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BPH: Minimally Invasive Management (Benign Prostatic Hyperplasia/Enlarged Prostate)

Throughout a man's life, his prostate may grow and start to cause problems as he ages. For many years, a prostatectomy was the only treatment for this very common problem. Although effective, such major surgery requires patients to spend significant time in the hospital and at home in recovery. It also is associated with more side effects. Fortunately, today's technological advances now provide urologists with an array of minimally invasive techniques to treat BPH. What are some of these new treatments available? The following should help answer that question as well as others.

What is the prostate?

The prostate, a part of the male reproductive system, is about the same size and shape as a walnut and weighs about an ounce. It is located below the bladder and in front of the rectum and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce ejaculatory fluid.

What is BPH?

Benign prostatic hyperplasia (BPH), previously referred to as prostatism, is a common urological condition caused by the non-cancerous enlargement of the prostate gland in aging men.

What are some of the risk factors for BPH?

Risk factors for developing BPH include increasing age and a family history of BPH.

What are some of the symptoms associated with BPH?

Since the prostate surrounds the urethra just below the bladder, its enlargement can result in symptoms that irritate or obstruct the bladder. A common symptom is the need to frequently empty the bladder, especially at night. Other symptoms include difficulty in starting the urine flow or dribbling after urination ends. Also, size and strength of the urine stream may decrease.

Fill out the AUA Symptom Score and share the results with your health care provider.

How is BPH diagnosed?

In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. The AUA diagnostic system includes a series of questions that target the frequency of the urinary systems identified above, and as a result, helps identify the severity of the BPH—ranging from mild to severe.

There are a number of diagnostic test procedures that can be used to confirm BPH. The tests vary from patient to patient, but the following are the most common: digital rectal examination (DRE), PSA test, transrectal ultrasound, urine flow study, bladder scan for residual urine, and cystoscopy.

What are some of the treatments available for BPH?

Watchful waiting: Is recommended as an important option for men who have mild symptoms and do not find them particularly bothersome. It is the least invasive treatment and avoids the risks, inconvenience and costs of medical and surgical treatments. In some men, symptoms improve over time as long as there are no high-risk symptoms like urinary retention, recurrent urinary tract infection, recurrent blood in the urine, bladder stones, kidney failure or bladder diverticula.

Medical therapy: Today's most common method for controlling moderate symptoms of BPH. Several medications are available to control moderate symptoms of BPH.

Alpha blockers: These drugs, originally used to treat high blood pressure, work by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and reduce bladder outlet obstruction. Although alpha blockers may relieve the symptoms of BPH, they do not reduce the size of the prostate. They are taken orally, once or twice a day and work almost immediately. Commonly prescribed alpha blockers include: alfuzosin, terazosin, doxazosin and tamsulosin. Side effects can include headaches, dizziness, lightheadedness, fatigue and difficulty breathing.

5-Alpha-Reductase Inhibitors: There are two medications available in this class, dutasteride and finasteride that work completely different than alpha blockers. In some men, dutasteride or finasteride can relieve BPH symptoms, increase urinary flow rate and actually shrink the prostate. Like all medical therapy, these drugs must be used indefinitely to prevent recurrence of symptoms. This class of medications is best suited for men with relatively large prostate glands. It may take as long as six months to a year, however, to achieve maximum benefits from this drug. Side effects can include impotence, decreased libido and reduced semen release during ejaculation.

What are some of the minimally invasive treatments available for BPH?

Prostatic stent (stenting): Anesthesia is not required for this procedure. The technology involves placing a spring-like contraption inside the prostatic part of the urethra to hold it open. There are many different kinds of stents but their overall use is limited. This is usually best suited for patients who have many medical problems or who are high-risk for surgery. Serious complications include urinary incontinence, dislodgement of stent position, stone formation on the stent with blockage and difficulty removing the stent. Minor complications include urinary frequency and urgency, dribbling of urine, discomfort and light bleeding. Patients with certain conditions are often advised against stent placement including those with strictures (narrowing) in the urethra, urinary infection, bladder stones, weak bladder and cancer, and patients who will be undergoing other procedures performed through the urethra soon after stent placement (e.g., treatment of kidney stones). Generally, prostatic stents are used for the same patients who would otherwise use an indwelling catheter or transurethral microwave thermotherapy (TUMT).

High-intensity focused ultrasound (HIFU): Anesthesia is usually required for this procedure. A special ultrasound probe is placed into the rectum near the prostate. Ultrasound waves heat the prostate up to very high temperatures, which causes destruction to the prostate tissue. The heated prostate tissue is destroyed and initially swells but then shrinks. The need for catheterization due to retention of urine and blood in the urine has been a problem postoperatively.

Holmium laser enucleation of prostate (HoLEP): After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the penis into the urethra. A visual lens and laser are passed through the hollow center of the instrument. The prostate tissue is vaporized using the holium:YAG laser. There is very little bleeding and recovery time is cut significantly. Typically, the patient has a catheter removed the next day and stays overnight in the hospital one day.

Interstitial laser coagulation: Anesthesia is usually required for this procedure, but patients can usually go home the same day. The technology involves placing a "cystoscope" (metal tube through which the visual lens and laser can be passed). A laser is used to pierce through into the prostate and the laser energy burns the tissue. Studies to date have shown limited long term benefits.

Transurethral electroevaporation of the prostate (TUVP): After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the penis into the urethra. An electrode moves across the surface of the prostate and transmits current that vaporizes prostate tissue. The vaporizing effect penetrates below the surface area being treated so underlying blood vessels are coagulated and sealed. Bleeding and fluid absorption are minimal and patients can usually return home without a catheter after an overnight hospital stay.

Transurethral microwave thermotherapy of the prostate (TUMT): This is an office-based procedure performed with topical and oral pain medication and does not require anesthesia. Computer-regulated microwaves are sent through a catheter to heat portions of the prostate. A cooling system is required in some types for better tolerance. Traditionally, the best use of this procedure has been for patients who have too many medical problems for more invasive surgery or for patients who truly wish to avoid any type of anesthesia. Benefits are that there is no need for anesthesia and there is no blood loss or fluid absorption (these would be significant benefits in a person with a weak heart). Patients usually go home the same day. Many urologists have the technology available in their practice and results are pretty reliable regardless of who performs the procedure. The use of TUMT has been expanding to a broader patient population and there are several types of TUMT machines available.

Transurethral radio frequency needle ablation of the prostate (TUNA): The procedure involves anesthesia and medications to make the patient sleepy. The technology involves heating of tissue using radio frequency energy transmitted by needles inserted directly into the prostate. High frequency radio waves heat the prostate up to very high temperatures. The heated prostate tissue is destroyed and initially swells but then shrinks. Most men require a catheter for a period of time after this procedure. Advantages in the use of TUNA include the limited anesthesia requirement, the ability to perform the procedure in an office setting and avoidance of serious complications sometimes associated with other procedures.

Photoselective vaporization of the prostate (PVP): This is fast becoming a very popular procedure performed either in a well equipped office or as an out-patient at the hospital. It uses a high-powered laser that vaporizes the obstructing prostate tissue with minimal bleeding or side effects. This procedure can serve to get men off of medical therapy. It is effectively replacing more invasive surgical treatment.

Catheterization: Placement of a catheter into the bladder will temporarily drain urine. Catheters can be placed intermittently every six to eight hours—clean intermittent catheterization—or left in place for one to three months at a time (indwelling). Catheters can be placed either through the urethra or by making a small puncture into the bladder above the pubic bone (called a suprapubic tube). Infection is the biggest risk of having a catheter in place for long periods, as bacteria can stick to the surface of the catheter, making it difficult for the body's immune system or antibiotics to clear the organisms. Another risk is that after a few years there is a higher risk of bladder cancer due probably to the long-term irritation caused by the catheter sitting in the bladder. Catheterization, performed by the individual or a caregiver every six to eight hours, minimizes the risk of infection and cancer compared with an indwelling catheter. Catheters are most useful as a treatment of choice for temporary drainage while waiting for medication to start working, surgery to be scheduled, or clearance of infection. They also might be the most appropriate choice for a patient with multiple medical problems and a short life expectancy, where the risk and discomfort of surgery outweigh the risk of infection or cancer. Catheterization is the treatment of choice over medications or surgery for patients who have neurogenic bladder in addition to prostatic obstruction.

Frequently Asked Questions:

Is BPH a rare condition?

No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

Does BPH lead to prostate cancer?

No, BPH is not cancer and cannot lead to cancer. Still, both problems can happen at the same time. There may not be any symptoms during the early stages of prostate cancer. So whether their prostate is enlarged or not, men should talk to their health care providers about whether prostate cancer screening is right for them.

Which type of drugs are the best?

To date, there are not enough research data to predict who will respond to medical therapy or which drug will be better for an individual patient.

How do I know if oral medications are the best treatment for me?

If you are diagnosed with BPH, you should discuss all treatment options with your urologist. Together, you can decide whether medication or surgical treatment is best for you.

If I am 65 and healthy with mild urinary symptoms, which is the best treatment for me?

As long as your symptoms are mild, your quality of life is not very affected and you do not have any compelling reason to have invasive surgical therapy right away, you can start with watchful waiting or the medical therapies. If those options are ineffective or your symptoms worsen over time, then minimally invasive therapy or surgical treatment may be the answer.

I am 77 with severe heart disease. My cardiologist tells me we cannot fix my heart. Meanwhile, although I am taking tamsulosin I am still having very bothersome urinary symptoms all night long. Which procedure is the best for me?

Most people can have a PVP without adverse events, but it is much riskier for someone with your medical history. After discussing your options with your urologist, one of the minimally invasive procedures that does not require anesthesia might be a better choice for you, for example, TUMT. Also, a combination of medical therapies may help.

Where can I get more information?

Benign Prostatic Hyperplasia (BPH) Treatment Choices

BPH: Enlarged Prostate

Hormone Health Network's Enlarged Prostate Fact Sheet

Common terms for BPH: enlarged prostate, big prostate



Reviewed: January 2011

Last updated: April 2013

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BPH: Minimally Invasive Management (Benign Prostatic Hyperplasia/Enlarged Prostate) Glossary
  • ablation: Removal of diseased or unwanted tissue from the body by surgery or other means.

  • anesthesia: Loss of sensation in any part of the body induced by a numbing or paralyzing agent. Often used during surgery to put a person to sleep.

  • antibiotic: Drug that kills bacteria or prevents them from multiplying.

  • bacteria: Single-celled microorganisms that can exist independently (free-living) or dependently upon another organism for life (parasite). They can cause infection and are usually treated with antibiotics.

  • bladder: The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.

  • bladder diverticula: They are pouches in the bladder wall that a person is born with (congenital) or later acquires. A congenital bladder diverticulum represents an area of weakness in the bladder wall through which some of the lining of the bladder is forced out. (A small balloon squeezed in a fist will create a diverticular-like effect between the fingers.) Bladder diverticula may be multiple and they often occur at the entrance of the upper urinary system into the bladder.

  • bladder neck: Area of thickened muscle fiber where the bladder joins the urethra. Acting on signals from the brain, bladder neck muscles can either tighten to hold urine in the bladder or relax to allow urine out and into the urethra. These muscles also tighten during ejaculation to prevent backflow of semen into the bladder.

  • BPH: Also known as benign prostatic hyperplasia. An enlarged prostate not caused by cancer. BPH can cause problems with urination because the prostate squeezes the urethra at the opening of the bladder.

  • cancer: An abnormal growth that can invade nearby structures and spread to other parts of the body and may be a threat to life.

  • catheter: A thin tube that is inserted through the urethra into the bladder to allow urine to drain or for performance of a procedure or test, such as insertion of a substance during a bladder X-ray.

  • catheterization: Insertion of a narrow tube through the urethra or through the front of the abdominal wall into the bladder to allow urine drainage.

  • clean intermittent catheterization: Also known as CIC. Periodic insertion of a clean catheter into the urethra after washing your hands to drain the urine from the bladder.

  • continence: The ability to control the timing of urination or a bowel movement.

  • cyst: An abnormal sac containing gas, fluid or a semisolid material. Cysts may form in kidneys or other parts of the body.

  • cystoscope: A narrow, tube-like instrument fitted with lenses and a light passed through the urethra to look inside the bladder. The procedure is called cystoscopy (sis-TAW-skuh-pee).

  • cystoscopy: Also known as cystourethroscopy. An examination with a narrow, flexible tube-like instrument passed through the urethra to examine the bladder and urinary tract for structural abnormalities or obstructions, such as tumors or stones.

  • digital rectal examination: Also known as DRE. Insertion of a gloved, lubricated finger into the rectum to feel the prostate and check for any abnormalities.

  • diverticula: Plural of diverticulum. A pouch or sac in the lining of the mucous membrane of an organ.

  • DRE: Also known as digital rectal examination. Insertion of a gloved, lubricated finger into the rectum to feel the prostate and check for any abnormalities.

  • ejaculation: Release of semen from the penis during sexual climax (orgasm).

  • ejaculatory: Involved in or related to the structure involved in the release of semen from the penis during orgasm.

  • ejaculatory fluid: Semen.

  • frequency: The need to urinate more often than is normal.

  • gland: A mass of cells or an organ that removes substances from the bloodstream and excretes them or secretes them back into the blood with a specific physiological purpose.

  • high blood pressure: Medical term is hypertension.

  • hyperplasia: Excessive growth of normal cells of an organ.

  • immune system: The body's system for protecting itself from viruses and bacteria or any "foreign" substances.

  • impotence: The inability to get or maintain an erection of the penis for sexual activity. Also called erectile dysfunction.

  • impotence: Also called erectile dysfunction or ED. The inability to get or maintain an erection for sexual activity.

  • incontinence: Loss of bladder or bowel control; the accidental loss of urine or feces.

  • infection: A condition resulting from the presence of bacteria or other microorganisms.

  • intermittent catheterization: Periodic insertion of a narrow tube through the urethra or through the front of the abdominal wall into the bladder to allow urine drainage.

  • invasive: Having or showing a tendency to spread from the point of origin to adjacent tissue, as some cancers do. Involving cutting or puncturing the skin or inserting instruments into the body.

  • invasive: Not just on the surface; with regard to bladder cancer, a tumor that has grown into the bladder wall.

  • ions: Electrically charged atoms.

  • kidney: One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.

  • kidney stone: A stone that develops from crystals that form in urine and build up on the inner surfaces of the kidney, in the renal pelvis or in the ureters. (Also see nephrolithiasis.)

  • laser: Device that utilizes the ability of certain substances to absorb electromagnetic energy and re-radiates as a highly focused beam of synchronized single wave-length radiation.

  • laser coagulation: The coagulation (clotting) of tissue using a laser. A coagulation laser produces light in the visible green wavelength that is selectively absorbed by hemoglobin, the pigment in red blood cells, in order to seal off bleeding blood vessels.

  • libido: Sexual desire.

  • microwave thermotherapy: Use of controlled heat for treatment.

  • neurogenic: Causing or relating to the disorder of nerves.

  • neurogenic bladder: Also called neuropathic bladder. Loss of bladder control caused by damage to the nerves controlling the bladder.

  • nocturia: Excessive urination at night.

  • obstruction: something that obstructs, blocks, or closes up with an obstacle

  • penis: The male organ used for urination and sex.

  • postoperative: Occurring after a surgical operation.

  • probe: Small device for measuring and testing.

  • prostate: A walnut-shaped gland in men that surrounds the urethra at the neck of the bladder. The prostate supplies fluid that goes into semen.

  • prostatectomy: Surgical procedure for the partial or complete removal of the prostate.

  • prostatic: Pertaining to the prostate.

  • prostatic stent: A wire device that expands after surgical placement thus pushing prostate tissue away allowing for easier urination.

  • prostatism: A disorder of the prostate gland, especially enlargement that block or inhibits urine flow.

  • PSA: Also referred to as prostate-specific antigen. A protein made only by the prostate gland. High levels of PSA in the blood may be a sign of prostate cancer.

  • PSA test: Also referred to as prostate-specific antigen test. A blood test used to help detect prostate cancer.

  • pubic bone: Also referred to as the pubis. Lower front of the hip bone.

  • radio waves: Electromagnetic waves.

  • rectal: Relating to, involving or in the rectum.

  • rectal ultrasound: A diagnostic test that uses very high frequency sound waves to produce an image of the rectum.

  • rectum: The lower part of the large intestine, ending in the anal opening.

  • resectoscope: A tube-shaped instrument used by the urologist to scoop a tumor from the bladder lining.

  • residual urine: Amount of urine remaining in the bladder after urination.

  • retention: In ability to empty urine from the bladder, which can be caused by atonic bladder or obstruction of the urethra.

  • semen: The thick whitish fluid, produced by glands of the male reproductive system, that carries the sperm (reproductive cells) through the penis during ejaculation.

  • semen: Also known as seminal fluid or ejaculate fluid. Thick, whitish fluid produced by glands of the male reproductive system, that carries the sperm (reproductive cells) through the penis during ejaculation.

  • Side effects: An action or effect of a drug other than that desired. Commonly it is an undesirable effect (e.g., nausea, headache, insomnia, acute toxic reaction or drug interaction).

  • stage: Classification of the progress of a disease.

  • stent: With regard to treating ureteral stones, a tube inserted through the urethra and bladder and into the ureter. Stents are used to aid treatment in various ways, such as preventing stone fragments from blocking the flow of urine.

  • stone: Small hard mass of mineral material formed in an organ.

  • stricture: Abnormal narrowing of a body passage.

  • suprapubic: An area of the central lower abdomen above the bony pelvis and overlying the bladder.

  • tissue: Group of cells in an organism that are similar in form and function.

  • topical: Describes medication applied directly to the surface of the part of the body being treated.

  • transrectal ultrasound: Also referred to as TRUS. This is a special kind of ultrasound test in which the sound waves are produced by a probe inserted into the rectum. In men, the structures most commonly examined with this test are the prostate, bladder, seminal vesicles and ejaculatory ducts.

  • transurethral: Through the urethra. Several transurethral procedures are used for treatment of BPH. (See TUIP, TUMT, TUNA or TURP.)

  • transurethral microwave thermotherapy: Also referred to as TUMT. Destroys excess prostate tissue interfering with the exit of urine from the body by using a probe in the urethra to deliver microwaves. Treatment for BPH.

  • TUMT: Also referred to as transurethral microwave thermotherapy. Destroys excess prostate tissue interfering with the exit of urine from the body by using a probe in the urethra to deliver microwaves. Treatment for BPH.

  • TUNA: Also referred to as transurethral needle ablation. Destroys excess prostate tissue with electromagnetically generated heat by using a needle-like device in the urethra. Treatment for BPH.

  • ultrasound: Also referred to as a sonogram. A technique that bounces painless sound waves off organs to create an image of their structure to detect abnormalities.

  • urethra: A tube that carries urine from the bladder to the outside of the body. In males, the urethra serves as the channel through which semen is ejaculated and it extends from the bladder to the tip of the penis. In females, the urethra is much shorter than in males.

  • urethral: Relating to the urethra, the tube tha carries urine from the bladder to outside the body.

  • urge: Strong desire to urinate.

  • urgency: Strong desire to urinate.

  • urinary: Relating to urine.

  • urinary frequency: Urination eight or more times a day.

  • urinary incontinence: Inability to control urination.

  • urinary incontinence: Involuntary loss of urine associated with a sudden strong urge to urinate.

  • urinary retention: Failure to empty the bladder totally.

  • urinary tract: The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.

  • urinary tract infection: Also referred to as UTI. An illness caused by harmful bacteria, viruses or yeast growing in the urinary tract.

  • urination: The passing of urine.

  • urine: Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.

  • urine flow study: A test in which the patient urinates into a special device that measures how quickly the urine is flowing.

  • urologist: A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. (Download the free Acrobat reader.)

  • urology: Branch of medicine concerned with the urinary tract in males and females and with the genital tract and reproductive system of males.

  • vas: Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.

  • void: To urinate, empty the bladder.

  • watchful waiting: An approach to handling localized, slow-growing prostate cancer by having regular checkups instead of immediate treatment.

BPH: Minimally Invasive Management (Benign Prostatic Hyperplasia/Enlarged Prostate) Anatomical Drawings

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