Benign Prostatic Hyperplasia (BPH)

Lower Urinary Tract Symptoms

The Procedure

The cause of BPH not fully understood but hereditary factors and the presence of testosterone believed to be involved. The process involves an imbalance between increased glandular cell proliferation and decreased apoptosis or programmed cell death.

The process begins as early as 25-30 yrs. Microscopic changes present in 90% of men over 85 yrs and half of these men will have actual prostate gland enlargement. 1 adrenergic receptors in bladder base, bladder neck and prostate may be associated with a dynamic component of bladder outlet obstruction.

The natural history of the condition is that it may may wax and wane over time. However, 5-10% of patients progression to surgery within 4 years.

Benign Prostatic Hyperplasia
  • Obstructive (voiding) symptoms
    • Hesitancy
    • Weak stream
    • Intermittent stream
    • Straining to void
    • Sensation of incomplete bladder emptying
    • Terminal dribble
  • Irritative (storage) symptoms
    • Urgency
    • Urge incontinence
    • Frequency
    • Noctur
  • Mid stream urine for culture
  • Serum creatinine
  • PSA test is optional
  • Ultrasound of the urinary tract with post void residual
  • Urodynamics is an invasive measurement of bladder pressure and urinary flow parameters. It is indicated for patients with neurological conditions or unusual symptoms such as marked irritative symptoms and incontinence. An urologist can arrange this if he feels it is necessary.
Drug Treatment

Minimal bother is best managed with conservative measures
Options include modifying fluid intake eg. restrict evening fluids or change timing of diuretic dosing. Patients may consider consider phytotherapy/”natural remedies” with agents such as serenoa repens (saw palmetto).

Mild to moderate bother best managed with medical therapy
1 adrenergic receptor blockers such Tamsulosin (Flomaxtra), or non-selective blockers such as prazosin (Minipress and Pressin). These drugs relax the prostate and 50-70% of patients will experience some improvement of symptoms within days (particularly flow). Benefit is only derived while patient remains on drug.
Side effects include postural hypotension and dizziness, headache, reetrograde ejaculation, stuffy nose and tiredness. Patients need to inform their ophthalmologist and urologist if you have cataracts and cataract surgery is being considered.

Dutasteride (Avodart) blocks the enzyme 5 reductase which converts testosterone into its more active metabolite dihydrotestosterone (DHT). Dutasteride is usually used in combination with Tamsulosin (Duodart). The drug works by reducing prostate size by 20-30%, which in turn, can reduce outflow obstruction.This drug is more effective in patients with significantly enlarged prostates. Note that it will reduce PSA levels by up to 50%. May take 3-6 month to see maximal benefit. Prostate size will increase again with cessation of medication. Reduces the need for surgery by up to 50%.
Side effects must be noted. They include: Diminished libido (10-30% of patients will suffer to some degree), erectile dysfunction (10-30% of patients will suffer to some degree), gynaecomastia (breast tenderness or breast enlargement occurs in 1-2% and can uncommonly be permanent). Drug must be stopped as soon as any breast tingling or discomfort noted. Decreased volume of ejaculate is occur often. A statistical finding of a 0.5% increased risk of higher grade prostate cancer was noted in a number of studies.

Surgical Treatments

Severe symptoms, failure of medical therapy or complications of BPH such as acute retention, recurrent infections or bladder stones best treated with surgical treatment

Transurethral resection of the prostate (TURP)
This operation is still considered to be the gold standard of treatment and 80-90% of patients will experience significant and sustained improvement of symptoms. An electric loop is used to shave away chips of prostate
Side effects include rare urinary incontinence is rare (1%), retrograde ejaculation (at least 80% of patients). New erectile dysfunction is very rare. Likelihood of repeat procedure at 10 years is approximately 20%

Bladder neck incision
Is used for patients with smaller prostates or younger patients where the majority of narrowing of the bladder outflow is seen to be at the level of the bladder neck. Longitudinal incisions are made with a cautery in the bladder neck and prostate to widen the bladder outlet. Incidence of retrograde ejaculation is significantly lower at around 25%.

Open prostatectomy for BPH
Enucleation of the transitional zone of the prostate via a suprapubic incision. Performed only for very large prostates or when concomitant treatment of bladder stones or diverticula is required.

Laser treatments
Laser vaporisation of the prostate uses a high energy KTP or “green light” laser beam to vaporise prostate tissue via a fibre introduced through a cystoscope. High absorption of this wavelength of light makes procedure very good at preventing bleeding making this procedure useful for patients on blood thinners.
The procedure is more suitable for smaller prostate glands. It can cause severe urinary burning and urinary frequency and burning for several months.

Laser resection of the prostate uses a Holmium laser beam used to cut away prostate tissue.

Prostatic urethral lift procedure
The Urolift procedure is a minimally invasive, mechanical approach to treating BPH that uses non-absorbable suture implants with a metallic anchor at each end to pull the lateral lobes of the prostate apart. The implants are placed under transurethral, cystoscopic guidance. In previous studies, this procedure has been shown to offer rapid and significant relief of lower urinary tract symptoms with minimal side effects, as well as preservation of erectile and ejaculatory function.

Transurethral Resection of Prostate
Andrology Australia

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