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BENIGN PROSTATE HYPERPLASIA (BPH)

The prostate is a gland that looks like a chestnut on urethra of male individuals and surrounds the lower bladder called urethra. The older male individuals get, the bigger the prostate becomes and may block the urinary tract. This causes the symptoms of prostate hyperplasia. Common diseases seen in the prostate are prostatitis, prostate hyperplasia (benign prostate hyperplasia/BPH) and prostate cancer.

For the prostate hyperplasia that is regarded as benign after prostate examination, blood tests and prostate needle biopsy conducted when needed, monitoring of the patients or treatment through medication or operation are decided to depend on the level of symptoms.

Diagnosis techniques applied to decide whether the prostate is benign are the digital exam, PSA in the serum (total and random PSA), urinary ultrasonography, uroflowmetry, the prostate biopsy (when needed) and cystoscopy (monitoring prostate and bladder through a camera-display).

Symptoms of Benign Prostate Hyperplasia;

BPH symptoms are divided into two as obstructive and irritative ones. Obstructive symptoms are remission, the decrease in the urine caliber, split stream urination, incomplete urination, difficulty during urinating. And irritative symptoms are the immediate need of urinating, polyuria and nocturia. These symptoms mentioned can be seen in any stage of BPH.

These symptoms can be seen in a combined way during the compensated stage which is considered as the first stage of the prostate. In this stage, the bladder has hypertrophy to deal with the increasing workload (swelling of bladder smooth muscle cells), trabeculation of intravesical area develops and cellular and diverticula structures are formed in some areas. In the late stage, or in other words the decompensated stage, intravesical pressure can’t handle the prostate obstruction and bladder outflow resistance, and as a result, urination wouldn’t be possible to the blockage. This condition is called glob vezikale (retention). Additionally, creatinine increase due to hematuria, urinary tract infection, affected kidneys may develop.

Bladder and kidneys are affected in the cases where the patients aren’t treated depending on the bladder outflow resistance. Hypertrophy develops on the bladder smooth muscle cells as a result of the accumulation of the urine that can’t be discharged from the bladder. In the following period; stone, diverticulitis in the bladder, dilatation, urinary tract infection, and acute pyelonephritis on the ureters due to obstruction of both ureters and vesicoureteral reflux may develop. Last but not least, the patients might have the chronic renal failure due to hydronephrosis (enlargement of kidneys due to parenchyma damage) and disorders in the kidney functions caused by the disorder during the transfer of the urine to the bladder.

When the patients have these symptoms mentioned above, examination of patient history, physical examination, and some tests are conducted. Prostatism symptoms and their severities are determined through the anamnesis conducted. After the detailed physical examination, digital rectal exam and prostate examination would be required. Then the urine flow rate should be analyzed, the symptom score questionnaire developed by the American Urology Association (AUA) should be conducted, residue urine amount in the bladder after urination should be measured, size of the prostate should be measured, PSA level of the patient should be measured and prostate biopsy should be conducted in case of any high levels and upper urinary system and the bladder should be examined through imaging methods in order to obtain an objective evaluation of the patient.

AUA symptom score consists of symptom rating ranging between 0 and 35 and it’s the most significant tool for the evaluation of patients. 0-7 means the mild level, 8-19 means the middle level, and 20-35 means the severe level symptoms.

Uroflowmetry (urine test) is a computer-assisted device measuring the urine flow rate. The urine flow rate of a healthy adult is 20ml/sec. Values under this level show the outflow resistance.

Treatment Options for Benign Prostate Hyperplasia;

MONITORING: In the cases where the symptoms of prostate hyperplasia are mild, it is a good option for the patients who would like to wait until the symptoms are more obvious. Protective measures can be taken. These can be regulating eating habits, lowering the amount of alcohol consumed, preventing constipation, regular sexual life, avoiding to sit for long periods and lowering the high amount of water drunk before going to sleep.

MEDICATION: The medication of this health problem would be the medications relaxing urethra or bladder neck, medications slowing down prostate hyperplasia and blood build-up through hormonal blocking and herbal medications effecting in both ways.

In the medical treatment, alpha-blocker medications and the medications which are the 5-alpha-reductase inhibitor and reducing the size of the prostate by preventing the transformation of testosterone into dihydrotestosterone are used. Alpha blockers reduce the flow resistance by preventing the contraction of smooth muscle cells in the prostate stroma and bladder neck. Side effects of these medications depend on the dosage and are hypotension, dizziness, fatigue, retrograde ejaculation, rhinitis and headache. The side effects mentioned decreased with the alpha1a receptor specific medications.

5-alpha reductase inhibitors may reduce the symptoms by decreasing the size of the prostate. However, in order for these medications to be effective, prostate size should be less than 40cc. The most significant side effects are impotence, loss of libido and decrease in the sperm amount. Additionally, it makes the diagnosis of cancer more difficult since it causes a 50% decrease in PSA values, therefore the PSA levels of the patients measured should be multiplied by 2. Medications produced from herbal extracts called phytotherapy are also used for BPH. Various herbal extracts containing chopped date palm fruit, Pygeum afrinacum peel, Echinacea purpurea, and Hypoxis rooperi roots were introduced in Europe and became popular. The effect mechanism of this phytotherapy aren’t completely known and their credibility and effectiveness weren’t tested through multicenter, randomized, double-blind, placebo-controlled studies.

SURGICAL TREATMENT: Surgical treatment is applied in cases where there are severe symptoms of prostate hyperplasia, medical treatment is not sufficient, blood in the urine detected, urinary tract is inflamed (cystitis, prostatitis), there is a stone in the kidney, urine flow stops completely (where catheter is needed) and renal failure occurs.

Alternatives for Surgical Treatment;

TUR-P (TRANSURETHRAL PROSTATE RESECTION):

In other words, laparoscopy is the most common surgical method applied to BPH. It’s conducted with bipolar energy, plasma kinetic energy or monopolar energy. Swollen tissues are cut and taken through these energy sources. This operation which is a quite easy one doesn’t need and section or stitches outside of the body, the patient lives with a catheter for two or three days and hospitalization period is one day. After a well-conducted TUR-P (laparoscopy), long-lasting complaints of most of the patients are cured. Routine activities can be maintained following the operation.

(TUR-PLASMA KINETIC SURGERY)

OPEN PROSTATECTOMY (OPEN SURGERY):

It’s used for the patients with very big (over 100-150 grams) prostate. The prostate is taken out by opening a section under the abdomen. Its disadvantages are the bleeding risk and long hospitalization and catheter use periods.

TRANSURETHRAL INCISION OF PROSTATE (TUIP)

This procedure is applicable for patients with mid or mild level symptoms and prostate is incised with the help of electrocautery on the prostate posterior level. Patients with small prostate size are the suitable ones for this procedure. The prostate is not taken in this procedure and the risk of postoperative repetitive prostatism symptoms is high. The good part about this procedure is that it takes a short time and relatively low morbidity.

LASER PROSTATECTOMY

The use of the laser during prostatectomy has also become common with the increase of laser use. Working principle of lasers is the stimulated emission of radiation. There are 4 types of lasers (Nd YAG LASER, KTP, Ho YAG LASER, DİOD LASER) that are used for the treatment of the prostate. The effect of lasers on the prostate is coagulation or evaporation method. Prostatectomy in this way can be conducted by keeping the bleeding under control. Hospitalization period is shorter than other methods. Postoperative dysuria complications or late period bleeding can be seen. This method is an alternative for patients with bleeding disorders and is not suitable for spinal or general anesthesia.

In the patients with untreated or late to treat BPH, urine flow from the bladder would increase intravesical pressure due to prostate pressure. This increased intravesical pressure would strain the bladder and cause thickening of bladder muscles first and thinning and weakening in the later stages and renal failure due to urine going to kidneys.

The weakness of the bladder muscle causes residue urine in the bladder called postvoiding residue (PVR). The presence of residue urine in the bladder is a potential risk for an infection in the urinary tract that could reach until kidneys.

When the patients with severe BPH symptoms are late for the operation, permanent and irrevocable bladder and urinary tract damages may occur and therefore the operation is vital in terms of high life quality.

Besides that, we recommend our patients to visit their doctors for periodical PSA measurement and urology check in order not to miss an underlying prostate cancer after the age of 50 (after the age of 40 if you have any relatives diagnosed prostate cancer). With the development of technology in our day, BPH and prostate cancer can be treated swiftly.