Benign Prostatic Hyperplasia Treatment

At the age of 40, the prostate can start to grow and cause urinary symptoms. This is called Benign Prostatic Hyperplasia (BPH)

At The Urology Group, we have an organized approach to treating men with enlarged prostate (BPH).

First visit

At the initial visit, we may check the following:

• Symptom questionnaire – allows assessment of the severity of symptoms and provides tool for tracking progress over time
• Urinalysis – check for urinary infection, sugar in urine (may be seen in diabetes), blood, protein, infection in
• 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 – manual exam of the prostate by the healthcare provider
• Bladder diary – patient records fluid intake, and time and amount of voids for 3 days

Imaging

Pictures of the prostate are used to determine size and shape of the prostate and helps guide best treatment options. Pictures of the prostate may include:

• Pelvic ultrasound
• Transrectal ultrasound
• Prostate MRI
• CT scan

Reasons enlarged prostate is treated

• 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 (lots of urine is left in the bladder after urinating)
• Bladder stones
• Urinary retention (unable to urinate at all)
• Kidney damage from back pressure caused by retaining large amounts of urine in the bladder

Treatment options

Lifestyle changes

Fluid and diet changes to avoid bladder irritants, strategies to decrease nighttime urination

Medication

Alpha blockers - relax the prostate to ease the passage of urine. These medications include Flomax (tamsulosin), Uroxatral (alfuzosin), Rapaflo (silodosin), Hytrin (terazosin), Cardura (doxazosin)
Tadalafil (Cialis) 5 mg daily - treats enlarged prostate and erectile dysfunction
5 alpha dedicates inhibitors - Proscar (finasteride) or Avodart (dutasteride) are used in for large prostates (over than 40 cc). These medications decrease production of the hormone dihydrotestosterone (DHT), which fuels the growth of the prostate.

Prostate artery embolization

Surgery may be performed for men who do not want to be on lifelong medication or if medication has side effects or is not effective.

Radiology procedure performed by our interventional radiologists. A blood vessel in the groin is entered to plug the blood vessels to the prostate. This shrinks the prostate to improve urine flow and urinary symptoms. This is an office procedure under sedation (light anesthesia). It does not typically require a catheter.

Surgical options

Surgery may be performed for men who do not want to be on lifelong medication or if medication has side effects or is not effective. Surgery may be performed in men who are not candidates for embolization or embolization was not effective enough.

• 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 electrical energy called cautery. Often performed with bipolar energy (Button TURP)
• Aquablation - vaporizes excess prostate tissue using a water jet and robotic technology
• 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.

Follow up appointment

After one to two months, the patient returns for reevaluation. Assessment at the follow-up visit include

• Symptom questionnaire
• Review of bladder diary
• Urine flow study – patient voids into device that measures force of urinary flow. This provides information about degree of blockage.
• Bladder scan (PVR) - ultrasound to look at bladder to see how much urine is left after voiding

Additional studies

• Cystoscopy - a small flexible camera is placed 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
• Urodynamics - a test to learn more about bladder pressure. A small plastic tube called catheter is placed in the bladder. Another catheter is placed in the rectum. The bladder is filled with water then the patient is asked to urinate. This gives information
  This study may be ordered if the patient has had previous prostate or bladder procedures. It can help determine if the issue is large prostate or weak bladder (can seen in long standing diabetes, neurologic problems and other medical problems).

Ongoing Followup

Patients reevaluated periodically or if symptoms get worse.

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.