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Prostate Enlargement (Benign prostatic hyperplasia/BPH)- Treatment

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How is benign prostatic hyperplasia treated?

The benign prostatic hyperplasia can be treated by the following options, depending upon the severity of the symptoms, its effects on the quality of life and one’s personal preference.

• Watch full waiting with or without lifestyle changes

• Medicines

• Minimally invasive procedures and surgeries

Some men may have enlarged prostate however with no symptoms. These men and one with mild symptoms may not need treatment at all. Whereas, in some men, more than one treatment may be required to relieve the symptoms.

Watch full waiting with or without lifestyle changes

This is generally recommended for men who have minimal or mild symptoms. Men would be advised to keep a check on their symptoms and get regular check up as advised by the doctor.

Lifestyle changes

• Limit intake of water depending upon the your assessment which could be less than 2 liters in a day.

• Avoid fluid intake before traveling and within 2 hours of bedtime

• Avoid caffeine and alcohol

• Bladder training to hold more urine for longer periods

• Pelvic floor muscle exercises to strengthen the muscles

• Avoiding or consulting your doctor before taking certain medicines such as decongestants, antidepressants, antihistamines and diuretics

Weight reduction, if a person is overweight or obese (with BMI 30 or more)

Treatment for people with bothersome symptoms:

Medicines

To manage the symptoms of BPH the doctor may prescribe medicines that reduces the size of the prostate or stop its further growth. These medicines may also cause relaxation of the muscles of urethra or prostate capsule causing better flow of urine and providing relief in the symptoms.

The following medicines are

• Alpha blockers

• 5-alpha reductase inhibitors

• Phosphodiesterase-5 inhibitors

• Combination of these medicines

Alpha blockers:

These are the medicines that relaxes the smooth muscles of your prostate and the bladder neck to improve your urine flow. These medicines don’t reduce the size of the prostate. They are considered suitable for all symptomatic patients, irrespective of the size of prostate. Considered suitable for men with moderate to severe symptoms.

Following are alpha blockers that can be used for BPH:

• Alfuzosin

• Terazosin

• Doxazosin

• Tamsulosin

• Silodosin

Benefits: they start to show their effect immediately.

Precaution: to be avoided ifa cataract surgery is planned in near future.

Side effects: lightheadedness, dizziness, tiredness, and problems in ejaculation.

5-alpha reductase inhibitors:

Are the medicines that blocks the production of a male hormone called DHT which is considered to be responsible for the prostate growth in some people. These medicines can reduce the size of the enlarged prostate or prevents it from growing further and thus helps in managing symptoms. Considered suitable for men with older men and men with very large prostate size.
Following are the medicines that can be used:

• Finasteride

• Dutasteride

Benefits: they reduce the chances of complications or the need of surgery.

Precaution: May cause sexual issues in some men. May take long to show effect.

Side effects: may cause reduced sex drive or erectile dysfunction in some men.

Combination medications:

Sometimes, your doctor would prescribe both medicines together, an alpha blocker and a 5-alpha reductase inhibitor. Many studieshave shown that combining these two medicines provide better relief in symptoms and improve urine flow and quality of life.
Following medicines can be combined together:

• Dutasteride and tamsulosin

• Finasteride and doxazosin

• alpha blockers and antimuscarinics

Side effects: can be more as compared to using a single medicine. You may experience side effects such as erectile dysfunction,dizziness, weakness or fatigue, and sudden drop in BP on standing.

Phosphodiesterase-5 inhibitors:

These medicines are mainly used for erectile dysfunction. Your doctor prescribe you this medicine when you have BPH and erectile dysfunction together.

These medicines work in BPH by causing relaxation of the smooth muscles in your lower urinary tract. This helps in reducing the symptoms of the lower urinary tract. Tadalafil is the medicine that belongs to this category.

How to choose which medicines is suitable for your specific sign and symptoms

Medicines for predominant symptoms of bladder outlet obstruction

 

Small prostate and/or low prostate-specific antigen level (1.5 ng/mL or less)Larger prostate and/or high prostate-specific antigen level (more than 1.5 ng/mL)
Medicinesα₁-adrenergic blockerα₁-adrenergic blocker with/ without 5α-reductase inhibitor therapy
DoseAlfuzosin Oral tablet, extended-release; Adult males: 10 mg PO once daily with foodFinasteride Oral tablet [Benign Prostatic Hyperplasia]; Adult males: 5 mg PO once daily.

Dutasteride Oral capsule; Adult males: 0.5 mg PO once daily.

Dutasteride, Tamsulosin Hydrochloride Oral capsule; Adult Males: 1 capsule (0.5 mg dutasteride and 0.4 mg tamsulosin) PO once daily about 30 minutes after the same meal each day.

Tamsulosin Hydrochloride Oral capsule; Adult males: 0.4 mg PO once daily, 30 minutes following a meal
Silodosin Oral capsule; Adults: 8 mg PO daily with a meal.

Medicines for mixed symptoms of overactive bladder and bladder outlet obstruction

You may have the following signs and symptoms:

• Frequent passing of urine

• Passing urine several times after sleeping

• Urgency to pass urine, with or without incontinence

Your doctor may start with antimuscarinic medicine and add alpha blocker if your symptoms continue to be bothersome.
The medicines work by relaxing the muscles of the urinary bladder.

• Oxybutynin tablet: initially, 5—10 mg (orally) once in a day. Can be increased to 30 mg per day with 5 mg increase after every week.

• Darifenacin tablet: 7.5 mg (orally) once in a day.

Medicines when BPH and erectile dysfunction occur together

Phosphodiesterase-5 inhibitors is found helpful in some of these men. Tadalafil tablet 5 mg(orally) once in a day at about the same time every day.

Minimally Invasive Procedures and surgeries

Your doctor would recommend you to undergo minimally invasive or surgical therapies in following situations:

• Moderate to severe symptoms

• Failure of medicines to relieve symptoms

• Definitive treatment, is what you are looking for

• Complications, you have complicating factors such asUTI, blood in urine, bladder stones, or kidney problems

You might need to avoid minimally invasive procedure or surgical therapies if you have:

• Urinary tract infection (UTI)

• Stricture/narrowing in your urethra

• History of urinary tract surgery or radiation therapy to prostate

• Neurological condition such as multiple sclerosis or Parkinson’s disease

There are number of surgeries and minimal invasive procedure available which have different pros and cons and different utility for specific circumstances. The options are as follows

• Transurethral resection of the prostate (TURP)

• Transurethral incision of the prostate (TUIP)

• Transurethral microwave thermotherapy (TUMT)

• Laser therapy

• Prostatic urethral lift (PUL)

• Open prostatectomy

TURP

is the commonest procedure done for BPH. Here, after giving anesthesia the urologist passes a tube-like instrument called resectoscope through the tip of your penis into the urethra. The instrument consists of an electrified wire loop which scrapes away the pieces of enlarged prostate tissue which blocks the urethra. This provides enlarged passage for the outflow of urine.

After this, the cut pieces are removed by flushing them into the bladder and then out of the body. You may be required to use a catheter for a day or two to help you recover from the surgery.

TURP 1 2 scaled

• Benefits: considered as a gold standard treatment to manage BPH and relieve its symptoms. Usually, the surgery provides a marked improvement in symptoms. The treatment usually remains effective for 15 years or more.

• Side effects: urinary tract infections immediately after the surgery, retrograde ejaculation, erectile dysfunction, and urinary incontinence.

TUIP

this is usually preferred if you have a mild prostatic enlargement but significant blockage of urethra. Here, the urologist inserts a cystoscope through the urethra to reach to neck of the bladder. Then he uses an instrument that make few cuts in the urethras and adjacent prostate to relive compression on the urethra. No prostatic tissue is removed in this procedure. The cuts are made by using either electric current or a laser beam. After the surgery, a catheter is kept inserted for 1 to 3 days.

• Benefits: the procedure may less likely interfere with ejaculation than TURP.

• Side effects: could be urinary tract infection, incontinence, and erectile dysfunction.

TUMT

in this procedure the doctor inserts a special electrode through your urethra into the obstructive prostate tissue. Microwave energy emitted from the electrode destroys the targeted prostatic tissue by heating it.A cooling system used protects the urinary tract from the heat damage. This procedure is generally used only on smaller prostates in special circumstances .

Laser procedures

BPH can also be treated using laser procedures where a high energy laser is used to destroy or remove the enlarged portion of the prostate. These procedure have a lower risk and can be done in men who are not good candidates for a more invasive procedure.

Ablative laser procedures: here the laser is used to vaporize the overgrown prostate tissue to increase the urine flow. A commonly used ablative procedure is photoselective vaporization of the prostate (PVP). Here a urologist passes a thin tube like cystoscope into the urethra and reaches the prostate. There he use a laser to destroy the obstructing prostate tissue and stop the bleeding. This procedure is useful in men with small to medium sized heart and those who are at higher risk for more invasive surgery.

• Benefits: doesn’t require admission, where it is done as an OPD procedure. The procedure causes only little bleeding and thus can be used in men with weak heart or on blood thinning medicines.

Enucleative laser procedures: an example for such procedure is holmium laser enucleation of the prostate (HoLEP). Here, the obstructive part of prostate is destroyed and removed using a laser. The removed tissue can be examined to look for cancer and other conditions. This procedure is done on men with larger prostate. This procedure requires at least a days stay at the hospital.

Prostatic urethral lift (PUL)

Here the doctor uses a needle to put tiny implants in the prostate which lifts and hold the prostate, improving the urine flow. This procedure doesn’t involve any cutting or heating to destroy or remove the excess prostatic tissue. This procedure is found to cause lesser sexual side effects than other type of procedures. However, this a newer technique and the long term success of the treatment til now are not very supportive.

Open prostatectomy

Here, the doctor makes a cut through the skin to reach the prostate and remove all or a part of the prostate. This surgery is typically performed if you have a markedly enlarged prostate, bladder damage or other complications. Typically you would need general anesthesia, a longer hospital stay and longer time for recovery than other procedures.

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