Benign Prostatic Hyperplasia BPH - Causes, Symptoms And Treatments

Everything in life has its zeniths and nadirs. That’s what we call the rise and fall. The male urinary stream is no exception, as it falls prey to the might of the enlarging ‘prostate’ that engulfs the ‘prostatic urethra’ with advancing age.

A LITTLE MORE ABOUT THE PROSTATE

This chestnut shaped secretory gland is broader than it is long and serves no other purpose than to bulk the volume of semen and nourish sperm. It lies just below the bladder and surrounds the first 3 cm of urethra. This portion of the urethra which runs through the prostate is known as the ‘prostatic urethra’.
The prostatic urethra receives the opening of two prostatic ducts which carry the prostatic secretions. Another set of sex juice glands, the ‘Seminal Vesicles’ also deposit their secretions via the ejaculatory ducts here into the prostatic urethra. Enlarged prostate leads to compression and progressive occlusion or ultimately obstruction of the ‘Prostatic urethra’.

The Enlarged Prostate Problem

Benign Prostatic Hyperplasia or BPH is nothing but a non malignant increase in the prostatic tissue mass or size and occurs in men over 50 years of age; by age 60, 50% of men have histological (microscopic) evidence of BHP and 15% have lower urinary tract symptoms.

WHAT CAUSES PROSTATIC ENLARGEMENT?

As serum Testosterone levels decline slowly but significantly with advancing age, there occurs an imbalance between Testosterone and the feminine hormone estrogen (which is also present in men albeit in low quantities).
This relative rise in estrogen levels stimulates growth in the submucus glands of the ‘Transitional zone’. The enlarging TZ glands compress the ‘Peripheral Zone’ giving rise to typical lateral lobes and a false capsule.

‘PROSTATISM’ – SYMPTOMS OF AN ENLARGED PROSTATE

BHP has a chronic and an insidiously progressive course during which symptoms arise either out of irritation or obstruction to the urinary tract.

IRRITATIVE

Frequency (increased frequency of urination), Nocturia (excessive urination at night), Urgency (heightened desire to urinate), Urge incontinence (inability to hold urine the moment the desire to urinate sets in).

OBSTRUCTIVE

Hesitancy (desire to urinate, but very little or no urine flows), Poor flow (the urine flow is with a low pressure and appears as though it is coming from a choked pipe!), Intermittent stream (urine flows then ceases then re-starts, all the while with low pressure), Dribbling (the urine flow pressure is very low and one can note rapid drops falling rather than a steady stream), Retention (inability to pass urine)

ASSESSMENT OF THE ENLARGED PROSTATE

RECTAL EXAMINATION
The urologist determines enlarged prostate vide digital palpation of the gland through the rectal mucosa. Distended bladder may also be felt.
TRANSRECTAL ULTRASOUND SCANNING
Accurate estimation of Prostatic size is possible.
PSA OR ‘PROSTATE – SPECIFIC ANTIGEN’
Values in excess of 4 nmol/l mandate ultrasound scanning and multiple transrectal biopsies. This test guides in discerning benign from malignant prostatic enlargement.

TREATMENT OF ENLARGED PROSTATE

Drugs are useful in men who are awaiting TURP surgery (see below), in those who are concerned about sexual dysfunction after surgery and in mild disease. The two cornerstones of drug therapy are Finasteride ( Proscar) and Terazosin.

ALPHA1 ADRENERGIC BLOCKERS

Tamsulosin (FLOMAX) and Terazosin (HYTRIN) are examples of this group of drugs. A1 adrenergic blockers work by affecting the dynamic component of urinary outflow obstruction.
These drugs relax the smooth muscle tone (alpha adreno receptor blockade) of the bladder, prostate and prostatic urethra thus improving urinary outflow. Therefore there is an increase in the urinary flow rate and pressure and more complete emptying of the bladder in up to 80% of patients with mild to moderate BHP.
FLOMAX or HYTRIN are the drugs of choice in treating BHP medically as they afford faster relief (within 2 weeks) as opposed to Finasteride (Proscar) which takes up to six months to produce clinical improvement.
Dizziness and retrograde ejaculations are the only significant side effects. Rarely postural hypotension, depression and nasal congestion have been reported.

5ALPHA REDUCTASE INHIBITORS

Finasteride (PROSCAR, PROPECIA, FINAST) and Dutasteride (AVODART ) are examples. Proscar works by preventing the formation of DHT or di hydro testosterone an active derivative of the male hormone testosterone. DHT is responsible for smooth muscle hypertrophy and prostatic glandular enlargement.
Proscar however needs a minimum of six months to bring about shrinkage of an enlarged prostate. Men with absolute prostatic volumes in excess of 40ml benefit most. Proscar is used in a dose of 5mg per day to achieve prostatic size reduction.
Side Effects Of Proscar include decreased libido, impotence, decreased ejaculate volume, skin rashes and swelling of lips.

COMBINATION THERAPY

This is the ideal method employed nowadays. A combo of Tamsulosin (FLOMAX) and Dutasteride (AVODART) is employed to achieve adequate urinary outflow as well as size reduction of the enlarged prostate.

Surgical Management OF Enlarged Prostate

Several options are available and each has its merits and disadvantages.

Transurethral Resection Of The Prostate (TURP)

This is an endoscopic procedure wherein strips of prostatic tissue are cut from the bladder neck downward up to the verumontanum using high-frequency diathermy current. Post operative bleeding and clot retention are problems. Delayed complications include impotence in approximately 14% cases and the need for repeat procedure in 20% cases within 10 years.

Transurethral incision of the prostate (TUIP)

TUIP is less damaging in terms of sexual dysfunction than TURP. This procedure aims at relieving pressure on the urethra. It is also less damaging than TURP and post operative clot retention problems are uncommon.

Transurethral Laser Induced Prostatectomy or TULIP

Transurethral Laser Induced Prostatectomy employs laser as the prostate cutting tool as opposed to diathermy in TURP.

Retropubic Prostatectomy Surgery

Retropubic Prostatectomy Surgery is the open surgical method of removing the prostate vis a vis the endoscopic methods listed above.

Managing Benign Prostatic Hyperplasia (Enlarged Prostate Problem)- Conclusion

Voiding the bladder is as essential as it is relieving. Any interference in the outflow of urine is both painful and distressing. Chronic retention, urinary infection, urinary calculi (stones) and renal insufficiency (kidney damage) are the complications to be expected in cases left unattended or poorly treated. With therapies ranging from FINAST to TURP, enlarging prostates are amenable to treatment.