Home >> Symptoms >> Enlarged Prostate >> Treatment

Enlarged Prostate - Treatment

Overview | Causes | Diagnosis | Treatment | FAQ

Prostatitis

The infectious form of prostatitis may be treated with antimicrobial medication. Acute prostatitis may be treated with antimicrobial medication for 7-14 days while chronic prostatitis may require up to 12 weeks of medication before the prostatitis is cleared.

The non-infectious form of prostatitis may be improved by taking hot baths, drinking more fluids, changing your diet, ejaculating frequently (to drain the prostate gland and relax the muscles), or pelvic floor physical therapy to help relax the mucles of the pelvis, which may cause pain with urination. Your physician may prescribe alpha blockers, drugs that relax the muscle tissue in the prostate and allows urine to flow more freely.

Follow your physician's recommendations and be sure to follow-up in the office with your physician as instructed to make sure your prostatitis has been completely cleared, even if your symptoms have disappeared.

Prostate Enlargement and Bladder Outlet Obstruction

Medical Therapy - Symptoms of BPH are often exacerbated by other medications which the patient may be taking. Therefore, the medical management of BPH may involve withdrawing or changing existing medications or adding new ones. Certain medications are detrimental to bladder function.

Alpha blockade: The concentration of alpha adrenergic receptors at the bladder neck and proximal urethra is responsible for the strategy of alpha-blocking drugs in the treatment of BPH. These receptors cause muscle fibers in the bladder and prostate to contract. Blocking them causes them to relax, and open the prostate thereby improving urine flow. These receptors have been characterized as primarily alpha-1 receptors. Phenoxybenzamine was the first alpha blocker to be used in the clinical treatment of BPH but it resulted in significant side effects such as hypotension, nasal stuffiness and dizziness. These side effects were caused primarily by blockage of alpha receptors outside the urinary tract.

In an attempt to limit these extra-urinary side effects more and more specific alpha-1 blockers have been developed. The alpha-1a subtype receptor has been identified as predominant at the bladder neck. Not unexpectedly, an agent has been designed to target the alpha-1a receptor. It must be cautioned that pharmacologic uroselectivity may not translate to better clinical outcomes. Theoretically the selectivity of the drug may permit increasing its dosage without increasing the severity of side effects due to activity outside of the urinary tract. Examples of these medications include Tamsulosin, Silodosin, Doxazosin, Alfuzosin, and Terazosin.

The affect of alpha-1 blockade appears to be relaxation of the muscle fibers in the prostate and the opening of the bladder, which improves urine flow by decreasing the pressure required for the bladder to squeeze urine past the Prostate.

Multiple randomized prospective studies involving the use of alpha-1 blocking agents have shown a definite improvement in symptom scores and urinary flow rates compared to placebo. These improvements are lost within a few weeks of discontinuing the medication, and therefore treatments with these medications must be continued indefinitely to preserve the benefit they give.

5 Alpha Reductase Inhibitors (5ARIs): The development of finasteride, ( the first 5ARI) for the management of BPH, is a fascinating story. In the 1960s a clinical syndrome was described, where patients had a deficiency in the enzyme that converts testosterone to dihydrotestosteorne (DHT). That enzyme is called 5 alhpha reductase. It was discovered that these patients never developed symptoms of BPH, and in fact had very small prostates. It was reasoned that an 5a -reductase inhibitor might be used to induce one aspect of this syndrome in an already developed male, which is involution of the prostate. Since this enzyme has no other known function in the body except the conversion of testosterone to dihydrotestosterone it was felt that blockade of the enzyme could be safely accomplished. The use of selective 5a -reductase inhibitor does not result in decreased sexual activity or breast growth as is the case with other androgen withdrawal therapies. In fact, the serum testosterone level in patients treated with 5ARIs is normal.

The efficacy of 5ARIs as a treatment for BPH has been well documented. Their long-term use may result in as much as a 30% diminution in the volume of the prostate gland but often requires up to 6 months to achieve that effect. Furthermore, it has not been shown in prostates less than 30 gm that there is a significant improvement in either flow rates or urologic symptoms. In patients with large prostate glands (>30 gm) the use of 5ARIs may decrease the ultimate risk of developing urinary retention. 5ARIs do decrease the serum PSA level by approximately 50% without diminishing the risk of prostate cancer. Therefore, its extended use may result in a false sense of security for the clinician who depends on the PSA level for the early diagnosis of prostate cancer.

Examples of 5ARIs include Finasteride and Dutasteride. Combination Therapy: In some patients a combination of both alpha blocking medications and 5ARIs may be used. Research has shown in patients with large (>30g) prostates the combination of both medications works better than either medication as monotherapy. Patients who continue to have significant bother from their symptoms despite maximal dosing of medical therapy will likely need invasive therapy to achieve any further benefit.

Phytotherapy: Phytotherapy is a rapidly emerging field. Patients are well aware of the availability of herbal preparations for the management of a variety of clinical conditions including BPH. Of the currently available phytotherapies, saw palmetto, is the most commonly mentioned and probably the most clinically useful. It is thought that saw palmetto has a mechanism of action similar to Finasteride. Although few, if any, good randomized prospective studies exist, the few data which are available suggest that saw palmetto is probably not harmful. It does not appear that saw palmetto materially affects serum PSA levels. A word of caution, supplements are not regulated by the FDA, and therefore make no claims of benefit, furthermore, there is no guarantee that any herbal supplement actually contains the ingredients in the purity and concentrations perported on the bottle. Thus far, it does not appear that ginseng, gingko, selenium, vitamin E, lycopene or other herbal preparations have any significant affect on BPH or its symptom complex.

Minimally Invasive Therapy

Thermotherapy: One strategy for the management of BPH and the resultant lower urinary tract symptoms involves the use of heat provided by various generators. The common sources of heat are currently focused-ultrasound, high-energy radiofrequency, laser, and microwave devices. Transurethral microwave therapy (TUMT) makes it possible to obtain high temperatures in the lateral lobes of the prostate while preserving the urethral mucosa. The theoretical advantage of this therapy is that it can be undertaken with local analgesia and sedation only. It does not require the removal of any tissue and because the urethral mucosa is maintained there is a much lower incidence of urinary bleeding and post-therapy obstruction. Clinical studies of the effectiveness of this form of therapy have shown only minimal increases in flow rates but the majority of patients reported an improvement in their symptoms and quality of life. In general, complications were mild but included hematospermia and in the early phases of the development of microwave therapy, thermal injury to both the urethra and the rectum. Part of the value of this and other "heat therapies" may be destruction of sensory nerves in the prostate and urethra.

TUNA: Another variation on the administration of heat to prostatic tissue is the transurethral needle ablation of the prostate procedure (TUNA). The instrument consists of a pair of retractable needles which are advanced into the prostatic adenoma. Taking advantage of the high resistance of prostatic tissue to electrical current, heat is generated as current is passed between the needles which results in tissue destruction. This is another therapy which has a theoretical advantage of preserving the urethral mucosa and allows some measure of control regarding the extent of tissue destruction. As with other heat related therapies there is necrosis and edema of tissue, creating a moderate probability of urinary retention postoperatively.

Mechanical Therapies - At least two mechanical therapies for management of BPH deserve mention.

Expandable intraurethral prostatic stent. This apparatus can be introduced through a standard cystoscope under assisted local anesthesia and then can be expanded merely by removing it from a sheath. The initial result is a 36-French lumen in the prostatic urethra which greatly facilitates voiding. Because this metal mesh causes little tissue reaction, infection and rejection are unlikely. However, there is an ingrowth of prostatic epithelium over time so that the wire mesh is ultimately covered by polypoid appearing collections of epithelial cells. The obvious potential complications of the use of this technology are transmigration of the stent into the bladder or through the prostate by direct pressure and erosion. A second risk is encrustation of the device over a long period of time. Because of these risks, and the serious complications that can result combined with the extreme difficulty in managing these issues. This treatment is rarely used today, and probably should only be used in patients who otherwise could not perform intermittent catheterization,and are unable to have a chronic indwelling urethral or suprapubic catheter.

Balloon dilation of the prostate. This was one of the earliest forms of minimally invasive therapy for BPH. This strategy involved placing an inflatable balloon across the bladder neck in the prostatic urethra and then expanding it to 36-French. This results in a fracture of the adenoma which must then heal spontaneously. Clinically the procedure was well tolerated but the results are not durable. This procedure is currently seldom utilized.

Urolift: This procedure was FDA approved in 2013, and has promise to replace many of the other mechanical/thermal therapies listed above. The UroLift System consists of a delivery device and tiny permanent implants. This unique technology works by directly opening the urethra with tiny implants that hold the enlarged tissue out of the way, like tiebacks on a window curtain. No cutting, heating, or ablating tissue is involved, making the UroLift System the first and only BPH treatment that does not remove prostate tissue and does not negatively impact a man’s sexual function. This treatment is best utilized in men with smaller < 60 g prostates who do not have a large ingrowth of their prostate into the bladder called a median lobe.

Incisional / Ablative Therapies

TUIP: Intermediate in effectiveness between the heat therapies and ablative therapies for BPH is transurethral incision of the prostate. This procedure is performed through a cystoscope and involves the use of an electrical device for dividing the bladder neck and prostate to the level of the veru montanum. This is accomplished by passing current through a cutting wire and then incising the bladder neck musculature, prostatic adenoma, and prostatic capsule. Because only a single incision is utilized there is minimal bleeding. No prostatic tissue is removed. In selected patients this has been a very useful procedure and reduces the risk associated with a standard transurethral resection of the prostate. Those patients most likely to benefit from TUIP are young patients with small lateral lobes and elevated bladder necks. This procedure also has the advantage of potentially preserving antegrade ejaculation, required for normal fertility, and is best utilized in patients who wish to preserve their future fertile potential following surigical treatment for BPH.

TURP: The gold standard surgical procedure for managing BPH is transurethral resection of the prostate (TURP). This classic procedure is performed through a cystoscope and involves the use of a cutting loop. The prostate is excavated from the level of the bladder neck to the veru montanum. This results in debulking of the lateral adenoma. TURP has resulted in the most objective improvement in flow rate and the best subjective improvement in symptoms. Patients with irritative voiding symptoms will often be unimproved by TURP. Morever, TURP is subject to a number of potential complications. Bleeding is a common problem and may occasionally be severe. The development of scar tissue at the bladder neck (bladder neck contracture) can result in significant obstruction post surgery. Because of the proximity of the external striated sphincter damage incurred during a TURP can result in continuous urinary incontinence. Up to 15% of men report erectile dysfunction or frank impotence following TURP, although the mechanism of the impotence in this setting is not well understood.

Laser Technology

Lasers may be used to vaporize tissue resulting in a reduction of prostatic tissue comparable to TURP. Interstitial laser therapy induces necrosis of the prostatic tissue while preserving the urethral mucosa. Studies have shown comparable efficacy with the gold standard TURP treatment with shorter hospital stay, quicker return to normal function following surgery. Laser ablation therapies such as Green Light, have a slightly higher incidence of irritative voiding symptoms such as urgency, frequency, and urge incontinence, however; this is usual a short term problem, which resolves over time.

As with all medical interventions, particularly surgical interventions, the key to successful outcomes is patient selection. For instance, TURP has a high probability of retrograde ejaculation and would be a poor selection in a young man for whom fertility is an issue. In that patient population a less invasive and less aggressive approach such as microwave therapy or transurethral incision of the prostate would be more appropriate.

Likewise, in older patients or patients in poor health, a laser-induced prostatectomy or a prostatic stent might be a better choice. Even after appropriate measures have been taken to exclude alternative causes of LUTS, the prevailing attitude of most clinicians and patients is that at least a trial of medical therapy should be tried. After that, a sober evaluation of the risks and benefits of surgical intervention should be undertaken.

[Top]

Bibliography

  • BPH Phytotherapy

    • Wilt, T J; Ashani, A; Stark, G; MacDonald, R; Lau, J; Mulrow, C. Saw Palmetto Extracts for Treatment of Benign Prostatic Hyperplasia: JAMA, Vol. 280 (18):1604-1609, November 11, 1998.

    • Vann, Ana. The Herbal Medicine Boom: Understanding What Patients are Taking. Cleveland Clinic Journal of Medicine. Vol. 65(3):129-132, March 1998.

    • Gerber, G S.: Phytotherapy in the Treatment of Benign Prostatic Hyperplasia. Mediguide to Urology. Vol. 11(2):2-8.

  • Minimally Invasive Therapy

    • Laser: Kabalin, J N; Gilling, P J; Fraundorfer, M R: Application of the Holmium: YAG Laser for Prostatectomy. J of Clinical Laser Medicine & Surgery; Vol 16(1):21-27,1998.

  • Thermal Therapy

    • Ramsey, E W; Miller P D; Parsons, K: A Novel Transurethral Microwave Thermal Ablation System to Treat Benign Prostatic Hyperplasia: Results of a Prospective Multicenter Clinical Trial. J of Urology, Vol. 158:112-119; July 1997.

    • Larson, T R; Collins, J M; Corica, A: Details Interstitial Temperature Mapping During Treatment with a Novel Transurethral Microwave Thermoablation System in Patients with Benign Prostatic Hyperplasia. J of Urology, Vol 159:258-264, January 1998.

      • Larson, T R; Bostwick, D G; Corica, A: Temperature-Correlated Histopathologic Changes Following Microwave Thermoablation of Obstructive Tissue in Patients with Benign Prostatic Hyperplasia. Urology, 47(4):463-469, 1996.

[Top]