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by Kevin T. McVary, MD

Dr. Kevin T. McVary is Professor and Chairman of Urology at Southern Illinois University School of Medicine in Springfield, IL and a specialist in prostate diseases and erectile dysfunction

Kevin T. McVary, MD ©photo by Cissy Lacks
BPH (Benign Prostatic Hyperplasia) is one of the most common conditions of the aging male.

It is a non-cancerous enlargement or growth of the area in the prostate gland that is nearest the urethra. This growth can block or constrict the urethra, causing urination problems.

Although BPH is a common condition, it doesn’t always result in symptoms that need treatment. LUTS (Lower Urinary Tract Symptoms) is the name given to the actual symptoms, not the condition. LUTS affects when and what treatments should be prescribed.

Recent information shows an association between LUTS and erectile dysfunction (ED) in that lifestyle factors exercise, weight gain and obesity also appear to have an impact on LUTS.

Treat When Bothersome

Research in BPH is focusing on growth factors that promote prostate enlargement. Two areas of special interest are: the study of nerve activity which causes the prostate to grow faster and hormone production which affects growth of the prostate.

Having symptoms is one thing. Being bothered by them is another.

The patient is the only one who can tell the severity of his symptoms by the sense of “bothersomeness.”

For example, some men don’t mind getting up in the middle of the night to go to the bathroom. They go right back to bed. Others, once they wake up, can’t get back to sleep. For them, the symptom creates a major problem and they want it to be treated.

For example, some men don’t mind getting up in the middle of the night to go to the bathroom. They go right back to bed. Others, once they wake up, can’t get back to sleep. For them, the symptom creates a major problem and they want it to be treated.

BPH is common, but bothersome symptoms shouldn’t be accepted. Treating LUTS is one of the gratifying aspects of being a urologist. After conventional treatment, whichever option is used, patients almost always have less bothersome symptoms.

On the other hand, all treatments from medications to surgery have some risk; therefore, men should not begin any treatment until their symptoms are bothersome unless there are signs that overall health is being impacted.

Bothersome Symptoms

The following are symptoms, and their causes, which can be bothersome:

Need to urinate often during the day and night (called nocturia) is a first symptom.

A weak or interrupted urinary stream (called intermittency) results when the prostate obstructs the urethra, causing the bladder to work harder to increase the pressure.

Eventually, the bladder, as a pump, starts to weaken and symptoms increase as the pump increasingly fails.

Even when the bladder feels full, it’s difficult to start the urine flow. The weak bladder needs more time to build up strength to pump out the urine.

Feeling the bladder isn’t completely empty is also caused by a weakened bladder functioning as a less effective pump.

Symptoms Mandating Treatment

Men should know the signs that mandate treatment:

Recurrent infection of the urinary tract that relates to the blockage.

Bladder stones that develop because the urine stays in the bladder too long, resulting in urine salts accumulating and forming bladder stones.

An increasing amount of post void residual urine, which causes the urine left behind to make the bladder floppy. A urologist will be able to diagnose this condition.

Recurrent blood in the urine.

Renal, or kidney, deterioration because of increased bladder pressure.

With any of the above symptoms, a urologist should be telling the patient, “It’s time to get treatment now.”

Treatments

Treatments vary from prescription drugs, minimally invasive therapy, and conventional surgical treatment.

Men should begin by going to an experienced urologist who prescribes and performs a variety of treatments. If a patient goes to a urologist who specializes in one treatment, the others often aren’t given as options.

An enlarged prostate and prostate cancer have no apparent connection, but men having symptoms associated with an enlarged prostate should always check with a doctor to rule out prostate cancer before concluding they have BPH.

Drug Treatment

Although surgery has the best outcomes, patients often choose to start treatment with drugs or minimally invasive procedures.

When patients have the option of choosing less risk, knowing it’s also with less benefit, they seem first to choose the treatment with the least risk. Usually that means starting with drugs.

What seems to be the most effective drug treatment now is a combination therapy of both alpha blockers (Hytrin (terazosin), Cardura (doxazosin), Flomax (tamsulosin), Uroxatral (alfuzosin) or Rapaflow (silodosin), which relax the smooth muscle of the prostate and bladder neck, and finasteride (Proscar) or dutasteride (Avodart), also known as 5-Alphareductase Inhibitors (5-ARIs) which can stop growth of the prostate or possibly shrink it.

Considerations When Taking Drugs

I agree with Dr. Catalona who informs patients that taking Proscar or Avodart has the potential of masking prostate cancer symptoms by lowering PSA levels.

Accordingly, I do not recommend these medications unless patients are at risk of developing urinary retention and of needing surgery to relieve it.

In these cases, if their PSA is higher than 2.5 or their PSA velocity is higher than 0.35, I, and Dr. Catalona, recommend performing a prostate biopsy to rule out prostate cancer before beginning the 5-alpha-reductase inhibitor (5-ARI).

Once the 5-ARIs have been started, it is important to monitor the PSA values to ensure they respond accordingly. They should drop by 50% within 4-6 months.

Alpha blockers, on the other hand, are now known to have the potential for creating complications during cataract surgery. Men need to inform their doctors about planned surgery, and they should avoid starting on alpha blockers until their cataract surgery is completed.

Men seem drawn to the appeal of reducing symptoms with dietary supplements. Rigorous studies showed no benefit from supplements, and they are not recommended.

Newly Approved

Recently, Cialis (tadalfil), once-a-day, was approved for the treatment of LUTS secondary to BPH. It is quite interesting that a medication to improve erectile dysfunction would also improve urinary symptoms but that is clearly the case. The level of improvement noted with Cialis is similar in scope to what one sees when using alpha blockers.

Minimally Invasive Therapies

Minimally invasive therapies (microwave, electrovaporization, laserresection) need to be tailored to the individual patient.

In 50% of my patients, I would not recommend these minimally invasive alternatives.

For example, if the prostate gland is too small, the procedures are not safe because they could cause damage in areas beyond the prostate.

In glands that are too big, the procedures can’t take out the necessary amount without causing other problems, such as swelling.

Minimally invasive therapies can be effective but only for certain patients.

Surgical Therapy

In terms of surgery, the most common operation is TURP (transurethral resection of the prostate) where parts of the enlarged tissue are peeled off. If drugs can’t prevent acute urinary retention, TURP is often the only treatment choice.

But even without acute urinary retention, TURP is the choice with potentially the best results for alleviating symptoms from an enlarged prostate.

Generally, transurethral laser approaches have been associated with shorter catheterization time and length of stay with comparable improvements in symptoms compared to open surgery.

As with all new devices, given the rapid evolution in technologies, study comparisons between procedures should be researched carefully.

The choice of approach should be based on the patient’s condition, his anatomy, the surgeon’s level of training and experience, and a discussion of the potential benefits and risks for complications.

Some men worry about the risks of impotency and incontinence with TURP. In some studies, the surgery has been linked to erectile dysfunction in 14% of men treated and urinary incontinence in 5%, but these outcomes have not been linked directly to the operation and possibly would occur in this percentage of men without the surgery.

With an experienced urologist, TURP is an excellent and usually most effective treatment choice.

AUA Guidlines

The most recent guidelines for diagnosing and treating BPH can be found at auanet.org (website of the American Urological Association or the specific URL address: http://www.auanet.org/content/clinical-practiceguidelines/clinical-guidelines.cfm

When at the homepage of the AUA website, open Products in the top categories and click on “clinical guidelines.”

Scroll down to “Under Clinical Practice Guidelines” and click on “Benign Prostatic Hyperplasia (BPH).”

Also, by searching the topic on the AUA homepage, readers can get doctors’ comments about the guidelines.

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