Benign prostatic hyperplasia (BPH)

Diagnosis

The diagnosis for benign prostatic hyperplasia starts with the assessment of medical history, discussing the existing symptoms and performing a physical exam. This usually includes:

• Rectal examination: This examination allows the doctor to evaluate the prostate size, shape, and consistency essential for proper diagnosis. The doctor will place a lubricated finger into the rectum to palpate the wall of the prostate gland. This procedure usually takes 10-15 seconds.
• Urinalysis: An infection or other illnesses that can produce similar symptoms can be ruled out with the use of a urine sample analysis. This test examines the urine sample for significant elements like blood, infection symptoms, glucose (sugar), protein, and other elements that might help determine the root of the symptoms.
• Blood test: This test examines the blood sample for elements that can point to kidney issues.
• Prostate-specific antigen (PSA) blood test: Very low PSA is detected in the blood when the prostate is healthy. PSA levels may increase as a result of prostate inflammation or benign (non-cancerous) enlargement of the prostate (prostatitis). It can also indicate serious causes such as cancer.

To confirm the diagnosis and rule out other diseases, the doctor may require more tests, such as:

• Uroflowmetry: This test tracks the speed of the urine stream, amount which flows out and how long it takes. Results from tests can be used to assess the urinary tract functions and if the condition improves or worsens over time.
• 24-hour urine monitoring: If more than one-third of the normal daily urination happens at night, keeping track of the frequency and volume of the urination may be very beneficial.
• Postvoid residual volume (PVR): After urinating, a catheter can be inserted into the bladder to measure how much urine remains. This test aims to determine if the patient can totally empty his bladder. This can also be performed using ultrasound technology.

Depending on the severity of symptoms, additional tests may be needed:

• Prostate biopsy: This procedure will help to identify prostate cancer or rule it out by obtaining and looking at the tissue samples of the prostate. The biopsy is usually done with ultrasound guidance.
• Transrectal ultrasound: This uses sound waves to create an image of the prostate gland. This will allow the doctor to see the size and shape of the prostate. In this procedure, a probe will be inserted into the rectum to examine.
• Cystoscopy: This procedure is done under local anesthesia, uses a cystoscope to examine the bladder or urethra. A cystoscope is a pencil-sized illuminated tube with a lens or camera often used by urologist to treat urinary tract problems.
• Urodynamic pressure flow studies: It tests the pressure of the bladder during urination and assess how well the bladder muscles are functioning. This procedure is often recommended to those who have recurring symptoms even after having a prostate surgery. During the procedure, a catheter is inserted into the bladder, then, it will slowly receive an injection of water or, less frequently, air into the bladder.

Treatment

The treatment plan for benign prostatic hyperplasia focuses on the management of the symptoms. The treatment options include medication, surgery, and minimally invasive treatments. The healthcare provider will discuss the best option, which in some cases, a combination of treatments. Factors such as size of prostate, age, general health condition and symptoms are considered in curating an effective treatment plan.

If the symptoms are mild, treatment may not be necessary. However, the doctor might advise a “watchful waiting” or active surveillance strategy, which includes arranging routine appointments to make sure that the BPH does not develop or progress. The doctor may also recommend some lifestyle changes such as diet and exercise to prevent or manage symptoms.

Medication

If the symptoms worsen, prescription drugs may be recommended as part of the treatment. Types of medication include:

• Alpha blockers: These drugs work immediately. They relax the muscles in the bladder and prostate to lessen BPH symptoms. They do not shrink the prostate, but if there is a blockage, they might enhance urine flow. Dizziness, lightheadedness, weariness, and problems ejaculating are possible side effects.

Commonly used alpha-blockers are alfuzosin, doxazosin, tamsulosin and silodosin. It is often recommended for men with moderate to severe BPH.

• 5-alpha reductase inhibitors: These drugs lower the production of dihydrotestosterone (DHT), a more aggressive form of testosterone, that can cause prostate enlargement. Blocking the DHT could reduce the likelihood of BPH issues and the requirement for surgery. Erectile dysfunction, retrograde ejaculation and a decreased libido are the potential side effects. Finasteride and dutasteride are the two 5-alpha reductase inhibitors available. It may take up to six months for these medications to start working.
• Combination drug therapy: Combination of two drugs, alpha blocker and 5-alpha reductase inhibitor may work better together if using only one cannot effectively alleviate the symptoms of BPH. This is often recommended for men with larger prostates. Dizziness, erectile dysfunction, fatigue or a lack of energy, and a dip in blood pressure upon rising from a sitting or lying position are a few possible adverse effects.
• Tadalafil (Cialis): Medicine that treat erectile dysfunction could also be used to treat prostate enlargement.

Surgery

Other treatment options such as minimally invasive procedures and surgery are advised if the symptoms are moderate to severe, medications do not improve the symptoms, pre-existing condition such kidney problem, bladder stones, blood in the urine, or urinary tract obstruction, or surgical procedure are preferred treatment.

Surgery or less invasive therapy may not be an alternative for patients who have:

• Untreated urinary tract infection
• Illness with urethral stricture
• Prior prostate radiation therapy or urinary tract surgery
• Neurologic disease, such as multiple sclerosis or Parkinson’s disease

There are many treatments for BPH that are minimally invasive or surgical.

• Transurethral resection of the prostate (TURP): TURP requires slicing the tissue of the prostate and removing it using an electric current of laser. The doctor uses a resectoscope which provides an electrical loop, irrigating fluid, and light during the surgical procedure. The electrical loop closes the blood vessels while severing the tissue. A catheter is used to flush the excised tissue into the bladder and out of the body. Many men see a quicker relief from symptoms after TURP, and their urine flow usually improves right away. TURP is often recommended for men who need surgery due moderate to severe symptoms.
• Transurethral incision of the prostate (TUIP): TUIP is done to expand the urethra. This improves urination and reduces the strain of the prostate on the urethra. During the procedure, the surgeon will make tiny incisions in the prostate gland and the bladder neck to facilitate urine passage via the urethra. After the surgery, a catheter is placed in the bladder for one to three days. This procedure is an option for men with existing health issues and men who do not want to have their prostate completely removed.
• Transurethral microwave thermotherapy (TUMT): TUMT uses microwave energy to shrink the enlarged prostate gland and improve urine flow by destroying the prostate. It can eliminate blockage in the bladder. During the procedure, a urologist puts a catheter through the urethra to the prostate. The microwaves are sent through the catheter to heat up and destroy the enlarged tissue. This is considered a low-risk treatment and is often recommended to those with existing medical issues and small prostates in unusual cases.  It could take some time before improvements from TUMT is felt.
• Transurethral needle ablation (TUNA): TUNA uses radio waves to heat and burn away extra prostate tissue that is obstructing urine flow. During the surgery, radiofrequency needles are inserted through the urethra then targets the prostatic tissue that is pushing or protruding on the urethra. Although the treatment is no longer frequently utilized, TUNA may still be used in some circumstances.
• Laser therapy: In comparison to non-laser surgery, laser therapy can provide an immediate relief from BPH symptoms. Lasers can get rid of overgrown prostate tissue. Men who are using blood-thinning medications, those with weak hearts and those that are not eligible for other prostate operations may be the best candidates for laser therapy as this carries minimal risk of adverse effects.

Common laser treatments are:

• • Ablative procedures: Prostate tissue can be vaporized through photoselective vaporization (PVP) and holmium laser ablation of the prostate (HoLAP). To improve urine flow, these techniques vaporize the obstructing prostate tissue. Except those with the large prostates, most men can benefit from this treatment. However, some patients might experience uncomfortable urinary symptoms following the surgery.
  • Enucleative procedures: Holmium laser enucleation of the prostate (HoLEP) and Thulium laser enucleation of the prostate (ThuLEP) aims to stop further tissue growth and destroy excess prostate tissue that is obstructing urine flow. Prostate cancer and other diseases can be detected in the excised tissue. HoLEP and ThuLEP have the same procedure but uses different type of laser. Both does not require any incisions.
• Prostatic urethral lift (PUL): PUL inserts microscopic implants into the prostate using a needle. The swollen prostate is lifted and compressed by these implants, clearing the urethra, and allowing easier urination. Depending on the size of the prostate, the doctor may put two to six implants. This is often recommended for men who are concerned about how therapy would affect their erectile dysfunction and ejaculatory issues, and those who experience lower urinary tract symptoms.
• Embolization: This procedure reduces the size of the prostate by specifically cutting off the blood supply to or from the prostate. This treatment is an ongoing research and experimentation and has no significant evidence of its effectiveness.
• Open or robot-assisted prostatectomy: A prostatectomy involves laparoscopic or robotic surgery to remove the entire prostate gland. The procedure requires to open the lower abdomen to access the prostate and remove the tissue. This is often performed with a robotic device and is only available to individuals with large prostate glands, bladder injury, or other health complications. The patient may be required to spend a few days in the hospital and temporarily use a catheter after the surgery. Prostatectomy is a permanent solution to BPH.