Benign Prostatic Enlargement

Benign Prostatic Enlargement (BEP) is a common problem affecting the elderly men. The prostate is present only in men and is responsible for production of a part of the semen. In humans, BEP starts after the age of 40 yrs. However this process is slow and the symptoms generally start manifesting after the age of 60 yrs. Due to the gradual progression, many men are not able to appreciate the symptoms and present late for treatment. The common symptoms of BEP are nocturia, frequency, urgency, poor stream of urine, straining at micturition and occasionally urinary incontinence. If not treated, this may progress to retention of urine, hematuria, urinary tract infection, bladder stones and sometimes even affect the renal function. It is important to note that not all men having BEP manifest with these symptoms. Thus although the pathological process of BEP affects majority of the elderly men, only some develop the symptoms.

Evaluation

Detailed history about LUTS

Examination, urinalysis, blood investigations like Sr Creatinine and Sr PSA.

Ultrasound to assess prostate size and its effects on the bladder/kidneys and also to rule out other causes of LUTS (eg bladder stone, Ca Bladder). If the diagnosis is still in doubt, further evaluation is required eg uroflowmetry, urodynamic study etc.

During evaluation rule out other causes of LUTS eg bladder stone, carcinoma of the bladder/prostate.

It is important to understand that prostate size does not co-relate with the symptoms. For example a patient may have a 20 gm prostate which is a normal size of the gland but may still land up in retention whereas another patient may have a 100 gm prostate and may still not have any symptoms. This is because, the prostate contains smooth muscle cells which are under the influence of the adrenergic nervous system. Stimulation of the adrenergic nervous system results in a dynamic increase in prostatic urethral resistance. Thus an ultrasound report showing an enlarged prostate is not the sole indication for treatment for BEP. This decision is based on the severity of the symptoms, the degree of bother to the patient and the result of the investigations.

A patient with an enlarged prostate without any symptoms may not need any treatment. However if the symptoms affect the quality of life, then treatment is indicated.

Treatment of BEP

The choice of treatment of BEP, whether by medicines or by surgery, is based on many parameters. In some cases a surgery is indicated straightaway. The absolute indications for surgery are retention of urine, recurrent UTI, recurrent gross hematuria, bladder calculi secondary to obstruction, failure of medical treatment and obstructive nephropathy. In remaining cases medical treatment is preferred.

The medical treatment consists of two groups of drugs ie. α adrenergic blockers and 5 α Reductase Inhibitors. These need to be taken once in a day and are prescribed for at least 5 yrs or till there is progression in the symptoms. In the later case, surgery is required. These medicines are safe and have a low incidence of side effects.

he surgery for BEP has undergone a revolutionary change in the last few decades. Before this era, BEP was treated by open surgery. This was a morbid procedure due to the incision, post-op pain, late recovery of the patient and a bad cosmetic result due to the sacr. Due to the technological advances in the 20th century, today > 95 % of the cases are treated by endoscopic surgery. Out of the various endoscopic methods to treat BEP, Transurethral Resection of Prostate (TURP) is considered as the “Gold Standard” treatment. It is a minimally invasive surgery, done via the urethra. There is no incision or post-op pain and the patient is discharged from the hospital after 48 hrs.

Other modalities of treament of BEP incluce Laser Enucleation of the Prostate, Transurethral needle ablation of Prostate (TUNA), Transurethral microwave therapy (TUMT), Transurethral vaporization of the prostate (TUVP) etc. However these treatments are yet to surpass the efficacy of TURP and TURP is still considered as the GOLD STANDARD treatment for BEP. An exception is a very large prostate, in which Endoscopic Holmium Laser Enucleation (HOLEP) or an open surgery may be preferred.