Benign Prostatic Hyperplasia

Lower urinary tract symptoms or LUTS associated with benign prostatic hyperplasia include:

• Increased frequency of urinary
• Recurrent urinary tract infections due to urine stagnation
• Recurrent fevers
• Nocturia or increased frequency of urination at night
• Poor stream or force of urine
• Feeling of incomplete voiding or incomplete emptying of the bladder
• Rarely due to backpressure changes, there may be obstruction of urine in the kidneys called hydronephrosis
• Dribbling of urine
• Blood in urine called hematuria (rare)

Why does the prostate enlarge in size?

As age advances, the prostate increases in size in most males, (especially those above 60) due to hormonal changes. Testosterone secreted from the testes is the main factor, which increases as age advances and causes gland enlargement.

What is the normal size of the gland?

Normally the prostate weighs 25 – 30 gm. An increase in size above that is taken as an enlarged gland. However, the size does not determine symptoms. Even a mildly increased gland may cause severe symptoms, while an extremely large gland may have no symptoms.

Is BPH a common problem?

BPH is very common in the adult male population above the age of 60. It is said that by age 90, 90% of people will have BPH.

Is BPH and prostatic carcinoma different?

BPH and prostatic carcinoma are two different conditions. BPH does not increase the risk of prostatic carcinoma. BPH affects the central gland, while prostatic carcinoma affects the outer peripheral gland. Symptoms may be similar, therefore malignancy with screening blood tests (PSA levels) should be done to rule out malignancy.

• An ultrasound abdomen and pelvis including pre void and post void urine residual volume
• Sometimes a trans-rectal ultrasound may be suggested
• Free and total PSA (prostate specific antigen) level – this is elevated in prostate carcinoma, but not in BPH
• Sometimes, MRI prostate, if there is a suspicion of malignancy
• Routine urine tests with culture
• Complete blood count to look for infection
• Renal function tests to make sure the kidney function is intact
• Urodynamic studies to confirm urine obstruction and make sure the symptoms are not due to urinary bladder problems like weak bladder muscle activity

How is Benign Prostatic Hyperplasia graded?

Benign Prostatic Hyperplasia's severity can be graded based on questionaries like QOL (Quality of Life) and IPSS (International Prostate Symptom Score). Based on IPSS, BPH can be graded as:

• With a score of 7 or less: indicates mild BPH
• With a score of 8 to 19: indicates moderate BPH
• With a score of 20 to more than 20: indicates severe BPH

Mild to moderate Benign Prostatic Hyperplasia  can be controlled with medication alone. Moderate to Severe BPH may require endovascular or surgical intervention.

Medications commonly prescribed to control Benign Prostatic Hyperplasia

The common purpose of any medication is to provide relief of symptoms of LUTS to the patients. These medicines provide relaxation in the prostate muscle and thus reducing the symptoms generated due to the urethral compression. The medicines prescribed are:

• Silodosin
• Terazosin
• Alfuzosin
• Tamsulosin

This medicine is given to the patient so their hormone production reduces. Reduction in testosterone production will stop the speed at which your prostate gland will grow. They may be prescribed for long term usage.

Surgical Options for Benign Prostatic Hyperplasia

For extremely large prostate and with no effective medical therapy, endovascular or surgical options may be required. TURP is the gold standard. It stands for trans-urethral resection of the prostate. It involves removing the central portion of the gland using the urethral approach and using a scope. Symptom relief is immediate. However, it can have issues like post procedure strictures, retrograde ejaculation and loss of sphincter control.

Surgical options include:

• Embolization – Prostate Artery Embolization
• TURP - Trans-urethral Resection of Prostate
• Open Total Prostatectomy
• UroLift
• Water vapor thermal therapy (WVTT)
• Robotic Waterjet Treatment
• Transurethral Microwave Thermotherapy (TUMT)
• Transurethral Incision of the Prostate (TUIP)
• Laser Therapy
• Prostate Lift
• Robot Assisted Prostatectomy

Prostatic artery embolization (PAE) is a minimal invasive treatment undertaken by an Interventional radiologist to improve lower urinary tract symptoms caused by benign prostatic hyperplasia (BPH). It involves access through your leg/groin or radial artery into the artery supplying the prostate. This artery is then blocked using PVA particles, a procedure called embolization. By reducing the blood supply to the gland, the prostate shrinks in size of 3 weeks – 3 months and causes LUTS symptom relief.

PAE is performed by an Interventional Radiologist who is a doctor specializing in endovascular techniques and embolization.

Advantages of PAE

• As compared to TURP, PAE is performed through the vascular route. It does not involve meddling with the urethra or urethral sphincter in any way. Therefore, complications associated with TURP are nil with PAE.
• No chances of urethral stricture, sphincter dysfunction or retrograde ejaculation
• Can be done under local anesthesia
• Can be done while the patient is on antiplatelets and anticoagulants
• Minimal and shorter hospital stay
• Does not affect sexual function

Success rate of PAE 

When done by the correct doctor and in the right patient, PAE has a clinical success of over 90%, and good long term efficacy of 70-80% at 3 years and around 70% at 5 years. The biggest advantage of PAE is the absence of side effects/complications and can be done in those on antiplatelets and in patient in whom general anesthesia cannot be given.

PAE has excellent short and long term results and recently the American Urology Association (AUA) Guidelines has recognised PAE as a safe and effective treatment in the management of BPH. This is a considerable step in the exceeding role of minimally invasive endovascular therapies and interventional radiological techniques in the management of BPH.