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Benign Prostatic Hypertrophy

Introduction

The prostate is a gland that forms part of the male reproductive system. The gland is made of two lobes, enclosed by an outer layer of tissue. It is located in front of the rectum and just below the bladder, where urine is stored. The prostate also surrounds the urethra, the canal through which urine passes out of the body. It is common for the prostate gland to become enlarged as a man ages. We call this condition benign prostatic hypertrophy (BPH).

Why BPH Occurs

The cause of BPH is not well understood but it occurs mainly in older men. As it doesn’t develop in men whose testes were removed before puberty some people believe that factors related to aging and the testes may spur the development of BPH. Throughout their lives, men produce male hormone testosterone. It is postulated that dihydrotes-tosterone (DHT), a substance derived from testosterone in the prostate cause prostate enlargement. With age older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage the growth of prostatic cells and causes BPH.

Symptoms

Many symptoms of BPH arise from obstruction of the urinary passage and gradual loss of bladder function. This eventually results in incomplete emptying of the bladder. The symptoms of BPH vary and the size of the prostate does not always determine how severe the obstruction or the symptoms will be, but the most common ones involve changes with urination, such as:

  • A hesitant, interrupted, weak stream.
  • Urgency and leaking or dribbling.
  • More frequent urination, especially at night.

Complications

Severe BPH can cause serious problems over time.

  • A person with BPH may not have symptom until he develop acute retention of urine. Acute urinary retention, sudden inability to pass urine at all, may be triggered by taking over-the-counter cold or allergy medicines.
  • Urine retention and strain on the bladder can lead to urinary tract infections, bladder or kidney damage, bladder stones, and incontinence.
  • If the bladder is permanently damaged, treatment for BPH may be ineffective.

Diagnosis

It is important to tell your doctor about urinary problems such as those described above. In 8 out of 10 cases, these symptoms suggest BPH, but they also can signal other more serious conditions i.e. cancer of prostate that require prompt treatment. Have a yearly check-up. Several tests help identify the problem and these tests vary from patient to patient, but the following are the most common:

where a probe is inserted in the rectum to directs sound waves at the prostate and the echo patterns of the sound waves form help to detect problems of the prostate. **Both PSA and ultrasound tests enhance detection when added to DRE screening. But they are known to have relatively high false-positive rates, and they may identify a greater number of medically insignificant tumors.

  1. Digital Rectal Exam (DRE).
  2. Usually the first exam test done by inserting a gloved finger into the rectum and feels the part of the prostate next to the rectum. This exam gives a general idea of the size and condition of the gland.

  3. Prostate Specific Antigen (PSA) Blood Test.
  4. A blood test which may help to rule out cancer as a cause of urinary symptoms. PSA, a protein produced by prostate cells, is frequently raised levels in the blood of men who have prostate cancer.

  5. Rectal Ultrasound

Other specific test includes:

  1. Urine Flow Study
  2. where a patient urinate into a special device which measures how quickly the urine is flowing. A reduced flow often suggests BPH.

  3. Intravenous Pyelogram (IVP)
  4. an x-ray of the urinary tract where a dye is injected into a vein, excreted via the kidney and the x-ray is taken. The dye makes the urine visible on the x-ray and shows any obstruction or blockage in the urinary tract.

  5. Cystoscopy
  6. where the doctor inserts a small tube through the opening of the urethra in the penis after local anesthesia. The tube, called a cystoscope, contains a lens and a light system, which help see the inside of the urethra and the bladder. The cystoscope helps determine the size of the gland and identify the location and degree of the obstruction.

Treatment

Men who have BPH with symptoms usually need some kind of treatment at some time. Doctors generally advise going ahead with treatment once the problems become inconvenience and very bothersome or when it pose a threat to patient’s health. Some researchers report that early treatment may not be needed because the symptoms of BPH clear up without treatment in as many as one-third of all mild cases. Instead of immediate treatment, regular checkups by doctors to watch for early problems are more beneficial.

Drug Treatment

Drug are available that inhibits production of the hormone DHT. These drugs shrink or at least stop the growth of the prostate without using surgery.

Drugs that act by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and to reduce bladder outlet obstruction are also available. They belong to the class of drugs known as alpha blockers.

Nonsurgical Treatment

Because drug treatment is not effective in all cases, in recent years there have been development of a number of procedures that relieve BPH symptoms but are less invasive than surgery. These include:

  1. Transurethral Microwave thermotherapy
  2. a device that uses computer-regulated microwaves through a catheter to heat and destroy excess selected portions of the prostate tissue. A cooling system protects the urinary tract during the procedure.

  3. Transurethral Needle Ablation
  4. delivers low-level radiofrequency energy through twin needles to burn away a well-defined region of the enlarged prostate. Shields protect the urethra from heat damage.

Surgical Treatment

Surgery involves removal of the enlarged part of the prostate and this relieves the obstruction and incomplete emptying. Is the best long-term solution for patients with BPH. They include:

  1. Transurethral resection of the prostate (TURP) Surgery
  2. Used for 90 percent of all prostate surgeries done for BPH and no external incision is needed. After giving anesthesia, the surgeon reaches the prostate by inserting a scope (tube) through the penis and urethra. The surgeon uses the scope’s wire loop to remove the obstructing tissue one piece at a time. Transurethral procedures are less traumatic and have a shorter recovery period.

  3. Open Surgery
  4. In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired.

  5. Laser Surgery
  6. A surgical procedure that employs side-firing laser fibers to vaporize obstructing prostate tissue and causes shrinkage. This is available in US. One advantage of laser surgery over TURP is that laser surgery causes little blood loss.

It will probably take a couple of months to heal completely. During the recovery period, the following are some common complicatingproblems that can occur:

  1. Problems Urinating
  2. The urinary stream is stronger right after surgery, but it may take awhile before normal urination regain.

  3. Inability to Control Urination (Incontinence)
  4. As the bladder returns to normal, there may be some temporary problems controlling urination although long-term incontinence rarely occurs.

  5. Bleeding
  6. In the first few weeks after transurethral surgery, the scab inside the bladder may loosen, and blood may suddenly appear in the urine.

  7. Sexual Function After Surgery
  8. It takes awhile for sexual function to return fully but with time, most men are able to enjoy sex again. Complete recovery of sexual function may take up to 1 year, lagging behind a person’s general recover.

Aspects of sexual function changes are as follows:

Most men find little or no difference in the sensation of orgasm, or sexual climax, before and after surgery. It take some time to get used to retrograde ejaculation, you should eventually find sex as pleasurable after surgery as before. Understanding the surgical procedure and talking over any worries with the doctor before surgery often help men regain sexual function earlier. Many men also find it helpful to talk to a counselor during the adjustment period after surgery.

Although most men are able to continue having erections after surgery, a prostatectomy frequently makes them sterile (unable to father children) by causing a condition called “retrograde ejaculation” or “dry climax.” During sexual activity, sperm from the testes enters the urethra near the opening of the bladder. Normally, a muscle blocks off the entrance to the bladder, and the semen is expelled through the penis. Following surgery, the semen takes the path of least resistance and enters the wider opening to the bladder rather than being expelled through the penis. Later it is harmlessly flushed out with urine.

  • Erections
  • Surgery rarely causes a loss of potency. However, surgery cannot usually restore potency that was lost before the operation.

  • Ejaculation
  • Orgasm
Last Review : 26 April 2012
Writer : Dr. Yau Weng Keong
Reviewed : Dr. George Taye