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Enlarged Prostate - Treatment

Overview | Causes | Diagnosis | Treatment | FAQ

Prostatitis

  • The infectious form of prostatitis may be treated with antimicrobial medication. Acute prostatitis may be treated with antimicrobial medication for 7-14 days while chronic prostatitis may require 4 to 12 weeks of medication before the prostatitis is cleared.

  • The non-infectious form of prostatitis may be improved by taking hot baths, drinking more fluids, changing your diet, and ejaculating frequently (to drain the prostate gland and relax the muscles). If muscle relaxation improves your symptoms, your physician may prescribe alpha blockers, drugs that relax the muscle tissue in the prostate and allows urine to flow more freely.

Follow your physician's recommendations and be sure to follow-up in the office with your physician as instructed to make sure your prostatitis has been completely cleared, even if your symptoms have disappeared.

Prostate Enlargement and Bladder Outlet Obstruction

  • Medical Therapy - Symptoms of BPH are often exacerbated by other medications which the patient may be taking. Therefore, the medical management of BPH may be as involved with withdrawing or changing existing medications as adding new ones. Specifically anticholinergic type medications, narcotic analgesics, and sophorifics are detrimental to bladder function. Likewise, alpha adrenergic agents may increase resistance at the bladder neck. Smooth muscle relaxants are another category of drugs which may worsen symptoms of bladder outlet obstruction, because they adversely affect detrussor function.

    • Alpha blockade: The concentration of alpha adrenergic receptors at the bladder neck and proximal urethra is responsible for the strategy of alpha-blocking drugs in the treatment of BPH. These receptors have been characterized as primarily alpha-1 receptors. Phenoxybenzamine was the first alpha blocker to be used in the clinical treatment of BPH but it resulted in significant side effects such as hypotension, nasal stuffiness and dizziness. These side effects were caused primarily by blockage of alpha-2 receptors outside the urinary tract.

      In an attempt to limit these extra-urinary side effects more and more specific alpha-1 blockers have been developed. The alpha-1c subtype receptor has been identified as predominant at the bladder neck. Not unexpectedly, an agent has been designed to target the alpha-1c receptor. It must be cautioned that pharmacologic uroselectivity may not translate to better clinical outcomes. Theoretically the selectivity of the drug may permit increasing its dosage without increasing the severity of vasogenic side effects. The affect of alpha-1 blockade appears to be smooth muscle relaxation in the prostatic capsule and at the bladder neck and clearly addresses only the dynamic component of bladder outlet obstruction. It is also felt that alpha-1 blockade may improve the symptoms of bladder outlet obstruction by a separate mechanism which is neurologically mediated.

      Multiple randomized prospective studies involving the use of alpha-1 blocking agents have shown a definite improvement in symptom scores and a marginal improvement in flow rates compared to placebo. These improvements are lost within a few weeks of discontinuing the medication.

    • Finasteride: The development of finasteride, (5a -reductase inhibitor) for the management of BPH, is a fascinating story. In the 1960s a clinical syndrome called "pseudovaginal penoscrotal hypospadias" was described. In this syndrome the affected subjects had a 46 XY karyotype with normally differentiated testes, normal male internal ducts and ambiguous genitalia. It was discovered that these patients had a deficient or defective type 2, 5a -reductase enzyme. Once it was recognized that a deficiency of this enzyme would produce a clinical syndrome of decreased secondary sexual development it was reasoned that an 5a -reductase inhibitor might be used to induce one aspect of this syndrome in an already developed male, which is involution of the prostate. Since this enzyme has no other known function in the body except the conversion of testosterone to dihydrotestosterone it was felt that blockade of the enzyme could be safely accomplished. The use of selective 5a -reductase inhibitor does not result in decreased sexual activity or breast growth as is the case with other androgen withdrawal therapies. In fact, the serum testosterone level in patients treated with finasteride is normal.

      The efficacy of finasteride as a treatment for BPH has been questioned. The long-term use of finasteride may result in as much as a 30% diminution in the volume of the prostate gland but often requires up to 6 months to achieve that effect. Furthermore, it has not been shown in prostates less than 60 gm that there is a significant improvement in either flow rates or urologic symptoms. In patients with large prostate glands (>60 gm) the use of finasteride may decrease the ultimate risk of developing urinary retention. Finasteride does decrease the serum PSA level without diminishing the risk of prostate cancer. Therefore, its extended use may result in a false sense of security for the clinician who depends on the PSA level for the early diagnosis of prostate cancer.

    • Androgen blockade: One strategy which may be useful in the management of elderly or infirm patients with BPH is the use of androgen blockade. GNRH agonists such as Lupron®; and Zoladex®; may be useful in diminishing prostatic volume by 30% without the need for surgical intervention. The side effects of this treatment include hot flashes and in some cases the loss of bone density and muscle mass. These injections are expensive and may require several months to show any clinical effect. LHRH agonists are not recommended for the treatment of most patients with BPH.

    • Phytotherapy: Phytotherapy is a rapidly emerging field. Patients are well aware of the availability of herbal preparations for the management of a variety of clinical conditions including BPH. Of the currently available phytotherapies, saw palmetto, is the most commonly mentioned and probably the most clinically useful. It is thought that saw palmetto has a mechanism of action similar to finasteride. Although few, if any, good randomized prospective studies exist, the few data which are available suggest that saw palmetto is probably not harmful and may be helpful. It does not appear that saw palmetto materially affects serum PSA levels. Thus far, it does not appear that ginseng, gingko, or other herbal preparations have a significant affect on BPH or its symptom complex.

Minimally Invasive Therapy

    • Thermotherapy: One strategy for the management of BPH and the resultant lower urinary tract symptoms involves the use of heat provided by various generators. The common sources of heat are currently focused-ultrasound, high-energy radiofrequency, laser, and microwave devices. Transurethral microwave therapy (TUMT) makes it possible to obtain high temperatures in the lateral lobes of the prostate while preserving the urethral mucosa. The theoretical advantage of this therapy is that it can be undertaken with local analgesia and sedation only. It does not require the removal of any tissue and because the urethral mucosa is maintained there is a much lower incidence of urinary bleeding and post-therapy obstruction. Clinical studies of the effectiveness of this form of therapy have shown only marginal increases in flow rates but the majority of patients reported an improvement in their symptoms and quality of life. In general, complications were mild but included hematospermia and in the early phases of the development of microwave therapy, thermal injury to both the urethra and the rectum. Part of the value of this and other "heat therapies" may be destruction of sensory nerves in the prostate and urethra.

    • TUNA: Another variation on the administration of heat to prostatic tissue is the transurethral needle ablation of the prostate procedure (TUNA). The instrument consists of a pair of retractable needles which are advanced into the prostatic adenoma. Taking advantage of the high resistance of prostatic tissue to electrical current, heat is generated as current is passed between the needles which results in tissue destruction. This is another therapy which has a theoretical advantage of preserving the urethral mucosa and allows some measure of control regarding the extent of tissue destruction. As with other heat related therapies there is necrosis and edema of tissue, creating a moderate probability of urinary retention postoperatively.

Mechanical Therapies - At least two mechanical therapies for management of BPH deserve mention.

    • Expandable intraurethral prostatic stent. This apparatus can be introduced through a standard cystoscope under assisted local anesthesia and then can be expanded merely by removing it from a sheath. The initial result is a 36-French lumen in the prostatic urethra which greatly facilitates voiding. Because this metal mesh causes little tissue reaction, infection and rejection are unlikely. However, there is an ingrowth of prostatic epithelium over time so that the wire mesh is ultimately covered by polypoid appearing collections of epithelial cells. The obvious potential complications of the use of this technology are transmigration of the stent into the bladder or through the prostate by direct pressure and erosion. A second risk is encrustation of the device over a long period of time. This treatment is generally reserved for patients who are poor surgical risks and who otherwise would require chronic indwelling urethral catheters.

    • Balloon dilation of the prostate. This was one of the earliest forms of minimally invasive therapy for BPH. This strategy involved placing an inflatable balloon across the bladder neck in the prostatic urethra and then expanding it to 36-French. This results in a fracture of the adenoma which must then heal spontaneously. Clinically the procedure was well tolerated but the results were not durable. This procedure is currently seldom utilized.

Incisional / Ablative Therapies

    • TUIP: Intermediate in effectiveness between the heat therapies and ablative therapies for BPH is transurethral incision of the prostate. This procedure is performed through a cystoscope and involves the use of an electrical device for dividing the bladder neck and prostate to the level of the veru montanum. This is accomplished by passing current through a cutting wire and then incising the bladder neck musculature, prostatic adenoma, and prostatic capsule. Because only a single incision is utilized there is minimal bleeding. No prostatic tissue is removed. In selected patients this has been a very useful procedure and reduces the risk associated with a standard transurethral resection of the prostate. Those patients most likely to benefit from TUIP are young patients with small lateral lobes and elevated bladder necks.

    • TURP: The most effective surgical procedure for managing BPH is transurethral resection of the prostate (TURP). This classic procedure is performed through a cystoscope and involves the use of a cutting loop. The prostate is excavated from the level of the bladder neck to the veru montanum. This results in debulking of the lateral adenoma. TURP has resulted in the most objective improvement in flow rate and the best subjective improvement in symptoms. Patients with irritative voiding symptoms will often be unimproved by TURP. Morever, TURP is subject to a number of potential complications. Bleeding is a common problem and may occasionally be severe. The development of scar tissue at the bladder neck (bladder neck contracture) can result in significant obstruction post surgery. Because of the proximity of the external striated sphincter damage incurred during a TURP can result in continuous urinary incontinence. Up to 15% of men report erectile dysfunction or frank impotence following TURP, although the mechanism of the impotence in this setting is not well understood.

  • Laser Technology

    • Lasers may be used to vaporize tissue resulting in a reduction of prostatic tissue comparable to TURP. Interstitial laser therapy induces necrosis of the prostatic tissue while preserving the urethral mucosa. The theoretical advantage of both is less blood loss.

As with all medical interventions, particularly surgical interventions, the key to successful outcomes is patient selection. For instance, TURP has a high probability of retrograde ejaculation and would be a poor selection in a young man for whom fertility is an issue. In that patient population a less invasive and less aggressive approach such as microwave therapy or transurethral incision of the prostate would be more appropriate.

Likewise, in older patients or patients in poor health, a laser-induced prostatectomy or a prostatic stent might be a better choice. Even after appropriate measures have been taken to exclude alternative causes of LUTS, the prevailing attitude of most clinicians and patients is that at least a trial of medical therapy should be tried. After that, a sober evaluation of the risks and benefits of surgical intervention should be undertaken.

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Bibliography

  • BPH Phytotherapy

    • Wilt, T J; Ashani, A; Stark, G; MacDonald, R; Lau, J; Mulrow, C. Saw Palmetto Extracts for Treatment of Benign Prostatic Hyperplasia: JAMA, Vol. 280 (18):1604-1609, November 11, 1998.

    • Vann, Ana. The Herbal Medicine Boom: Understanding What Patients are Taking. Cleveland Clinic Journal of Medicine. Vol. 65(3):129-132, March 1998.

    • Gerber, G S.: Phytotherapy in the Treatment of Benign Prostatic Hyperplasia. Mediguide to Urology. Vol. 11(2):2-8.

  • Minimally Invasive Therapy

    • Laser: Kabalin, J N; Gilling, P J; Fraundorfer, M R: Application of the Holmium: YAG Laser for Prostatectomy. J of Clinical Laser Medicine & Surgery; Vol 16(1):21-27,1998.

  • Thermal Therapy

    • Ramsey, E W; Miller P D; Parsons, K: A Novel Transurethral Microwave Thermal Ablation System to Treat Benign Prostatic Hyperplasia: Results of a Prospective Multicenter Clinical Trial. J of Urology, Vol. 158:112-119; July 1997.

    • Larson, T R; Collins, J M; Corica, A: Details Interstitial Temperature Mapping During Treatment with a Novel Transurethral Microwave Thermoablation System in Patients with Benign Prostatic Hyperplasia. J of Urology, Vol 159:258-264, January 1998.

      • Larson, T R; Bostwick, D G; Corica, A: Temperature-Correlated Histopathologic Changes Following Microwave Thermoablation of Obstructive Tissue in Patients with Benign Prostatic Hyperplasia. Urology, 47(4):463-469, 1996.

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