Enlarged Prostate

THE AGING PROSTATE

The prostate is a walnut sized gland that sits below the bladder. The entire function of the prostate is unclear but it does make fluid that is important in male reproduction. The urethra travels through the center of the prostate. At about the age of 40 the prostate gland begins to grow(BPH) and has the ability to choke off the urethra causing urinary symptoms. Not every man develops an enlarged prostate and in those men who have enlargement it is not always progressive. Statistics show that 4 out of 10 men over age 55 have an enlarged prostate. This number increases to 7 out of 10 as men get into their 70's.

As men get older their prostate gland enlarges and slowly constricts the urethra that travels through the prostate. As this enlargement progresses men develop urinary symptoms such as a decrease urinary stream, frequency, urgency and nocturia (waking up at night to urinate). As the prostate causes more blockage the bladder has to work harder to push out the urine. As the process progresses the bladder wall becomes thicker to compensate for this blockage. At some point the bladder is unable to exert higher and higher pressures to overcome this blockage and it begins to decompensate. During this decompensation the bladder becomes unable to empty which a patient may or may not be able to feel. This residual can predispose men to urinary tract infections, bladder stones and in rare instances kidney failure. If this blockage becomes too severe, patients can develop urinary retention or the inability to urinate. Urinary retention is a urological emergency and does require placement of a catheter through the penis into the bladder, to relieve the obstruction and empty the bladder.

Our Expertise

• Urogynecology
• Cryosurgery
• Robotic Prostatectomy
• Enlarged Prostate
• Vasectomy
• Sexual Dysfunction
• Pediatric Urology

EVALUATION AND TESTING

When and if your symptoms become bothersome your urologist may want to perform tests to help identify if your enlarged prostate is responsible for your symptoms. As part of the evaluation prostate cancer will be ruled out by performing a digital rectal examination and a blood test called a PSA. During the digital rectal examination the prostate is examined for any abnormalities and your urologist will try to assess the size of your prostate. Your urologist will also assess the status of your symptoms by asking questions about the severity of your symptoms(Symptom Score) and checking your urine(Urinalysis). Additionally your urologist may want to perform other tests to help determine if your symptoms are from your prostate.

• Uroflow - Measuring the force of the stream of urine
• Bladder Scan - Sound wave test measuring how much urine is left over after voiding
• Cystoscopy - Looking directly into the bladder using a small telescope
• Videourodynamics - Measuring the pressures in the bladder during voiding to help determine if the prostate is responsible for bothersome symptoms
• Transrectal Ultrasound(TRUS) - Sound wave test to measure the size of your prostate

Based on all these findings your urologist will recommend treatment options.

WATCHFUL WAITING

Watchful waiting means that you and your doctor have decided on no treatment. Instead, you will be followed with routine office visits every 6-12 months to monitor your problem. Digital rectal exams and PSAs will be checked at least once a year to check for prostate cancer. If your symptoms become progressively worse prior to your scheduled appointment please call for an earlier appointment.

MEDICAL TREATMENTS FOR BPH

Medical treatment for prostate disease has gone in two directions over the past few years. The first has been in the use of phytotherapy or plant extracts(Vitamins). The second has been in the use of drugs either to reduce the size of the prostate or to relax the muscles of the prostate to allow an easier flow through the urinary channel.

PHYTOTHERAPY

The use of phytotherapeutic agents, also known as plants or plant extracts, varies widely in different parts of the world. These products have been widely used in Europe as the initial treatment for benign prostatic enlargement. The problem with these products has been that there are not many controlled studies with these agents. Secondly most plant extracts are complex products that contain multiple components. In many cases it is not clear which, if any, of the ingredients are active. In addition, there may be marked differences in the chemical composition of natural products that are sold by different companies. These companies are not under FDA (Federal Drug Administration) control. The most popular agent in use for prostatic enlargement is Saw Palmetto (Serenoa repens) which is derived from the berry of the American dwarf palm tree. Saw palmetto is well tolerated with few adverse effects. Some patients experience improvement of their symptoms on a dosage of 320 mg daily.

PROSTATE SHRINKING MEDICATION

This class of drugs is called 5 alpha-reductase inhibitors. They work to shrink the prostate by blocking the formation of a key nutrient for prostate growth. These medications (Avodart and Proscar)will affect PSA so your urologist will monitor this more frequently. Commonly seen side effects include a 3% incidence of impotence and ejaculatory disturbances and rare cases of breast enlargement. These side effects are reversible once the drug is stopped.

MEDICATION THAT RELAXES THE PROSTATE

This class of medication works by relaxing the prostate and are called alpha blockers. These drugs (Hytrin, Cardura, Flomax and Uroxitral) were originally developed as blood pressure medicines and were found to make men urinate better. When taking these medications, many men will experience both subjective and objective improvements in urination. The medicine will not stop the growth of the prostate, and theoretically, as the prostate continues to grow, these medicines may become ineffective. Common side effects include dizziness, hypotension, fatigue, swelling of their legs and nasal stuffiness.

There are many men currently who are on both classes of drugs simultaneously. They take both an alpha blocker and a 5 alpha reductase inhibitor. Since these drugs work on different areas of the prostate gland their effects are often additive.

SURGICAL TREATMENTS FOR BPH

TRANSURETHRAL RESECTION OF PROSTATE (TURP)

Transurethral resection of the prostate (TURP) has been the primary choice and the gold standard of treatment for BPH in the past. It is the treatment against which all others are compared. TURP has been performed less often with the advent of medications and less invasive surgical treatments. Essentially, TURP is like a roto-rotor job where the tissue on the inside of the prostate is scraped away enlarging the channel through which you urinate. Because all the prostate tissue is not removed, there is a chance that it can regrow in the future. Only about 5% of patients will need a repeat procedure for this regrowth at some point following their initial TURP. The procedure is performed in an operating room with anesthesia (usually spinal anesthesia).

TURPs are performed less frequently because of the advent of more minimally invasive surgery.

MINIMALLY INVASIVE SURGICAL THERAPY

There are numerous minimally invasive therapies to reduce prostate size using varying energy sources such as laser, microwave, or radiofrequency waves. They all impart an energy source to the prostate gland that over the course of weeks will cause destruction and loss of some of the prostate tissue.. Currently we are performing GreenLight Laser (PVP) ,Transurethral Needle Ablation of prostate (TUNA), and Transurethral Microwave Thermotherapy(TUMT).

Many men are choosing these minimally invasive therapies to avoid taking medications the rest of their life. This way they can have the same or better results as a "one time shot". For the most part these procedures have eliminated the use of TURP in that their morbidity is less with better or the same results.

GreenLight Laser - Photoselective Vaporization of the Prostate (PVP)

This procedure really is a "bloodless TURP" It is done much the same way as a TURP but with laser energy. It is called a greenlight laser because the laser beam is green! A laser fiber is inserted into the prostate area via a scope. The laser is used to vaporize the prostate widening the channel through which you urinate just like a TURP. During this vaporization there is usually only minimal bleeding. Generally a catheter is left over night with patients being able to return to their normal activities in about one week. Strenuous activity can be resumed in two weeks. There is a small risk of delayed bleeding and infection,. Some men may experience retrograde ejaculation. This procedure is done at The Stone Center of New Jersey. This is located at The UMDNJ campus in Newark.

TUNA - Transurethral Needle Ablation of the Prostate

The TUNA procedure is currently performed in our office as an outpatient. In our office the patient receives some oral pain medicine and an oral sedative. A nerve block is placed around the prostate using an ultrasound machine. Some local anesthesia jelly is placed through the penis. A cystoscope is passed through the penis and the prostate is visualized. Small needles are placed through the urethra into the prostate and the prostate gland is heated up with low level radio frequency waves. This energy shrinks and destroys prostate tissue. It will ultimately shrink the prostate and relieve the obstruction. The procedure generally takes about one half an hour though your visit maybe longer in order to prepare you for the procedure and prepare you to go home. You will be sent home from the office with a catheter (a tube in the penis). This catheter will be left in a few days. Generally it will take 4-6 weeks to start to improve and may continue to improve for two to three months. In fact for the first couple of weeks you may have more symptoms then you had initially. Your doctor will probably keep you on all your medicines till the procedure has had a chance to work. Most patients are able to return to their normal activities within a few days. The procedure has had little effect on erectile dysfunction with less than 2% of patients reporting difficulty and less than 1% of patients reporting retrograde ejaculation. There were no reported cases of incontinence in the clinical trials.

The advantages of the TUNA procedure is that it is simple with a short recuperation time performed in the office setting.

COOLED THERMOTHERAPY OR MICROWAVE THERAPY

Cooled Thermotherapy is another office alternative that is popular to treat Benign Prostatic Enlargement (BPH). Cooled Thermotherapy uses microwave energy to heat and destroy enlarged prostate tissue, while a unique cooling system protects surrounding healthy tissue such as the urethra. Cooling of the urethra allows for delivery of higher amounts of energy and heat to the prostate gland.

The therapy is an in office procedure performed with local anesthesia. The actual procedure time is 30 minutes with the patients being in our office for about 2 hours. Patients are started on some medicines, such as an antinflammatory and an alpha-blocker two days prior to the procedure. The morning of the procedure you will take a tablet of an antibiotic by mouth and a Fleets enema rectally. On arriving in our office you will have your blood pressure taken and will be given a sedative and a pain medicine by mouth. About a half hour later you will be escorted to the treatment room where some local anesthesia will be administered through the penis. Subsequently a catheter will be inserted and the microwave energy will be applied. The procedure will take about a half hour. At the end of the procedure a new catheter will be placed. You will go home with this catheter attached to a leg bag. You will be instructed in its use while at our office. The catheter will be removed 3 days later at our office. The recovery and risks are the same as the TUNA procedure.

Comparison of Various Treatment Options

In summary there are numerous options available for the treatment of prostatic enlargement. Ultimately you and your doctor will need to decide what the best option for you is. Your doctor would be happy to address any questions you might have at your next appointment.