Benign Prostate Hyperplasis (BPH)

The prostate is a small gland just below the bladder which is traversed by the prostatic segment of the urethra- the tube that carries urine from the bladder. In addition, seminal fluid containing sperm flows into the prostatic urethra at the time of ejaculation, combining with prostate enzymes that ultimately contribute to the process of conception.

A majority of men will develop an increase in prostate size (benign prostate hyperplasia or BPH) as they get older. In some (but not all), this may lead to painful obstruction of the urinary tract with symptoms of frequent urination, hesitation in beginning voiding, slow stream, sense of incomplete emptying, and getting up frequently at night to urinate. In extreme cases, urinary retention (inability to void) may require emergency insertion of a catheter to empty the bladder. Other less common consequences include blood in the urine, bladder decompensation (stretched bladder muscle), kidney failure, or urinary tract infection.

Symptoms caused by benign enlargement of the prostate can be confused with infection and inflammation of the prostate (acute or chronic prostatitis) or prostate cancer. Therefore, a thorough assessment is needed to distinguish among these prostate diseases so that the proper treatment plan is implemented.

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Evaluation

History and review of symptoms are important steps in evaluation of voiding difficulties in men. Severity of symptoms is best measured using a questionnaire (the American Urologic Association Symptom Score Index) that assesses the scale of severity for seven symptoms associated with enlarged prostate.

In men age 50 years or older (or in men age 45 years with risk factors associated with prostate cancer such as family history or African-American), a PSA blood test is needed to identify those who should undergo prostate biopsy. Digital rectal exam provides an estimate of prostate size and determines the presence or absence of prostate nodules that may indicate prostate cancer. More accurate measures of prostate size would include prostate ultrasound (in the office) or CT scan or MRI (imaging studies performed in radiology). A bladder scan immediately after voiding provides an estimate of the efficiency of bladder emptying by measuring post-void residual urine (PVR).

Urine is collected and analyzed to determine the presence or absence of infection or blood. When symptoms raise the suspicion of prostatitis (perineal pain, pain with voiding), prostatic fluid is collected after prostate exam and viewed under the microscope to assess for the presence of white blood cells.

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Treatment

BPH

BPH does not always require immediate treatment as its progression is highly variable among individuals. For many men, symptoms may remain unchanged for years and may even improve. Frequent nighttime urination is a symptom of BPH, but it does not predict who will need future treatment for BPH. When we determine that treatment is needed, there are both medical and surgical options.

Pharmacologic treatment is generally divided into two classes of medication: one class relies upon decreasing nerve activity allowing the “internal sphincter” at the top of the prostate to relax (alpha-blockers); the other inhibits the conversion of testosterone to dihydrotestosterone by blocking the enzyme (5 alpha-reductase) that is responsible for this conversion. Dihydrotestosterone promotes prostate enlargement. By decreasing its concentration in the prostate tissues, the prostate size is decreased and the symptoms are improved.

Surgical treatment of BPH involves removing the part of the prostate that is pressing on the urethra and causing the symptoms. Unlike surgery for prostate cancer, traditional surgical removal of prostate tissue for relief of voiding symptoms only removes the inner core of the prostate. This procedure is called transurethral resection of the prostate (TURP) and is performed through a telescopes using electrical energy to resect the obstructing tissue that is removed from the prostate and examined by a pathologist. More recently, techniques which use other energy sources (laser, microwave, radiofrequency) can vaporize (laser energy) or heat (radiofrequency, microwave, or laser) the tissue to relieve the obstruction. One technique that uses radiofrequency energy to heat the obstructing prostate tissue can be performed in the office under sedation and local anesthesia. This is called a transurethral needle ablation or TUNA. Rarely, open surgery is indicated if the prostate volume exceeds our capability to remove or vaporize through the telescope.

Prostatitis

Prostatitis (inflammation of the prostate) is divided into three classifications: acute, chronic, and abacterial. Acute prostatitis implies infection causing inflammation. We confirm the diagnosis by examining expressed prostatic secretions under the microscope and seeing a high number of white blood cells (inflammatory cells). Treatment includes antibiotics and anti-inflammatory medications. Prostatitis, unlike bladder infections, requires prolonged treatment to achieve elimination of inflammation.

Unfortunately, prostatitis may recur or may progress to a chronic prostatitis with or without bacterial infection. Treatment plans must be individualized to obtain maximum relief of pain and voiding symptoms. Rarely, removal of the central portion of the prostate may be indicated.

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The University of Cincinnati Urology Division is one of the leading urology programs, not just in Cincinnati, but in the U.S. UC Urology provides quality health care using the most advanced technology and state-of-the-art diagnostic treatments. Many of our urologists are recognized in multiple national and local "Best Doctors" and "Top Doctors" listings. We provide minimally invasive surgical treatments which include laparoscopic, robot-assisted laparoscopic and endourologic procedures as well as comprehensive care for all urologic conditions.