Men's Health Issues: An Update on BPH

Benign prostatic hyperplasia (BPH) may be described as a quality-of-life disorder, affecting a man's ability to initiate and terminate a urinary stream; associated symptoms include urgency, frequency, and low-volume urination. Prostate cancer, on the other hand, is a life-threatening problem with more than 189,000 new cases diagnosed in 2000. Men have a lifetime risk of 10% of having cancer of the prostate, with a risk of dying with prostate cancer of 3%. Prostate cancer is the second leading cause of cancer-related deaths in men.

Benign Prostatic Hyperplasia
Benign prostatic hyperplasia is an enlargement of the prostate gland sufficient enough to provide lower urinary tract symptoms (LUTS). Regardless of the cause of BPH or the size of the prostate, LUTS occur when hyperplasia encroaches on the urethral diameter and limits flow. The actual size (volume) of the prostate may not be the primary issue.

Symptoms of BPH are divided into obstructive voiding symptoms (poor force of urinary stream, feelings of incomplete bladder emptying, intermittency of stream, and straining to urinate) and irritative voiding symptoms such as nocturia (3 or more times a night for a man older than 60 years), frequency, and urgency of urination. The American Urological Association-International Prostate Symptom Score (AUA/IPSS) is the outcome of a series of urination function questions (35 is the highest score, representing the most severe symptoms) used to evaluate the severity of the symptoms and guidance to improve prostate health. A score of 0-7 is mild, 8-19 moderate, and 20-35 severe.

Evaluating BPH
Further evaluation of BPH and LUTS may include urinary flow rate, postvoid residual volume measurement, and urodynamics/voiding pressure studies. An intravenous pyelogram or cystoscopy is rarely needed. Completion of the evaluation should include, but not be limited to, a urinalysis to rule out hematuria or infection and a serum creatinine to rule out obstructive causes of LUTS.

Prostate-specific antigen (PSA) and digital rectal examination (DRE) are also indicated for a comprehensive examination. The practitioner should also consider other factors than BPH for the cause of LUTS. Neurologic lesions or disorders, metabolic disorders resulting in peripheral polyneuropathies (diabetes, alcoholism), and medications (antidepressants, antispasmodics, calcium channel blockers) may be the cause and, if so, therapy should be focused on those problems.

Treatment of BPH
Treatment of BPH should be directed according to the patient's symptom score or "bother" score. If the patient is not at risk of obstructive uropathy, then treatment should be directed toward the degree of "bother" the symptoms give the patient, not the AUA-IPSS score. If the patient elects treatment, it should begin with patient education and hygienic measures (time and amounts of fluids taken as well as prescription and over-the-counter medications that can increase symptomatology).

If additional intervention is needed, over-the-counter medications and prescription medications are available to resolve LUTS. However, there is always a concern about regulation of quality and consistency with these medications. Saw palmetto, with an active ingredient similar to a 5-alpha reductase-blocking agent (finasteride), is available. Issues include varying efficacy according to the plant it was extracted from and the concentration in each preparation. The magnitude of effect is modest, as is the side-effect profile. Other over-the-counter remedies are available (horse chestnut, nettle, pumpkin, sea holly, and bee pollen), but these appear to have minimal input, if any, on BPH symptomatology.

Nonpharmacologic and Surgical Therapy
Nonpharmacologic therapy includes surgical treatment such as open prostatectomy, transurethral resection of prostate (TURP, the gold standard), transurethral incision, and newer alternatives such as VaporTrode, laser techniques, transurethral microwave thermotherapy of the prostate (TUMT), and transurethral needle ablation (TUNA).

The open prostatectomy is usually reserved for patients with very substantial prostate enlargements, while the TURP has demonstrated the most success, with the average IPSS score falling 10 points. The VaporTrode uses high energy from electrocautery to "vaporize" prostatic tissue, resulting in midrange results comparable to TURP. Laser techniques employ laser energy to coagulate prostate tissue, resulting in less bleeding and short hospital stays. However, the prolonged edema associated with this intervention results in prolonged catheter use.

Microwave therapy uses energy to "cook" prostate tissue. Care must be taken to cool the rectum and urethra. Long-term results of TUMT are not impressive. TUNA employs radiofrequency energy via needles that pierce the prostate and create necrosis. Long-term results for TUNA also indicate very little improvement beyond medical therapy. Postoperative issues include varying degrees of incontinence, impotence, and urinary obstruction requiring indwelling catheters postoperatively.

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