BPH

Courtesy Salt Lake Research, Salt Lake City LIVING WELL Magazine

Since the completion of my residency in Urology in 1979, I have seen many changes in the field. Certainly, the diagnosis and treatment of benign prostatic hypertrophy (BPH) has undergone a remarkable transformation. BPH refers to the gradual enlargement of the prostate gland that normally occurs in men as they age. The prostate is a secondary sexual organ that produces several components to semen, which, essentially, provide nourishment to sperm cells. The prostate gland is rather strategically located at the base of the urinary bladder. The male urethra extends from the bladder base to the tip of the penis and is the exit route for both urine and semen. The first inch or two of the urethra travels directly through the center of the prostate gland.

As the prostate enlarges, it compresses or “squeezes” the urethral tube and, over time, slows the flow of urine. Eventually, the bladder is unable to completely empty. It is this residual urine that remains in the bladder after voiding, which results in urinary frequency. This is because the effective bladder capacity is considerably reduced.  Patients also experience nocturia (awakening more than once during the night to void), and slow or intermittent stream. If this condition remains untreated, the patient may eventually experience urinary retention (total inability to void) and require emergency catheter placement. In some patients, this increased bladder pressure may lead to kidney damage or renal failure.

Prior to the development of modern instrumentation and surgical techniques, patients with severe BPH were forced to endure permanent or intermittent self catheterization.

Since the 1930s, we have had several surgical remedies available for symptomatic BPH.

The most commonly performed operation was the TURP (transurethral resection of the

prostate). This procedure is accomplished through a special instrument, which is advanced up the urethral tube and, under direct vision, the obstructing tissue inside the prostate is gradually “scooped” away using an electrically heated wire loop. The second traditional procedure is an open operation where the inner portion of the prostate is removed through a lower abdominal incision and is called a suprapubic prostatectomy.

Although these procedures are still widely used today, there has been an ongoing search for less invasive procedures. Transurethral microwave therapy (TUMT) is delivered via a specialized catheter, which contains a microwave antenna. The catheter is advanced into the urethra and microwave energy radiates into the prostate, destroying tissue and relieving blockage. This procedure has been widely used and has had an excellent safety record. It has the advantages of eliminating the need for general anesthesia and can be performed in an office setting. Patients, however, usually require a catheter for a few days post op and many experience  discomfort during the  treatment, despite local anesthesia.

Laser vaporization techniques have become more refined in recent years. They still require hospitalization and general or spinal anesthesia, but recovery is quick and, as with TUMT, there is generally very little blood loss. Laser technology also allows the surgeon to visualize how effectively the urethral obstruction has been cleared.

Transurethral needle ablation (TUNA) is also available and utilizes an instrument to direct specialized needles into the prostate to destroy tissue with thermal energy.

Currently there are new office-based technologies being studied in research projects that may prove both efficacious and safe. Because these technologies have not been yet approved by the Federal Drug Administration, I cannot yet disclose the exact nature of  these particular novel therapies. If any do meet standards for FDA approval, news of this approval will be widely reported in the media and on the Internet. So stay informed!

With regard to pharmaceutical agents, there currently are two main classes of drugs. Oral medicines called alpha blockers act by relaxing certain kinds of muscular tissue. This  type of muscle encircles the urethra as it passes through the prostate. These medications relax this “muscular tunnel.” This reduces the squeeze on the urethra and promotes free urinary flow. The problem is that alpha blockers also affect similar muscle groups in other parts of the body and sometimes cause low blood pressure, dizziness, and sexual dysfunction. Research efforts continue in hopes of developing more selective alpha blockers that will work only on prostatic tissues and eliminate these bothersome side effects.

Meanwhile, 5-alpha reductase inhibitors are oral medications also frequently prescribed for symptoms of enlarged prostate. Let’s not go biochemical now! In short, these agents block testosterone activity. Prostate tissue atrophies (shrinks) in the absence of testosterone effect and this process, over time, can relieve BPH symptoms. However decreased testosterone function can result in impotence, decreased libido, and thinning of the bones.

The field of phytotherapy (the study of medicinal uses for herbs and natural extracts) may also yield additional aids in the treatment of BPH and legitimate, double-blind, placebo controlled studies are now underway for several of these compounds. In the past, many herbal preparations have been marketed with little more than anecdotal support. Now we can establish scientifically accepted proof of efficacy if the studies prove to be fruitful.

If you or a family member has BPH symptoms, I strongly recommend medical consultation. Prostate cancer can present with the same signs and must be ruled out. Only with a thorough review of your medical and medication history, physical exam, and appropriate laboratory tests can your doctor offer a rational treatment plan.

Dr. Richardson is currently conducting clinical trials involving new medication regimens and noninvasive surgical techniques for BPH at Salt Lake Research Clinic and can be reached at 801-288-9778 or fax at 801-288-9778.