Treatment of Benign Prostatic Hyperplasia

Men who have BPH with symptoms usually need some kind of treatment at some time. However, a number of recent studies have questioned the need for early treatment when the gland is just mildly enlarged. These studies report that early treatment may not be needed because the symptoms of BPH clear up without treatment in as many as one-third of all mild cases. Instead of immediate treatment, they suggest regular checkups to watch for early problems. If the condition begins to pose a danger to the patient's health or causes a major inconvenience to him, treatment is usually recommended.

Since BPH may cause urinary tract infections, a doctor will usually clear up any infections with antibiotics before treating the BPH itself. Although the need for treatment is not usually urgent, doctors generally advise going ahead with treatment once the problems become bothersome or present a health risk. The following section describes the types of treatment that are most commonly used for BPH.

Surgical Treatment

Most doctors recommend removal of the enlarged part of the prostate as the best long-range solution for patients with BPH. With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed; the rest of the inside tissue and the outside capsule are left intact. Surgery usually relieves the obstruction and incomplete emptying of the bladder caused by BPH. The following section describes the types of surgery that are used.

• Transurethral Surgery: In this type of surgery, no external incision is needed. After giving anesthesia, the surgeon reaches the prostate by inserting an instrument through the urethra.

  A procedure called TURP (transurethral resection of the prostate) is used for 90 percent of all prostate surgeries done for BPH. With TURP, an instrument called a resectoscope is inserted though the penis. The resectoscope, which is about 12 inches long and 1/2 inch in diameter, contains a light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels.

  During the 90-minute operation, the surgeon uses the resectoscope's wire loop to remove the obstructing tissue one piece at a time. The pieces of tissue are carried by the fluid into the bladder and then flushed out at the end of the operation.

  Although this procedure is delicate and requires a skilled surgeon, most doctors suggest using TURP whenever possible. Transurethral procedures are less traumatic than open forms of surgery and require a shorter recovery period.

  Another surgical procedure is called transurethral incision of the prostate (TUIP). Instead of removing tissue, as with TURP, this procedure widens the urethra by making a few small cuts in the bladder neck, where the urethra joins the bladder, and in the prostate gland itself. Although some people believe that TUIP gives the same relief as TURP with less risk of side effects such as retrograde ejaculation, its advantages and long-term side effects have not been clearly established.

• Open Surgery: In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. The location of the enlargement within the gland and the patient's general health help the surgeon decide which of the three open procedures to use.

  With all the open procedures, anesthesia is given and an incision is made. Once the surgeon reaches the prostate capsule, he scoops out the enlarged tissue from inside the gland.

• Laser Surgery: Some researchers are exploring the use of lasers to vaporize obstructing prostate tissue. Early studies suggest that this method may be as effective as conventional surgery.

Nonsurgical Treatment

• Balloon Urethroplasty: In this procedure, a thin tube with a balloon is inserted into the opening of the penis and guided to the narrowed portion of the urethra, where the balloon is inflated. This action widens the urethra, easing the flow of urine.

  Balloon urethroplasty is a simple procedure that can be done on an outpatient basis, so it may eventually offer men a safe alternative to surgery. Since the procedure doesn't actually remove the tissue causing the obstructions, more studies are needed to judge its long-range effectiveness.

• Transurethral Hyperthermia: Researchers are also investigating a procedure that uses heat to shrink the prostate. During a series of treatments spread over several weeks, a doctor inserts a catheter containing a heating antenna into the urethra and then applies concentrated heat to the enlarged tissue, gradually shrinking it and relieving the obstruction. However, the long-range effectiveness of hyperthermia is not clear, and studies have indicated that the frequent insertion of a catheter and the use of heat can cause side effects such as irritation of the urethra, bleeding, or painful bladder spasms.

• Prostatic Stents: Doctors in Europe are studying the use of devices, or stents, which are inserted through the urethra to the narrowed area and allowed to expand, like a spring. The stent pushes back the prostatic tissue, widening the urethra.

• Drug Treatment: The Food and Drug Administration (FDA) has approved three drugs for the medical treatment of benign prostatic hyperplasia (BPH). These drugs may relieve common symptoms associated with an enlarged prostate.

  Finasteride (marketed as Proscar), which was approved by the FDA on June 19, 1992, inhibits production of the hormone that is involved with prostate enlargement. Its use can actually shrink the prostate in some men.

  The FDA also approved the drug terazosin (marketed as Hytrin) on September 29, 1993, and doxazosin (marketed as Cardura) on February 6, 1995, for the treatment of BPH symptoms. Both drugs act by relaxing the smooth muscle of the prostate and bladder neck in improving urine flow and to reduce bladder outlet obstruction. Terazosin and doxazosin belong to the class of drugs known as alpha blockers.

Is Further Treatment Needed?

In the years after your surgery, it is important to continue having a rectal exam once a year and to have any symptoms checked by your doctor.

Since surgery for BPH leaves behind a good part of the gland, it is still possible for prostate problems, including BPH, to develop again. However, surgery usually offers relief from BPH for at least 15 years. Only 10 percent of the men who have surgery for BPH eventually need a second operation for enlargement. Usually these are men who had the first surgery at an early age.

Sometimes, scar tissue resulting from surgery requires treatment in the year after surgery. Rarely, the opening of the bladder becomes scarred and shrinks, causing obstruction. This problem may require a surgical procedure similar to transurethral incision. More often, scar tissue may form in the urethra and cause narrowing. This problem can usually be solved during an office visit when the doctor stretches the urethra.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.