Non-Surgical Treatments for BPH (an enlarged prostate) Q&A
An enlarged prostate is most likely caused by benign prostatic hyperplasia (BPH), which is a noncancerous growth of the prostate. While prostate enlargement doesn’t always cause problems it can potentially lead to urinary symptoms or other issues. BPH is very common, affecting up to 80 percent of men over the age of 60.
The prostate is a walnut-sized gland located between the bladder and the penis at the bladder neck. It’s responsible for producing semen, which carries sperm during ejaculation. The prostate also helps to control urine flow since the prostate surrounds the urethra (the tube that drains urine from the bladder).
The cause of BPH is unknown, but it’s thought to be linked to hormones and aging. As you age, your prostate may gradually get larger. This is a result of changes in hormone levels during aging, which can stimulate noncancerous growth of the prostate.
The risk factors include:
- Family history. If you have a father or brother with BPH, you’re more likely to develop the condition.
- Excess weight. Being overweight or obese may increase your risk of developing BPH.
- Race. African-American men are more likely to develop BPH than men of other races.
While an enlarged prostate itself isn’t cancerous, the condition is closely linked to an increased risk of developing prostate cancer. Men with BPH are about three times more likely to develop prostate cancer than men without BPH.
While an enlarged prostate doesn’t always cause symptoms, it can potentially lead to urinary problems, urinary incontinence or other issues. This is because the prostate gland surrounds the urethra which carries urine from the bladder out through the penis. As the prostate enlarges it causes benign prostate obstruction (BPO). The most common symptom of BPH or BPO is difficulty urinating. Lower urinary tract symptoms (LUTS) include
- A weak or interrupted urinary stream
- Delayed start of urination
- Dribbling at the end of urination
- Frequent urination, especially at night (nocturia)
- Increased urinary urgency and urgency incontinence .
- Straining to urinate
In severe cases where prostate cell growth, an enlarged prostate can block the urethra and cause urinary retention. This may lead to overflow incontinence, urinary tract infections, bladder stones, and enlarged bladder muscles. Besides disrupting bladder function refluxing urine can cause kidney damage. These kidney diseases include reflux, hydronephrosis and urinary tract infections. The chronic inflammation caused by bladder stones can lead to bladder cancer.
Your doctor will likely start with a physical exam and questions about your medical history and symptoms. They may also recommend one or more of the following tests:
Digital rectal exam. During this exam, your doctor inserts a gloved, lubricated finger into your rectum to feel for any abnormal areas on your prostate. Prostate cancer often causes hard, lumpy areas on the gland. Imaging studies are more accurate and may be preferred.
Prostate-specific antigen test. This blood test measures the level of prostate-specific antigen (PSA) in your blood. PSA is a substance that’s produced by the prostate. While an elevated PSA level can be a sign of prostate cancer, it can also be caused by other conditions, such as BPH or prostatitis.
Urinalysis. This test can help rule out urinary tract infections or other conditions that may cause your symptoms.
Ultrasound. This imaging test uses sound waves to create pictures of your prostate gland. It can give a measure of the volume of the gland.
Magnetic Resonance Imaging (MRI). This imaging test uses a magnetic field to create pictures of your prostate gland. Magnetic Resonance Angiography can be used to define the anatomy of the pelvic and prostate arteries.
There are a range of treatments available from conservative, non surgical treatments for milder symptoms to conventional, surgical procedures like tansurethral resection of the prostate (TURP) for more major symptoms. Recently there are emergiing, non surgical procedures for major symptoms too.
Your doctor will likely recommend conservative (nonsurgical) treatment options first. If these don’t relieve your symptoms or if you have complications from BPH, such as urinary retention, you may need one of the more invasive treatment options. The type of treatment recommended will depend on the severity.
Non surgical treatments for milder symptoms of benign prostatic hyperplasia
For milder symptoms your doctor may elect for:
Watchful waiting (or active surveillance) involves waiting to see if mild symptoms get worse over time.
Lifestyle changes may help to improve your urinary symptoms, including:
- Reducing fluid intake before bedtime
- Quitting smoking if you smoke
- Doing regular exercises for your pelvic floor muscles (eg Kegel exercises) to strengthen the muscles around your urethra.
Medications can be used to try and improve urinary symptoms or top prevent progression of the condition. These include:
- 5-alpha reductase inhibitors (e.g. finasteride, dutasteride) is a medical therapy that can be used to shrink the prostate gland.
- Alpha blockers (e.g. tamsulosin, terazosin). The drugs relax smooth muscle in the prostate and bladder neck making it easier to urinate. Common side effects include a drop in blood pressure upon standing (orthostatic hypotension), lightheadedness, dizziness, and fatigue. Alpha blockers include terazosin (Hytrin®), doxazosin (Cardura®), tamsulosin (Flomax®), and alfuzosin (Uroxatral®)./li>
- Phosphodiesterase type-5 inhibitors (e.g. sildenafil, vardenafil, tadalafil), when combined with an alpha blocker can improve urinary symptoms by relaxing both smooth muscle groups
- Anticholinergics (oxybutynin, tolterodine, solifenacin, trospium) can be used if you have urinary frequency and urgency as they work by relaxing the detrusor muscle in the bladder wall
Treatments for moderate symptoms of benign prostatic hyperplasia
If conservative treatments don’t work or if you have moderate-to-severe symptoms, more invasive treatment options may be recommended. These include:
Conventional surgical treatments for benign prostatic hyperplasia include transurethral resection of the prostate (TURP). TURP complications include altered sexual function eg loss of erections. Besides erectile dysfunction, other complications include retrograde ejaculation, difficulty emptying the bladder, retrograde ejaculation, and urinary incontinence.
Less invasive surgical treatments for benign prostatic hyperplasia including transurethral needle ablation of the prostate (TUNA), laser ablation, and microwave thermotherapy.
Prostate artery embolization (PAE) is an emerging non surgical, "pinhole" procedure more men are choosing. It involves permanently cutting off blood flow to the prostate, which then shrinks the gland. It is an outpatient, same day procedure and you go home with a Band-Aid.
Treatments for severe symptoms of benign prostatic hyperplasia
TURP is one surgical treatment for major symptoms due to prostate growth - including urinary retention. Other surgical and non surgical options are available. These prostate surgery methods are to deal with very large prostate glands.
Surgical options for severe lower urinary tract symptoms include:
Transurethral resection of the prostate (TURP) where a resectoscope is inserted up the urethra to the prostate to remove excess enlarged prostate tissue from large prostate glands. This is an inpatient procedure performed under general anesthesia involving a longer recovery.
Open prostatectomy where an incision is made in the lower abdomen or perineum to expose and remove the prostate. This is an inpatient procedure performed under general anesthesia involving a longer recovery.
Laser surgery using a high-energy laser beam to vaporize and destroy prostate tissue Less invasive therapies that use heat or freezing techniques to destroy excess tissue include:
Transurethral microwave thermotherapy (TUMT) which involves inserting a microwave antenna through the urethra and into the prostate where it emits microwaves to heat and destroy enlarged tissue and may decrease BPH symptoms.
Transurethral needle ablation (TUNA) which involves inserting needles through the urethra into the prostate where they emit radiofrequency waves to heat and destroy excess prostate tissue.
High-intensity focused ultrasound (HIFU) which uses high-energy sound waves to target and destroy excess prostate tissue.
These procedures can be done on an outpatient basis; however, they may require repeat treatments.
Of the minimally invasive procedures prostate artery embolization (PAE) has over the last 20 years emerged as a leading, non surgical option for severe lower urinary tract symptoms (LUTS) from an enlarged prostate due to Benign Prostatic Hyperplasia (BPH) causing benign prostatic obstruction.
PAE is a procedure that blocks the blood flow to the prostate. PAE seals blood vessels starving prostate cells of nutrients, which then shrinks the gland and relieves the urinary obstruction and related symptoms. The embolization is accomplished by placing very small particles (microspheres) into the specific arteries supplying blood to the prostate. These tiny particles once they enter the artery, lodge in place and block the blood flow.
One advantage of PAE over other treatments options is that it offers a much shorter recovery time. Most men can return to their normal activities within a day or two after the procedure. There is also no need for general anesthesia, which reduces the risks associated with the procedure.
An imaging and interventional specialist will obtain a history and physical exam. They will order blood tests including a PSA blood test. An ultrasound of the prostate may be ordered to measure the size of your gland.
Other imaging tests used to diagnose prostate enlargement include:
- MRI of the pelvis
- MRA of the pelvis to define arterial anatomy
- CT scan of the pelvis
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