Enlargement of the prostate, known as benign prostatic hyperplasia (BPH), can constrict the flow of urine and impair emptying of the bladder, leading to urinary frequency, urgency and having to urinate at night.
The prostate is a walnut-sized gland whose primary function is to help in reproduction. Given its location in front of the bladder, however, enlargement of the prostate, known as benign prostatic hyperplasia (BPH), can constrict the flow of urine and impair emptying of the bladder, leading to urinary frequency, urgency and having to urinate at night.
BPH primarily affects men over the age of 40, of all races and ethnic backgrounds. In fact, approximately 80% of men over the age of 70 have some degree of BPH. Fortunately, not all men will suffer bothersome symptoms. Currently, it is estimated that 25%-50% of men with an enlarged prostate have some degree of bothersome urinary symptoms and can benefit from some form of medical or surgical treatment from a urologist.
Risks & Causes
Prostatic growth and enlargement is a natural process that normally occurs in men. It occurs to varying degrees; in some men, growth can be excessive and can obstruct the flow of urine. Blockage of the urine occurs because as the prostate enlarges, tissue is forced inwards, thus compressing the urethra and blocking urinary flow.
Symptoms & Evalution
Symptoms related to bladder emptying:
- Urinary hesitancy or straining (i.e., difficulty starting a urine stream)
- Weak flow
- Dribbling after urination
- A sensation that the bladder is not completely empty
- Frequency or a sensation of needing to urinate again soon after urination
- Dysuria (i.e., pain during urination)
Symptoms related to bladder storage:
- Nocturia or waking up at night
- Frequent urination
- A sudden, uncontrolled urge to urinate
The degree of enlargement of the prostate may not always be correlated with the severity of urinary symptoms. In addition, other conditions such as overactive bladder, diabetes, urinary tract infections, neurologic disease and heart disease may cause similar symptoms.
When the bladder does not empty completely, the risk of developing a urinary tract infection increases. Other serious problems can occur, including the development of bladder stones, blood in the urine and overactive bladder. In rare cases, urinary retention, such as the inability to urinate or kidney damage, can occur.
Evaluation
Evaluation of an enlarged prostate can take several forms. First, a medical history and physical exam that focuses on the urinary tract are important. A neurological exam should be performed to determine whether your symptoms are related to a problem with the nerves controlling the bladder. A urinalysis should be performed. Often, other tests are performed, including a digital rectal exam to check the size and firmness of the prostate, a urine culture to evaluate for the presence of infection and a PSA to check for prostate cancer. If your symptoms are more severe, a postvoid residual test may be performed to evaluate the amount of urine left in the bladder after urination. A blood creatinine test assesses how well your kidneys are working. Urodynamics, or pressure-flow studies, may be used to distinguish whether your urinary symptoms are due to blockage from an enlarged prostate or to a problem with the bladder or its nerves. A transrectal ultrasound can measure the size of the prostate. Cystoscopy may also allow one to find out how much an enlarged prostate is blocking the urethra.
Treatment Options
Treatment for BPH focuses on reducing the symptoms associated with prostatic enlargement.
The decision on how to treat BPH depends on how bothersome your symptoms are. The American Urological Association (AUA) Symptom score is one way to measure how affected you are by your symptoms and how well you are responding to treatment.
Behavioral Changes
The first line treatment for BPH consists of behavioral changes, such as double voiding, timed voiding, avoidance of caffeine, alcohol and other diuretics, as well as night-time fluid restriction.
Medical Therapy
Medical therapy often consists of using alpha blockers, such as Flomax, Uroxatral, Rapaflo, Cardura, or Hytrin. Originally used to treat high blood pressure, these medications relax the muscle around the prostate and bladder neck, thereby increasing urinary flow and decreasing symptoms. Five-alpha reductase inhibitors (5ARIs), such as Proscar or Avodart, block the conversion of testosterone to dihydrotestosterone within cells of the prostate. This results in shrinkage of the prostate and a decrease in the associated blockage of urinary flow.
Often, alpha blockers and 5ARIs are used in combination to augment therapeutic effect. Anticholinergics, medications that inhibit bladder contractions, can also be used to further improve symptom relief. Finally, Cialis has been used to also help improve BPH-related symptoms.
Surgery
Surgery represents the most reliable way to relieve urinary symptoms, although it is typically reserved for patients for whom medications are not helpful, or for those unable to tolerate, or unwilling to take, medications.
Most surgeries for BPH today are endoscopic in nature and therefore do not require any incisions. Rather, surgical instruments are passed via the urethra to the level of the prostate.
The gold standard consists of transurethral resection of the prostate (TURP), where the core of the prostate is cut into small pieces and then removed. TURP may be performed using different types of electrosurgical as well as laser energy. Laser TURP is performed using lasers of various types and wavelengths (e.g. holmium laser, Greenlight™ laser) that carry the advantage of decreased risk of complications such as intraoperative bleeding and fluid absorption.
Newer electrosurgical technologies include the use of bipolar button or loop, which also decrease the risk of fluid absorption.
Other minimally invasive techniques include transurethral microwave therapy (TUMT), in which microwave energy is used to destroy a portion of the prostate through heating, as well as transurethral needle ablation (TUNA), in which a heated needle is used to destroy a portion of the prostate.
Finally, simple prostatectomy can be performed in open, laparoscopic, or robotic fashion, and is typically reserved for patients with very large prostates, where transurethral surgery would be difficult to perform safely. The prostate is accessed via incisions in the skin.
New Technologies for BPH
Newer technologies for BPH are continually being tested and evaluated. These include the Urolift procedure, which uses small anchors to mechanically retract enlarged prostatic tissue as well as Rezum therapy, which uses water vapor to destroy BPH tissue. Finally, the use of high pressure water jets, dubbed Aquablation therapy, is being tested to treat BPH.
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To request an appointment, please call our office at (646) 962-4811. Our phone staff are available to help you Monday-Friday, from 9AM-5PM (EST).
If you'd like to learn more about our providers that specialize in BPH (Enlarged Prostate), please view the "Our Care Team" page.