Benign Prostatic Hypertrophy (BPH)

Treatments for BPH

Treatments for BPH include:

Expectant Treatment (i.e. reassurance/wait and see)
Lifestyle changes (e.g. restricting fluid intake)
Medical Treatment (medication/drugs)
Interventional Treatment (prostate surgery/lasers etc).

In the past ten years or so, the number of operations for prostate problems has decreased by approximately 50% as BPH is better understood and medicines are increasingly used successfully.

Treatment is necessary only if symptoms are bothersome or if there are complications. With all the medical treatments, the affect on the average man may not be substantial, but could be sufficient to decrease the bother of the symptoms to enable a more normal life.

1. Expectant Treatment:

Many patients only require reassurance. Men may attend for many reasons in addition to LUTS; there may be a fear of cancer, anxiety about sexual function or disturbing their partner by urinating at night for example. Often reassurance, perhaps accompanied by life style changes, is sufficient. Generally, active treatment is offered only to men who perceive their symptoms as bothersome and then only following a trial of lifestyle changes (unless there are complications). The degree of bother from LUTS is very dependant on each individual.

2. Lifestyle changes:

As men age, the bladder is unable to accommodate the volumes of fluid drunk in the past. Many men drink just before retiring to bed and, when they rise to urinate, make another drink. If they experience nocturia, reducing fluid intake before bedtime could improve their symptoms considerably. Similarly, reducing fluid intake throughout the day (some drink four to five litres!) can also decrease day time frequency. A frequency volume chart is very helpful in identifying such patients. It is also worth considering taking less fluid in winter (when there is less sweat and more fluid goes to the bladder) than summer. Some bladders are sensitive to caffeine or fizzy drinks; reducing or stopping these can improve symptoms.

3. Medical Treatment:

There are two broad groups of medical therapy, alpha-blockers and 5-alpha reductase. However other kinds of drugs may help in specific situations.

Alpha Blockers: These reduce the pressure inside the prostatic part of the urethra, making it easier for urine to pass. They can increase maximum flow rates by 15-30% compared to baseline. Typically, total symptoms scores also improve by 30-45%, which is usually apparent after two weeks. Side-effects occur in 10-20% of men and include tiredness, dizziness, headaches and retrograde ejaculation.

5-alpha reductase: Over the first 6 months, these reduce the prostate size by up to 20-30%; it may also take up to 6 months for a benefit in symptoms to be seen. They have been shown to be of special value in men with very large prostates (>40gm). Side-effects are rare; about 5% of men report decreased libido, erectile dysfunction and decreased ejaculate.

Combination Therapy: Recent studies studying the combination of alpha-blockers and alpha-reductase tablets suggest that using them together may be more beneficial than using either alone.

Anti-cholinergics: These drugs reduce bladder irritability (detrusor instability) and can benefit some men with urgency who constantly have to rush off to pass urine. Care needs to be taken in those who are also obstructed because of BPH as there is a risk of urinary retention (when the urine is blocked and a catheter tube in the penis is needed). In men with BPH who have severe storage symptoms and are also obstructed, the combination of anti-cholinergic with alpha-blocker may reduce the risk of retention. Side-effects include dry mouth (which may encourage more fluid intake and negate the benefits) and constipation.

DDAVP: This can be recognised from a well completed frequency volume chart. In men with nocturnal polyuria (who make more urine made at night than during the day), this hormone may reverse the problem and return the normal rhythm of more urine made during daytime.

4. Interventional (prostate surgery/lasers etc)

Surgery: The gold standard procedure is transurethral resection of the prostate (TURP) although sometimes in small glands it is sufficient to incise the neck of the bladder (bladder neck incision) (BNI). These treatments tend to be reserved for patients in whom the objective tests show proof of bladder obstruction by the prostate and who have failed a trial of medical therapy. Some men are offered surgery immediately, for example those patients who stop passing urine at all and need a catheter (acute urinary retention). The operation can be performed under a general anaesthetic (with the man asleep) or a spinal anaesthetic (when an injection into the back numbs the lower half of the body. Generally a catheter is left in the bladder for a couple of days and nights after surgery until the urine is clear from bleeding and the healing process has begun. The entire prostate cannot be removed with these techniques and the outside layer remains; therefore the prostate can re-grow, occasionally requiring further surgery in the future. Other complications include bleeding, infection, retrograde ejaculation (where at orgasm sperm go into the bladder instead of out of the penis - this is harmless) and rarely erectile dysfunction.

Lasers: Lasers that are being studied appear to have benefits over TURP. Day-case treatment has become possible. Some have equivalent short-term benefit to TURP but at the moment, none have been tried for long enough to adequately compare benefits/side-effects with TURP.