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Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020
| Contributor Information
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Image from Wikimedia Commons | Steven Fruitsmaak.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
Benign prostatic hyperplasia (BPH) refers to an increase in the number of prostatic stromal and epithelial cells, leading to growth of the prostatic tissue, typically within the transition zone of the prostate.[1] As a result, the enlarged prostate can obstruct urine outflow which, in turn, can contribute to lower urinary tract symptoms (LUTS). Aging men commonly experience LUTS.[1]
The photograph above shows a prostate with a large upward bulging median lobe. A metal instrument is positioned in the urethra, which passes through the prostate.
This slideshow will present the evaluation of BPH, as well as different medical and surgical modalities that are used to treat this condition.
Image courtesy of Medscape.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
BPH is a chronic condition that has an increasing prevalence with age—an estimated three quarters of men older than 70 years are affected.[2] As early as 1978, McNeal demonstrated that BPH first develops in the periurethral transition zone of the prostate.[3]
An important feature of BPH is that the size of the prostate does not necessarily correlate with the degree of LUTS the patient experiences. Urethral resistance, the prostatic capsule, and anatomic changes are other significant factors in the development of clinical symptoms.[4]
Image from the National Cancer Institute (NCI).
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
Etiopathophysiology
A large portion of the prostatic gland is composed of smooth muscle controlled by the adrenergic nervous system.[4] Blockade of alpha-adrenergic receptors by medications such as tamsulosin causes a reduction in urethral resistance and allows for improvement of obstructive voiding symptoms.[4-6]
Additional evidence supports a multifactorial etiology of male LUTS, including adaptive changes within the bladder in response to bladder outlet obstruction from the prostate.[4] Two types of bladder changes can occur: Patients may experience decreased compliance of the bladder with increased urinary frequency and urgency, or decreased detrusor contractility worsens the force of the urinary stream despite relief of the obstructing prostate.[4]
Image courtesy of Olivia Wong, DO.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
Clinical and Diagnostic Evaluation
All patients who present with LUTS should undergo a complete history and physical examination, including a digital rectal examination (DRE) and a focused neurologic assessment, to exclude other causes of voiding dysfunction.[7-9] In addition, use the American Urological Association (AUA) Symptom Index (SI), a validated self-administered questionnaire (shown), and obtain a urinalysis.[7-9] The AUA-SI scores can provide clinicians with information regarding the symptom burden patients are experiencing, as well as assist with shared decision making for medical and/or surgical intervention.
Prostate-specific antigen (PSA) testing should occur in accordance with the AUA guidelines for prostate cancer screening.[10]
Image courtesy of Josh Palka, DO.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
The above urine flow rate curve obtained by uroflowmetry is from an older male who reported a weak stream and an AUA symptom score of 28. As the image shows, his maximum flow rate is less than 10 mL/s. Flow rates below 10 mL/s have been demonstrated to have a 70% specificity, 70% positive predictive value, and 47% sensitivity for bladder outlet obstruction.[11] The patient ultimately underwent a transurethral resection of the prostate (TURP), with significant improvement of his voiding symptoms.
Uroflowmetry, imaging studies, and cystoscopy
Men who present with LUTS should also undergo uroflowmetry to assess their voiding status before surgical intervention for BPH. A total voided volume of 150 mL is sufficient to perform a valid uroflowmetry. In addition, patients can be assessed for postvoid residual volume.
Other diagnostic options include obtaining imaging studies (eg, abdominal or transrectal ultrasonography, cross-sectional images with magnetic resonance imaging [MRI] or computed tomography [CT] scanning) or performing cystoscopy prior to surgical intervention to assess the size of the prostate.[7,8]
Image courtesy of Josh Palka, DO.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
A cystoscopic view of the prostate is shown, revealing obstructing lobes within the prostatic urethra.
Medical Therapy
After shared decision making, patients may be started on behavioral modification or administered medication. Some men may eventually require surgical intervention.
Alpha-adrenergic blockers are the most common first-line therapy for patients with BPH and LUTS.[12] These agents work to relax smooth muscle at the bladder neck and throughout the prostate.[5] Inform patients of the potential side effects, including dizziness, retrograde ejaculation, and rhinitis.[5] In particular, tamsulosin is associated with floppy-iris syndrome during cataract surgery.[13]
Image from Flickr | Jessica Johnson.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
5-Alpha-reductase inhibitors (5-ARIs) can also be prescribed for patients with BPH. These medications treat the obstructive component of BPH by reducing prostate volume.[12] 5-ARIs prevent conversion of testosterone into the potent androgen dihydrotestosterone (DHT),[5,12] which works locally, not systemically.[5]
Note that, due to the slow onset of action of 5-ARIs, patients may not notice a clinical effect for up to 3-6 months. Adverse effects associated with this class of medications in the first year of treatment include decreased libido, erectile dysfunction, ejaculatory disorder, gynecomastia (shown), breast tenderness, and rash.[14]
Combination therapy with alpha-blockers and 5-ARIs has also been shown to be beneficial for patients with moderate to severe LUTS and BPH who have prostatic volumes larger than 40 grams.[12]
Image courtesy of Josh Palka, DO.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
Occasionally, the prostate becomes so large that the patient is unable to void, and placement of a regular Foley catheter may be unsuccessful. In one study, BPH was the cause of acute urinary retention in 53% of patients who presented with this symptom.[15]
The best alternative to attempting Foley catherization is the use of a coudé catheter (pictured), which has a curved tip (arrow) that allows the catheter to negotiate the angulation caused by the enlarged prostate. The balloon port is orientated in the same plane as the angled tip to allow the practitioner to know that when the balloon port is up, the tip is also pointed up.
In the event neither a Foley nor coudé catheter can be placed, flexible cystoscopy (to place a Foley catheter) or insertion of a suprapubic tube may be required.[16]
Image courtesy of Josh Palka, DO.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
Surgical resection of adenomatous tissue with a bipolar resection loop is shown.
Surgical Treatment
According to the AUA guidelines for BPH, indications for surgical intervention include "renal insufficiency secondary to BPH, refractory urinary retention secondary to BPH, recurrent urinary tract infections (UTIs), recurrent bladder stones or gross hematuria due to BPH, and/or with LUTS attributed to BPH refractory to and/or unwilling to use other therapies."[7,8]
Transurethral resection of the prostate
TURP, with either monopolar or bipolar energy (as dictated by the surgeon's expertise), is the current gold-standard operative procedure for BPH. Most patients notice improvement in their voiding symptoms immediately after surgery. However, some patients may see a delay in their improvement if they initially presented with urinary retention or had some component of bladder dysfunction.
Note that dilutional hyponatremia TURP syndrome may occur when monopolar energy is used because it requires hypotonic solution,[7] which can be absorbed in the prostate resection bed.[17]
Image from Moldoveanu C, Geavlete B, Stanescu F, et al. J Med Life. 2013;6(3):272-7. [Open access.] PMID: 24146686, PMCID: PMC3786486.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
Transurethral vaporization and transurethral incision of the prostate
Patients with BPH can also undergo transurethral vaporization (TUVP) with bipolar energy.[7,8] This procedure is commonly performed using a separate component with either a button, roller ball, or mushroom-shaped attachment (shown) to vaporize the prostatic tissue.
Patients who wish to reduce the risk of retrograde ejaculation or who desire a smaller prostate size (≤30 g) can undergo a transurethral incision of the prostate (TUIP).[7,8]
Image from Boston Scientific, used with permission.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
Photoselective vaporization
The use of photoselective vaporization (PVP) is another type of surgical intervention for BPH.[7,8] This process utilizes a laser that possesses a low absorption coefficient for water but a high affinity for hemoglobin, leading to selective absorption by the oxyhemoglobin chromophore.
Results from the GOLIATH trial at 2-year follow-up revealed PVP to be noninferior to TURP with regard to the International Prostate Symptom Score (IPSS) and voiding velocity.[18] Note that patients with prostate volumes larger than 80 grams were excluded from this trial. In addition, the Greenlight XPS Laser Therapy System (shown) has been found to reduce bleeding complications when compared with monopolar TURP.
Image courtesy of Josh Palka, DO.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
This photograph was obtained from a patient with BPH and associated bladder stones. A holmium laser is featured, which can be used not only for performing lithotripsy of the stones but also for a holmium laser enucleation of the prostate (HoLEP) procedure.
Laser enucleation of the prostate
The use of holmium and thulium lasers (ThuL) is another option for operative intervention for BPH.[7-9] Due to the low depth of penetration and high vaporization, these two laser types are well suited for prostate surgery. The lasers are commonly employed for enucleation of the prostatic tissue, which is then morcellated endoscopically.
Some HoLEP or ThuLEP studies have shown a decreased need for postoperative transfusions, shorter postsurgical catheter times, and shorter hospital stays compared with TURP.[19] However, a disadvantage of using laser enucleation is a steep learning curve.[19]
Image courtesy of Josh Palka, DO.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
The photograph above features a prostate that was removed via an open suprapubic prostatectomy. The obstructive prostate had a significantly large median lobe and a total prostatic volume of approximately 140 grams.
Simple prostatectomy
For patients who present with BPH, LUTS, and a very large prostate (>80 g), or for those who have large bladder diverticula or bladder stones, simple prostatectomy remains a viable option. Note that blood loss and postoperative transfusion are cited as potential complications; minimally invasive techniques appear to lower the risk of these drawbacks.[19]
Image of the UroLift device courtesy of Josh Palka, DO.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
Prostatic urethral lift
The emergence of newer techniques and technologies offer minimally invasive approaches to BPH, such as prostatic urethral lift (PUL),[7-9] in which the enlarged prostatic tissue is lifted and held out of the way of the urethra. This technique lodges tissue-retracting implants with the assistance of a cystoscope. Approximately four to six implants are required.
Images courtesy of Josh Palka, DO.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
The left photo shows a preoperative view of obstructing lobes of the prostate. The right photo reveals a postoperative view of the anterior channel with the lateral obstructing lobes pulled to the side with UroLift implants.
Patient selection is paramount for PUL success and should include a prostate size that is less than 80 grams. Results from the 5-year LIFT study of patients who underwent this procedure revealed that they did not experience any erectile or ejaculatory dysfunction, and there was improvement of their voiding symptoms.[21]
Image of the Rezum Water Vapor Therapy System from Boston Scientific media kit, used with permission.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
Water vapor thermal therapy
Another minimally invasive technique is the use of convective water vapor therapy.[7-9] This technology delivers targeted and controlled doses of thermal energy directly into the prostate, thereby causing transitional zone cell death. The procedure can be performed in the office or in the operating room.
Adapted image from Boston Scientific media kit, used with permission.
Benign Prostatic Hyperplasia: Evaluation and Treatment
Josh Palka, DO | August 4, 2020 | Contributor Information
A study demonstrated a durable response (>4 years) of voiding improvement after therapy with the Rezum Water Vapor Therapy System.[22] Patients reported no adverse effects with sexual function. Moreover, the surgical retreatment rate was 4.4%.
Although urologic emergencies are relatively uncommon, prompt diagnosis and management are essential to prevent serious complications. Do you know how to recognize and best treat these 12 emergency urologic conditions?Mescape Reference Slideshow, July 2020
Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate.Medscape Drugs & Diseases, Jan 2019
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Contributor Information
Author
Josh Palka, DO
Detroit Medical Center
Detroit, MI
Disclosure: Josh Palka, DO, has disclosed
no relevant financial relationships.
Editor
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, NY
Disclosure: Olivia Wong, DO, has disclosed no relevant financial
relationships.
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References
Amin A. Prostate gland & seminal vesicles. Benign lesions/conditions: benign prostatic hyperplasia. PathologyOutlines.com. Revised: January 9, 2020. Available at: https://www.pathologyoutlines.com/topic/prostatenodhyper.html. Accessed July 24, 2020.
Wei JT, Calhoun E, Jacobsen SJ. Urologic diseases in America project: benign prostatic hyperplasia. J Urol. 2005 Apr;173(4):1256-61. PMID: 15758764
McNeal JE. Origin and evolution of benign prostatic enlargement. Invest Urol. 1978;15(4):340-5. PMID: 75197
Roehrborn CG. Benign prostatic hyperplasia: etiology, pathophysiology, epidemiology, and natural history. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 11th ed. Philadelphia: Elsevier; 2015: ch 103.
Deters LA, Costabile RA, Leveillee RJ, Moore CR, Patel VR. Benign prostatic hyperplasia (BPH). Medscape Drugs & Diseases. Updated: January 15, 2019. Available at: https://emedicine.medscape.com/article/437359-overview. Accessed July 24, 2020.
Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA guideline [reviewed and validity confirmed 2018]. J Urol. 2013 Aug;190(2):419-26. PMID: 23659877 [Full text]
Reynard JM, Yang Q, Donovan JL, et al. The ICS-'BPH' Study: uroflowmetry, lower urinary tract symptoms and bladder outlet obstruction. Br J Urol. 1998 Nov;82(5):619-23. PMID: 9839573
Kim EH, Brockman JA, Andriole GL. The use of 5-alpha reductase inhibitors in the treatment of benign prostatic hyperplasia. Asian J Urol. 2018 Jan;5(1):28-32. PMID: 29379733 [Full text]
Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg. 2005 Apr;31(4):664-73. PMID: 15899440
McConnell JD, Bruskewitz R, Walsh P, et al, for the Finasteride Long-Term Efficacy and Safety Study Group. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. N Engl J Med. 1998 Feb 26;338(9):557-63. PMID: 9475762 [Full text]
Willette PA, Coffield S. Current trends in the management of difficult urinary catheterizations. West J Emerg Med. 2012 Dec;13(6):472-8. PMID: 23359117 [Full text]
Thomas JA, Tubaro A, Barber N, et al. A multicenter randomized noninferiority trial comparing GreenLight-XPS laser vaporization of the prostate and transurethral resection of the prostate for the treatment of benign prostatic obstruction: two-yr outcomes of the GOLIATH Study. Eur Urol. 2016 Jan;69(1):94-102. PMID: 26283011
Kuntz RM, Ahyai S, Lehrich K, Fayad A. Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. J Urol. 2004 Sep;172(3):1012-6. PMID: 15311026
Xie JB, Tan YA, Wang FL, et al. Extraperitoneal laparoscopic adenomectomy (Madigan) versus bipolar transurethral resection of the prostate for benign prostatic hyperplasia greater than 80 ml: complications and functional outcomes after 3-year follow-up. J Endourol. 2014 Mar;28(3):353-9. PMID: 24229434
Roehrborn CG, Barkin J, Gange SN, et al. Five year results of the prospective randomized controlled prostatic urethral L.I.F.T. study. Can J Urol. 2017 Jun;24(3):8802-13. PMID: 28646935
McVary KT, Rogers T, Roehrborn CG. Rezum water vapor thermal therapy for lower urinary tract symptoms associated with benign prostatic hyperplasia: 4-year results from randomized controlled study. Urology. 2019 Apr;126:171-9. PMID: 30677455
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