 Fifty
percent of all men will develop the signs and symptoms of an enlarged
prostate. The question, does it need to be treated and when and how do you
treat this problem is frequently difficult to answer. The gland normally produces semen and is positioned around the neck of the
bladder, surrounding the urethra, or urine tube through which urine passes. It can enlarge
and obstruct the bladder neck and the urethra causing significant urinary symptoms. The
actual cause of this enlargement is not known, but appears to be related to the
testosterone/estrogen ratio which changes as men get older, causing the formation of an
enlarged prostate, otherwise known as benign prostatic hyperplasia (BPH). As men get
older, the glandular as well as the fibromuscular elements of the prostate gland increase
in size.
Even though the prostate can get quite large, some patients
often have no symptoms. Treatment is not necessary in these patients. On the other hand,
the prostate may cause symptoms such as urinary obstruction, hesitancy of urination,
decreased stream, frequent awakening at night (nocturia), frequency and urgency control
problems. In some situations the patients may go into urinary retention and, even more
rare, obstruction of the kidneys with hydronephrosis and possible kidney failure.
If there is kidney failure, or obstruction to the kidneys, or
urinary retention, treatment is necessary and usually limited to a surgical approach where
the obstructing tissue of the prostate, that is to say the benign tumor that has grown on
the prostate, is removed.
This can be done through an open operation in which an
incision is made in the lower abdomen and the benign tumor is removed from the prostate,
eliminating the obstructing tissue. It can also be accomplished by doing a transurethral
resection, in which an instrument is placed in through the opening of the penis into the
bladder, seeing the obstructing prostate tissue as it compresses the urethra and using a
rectoscope, a special electro cutting instrument, the inside of the prostate is removed in
chunks and pieces which are sucked out of the bladder. The procedure is similar to
removing the core of an apple, enlarging the lumen through which the urine passes.
Both open prostatectomy and transurethral resection involves
hospitalization, anesthesia a surgical procedure, in which tissue is resected (cut away)
with the potential of blood loss and need for transfusion. In the case of kidney failure
and urinary retention, these procedures are being done for relatively serious situations
that would require an aggressive approach. In general, however, considering the age of
most of these patients these procedures are safe and affective.
The bulk of patients who are symptomatic with benign
prostatic hyperplasias. and enlargement of the prostate fall into groups of patients who
have varying degrees of symptoms. Medication, or procedures to relieve the obstruction,
become, for all practical purposes, the decision of the patient since the medications and
procedures are being utilized basically to relieve symptoms and if the symptoms are not
uncomfortable for the patient, nor changes his lifestyle significantly, or the patient
himself feels uncomfortable, therapy is not necessary.
Most patients today also may be helped by pharmacological
treatment with either an alpha one blocker or a pharmacological inhibitor. For those
glands that are large and "juicy," drugs that block the conversion of
testosterone to the active intracellular dihydrotestosterone, such as Proscar by Merck may
be effective in approximately 50 percent of the patients. The drugs are slow acting so if
the symptoms are severe other therapy may be added or initiated.
Treatment takes at least three to six months to see an effect
and if one wants rapid results these drugs do not appear to be a good choice. Proscar or
Finasteride, also by Merck, is the drug of this type most easily available to patients.
Its side effects are almost none although a small percentage of patients may have sexual
function difficulties. There appears to be no significant drug interactions or
contraindications and its safety appears to be one of its great virtues.
Alpha one blockers including Hytrin, Cardura by Pfizer, and
Flomax by Boehringer Ingelheim are the main oral drugs used by patients who have mild to
moderate symptoms. These drugs do not shrink the prostate; however, they cause relaxation
of the fibromuscular component especially around the back of the bladder neck area. Since
the prostate does not shrink in time most patients will continue to develop enlarging of
the prostate and many will need other therapies.
On the other hand, most patients will get a significant
response to the alpha one blockers and may not need any other treatment. The side effects
of alpha one blockers include a decrease in blood pressure with associated dizziness and
generalized weakness. On rare occasions nasal stuffiness to a severe degree may occur
necessitating discontinuation of the drug. In general alpha one blockers appear to be
effective in two thirds of patients with significant but not severe urinary symptoms
related to enlargement of the prostate.
We have talked about drug therapy for benign prostatic
hypertrophy or BPH. However, what else is available to patients who have tried medical
therapy and have not gotten optimal results, are unable to tolerate the drugs, or for
various purposes do not wish to or cannot take medications. We have already talked a
little bit about transurethral resection which is indicated in those patients who have
kidney failure and probably urinary retention (unable to void).
There are, however, other less invasive procedures than
transurethral resection of the prostate in which the core of the prostate gland is removed
allowing for opening of the urinary passageway and proper voiding. Approximately 20% of
the patients who have this procedure which is normally done through the penis with
anesthesia may have bleeding, urinary incontinence, and possible sexual dysfunction, and
it is a true surgical procedure that requires cutting out of tissue and significant
anesthesia. Transurethral resection is a standard procedure which does the job, and in
most patients does it safely and appropriately.
On the other hand patients have alternatives. Firstly, a
stent similar to the stents placed in coronary arteries in patients with heart disease can
be placed in the urethra around which the prostate exists. The compression of the prostate
on the urethra is relieved by the expansion of the stent. The stent is a non-iron-bearing,
super-alloy, woven, metallic tunnel that expands and pushes outward after it is inserted
in the urethra without an incision and through the urine opening with special instruments.
The procedure takes less than ten minutes, requires minimal
anesthesia, no cutting, minimal bleeding, and over several months the lining of the
urethra will cover the stent as the stent becomes imbedded into the prostate tissue.
Preliminary studies indicate that the long-term eight year results with stents require
less surgery and problems than the eight to ten year results with transurethral resection.
Indigo laser treatment of the prostate is also simple and
safe. It requires a cystoscopic or urethral evaluation of the prostate gland as it
compresses the urethra. If it is only the lateral lobes that are obstructing the Indigo
laser probe can be pierced through the urethra into the substance of the prostate gland.
An Indigo laser light then penetrates through this rod into
the substance of the prostate increasing its temperature, coagulating the prostate, and
damaging the prostate tissue. It is this damage when it heals that causes to shrink up and
relieve the obstruction. This procedure is quite simple, takes approximately 20 to 30
minutes depending on how many sticks are necessary in the prostate, but usually requires
some form of catheterization for three to ten days post surgery, and many times several
weeks to months before optimal results are realized. Bleeding is uncommon, but it may
occur. And in appropriately selected patients it is quite a simple, effective, and safe
way of resolving the problem.
There are many other procedures that require the cooling or
heating of the prostate in order to injure the prostatic tissue and allow for shrinking up
of the prostate secondary to the injury. This would including transurethral microwave
therapy, other forms of contact and non contact laser prostatectomy, cryotherapy of the
prostate, and more recently the development of hot water balloon therapy of the prostate
in which the prostate is heated by hot water through a balloon that is placed in the
prostatic urethra.
Which form of minimally invasive or minimally surgical
procedure you desire should be made by discussion with your surgeon. His expertise in a
particular technique is one of the most important factors in deciding which procedure you
should have done to you. Most of these minimally invasive procedures work in the majority
of cases, and in those in which the procedure is not effective transurethral resection can
always be done and resolve the urinary obstructive symptoms.
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