Watchful waiting is a strategy of no immediate treatment with follow-up medical checks at regular intervals. The natural history of BPH is not necessarily progressive. Symptoms remain stable or may even get better in many patients. Watchful waiting is suitable for patients with minimal symptoms and no complications. The patients can be reviewed ± yearly with symptom scores, physical examination and flow rate analysis. During watchful waiting patients should avoid tranquilisers and over-the-counter cold and sinus remedies, which can worsen symptoms and may even lead to urinary retention.
Several simple measures can improve symptoms related to BPH. Alcohol and caffeine should be taken in moderation, especially in the evening prior to going to bed. Tranquilisers and anti-depressants impair bladder muscle function and effective bladder emptying. Cold and flu remedies usually contain decongestants, which cause increased tone in smooth muscle fibres in the bladder neck and prostate, leading to worsening symptoms.
Phytotherapy refers to the use of plant extracts for medicinal indications. These treatments for BPH-related symptoms have received attention in the popular press recently. Most widely known is the extract of serenoa repens (commonly known as Saw Palmetto). The mechanism of action of these phytotherapies is unknown and their effectiveness unproven. Suggested modes of action include an anti-inflammatory effect to reduce prostate swelling and possible inhibition of hormones controlling the growth of prostatic cells. It is highly possible that their only action is as a result of the placebo effect.
Two types of medication are effective in the treatment of BPH, namely alpha-blockers and 5-alpha reductase inhibitors.
The prostate and bladder neck contain large numbers of smooth muscle cells. The tone in these muscle cells is under sympathetic (involuntary) nervous system control. The receptors at the nerve endings are called alpha-receptors.
Alpha-blockers are drugs that block these alpha-receptors, thus decreasing the tone in the prostate and bladder neck. The net effect is an increase in flow rate and an improvement in prostatic symptoms. Alpha-receptors are found elsewhere in the body, especially in blood vessels. The original alpha-blockers were designed to treat high blood pressure. Not surprisingly, the most frequent side-effect of alpha-blockers is orthostatic hypotension (dizziness upon standing due to a fall in blood pressure).
Commonly used alpha-blockers are prazosin (Minipress®), doxazosin (Cardura®), terazosin (Hytrin®) and tamsulosin (Flomax®). Tamsulosin is a selective alpha 1A receptor blocker, specifically designed to block the sub-type of alpha-receptor found predominantly in the bladder and prostate.
Alpha-blockers are effective in patients without absolute indications for surgery and post void residual volumes of less than 300ml. Most studies indicate a 30-60% reduction of symptoms and a moderate increase in flow rate. All four alpha-blockers are effective at therapeutic dosages. The maximal effect is obtained within two weeks and the response is durable.
Ninety% of patients tolerate the treatment well. The main reasons for discontinuing treatment are dizziness due to hypotension and perceived lack of efficacy. No direct comparative studies between the various different alpha-blockers have been performed, and claims of relative superiority cannot be justified. Treatment usually needs to be life-long. A less common side effect is abnormal or retrograde ejaculation, which occurs in 6% of patients taking tamsulosin.
5-alpha reductase inhibitors:
The enzyme 5-alpha reductase converts testosterone to its active form, namely dihydrotestosterone within the prostate gland. Finasteride (Proscar®) blocks this conversion. In some men finasteride can relieve BPH symptoms, increase urinary flow rate and shrink the size of the prostate gland.
The improvements, however, are usually only modest and take up to six months to achieve. Recent studies indicate that finasteride may be more effective in men with bigger prostates and have little effect in men with smaller glands. Finasteride does reduce the incidence of urinary retention and the need for prostatic surgery by 50% over a four-year period.
Due to its cost, moderate efficacy and long time to achieve maximal benefit, finasteride is not widely used for BPH treatment in South Africa. Side-effects of finasteride include breast enlargement (0.4%), impotence (3-4%), decreased ejaculate volume and 50% reduction of PSA levels.
Prostatectomy is the most commonly performed urological procedure. About 200,000 prostatectomies are performed annually in the USA. A prostatectomy for benign disease (BPH) involves removal of only the inner portion of the prostate. This operation differs from radical prostatectomy for cancer in which all prostate tissue is removed. Prostatectomy offers the best and fastest chance of improving BPH symptoms, but may not alleviate all irritative bladder symptoms. This is especially true for men over 80 years of age, where bladder instability is thought to account for a large proportion of symptoms.
Indications for prostatectomy:
- Retention of urine
- Renal impairment secondary to obstruction
- Recurrent urinary tract infections
- Bladder stones
- Large residual volumes (relative indication)
- Failed medical treatment - ineffective or side-effects
- Patient not keen on medical treatment
Transurethral resection of prostate (TURP)
This procedure is still considered the “gold standard” of BPH treatments against which all other treatment options are measured.
TURP is performed using a resectoscope, which is passed through the urethra into the bladder. A wire loop carrying an electrical current cuts the prostatic tissue away from the inside. A catheter is left in place for one to two days and hospital stay is usually about three days. TURP is associated with little or no pain and full recovery can be expected by three weeks after surgery.
Marked improvement occurs in 93% of men with severe symptoms and 80% of those with moderate symptoms.
Complications of TURP include the following:
- Mortality less than 0.25%
- Bleeding requiring transfusion: 7%
- Stricture (narrowing) of urethra or bladder neck: 5%
- Erectile dysfunction: 5%
- Incontinence: 2-4%
- Retrograde ejaculation (passage of semen into the bladder with ejaculation): 65%
- Need for another TURP: 10% at five years
Variations of TURP
- Transurethral incision of prostate gland/prostatotomy/bladder neck incision
As in TURP, an instrument is passed into the bladder. An electrical wire knife is used instead of a loop, and one or more cuts are made into the prostate gland to relieve pressure on the urethra. Little or no prostate tissue is removed. In men with small prostates (< 30g), results of prostatotomy are similar to TURP, but it takes much less time to perform and has fewer complications. The incidence of retrograde ejaculation is much lower than with TURP.
- Transurethral vaporisation of prostate gland
This modification of TURP is also performed with a resectoscope through the urethra. However, instead of cutting away the tissue, a more powerful electrical current is applied to the prostate, resulting in vaporisation of tissue, with minimal bleeding. Possible advantages include shorter catheter time, shorter hospital stay and lower cost than TURP or laser prostatectomy.
- Open Prostatectomy
Very large prostates are less suitable for TURP, due to the high incidence of complications associated with longer resection times. Open prostatectomy is the procedure of choice for prostates greater than 70-80g. A transverse lower abdominal incision is used to expose the bladder and prostate. The prostate capsule is incised and the BPH tissue is enucleated, leaving the prostatic capsule behind. Alternatively, the bladder itself is opened and the prostate enucleated via the bladder. One bladder catheter is placed via the urethra and a second via the lower abdominal wall. The catheters are left in for about five days.
The results from open prostatectomy are very good, but it is a more major operation than TURP. Hospital stay and recovery period are longer and the complication rate slightly higher. However, it is a very effective way to remove all BPH tissue and very few patients fail to void adequately afterwards.
- Minimally invasive treatment of BPH
Despite the success of TURP there has been a constant search for a less invasive, safer and cheaper treatment option, which can be performed as a day case, preferably under local anaesthesia. A variety of energy sources have been applied to the prostate gland to cause local heat generation and subsequent sloughing of prostate tissue. These include laser, microwave thermotherapy, high intensity focused ultrasound, radiofrequency thermotherapy and transurethral needle ablation of the prostate (TUNA). All of these treatments trade less intra-operative complications for reduced efficacy and increased post-operative bother.
Hospital stay is shorter than with TURP, but catheter times are longer and many patients end up needing secondary treatment, usually in the form of TURP. Various laser treatments can be used on the prostate gland. Newest and most promising is holmium laser prostatectomy, which is similar to TURP in that the prostatic tissue is actually removed. Blood loss is reportedly less with holmium laser than with standard TURP.
- Circumventing the obstruction
Some patients are unfit for any kind of surgical intervention. In this case, intra-urethral stents can be placed inside the prostatic urethra to keep it open, allowing the patient to void normally. Stents can be inserted under local anaesthetic. Short-term results are good, but migration and other complications lead to stent removal in 14-33% of cases. Although long-term indwelling catheters are best avoided, sometimes they are the only viable option in ill, frail or bedridden patients. An alternative is intermittent clean catheterisation by the patient himself or a carer.