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BPH Treatment

About BPH Treatment of BPH

The need for treatment depends on symptoms, test results and whether any complications of BPH have developed, which is unusual. Generally, drug treatment is used for mild to moderate obstruction and surgery is reserved for more severe obstruction and for complications of BPH, which include urinary retention (inability to pass any urine, which needs to be relieved by inserting a catheter into the bladder), recurrent urinary infections, bladder stones, ‘overflow’ incontinence and kidney failure.

Watchful waiting
Alternative treatments
Drug treatment
  » alpha blockers
  » finasteride
Surgery
  » transurethral resection of the prostate (TURP)
  » laser vaporisation of the prostate.
  » laparoscopic prostatectomy

Watchful waiting


The natural history of urinary symptoms due to BPH is that, if left untreated and over a period of time, one-third will get better (due to the bladder muscle becoming more powerful, so overcoming the obstruction more effectively), one-third get worse and one-third stay the same. This is the rationale for watchful waiting (observation alone) in men with BPH whose urinary symptoms are not particularly bothersome. Men still need follow-up with objective tests as symptoms do not always accurately reflect the degree of bladder obstruction.

Alternative treatments


The natural plant extract saw palmetto can be used to reduces the size of the prostate via its oestrogenic effect and so relieve symptoms of BPH. The recommended dosage is 320 mg a day.

Drug treatment



alpha blockers relax smooth muscle at the exit of the bladder reducing the resistance to urinary flow. Approximately 2/3 patients notice an improvement in symptoms. This family of drugs was originally introduced to control high blood pressure and so is designed to be used daily indefinitely. Because it lowers the blood pressure it can cause dizziness, headache and tiredness.

5-alpha reductase inhibitors prevent the conversion of testosterone to its more powerful form dihydrotestosterone and so gradually reduce the size of the prostate over a period of years. They are only really effective in men with large (>40 ml) prostates. Possible side effects include reduced libido, impotence, breast tenderness and enlargement and a reduced sperm count. Women who are pregnant must avoid exposure to the drug because of possible side-effects to the foetus.

Surgery for BPH



TURP
Transurethral resection of the prostate (TURP) involves coring out the central part of the prostate (rather like one might core out the centre of an apple) to physically enlarge the channel one passes urine through. It was the first ‘keyhole’ operation and remains the standard to which other procedures for BPH are compared. It is performed under general or spinal anaesthetic, usually lasts 30 minutes and involves no incisions on the outside. It is performed using a hot wire loop, which is used to remove the prostate in slivers, inserted into the urethra via a telescope. These are washed out at the end of the operation and a catheter is inserted for 1-2 days, through which irrigation fluid flows into the bladder to rinse any blood in it.

BPH - Occlusive prostate
BPH - Post-TURP
An occlusive prostate
TURP in progress

Patients are discharged from hospital after 3 days and should avoid heavy physical exercise for 2 weeks. Urinary flow is usually markedly improved immediately but frequency may take 6-12 weeks to completely settle. All patients experience retrograde ejaculation after TURP i.e. sperm going back into the bladder at the time of climax, rather than coming out of the penis, and being washed out of the bladder the next time it is emptied. There is also a 5% risk of impotence after TURP, usually in men aged over 70 years.


GreenLight™ photoselective vaporisation of the prostate (PVP)
PVP uses a high-energy laser to vaporize prostate tissue and seal. Its advantages over TURP are less bleeding and a much shorter catheterisation time and hospital stay. The procedure is performed via a telescope inserted into the urethra under spinal or general anaesthetic and usually lasts 30-60 minutes. Its potential disadvantages are the absence of a speciment to send to the lab to exclude prostate cancer and burning on urination, which may last for several weeks after surgery.

BPH - Post-GreenLight laser prostate vaporisation
GreenLight laser vaporisation of the prostate

Laparoscopic prostatectomy
Very large (>200 ml) prostates might be more safely and efficiently removed from the outside-in, as opposed to the inside-out method of telescopic removal. Traditionally, this has been done via an incision on the lower abdomen but can equally be done telescopically using a similar technique to that used to performed laparoscopic prostatectomy for localised prostate cancer but without the risks to continence or potency.

Laparoscopic prostatectomy
Step 1
Step 2
Step 3

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