Well, the prostate is an organ that sits in the base of the bladder in men. Its function
is to add components to the semen to increase the chance of a sperm fertilising an ovum,
but with increasing age the prostate changes and there are alterations in the way the prostate
is made up with different amounts of fibrous and muscular tissue, and this increase in
size and increase in fibre of muscular tissue is known as benign prostatic hyperplasia or
BPH. You tend to find that the first evidence of BPH is presence in men at about 40 years
of age and increases in size beyond that and the approximate increase in size is about
10% every 5 years. What this means is that by the age of about 80 years old, about 80%
of men will have evidence of BPH: benign prostatic hyperplasia.
The prostate surrounds the urethra sitting at the base of the bladder and can inhibit
through passage of the urine through the urethra. It does this essentially in two ways. Firstly,
as the prostate increases in size it can a butt on the urethra and occlude the urethra.
This is called a static component of obstruction. There is also in addition a dynamic component
of this obstruction in that the blood the prostate is full of fibrous tissues but also
muscular tissue and this muscular tissue can contract and compress the urethra and squeeze
it shut. These two components often work together as such that they inhibit the free passage
of the urine along the urethra. This will manifest itself in symptoms such as the poor
flow of urine, a intermittency of passage of urine and the hesitancy and difficulty
starting to pass urine. There is another effect that benign prostatic hyperplasia can have.
In that, by obstructing the bladder, the bladder has to increase its pressure in order to overcome
the obstructing prostate. What happens as a result of this is that bladder can become
hyperactive and unstable. This will manifest itself in urinary symptoms of urinary frequency,
urinary urgency and nocturia. In other words, getting up three or four times at night to
pass urine. Benign prostatic hyperplasia or BPH may require
no treatment at all and really the treatment depends upon the presence of troublesome urinary
symptoms. The first step in management may be simple lifestyle changes: cutting down
the amounts of fluid you drink before you get to bed, cutting down the amounts of fluid
you drink before long car journeys or maybe cutting down the amount of caffeine and coffee
you drink which can affect the bladder symptoms. The next step would be medication in the form
of tablets. There are two main types of tablets that are offered for symptomatic BPH. Firstly,
there's the alpha blocker. The alpha blocker such as tamsulosin inhibits contraction of
the smooth muscle within the prostate. This has an effect on the dynamic components of
obstruction and may relieve some of the symptoms of obstruction. There is a second medication
the so called 5-alpha-reductase inhibitors such as finasteride. This has an effect on
the static component of obstruction. What 5-alpha-reductase inhibitors do is they cause
shrinkage of the prostate and relief of the static obstruction. It's important to be aware
that this occurs via shrinkage of the prostate which may take three to six months to have
its effect. So the effects of 5-alpha-reductase inhibitor medication isn't overnight and may
take a number of weeks before a symptomatic improvement is seen. One of the problems with
both these medications are that they have side effects and some patients don't like
to be on these medications due to these side effects. In a proportion of patients, further
treatment may be required. We're fortunate at the moment there are a number of different
options that can be tried. Firstly, prostatic artery embolization. This is a procedure that's
done in the radiology department where small pellets are placed by the radiologists into
the arteries that are supplying the prostate which cause the prostate to shrink. This is
done under local anaesthetic as an outpatient procedure. The second treatment option is
called UroLift. This is done by urologists. It can be done with the local anaesthetic
or general anaesthetic. It involves inserting a tube up the urethra and using staples to
staple the prostate open. The third and one of the newer forms of treatment is called
Rezum. Again, this is done by a urologist under the local anaesthetic or general anaesthetic
often as an outpatient or a day case procedure; and it involves a telescope being inserted
up the urethra to the prostate and using a tiny needle to inject steam into the prostate.
What that steam does is cause the prostatic cells to die and the prostate involutes and
allows opening of the prostate and improve in voiding. One of the issues with this is
that a patient would need to have a catheter following this procedure for two to five days
while the inflammation in the prostate settles. The advantage of all three of those treatments
are that they are minimally invasive and can often be done as a day case or under local
anaesthetic. However, there are cases where a more complete resection of the prostate
is required. The standard way this is done is using electricity: the so called trans
urethral resection of the prostate or TURP. This again is done by urologist under general
anaesthetic. It requires a two-night stay in hospital. With the advent and development
of lasers, in my view, the TURP has been improved upon and now lasers are used to do the same
procedure. The standard one that I would use is called a Holmium laser enucleation of the
prostate or HoLEP. This again is done by urologist under general anaesthetic as an in-patient.
Although, some patients can go home the same day, the majority are kept in overnight with
a one-night stay in the hospital. The HoLEP is my chosen technique over the TURP, I think
it is an improvement on TURP, because it does a more complete resection, there is less bleeding
and in the majority of patients can get home after one-night stay in hospital.
It's not possible to say what is the best treatment for BPH as this will differ from
patient to patient. If treatment is required, we're in the very fortunate time where a number
of different options are involved which all have advantages and disadvantages. It's absolutely
crucial that a patient is referred to a urologist to discuss these options. The question will
be what of the options that are available is best for an individual patient - and this
will depend on a number of factors such as the size of the prostate, the shape of the
prostate, the general health and comorbidity of the patient and of course the patient's
wishes and desires. I think what is absolutely crucial in this day and age that patients
get the opportunity to speak to a urologist who is knowledgeable about the full range
of treatment options and is able to fully discuss these options in an open and honest
way with the patients and with clinical equipoise. In addition, it's important that the urologist
should be able to provide all these different treatments or have the ability to refer the
patient on to another clinician who is able to provide the treatment option that he or
she is not able to provide.