Decisions regarding treatment are based on
the severity of symptoms (as assessed by the AUA Symptom Index), the extent
of urinary tract damage, and the man's and overall health. In general no treatment
is indicated in those who have only a few symptoms and are not bothered by them.
Intervention -usually surgical- is required in the following situations:
inadequate bladder emptying resulting
in damage to the kidneys
complete inability to urinate
after acute urinary retention
incontinence due to overfilling
or increased sensitivity of the bladder
infected residual urine
recurrent severe hematuria
symptoms that trouble the patient
enough to diminish his quality of life
Treatment decisions are more difficult for men with moderate symptoms. They
must weigh the potential complications of treatment against the extent of their
symptoms. Each individual must determine whether the symptoms bother him enough,
or interfere with his life enough, to merit treatment. When selecting a treatment,
both patient and doctor must balance the effectiveness of different forms of
therapy against their side effects and costs.
Treatment options for
Currently, the main treatment options for BPH are:
If medications prove ineffective in a man who is unable to withstand the rigors of surgery, urethral obstruction and
incontinence may be managed by intermittent catheterization or an indwelling Foley catheter (which has an inflated balloon at the end to
hold it in place in the bladder). The catheter can stay in place indefinitely (in which case, it is usually changed monthly).
Because the progress and complications of BPH are unpredictable, a
strategy of watchful waiting-meaning, no immediate treatment is attempted-is
best for those with minimal symptoms that are not especially bothersome.
Physician visits are needed about once a year to review the progress
of symptoms, carry out an examination, and do a few simple laboratory
tests. During watchful waiting, the man should avoid tranquilizers
and over-the-counter cold and sinus remedies that contain decongestants.
These drugs can worsen obstructive symptoms. Avoiding fluids at night
may lessen nocturia.
Drug treatment of BPH is a new development, and data is still being
gathered on the benefits and possible adverse effects of longterm
therapy. Currently, two types of drugs-5-alpha-reductase inhibitors
and alpha-adrenergic blockers-are used to treat BPH. Preliminary research
suggests that these drugs improve symptoms in 30 to 60% of men taking
them, but it is not yet possible to predict who will respond to medical
therapy, or which drug will be better for an individual patient.
Finasteride (Proscar) blocks the conversion of testosterone to dihydrotestosterone,
the major male sex hormone found within cells of the prostate. In
some men, finasteride can relieve BPH symptoms, increase urinary flow
rate, and actually shrink the size of the prostate, though it must
be used indefinitely to prevent recurrence of symptoms. It may take
as long as six months, however, to achieve maximum benefits from finasteride.
In a study of its safety and effectiveness two-thirds of the men taking
the drug experienced
at least a 20% decrease
in prostate size
(only about half had achieved this level of reduction by the one-year
one-third of patients
had improved urinary flow
and two-thirds felt
some relief of symptoms
One study published last year suggests that finasteride may be best suited for men with relatively large prostate glands.
An analysis of six studies found that finasteride only improved BPH symptoms in men with an initial prostate volume of
over 40 cc (cubic centimeters); finasteride did not reduce symptoms in men with smaller glands. Since finasteride shrinks
the prostate, men with smaller glands are probably less likely to respond to the drug because the urinary symptoms result
from causes other than physical obstruction (for example, smooth muscle constriction). A recent study showed that over a 4-year
period of observation, treatment with finasteride reduced the risk of developing urinary retention or requiring surgical treatment by 50%
Finasteride causes relatively few side effects. Impotence occurs in 3 to 4% of men taking the drug. Finasteride may also decrease
the size of the ejaculate. Another adverse effect is gynecomastia (breast enlargement). About 80% of those who stopped taking the drug
had a partial or full remission of their breast enlargement. A study from England found gynecomastia in 0.4% of patients taking the drug.
Because it is not clear that the gynecomastia is caused by the drug or increases the risk of breast cancer, men taking the drug are
being carefully monitored until these issues are resolved.
Finasteride can lower PSA levels by about 50%, but is not thought to limit the utility of PSA as a screening test for prostate cancer.
The fall in PSA levels, and any adverse effects on sexual function, disappear when finasteride is stopped.
To get the benefits of finasteride for BPH without compromising the detection of early prostate cancer, men should have a PSA test before
starting treatment with finasteride; subsequent PSA values can then be compared to this baseline value. If a man is already on finasteride
and no baseline PSA level was obtained, the results of a current PSA test should be multiplied by two to estimate the true PSA level.
A fall in PSA of less than 50% after a year of finasteride treatment suggests either that the drug is not being taken or that prostate
cancer might be present. Any increase in PSA levels while taking finasteride also raises the possibility of prostate cancer.
These drugs, originally used to treat high blood pressure, reduce
the tension of smooth muscles in blood vessel walls and also relax
smooth muscle tissue within the prostate. As a result, daily use of
an alpha-adrenergic bloeftv drug may increase urinary flow and relieve
symptoms of urinary freurgency, and nocturia. A number of alpha-l-adrenergic
drugs-doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin),and
tamsulosin (selective alpha I-A receptor blocker- FLOMAX) for example-have
been used for this purpose. One recent study found that 10 mg of terazosin
daily produced a 30% reduction of BPH symptoms in about two-thirds
of the men taking the drug. Lower daily doses of terazosin (2 and
5 mg) did not produce as much benefit as the 10 mg dose. Thus, the
authors of this report recommended that physicians gradually increase
the dose to 10 mg unless troublesome side effects occur. Possible
side effects of alpha-adrenergic blockers are: orthostatic hypotension
(dizziness upon standing, due to a fall in blood pressure), fatigue,
and headaches. In this study, orthostatic hypotension was the most
frequent side effect. The authors noted that this problem can be mitigated
by taking the daily dose of the drug in the evening. In another study
of over 2,000 BPH patients, a maximum of 10 mg of terazosin reduced
average AUA Symptom Index scores from 20 to 12.4 over one year, compared
to a drop from 20 to 16.3 in patients taking a placebo.
An advantage of alpha blockers, compared to finasteride, is that they work almost immediately; they have the additional benefit of treating
hypertension when it is present in BPH patients. However, whether terazosin is superior to finasteride may depend more on the size of the
prostate. When the two drugs were compared in a study published in The New England journal of Medicine, terazosin appeared to produce greater
improvement of BPH symptoms and urinary flow rate than finasteride. But this difference may have been due to the larger number of men in the
study with small prostates, who would be more likely to have BPH symptoms from smooth muscle constriction, rather than from physical obstruction
by excess glandular tissue. Doxazosin was evaluated in three different clinical studies involving 337 men with BPH. Patients took either a placebo or 4 to 12 mg of doxazosin a day. The active drug- reduced urinary symptoms by 40% more than the placebo, and increased the urinary peak flow by an average of 2.2 ml/s (compared to 0.9 ml/s in the placebo patients).
Despite the previously held belief that doxazosin was only effective for mild or moderate BPH, patients with severe symptoms experienced
the greatest improvement. Side effects-including dizziness, fatigue, hypotension (low blood pressure), headache, and insomnia-led to
withdrawal from the study by 10% of those on the active drug, and 4% of those taking the placebo. In men treated for hypertension, the
doses of other antihypertensive drugs may need to be adjusted to account for the blood-pressure-lowering effects of an alpha-adrenergic
blocker. These drugs may also induce angina in men with coronary heart disease. A doctor will be able to determine which individuals are
good candidates for their use.
Surgery ( Prostatectomy)
Prostatectomy is a very common-operation: About 200,000 of these procedures
are carried out annually in the U.S. A prostatectomy for benign disease
(BPH) involves removal of only the inner portion of the prostate (simple
prostatectomy). This operation differs from a radical prostatectomy
for cancer, in which all prostate tissue is removed. Simple prostatectomy
offers the best and fastest chance for improving BPH symptoms, but
may not totally alleviate discomfort. For example, surgery may relieve
the obstruction, but symptoms may persist due to bladder abnormalities.
Surgery is also associated with the greatest number of long-term complications, including:
(ejaculation of semen into the bladder rather than through the penis)
the need for a second operation (in 10% of patients after five years) due to continued prostate growth or a urethra stricture resulting
While retrograde ejaculation carries no risk, it may cause infertility and anxiety. The frequency of these complications depends
on the type of surgery.
Surgery is delayed until any urinary tract infection is successfully treated and kidney function is stabilized
(if urinary retention has resulted in kidney damage). Men taking aspirin should stop taking the drug 7 to 10 days prior to surgery,
since aspirin interferes with blood's ability to clot. Transfusions are required in about 6% of patients after TURP and 15% of patients
after open prostatectomy.
Since the timing of prostate surgery is elective, men who may need a transfusion-primarily those with a very large prostate,
who are more likely to experience significant blood loss-have the option of donating their own blood in advance, in case they need
it during or after surgery. This option is referred to as an autologous blood transfusion.
This procedure is considered the "gold standard" of BPH treatment-the
one against which other therapeutic measures are compared. It involves
removal of the core of the prostate with a resectoscope-an instrument
passed through the urethra into the bladder . A wire attached to the
resectoscope removes prostate tissue and seals blood vessels with
an electric current. A catheter remains in place for one to three
days, and a hospital stay of one to two days is generally required.
TURP is associated with little or no pain, and full recovery can be
expected by three weeks after surgery. In carefully selected cases
(patients with medical problems and smaller prostates), TURP may be
possible as an outpatient procedure.
Improvement after surgery is greatest in those with the worst symptoms. Marked improvement occurs in about 93% of men with severe symptoms
and in about 80% of those with moderate symptoms. The mortality from TURP is very low (0.1%); however, impotence follows TURP in about 5 to 10%
of men and incontinence occurs in 2 to 4%.
incision of the prostate (TUIP)
This procedure was first used in the U.S. in the early 1970s. Like
TURP, it is done with an instrument that is passed through the urethra.
But instead of removing excess tissue, the surgeon only makes one
or two small cuts in the prostate with an electrical knife or laser.
These incisions relieve pressure on the urethra. TUIP can only be
done on men with smaller prostates. It takes less time than TURP,
and can be performed on an outpatient basis under local anesthesia
in most cases. A lower incidence of retrograde ejaculation is one
of its advantages.
An open prostatectomy is the operation of choice when the prostate
is very large - e.g.>80 grams-(since transurethral surgery cannot
be performed safely in these men). However, it carries a greater risk
of life-threatening complications in men with serious cardiovascular
disease, since the surgery is more extensive than TURP or TUIP.
In the past, open prostatectomies
for BPH were carried out either through the perineum (the area between
the scrotum and the rectum)-called perineal prostatectomy--or through
a lower abdominal incision. Perineal prostatectomy has largely been
abandoned for the treatment of BPH due to the higher risk of injury
to surrounding organs, though it is still used for prostate cancer.
Two types of open prostatectomy for BPH-suprapubic and retropubic-employ
an incision extending from below the umbilicus (navel) to the pubis.
A suprapubic prostatectomy involves opening the bladder and removing
the enlarged prostatic nodules through the bladder. In a retropubic
prostatectomy, the bladder is pushed upward and the prostate tissue
is removed without entering the bladder. In both types of operation,
one catheter is placed in the bladder through the urethra, and another
through an opening made in the lower abdominal wall. The catheters
remain in place for three to seven days after surgery. The most common
immediate postoperative complications are excessive bleeding and wound
infection (usually superficial). More serious potential complications
include heart attack, pneumonia, and pulmonary embolus (blood clot
to the lungs). Breathing exercises, leg movements in bed, and early
ambulation are aimed at preventing these complications. The recovery
period and hospital stay are longer than for transurethral prostate
RETROPUBIC AND SUPRAPUBIC OPEN PROSTATECTOMY
Misop Han, M.D., M.S. Alan W. Partin,
M.D., Ph.D. Modified from Han and Partin -
Chapter 89, Campbell-Walsh Urology 9th Edition, 2006,
Editors: Wein, Kavoussi, Novick, Partin and Peters., Elsevier
INTRODUCTION: The treatment
options for bladder outlet obstruction due to benign prostatic
hyperplasia (BPH) have been expanded dramatically over the past
two decades with the development of medical and minimally invasive
therapies. Minimally invasive procedures include visual laser
ablation of the prostate (VLAP), transurethral electrovaporization
of the prostate (TVP), transurethral needle ablation (TUNA),
transurethral microwave thermotherapy (TUMT), interstitial laser
coagulation (ILC) and transurethral incision of the prostate
(TUIP). However, these approaches are usually reserved for men
with moderate symptoms and a small to medium-sized prostate
INDICATIONS: For patients
with acute urinary retention, persistent or recurrent urinary
tract infections, severe hemorrhage from the prostate, bladder
calculi, severe symptoms unresponsive to medical therapy and/or
renal insufficiency as a result of chronic bladder outlet obstruction,
transurethral resection of the prostate (TURP) or open prostatectomy
are indicated. When compared with TURP, open prostatectomy offers
the advantages of lower retreatment rate, more complete removal
of the prostatic adenoma under direct vision and avoids the
risk of dilutional hyponatremia (the TURP syndrome) that occurs
in approximately 2% of patients undergoing TURP. The disadvantages
of open prostatectomy, as compared with TURP, include the need
for a lower midline incision and a resultant longer hospitalization
and convalescence period. In addition, there may be an increased
potential for perioperative hemorrhage.
SURGERY DISCUSSION: Open prostatectomy
can be performed by either the retropubic or suprapubic approach.
In Retropubic prostatectomy, the enucleation of the hyperplastic
prostatic adenoma is achieved through a direct incision of the
anterior prostatic capsule. This approach to open prostatectomy
was popularized by Terrence Millin, who reported the results
of the procedure on twenty patients in Lancet in 1945.
The advantages of this procedure over the suprapubic
- excellent anatomic exposure of the prostate,
- direct visualization of the prostatic adenoma during enucleation
to ensure complete removal,
- precise transection of the urethra distally to preserve
- clear and immediate visualization of the prostatic fossa
after enucleation to control bleeding, and
- minimal to no surgical trauma to the urinary bladder.
The disadvantage of the retropubic approach,
as compared with the suprapubic prostatectomy, is that direct
access to the bladder is not achieved. This may be important
when one considers excising a concomitant bladder diverticulum
or removing bladder calculi. The suprapubic approach also may
be the preferred method when the obstructive prostatic enlargement
includes a large intravesical median lobe. Suprapubic prostatectomy,
or transvesical prostatectomy, consists of the enucleation of
the hyperplastic prostatic adenoma through an extraperitoneal
incision of the lower anterior bladder wall. This approach to
open prostatectomy was first carried out by Eugene Fuller in
New York in 1894; it was later popularized by Peter Freyer in
London, England, who described the procedure in 1900 and later
reported the results of his first 1000 patients in 1912.
The major advantage of this suprapubic procedure over the retropubic
approach is that it allows direct visualization of the bladder
neck and bladder mucosa.
As a result, this operation is ideally suited for patients
- a large median lobe protruding into the bladder,
- a clinically significant bladder diverticulum or
- large bladder calculi.
It also may be preferable for obese men, in whom it is difficult
to gain direct access to the prostatic capsule and dorsal vein
complex (. The disadvantage, as compared with the retropubic
approach, is that direct visualization of the apical prostatic
adenoma is reduced. As a result, the apical enucleation is less
precise, and this factor may affect postoperative urinary continence.
Furthermore, hemostasis may be more difficult because of inadequate
visualization of the entire prostatic fossa after enucleatioin.
SUMMARY: Open prostatectomy, whether performed
via a retropubic approach or a suprapubic approach, is an excellent
treatment option for
- men with symptomatic bladder outlet obstruction due to
benign prostatic hyperplasia causing a markedly enlarged prostate
- individuals with a concomitant bladder condition, such
as a bladder diverticulum or large bladder calculi and
- patients who cannot be placed in the dorsal lithotomy position
for a transurethral resection of the prostate gland.
With improved surgical technique, these procedures
can be routinely performed in a precise manner with minimal
hemorrhage. Efficacy, in terms of durable improvement in symptom
score and peak urinary flow rate, is superior than other treatment
options available for the obstructing prostate gland, including
transurethral resection of the prostate. Meanwhile, complications
are minimal and the length of hospitalization has been markedly
reduced. For most patients, the length of hospital stay is three
days or less. Thus, for the properly selected individual, an
open prostatectomy is a highly effective and well-tolerated
Treatments under investigation
A number of other treatment options have been -or are currently being - evaluated for BPH.
These procedures may alleviate symptoms by damaging nerves within
the prostate, which may cause smooth muscle relaxation similar to
that which occurs with alpha-adrenergic blocking drugs. In general,
this damage is accomplished by raising temperatures within the gland
to above 113' Fahrenheit. Various methods-microwaves, ultrasound,
and radio frequencies-are used to heat the prostate via devices placed
in the rectum or urethra. Several treatment sessions may be necessary,
and most men-will need additional treatment for BPH symptoms within
five years after their initial thermal treatment. Transurethral needle
ablation (TUNA) of the prostate uses low-energy radio waves, delivered
by tiny needles at the tip of a catheter, to heat prostatic tissue.
A six-month study of 12 men with BPH (age 56 to 76) found the treatment
reduced AUA Symptom Index scores by 61%, and produced minor side effects
(including mild pain or difficulty urinating for 1 to 7 days in all
the men). Retrograde ejaculation occurred in one patient. Another
thermal treatment, transurethral microwave thermotherapy (TUMT), is
a minimally invasive alternative to surgery for patients with bladder
outflow obstruction caused by BPH. Performed on an outpatient basis
under local anesthesia, TUMT damages prostatic tissue by microwave
energy (heat) that is emitted from a urethral catheter.