Male Urological Conditions

BPH (Benign Prostatic Hyperplasia) or Enlarged Prostate

Benign prostatic hyperplasia (BPH) is an enlargement of the prostate gland that affects 60% of men by the age of 60 years.  Due to the increasing numbers of men who are affected by the BPH, due in large part by the Baby Boomer generation, many men are finding that their urination is getting worse and that there problems with urination are starting to affect their sleep, work, and leisure activities.

Where is the prostate located?

The prostate is a walnut sized gland located directly underneath the bladder and in front of the rectum.  The urethra passes through the center of the prostate and is entirely surrounded by the prostate.  Here is a great video on “What is the prostate?”.

What is the role of the prostate?

The role of the prostate is to produce prostatic fluid.  The fluid helps transport and nourish sperm during ejaculation.  During male orgasm, ejaculation mixes sperm, prostatic fluid, and seminal vesicle fluid together.  Prostatic and seminal vesicle fluid make up about 95% of the ejaculate volume, and sperm only make up about 5%.

What causes the prostate to grow and become BPH?

Around the age of 40 years, a man’s prostate begins to grow due to hormonal changes in testosterone and related metabolites.

Do all enlarged prostates cause symptoms?

No.  Prostate size does not always indicate  that someone will have urinary problems or symptoms.  Sometimes even small prostates can cause urinary symptoms!

What are the symptoms of BPH?

BPH or benign prostate hyperplasia may produce symptoms of straining to urinate, decreased force of stream, trouble stopping the urine stream or dribbling, increased frequency of urination, trouble starting urination, and the sudden feeling of needing to urinate or urgency.  BPH may also cause the need to get up at night to urinate due to urgency at night.  BPH symptoms may be worsened when a man drinks alcohol, caffeinated beverages, and certain cold medicines with decongestants.  The American Urological Assocation endorses the use of the AUA Symptom Index to determine the severity of BPH symptoms.  Another survey evaluates how bothersome the symptoms are to a man’s life, called the BPH Impact Index.

How do the symptoms develop from BPH?

As the prostate grows, constriction of the urethra occurs.  The prostate may also grow into the bladder called the median lobe of the prostate.  The median lobe will block the bladder from emptying completely by creating a “cork” effect as the bladder contracts during voiding.  Oftentimes, the median lobe will continue to cause symptoms even though a man is on multiple medications for his enlarged prostate.  Having a median lobe may require a surgical procedure to allow the normal passage of urine out of the bladder and into the urethra.

How are the symptoms from BPH treated?

There are two parallel paths to treating BPH.  The first is medical treatment and the second is surgical treatment.  Medical treatment for BPH consists of alpha adrenergic blockers (aka alpha blockers or “relaxers” of the prostate) and 5-alpha-reductase inhibitors (aka 5-A.R.I.‘s or “shrinkers” of the prostate).  Alpha blockers work by inhibiting the smooth muscle in the prostate and the bladder neck from having tonic contraction.  By inhibiting the smooth muscle in the prostate and bladder neck, a man who takes this medication should have a stronger stream and more efficiently empty his bladder.  However, alpha blockers have a few caveats:  alpha blockers do not actually shrink the prostate so the prostate will continue to grow despite being on these medications, alpha blockers only work the night that you take them so you usually end up taking them for life, and alpha blockers have side effects such as retrograde ejaculation, dizziness or fatigue, and orthostatic hypotension.

Examples of alpha blockers or “relaxers” of the prostate include: Hytrin, Cardura, Flomax, Uroxatral, Rapaflo, tamsulosin, terazosin, doxazosin

5-A.R.I.‘s are the other class of medication used for the prostate.  These medications shrink the prostate by inhibiting an enzyme in the prostate that converts testosterone to a more potent metabolite called dihydrotestosterone (DHT).  The prostate grows faster with more DHT.  This would be a wonder drug, but again there are a few caveats with this medication.  Shrinking the prostate takes a long time.  Shrinkers of the prostate start to work at 1 month of continuous use, and do not achieve maximal shrinkage of the prostate until 12–18 months of use.  Side effects include possible breast enlargement, decreased sexual desire, and possibly erectile dysfunction.  Additionally, 5-A.R.I.‘s will lower the PSA by 50% within 1 month of usage.  So if you have a PSA of 10, your PSA with 5-A.R.I. use should be about 5 or lower after 1 month of use.  If your PSA does not decrease by 50%, or increases, then you will have to be evaluated by a urologist to see if you might need a prostate biopsy.  Besides BPH, the use of 5-A.R.I.‘s may be used to prevent prostate cancer however the studies are mixed thus far.

Examples of 5-alpha-reductase inhibitors or “shrinkers” of the prostate include: Proscar, Avodart, finasteride

The second path of treatment is by a surgical procedure.  There are non-surgical procedures such as microwave therapy, but these are less effective than surgical procedures and have short (<2y) durability.  The surgical treatment pathway is complex due to most of the decision being based on the patient’s symptom level and expectation of the treatment.  The types of treatments possible are:

Transurethral resection of the prostate (aka TURP, “rotor rooter”, monopolar or bipolar TURP)

Button plasmavaporization of the prostate (aka button TURP, button PVP, button procedure)

- Dr. Louie’s video on the button TURP

Greenlight photovaporization of the prostate (aka Greenlight procedure, laser vaporization, PVP)

Other Lasers: Diode/Thulium (these fall into the Greenlight category, but are much less common)

Open simple prostatectomy

Robotic simple prostatectomy

Holmium Laser Enucleation of the Prostate (aka HoLEP, emulates simple prostatectomy)

What should I choose for treatment of my BPH?

Choosing a treatment for your BPH symptoms is always based on your level of bother.  If you are not bothered by your symptoms, despite waking up 4 times a night and having a weak urinary stream, then you probably do not need to start any treatment.  However, if you think you need to improve your urination, then only a discussion with an expert urologist will be able to consider the complexities of your urination and expectations, and guide your education and eventual decision for treatment.