of a “clinical pathway”, allows treatment of each individual patient, and provides men the opportunity for an organized, comprehensive care plan for management of voiding bother associated with the enlarged prostate.