Initial treatment options for BPH symptoms are observation, medications, or a procedure to open the obstructing prostate.
Some men with mild BPH may choose to tolerate their symptoms for some time in order to delay starting a treatment program. To follow the progression of symptoms, routine evaluation every 6-12 months generally includes:
- PSA (blood test)
- Symptom Score
- Measurement of urine volume left in bladder after voiding (Ultrasound Post-Void Residual)
- Uroflow (flow curve generated by voiding into a measuring device)
Further evaluation may include these optional tests:
- Cystoscopy (look inside prostate and bladder with skinny scope)
- Prostate volume measurement by ultrasound
- Urodynamics (eval bladder function to help predict outcome from various treatment options)
Medications for BPH
Two classes of medication are available to treat BPH. The first type is the alpha-blockers. These drugs, which includes the generics, doxazosin and terazosin, as well as newer drugs, alfuzosin (Uroxatral), tamsulosin (Flomax), and Silodison (Rapaflo). These drugs act by relaxing the muscle fibers in the bladder outlet and prostate, lowering resistance to the flow of urine and facilitating improved bladder emptying. These drugs generally work within a few days, but they do not affect progression of the underlying problem, namely prostate growth. Common side effects of the alpha blockers include ligh-headedness or dizziness when arising from bed or a seated position, runny nose, and retrograde ejaculation. The generic drugs typically cause more light-headedness, but this usually resolves after a week or so on the drug. Syncope (passing out) is pretty uncommon, but forces some people to stop this drug and seek an alternate treatment.
The second class of BPH drugs includes the generic, finasteride, as well as the newer drug, dutasteride (Avodart). These drugs (5-alpha reductase inhibitors or 5-ARIs), works in an entirely different manner. These drugs decrease prostate growth and if taken long enough, will shrink the prostate. They function by decreasing the level of activated testosterone (DHT). These drugs work slowly, gradually shrinking the prostate over 9-24 months. Potential side effects of the 5-ARIs are a direct result of the effect on testosterone and include erectile dysfunction, breast enlargement, and nipple tenderness.
A common combination of BPH medications is doxazosin and finasteride. Both are available as generics, work via different mechanisms, and are proven effective both alone and in combination.
Minimally Invasive Procedures for BPH
Minimally invasive procedures to open up the bladder outlet are increasingly becoming first-line treatment for BPH. Many people do not want to be on a medication (or two) for the rest of their lives, preferring instead to undergo a routine procedure with a high-probability of restoring normal voiding. Prior to the availability of these newer technologies, the standard procedure to treat obstructive BPH was the transurethral resection of the prostate (TURP), known by most people as "Roto-Rooter." The TURP procedure
Problems with TURP
- Electrolyte imbalance (TUR syndrome)
Surgery for BPH
The best available method of opening up the obstructed prostate is Greenlight photovaporization of the prostate or "Greenlight PVP." With results that are equivalent to the traditional TURP or "roto-rooter" procedure, Greenlight PVP is seen by many urologists, Dr. Golden included, as the new "Gold Standard" for treating bladder outlet obstruction. The major advantages of the Greenlight procedure are minimal blood loss and no inpatient hospital stay. Focused laser energy is used to vaporize the inside of the prostate, enlarging the channel substantially, thereby improving urinary flow rates and bladder emptying. Unlike with the standard TURP, GreenLight laser stops bleeding as it vaporizes tissue, so patients lose very little blood. About 20% of the time, Dr. Golden's patients have so little bleeding that the catheter can be removed in the recovery room shortly after surgery. Most patients have a catheter for a day or two.
For extremely large prostates (over 150 grams), minimally invasive techniques are generally not the most effective means of opening up the urinary channel. The problem is that enough tissue can not be reliably removed in these circumstances, so the risk of recurrent obstruction is relatively high. Surgical removal of the obstructing center (adenoma) of the prostate, leaving the prostatic capsule and erectile nerves undisturbed, is a very effective treatment with long-term improvement in urinary symptoms. This operation was first performed in 1895! Known as "suprapubic prostatectomy" or "simple prostatectomy," this operation is still the most effective means of removing the obstruction caused by a truly huge prostate. Simple prostatectomy has been traditionally performed via open surgery through a lower midline incision. It is now possible to perform this same operation laparosocpically, or robotically, utilizing the da Vinci robot.