ALTERNATIVE TREATMENTS FOR BPH
Normal Prostate
Enlarged Prostate
Benign Prostatic Hyperplasia (BPH) is the term used to describe the
non-malignant growth of the prostate gland that is responsible for blocking the
flow of urine out of the urinary bladder.
In some men, the growth of prostate is outward giving the gland increased
overall size. This growth causes blockage by sheer increase in prostate size
with impingement on the urinary channel or urethra. In others, the outward
growth is minimal but the blockage is caused by increased muscle tone around the
urinary channel or urethra. Many men develop both types of obstruction, gland
growth and increased muscle tone.
NON-SURGICAL or MEDICAL TREATMENTS FOR BPH
Medical treatment for prostate disease has gone in multiple directions over the
period of the last few years. The two major thrusts are in reducing prostate
size and secondly, to relax the muscles that surround the prostate to allow flow
through urinary channel.
Hormone or Androgen Suppression
The drugs, Proscar (finasteride) or Avodart (dutasteride), suppresses the action
of the hormone testosterone in the prostate cells without affecting the level of
testosterone in the blood stream. This allows men to have normal libido, but at
the same time the prostate responds as if there is very little testosterone
present. Current studies suggest that 50-70 percent of properly selected
patients are experiencing reduction in prostate volume with reduction of their
symptoms over a four to twelve month period.
Both Proscar or Avodart are taken once a day, indefinitely, and more recent
studies have shown that the improvement in urinary symptoms persists as long as
the drug is taken. Another interesting advantage of these is the apparent
significant reduction in episodes of complete urinary blockage that might
require a trip to the emergency room for placement of a catheter into the
bladder. In addition, the use of these drugs reduced the need for surgical
treatment of prostate enlargement by more than 50%.
These drugs have been shown to be incredibly safe with very few minor side
effects. The only commonly seen side effect is a 3% (3 out of 100 men) incidence
of loss of sexual potency. They work best in men who's prostate glands are
larger than normal size. It has less effect on men who's prostate size is small
and the urinary blockage is on the basis of increased muscle tone.
The prostate specific antigen (PSA) test normally reduces about 50% after
Proscar or Avodart have been taken for 4-6 months. They do not really mask
prostate cancer but a new baseline PSA may need to be established. Proscar
(under the name Propecia using 1/5th of the normal Proscar dosage) has recently
been released as a treatment for male pattern baldness. There is data that
suggests that these drugs may protect against the development of cancer of the
prostate although the development of more aggressive cancers does not seem to be
avoided. This is NOT confirmed yet, and is not a guarantee that prostate cancer
will not occur later on. You will need to be seen on a yearly basis to have a
rectal examination and PSA blood test drawn. The cost is approximately $45 a
month.
Medication that relaxes the muscles that surround the prostate channel
The anatomy of the bladder and prostate is such that a special muscle surrounds
the urinary channel in its course from the bladder into the prostate. These
muscles are controlled by special nerves called "alpha sympathetics". In many
men, increased tone of this muscle occurs with aging and can be a cause of
significant blockage of urinary flow without significant prostate growth. This
muscle that runs around the prostate channel can be relaxed by taking specific
medications known as "alpha blockers". These drugs, Hytrin, Cardura, Uroxatral
or Flomax (terazosin, doxasin, alfuzosin or tamsulosin), also are used to lower
blood pressure in some patients with hypertension. The smooth muscles around the
neck of the bladder and prostate are relaxed by these medications, and many men
have both subjective and objective improvement of their urinary flow. These
improvement usually occur within the first few weeks of taking these
medications. These medications seem to work best in patients with smaller
prostates, but work in larger glands as well.
The medicine will not stop the growth of the prostate, and theoretically, as the
prostate grows over the years, these medicines may become ineffective in a small
percentage of users. A percentage of men will have difficulties because of the
lowering of their blood pressure to a point where dizziness and even fainting
can occur. Some men report chronic fatigue or non-specific malaise. The side
effects are also usually apparent soon after starting these medications. These
medications cost about $45 a month and must be taken indefinitely. Patients with
high blood pressure might be able to use these medications in combination with
other blood pressure treatment.
Combination therapy with "alpha blockers" (Hytrin, Cardura, Flomax or Uroxatral)
and androgen suppression medications (Proscar or Avodart) may work better that
either drug alone in some patients. For the most part, this combination would
only include those patients with larger prostate glands which would respond
better to the shrinkage created by the androgen suppression part of this
combination.
HERBAL THERAPY (PHYTOTHERAPY)
Herbal therapy is the use of naturally occurring plants or plant extracts
for the treatment of various diseases. The American Food and Drug Administration
(FDA) views these as food additives and makes little or no effort to control the
use or content of herbal therapy. No American studies have been done to
establish the safety or usefulness of any herbal treatment for prostate
enlargement or symptoms. In the last few years a number of European studies have
been done that suggest that herbal therapy can help relieve prostate symptoms.
These studies do not give any answers as to why herbal therapy works and none
have the safety investigations so necessary for American drug studies. Another
problem is the different amount of herbal extract in each product. This means
that the amount of herb in each preparation may be different. Many of the
preparations come with multiple herbs so that it may be impossible to determine
which herb is helping reduce prostate symptoms. Nevertheless many men in the
United States have used herbal therapy purchased through drug and health food
stores with some success. These drugs do not require prescriptions and are
rarely covered by insurance.
The most popular of these extracts is saw palmetto. Saw palmetto is sold under a
variety of names and often with a variety of other herbs or extracts. Saw
palmetto was originally thought to be similar to finasteride (Proscar). We now
believe this not to be true as saw palmetto doesn't lower the prostate specific
antigen and prostate volume like finasteride does. Some researchers feel that
saw palmetto may reduce prostate inflammation. As of now we do not know why saw
palmetto works. It does seem to be safe, without significant side effects.
Warner Lambert, a major US drug manufacturer, has come out with Quanterra
Prostate, which has 160 milligrams of Saw Palmetto. They recommend one table
twice a day.
Other less well know extracts include Pygeum Africanum, beta-sitosterol, pollen
extract, pumpkin seeds, South African star grass and stinging nettles,
meparticin, and radix urticae. These extracts all appear to be safe and well
tolerated. Their effectiveness has not been established with any American
studies.
Note: All herbal medications come with the disclaimer that:
These statements have not been evaluated by the Food and Drug Administration.
This product is not intended to diagnose, treat, cure or prevent any disease
SURGICAL or PROCEDURES TREATMENTS FOR BPH
Transurethral RESECTION of the Prostate (TURP)
Transurethral resection of the prostate (TURP) has been the primary choice
of treatment for the past 50 years for BPH that is causing obstruction of the
bladder outlet
Approximately 400,000 transurethral resections of the prostate are performed
annually in the United States. TURP is a safe procedure with four out of five
patients experiencing resolution of their voiding symptoms with improvement of
all of their urinary flow measurements. Essentially, TURP is the removal of the
obstructing portions of the prostate with a telescopic electric knife. The TURP
requires an anesthetic and takes about 30-60 minutes to perform. A tube or
catheter is inserted into the bladder and is left in place for 24 to 48 hours.
The hospitalization lasts from 1-3 days and requires two weeks of severe
activity restrictions and another two weeks of modest restrictions. No treatment
to date has bettered the long term effectiveness of TURP in alleviating
obstruction caused by benign prostatic hyperplasia.
TURP
But because TURP is a surgical procedure with some risks, and because of the
costs and time off work, other methods of therapy are being looked at
intensively by the medical community. These include medical treatments and
alternative surgical treatments which are less complicated than transurethral
resection of the prostate.
The picture below is a representation of the prostate gland after TURP
(transurethral resection of prostate), open prostatectomy, transurethral laser
removal of prostate, and transurethral vaporization of prostate.
Transurethral laser vaporization of prostate
The laser is a high energy source, which has been used in medicine since the
early seventies. The laser uses a high energy electric beam generated through a
special lens. Various types of lasers exists and two are currently used for
removing the obstructing part of the prostate gland- Holmium and Green Light.
The end results are similar to the standard transurethral resection (TURP), but
the recovery is typically much easier than with the TURP. Often patients can go
home from the hospital the same day as surgery, often without a catheter.
Patients usually have little or no bleeding and can return to normal activities
very quickly. The laser vaporization takes a bit longer than a TURP on the same
size prostate, so it is harder to do the laser procedure on larger prostates. If
much bleeding is encountered during the procedure, it may be necessary to switch
to a standard TURP.
With the laser procedures, there is no prostate tissue removed intact to
be examined under the microscope. Given the excellent diagnostic techniques
available today with PSA and ultrasound, the lack of tissue to rule out cancer does not seem to be
very important. Patients felt to be at risk for prostate cancer should usually be
evaluated with ultrasound and biopsy prior to the laser procedure. The
laser procedures have, to a degree, supplanted the TURP as the most commonly
used procedure to relieve blockage from an englarged prostate.
Transurethral INCISION of the Prostate (TUIP)
A transurethral incision of the prostate (TUIP) is the alternative to TURP
that comes closest to matching its results in both terms of symptom relief and
improvement in flow rates. The basic goal of the procedure is to remove just a
minimum amount of prostate tissue to allow adequate flow through the prostate.
This is done by making a simple cut or incision along the entire length of the
prostate. Because of the circular muscle fibers running around the prostate, the
TUIP allows the bladder neck to spring open and allows free urinary flow. TUIP
is particularly beneficial for smaller prostates and does have a lower incidence
of ejaculation disturbances. The success rates for TUIP are about the same as
transurethral resection of the prostate, but only in those patients that are
carefully selected (smaller prostate). Hospital stays and recovery are much
shorter.
Open Prostatectomy
Open prostatectomy refers to a major surgical procedure for removal of the
obstructing portion of the prostate. Open prostatectomy entails an incision on
the lower abdomen. The prostate can be approached either through the bladder (suprapubic)
or directly through the capsule of the prostate (retropubic). In either case,
the blocking or obstructing portion of the prostate is shelled out from the
prostate capsule in one piece. The end result is similar to the TURP in which
the obstructing portion of the prostate is removed, leaving the prostate capsule
behind. The reason to do an 'open' prostatectomy is the size of the prostate.
The telescopic approaches (TURP, TUIP, laser, hyperthermia and balloons) are
ineffective or impossible with prostate glands that are in the upper 5-10% of
size (usually greater than 75 - 100 grams). Open prostatectomy requires an
anesthetic (general or spinal) and usually 3-5 days of hospitalization. Some
prostates are large enough that open prostatectomy is the only treatment option.
Open prostatectomy, also called 'simple' or 'subtotal' prostatectomy' should not
be confused with 'radical' prostatectomy, an operation done for prostate cancer
in which the entire prostate including capsule is removed.
Balloon Dilation
In years past, balloon dilation was used clinically as an alternative to
prostatectomy. It is very similar to the angioplasties done for coronary artery
disease. Basically, the balloon is then inflated to stretch the prostate
channel. Balloons were largely abandoned although new experimental balloons with
microwave heating are being studied. For now, balloons are a thing of the past.
Transurethral vaporization of the prostate
Vaporization of the prostate is similar to transurethral resection of the
prostate and is preferred by some urologists. The vaporizer 'roller' uses a high
energy electric source similar to the electrical source used for transurethral
resection or incision of the prostate mentioned above. The difference is great
increase in the amount of electrical current used (all are safe) and the type of
contact made with the instrument. For transurethral resection, the electric
current is passed through a small wire and this allows cutting of the prostate
tissue to remove it, but if the current is turned to a higher setting and a
blunt roller ball is used (about the size of a large BB) the tissue actually
melts or vaporizes.
Essentially, the procedure consists of passing an electrode into the prostatic
channel under telescopic guidance. The electrode is then used to vaporize the
obstructing portions of the prostate. Compared to
transurethral resection, the advantages of the vaporization procedure are: less
bleeding and possible shorter hospitalization. The vaporization prostatectomy is
not optimum in the treatment of the very large prostate yet, because
vaporization is slower than resection and therefore may require multiple
treatments. Another concern is that no prostate tissue is removed so we cannot
be certain that cancer does not exist. Transurethral resection for biopsy
purposes, initially followed by vaporization, may solve this dilemma. The
biggest disadvantage of vaporization as compared to resection is that many
patients have more irritation in the recovery period because of the heat
transfer to nerves around the prostate.
'Urolume' Prostatic Stents
Stents are wire devices shaped like small springs or coils. Stents are
placed within the prostate channel and are used to keep the channel open.
Stents require about thirty minutes to place in the prostate, and the major
problems revolve around the irritation and debris that form on the stent. Stents
were approved for use in the United States in April, 1997, so that long term
experience is still lacking. Stents may offer a temporizing or permanent
solution to those patients too sick to undergo other surgical procedures. If
they unsuccessful or cause symptoms, removing them can be very difficult.
Transurethral Microwave Therapy of the Prostate (TUMT)
TUMT is done as an outpatient procedure with local anesthesia and mild
sedation. The procedure involves the use of a special catheter which houses a
microwave source at its tip. This catheter is placed through the penis so that
the microwave source is placed into the prostatic channel. The prostate is
heated up to temperatures above 105° Fahrenheit. This causes destruction of
prostate tissue and shrinkage of the gland. It also may act to relax the channel
through the prostate by affecting prostatic nerves. Again, no prostate tissue is
removed for pathologic diagnosis so we cannot be certain that cancer does not
exist. Patients with very large prostates or enlargement of the middle lobe of
the prostate are not felt to be good candidates for TUMT. Because the prostate
is likely to swell, initially most patients are discharged with a catheter in
the bladder for a few days to allow drainage until the prostatic swelling
subsides. Sexual functioning is not usually affected by TUMT. The FDA approved
the use of microwave hyperthermia in September, 1995. Newer advances in
microwave technology and shorter treatment times are currently being
investigated which will hopefully make microwave more effective.
TransUrethral Needle Ablation of the Prostate (TUNA)
TUNA is done as an outpatient procedure with local anesthesia and mild
sedation. With TUNA, a telescope is placed into the prostatic channel. Through
the telescope special needles are placed deep into the prostate tissue. High
frequency radiowaves are emitted from the end of the needles, which are similar
to radio antennas. The prostate is heated up to very high temperatures. This
causes destruction of prostate tissue. The heated prostate tissue is destroyed
and initially swells but then shrinks. Most men require a catheter for a period
of time after the TUNA procedure until the swelling resides. No prostate tissue
is removed so we cannot be certain that cancer does not exist.. The FDA has
approved the use of the TUNA procedure in the United States.
Indigo Treatment or Interstitial Laser Coagulation (ILC)
ILC or Indigo laser treatment of the prostate is another type of laser
treatment for prostate enlargement. ILC is done as an outpatient procedure with
local anesthesia and mild sedation. With ILC treatments, a telescope is placed
through the penis into the prostatic channel. Through the telescope special
needles are placed deep into the prostate tissue. Indigo laser beams are emitted
from the end of the needles which are similar to radio antennas. The prostate is
heated up to very high temperatures. This causes destruction of prostate tissue.
The heated prostate tissue is destroyed and initially swells but then shrinks.
Most men require a catheter for a period of time (usually three to eight days)
after the Indigo procedure until the swelling resides. As with other laser
procedures, no prostate is removed for pathologic diagnosis. The FDA has
approved the use of the ILC procedure in the United States.
TUMT and Indigo Laser
High Intensity Focused Ultrasound (HIFU)
A special ultrasound probe is placed into the rectum near the prostate.
Ultrasound waves are focused similar to a magnifying glass so that the point of
focus reaches temperatures close the the boiling point of water (212o Fahrenheit
or 100o centigrade). The prostate is heated up to very high temperatures. This
causes destruction to the prostate tissue. The heated prostate tissue is
destroyed and initially swells but then shrinks. Most men require a catheter for
a period of time after the HIFU procedure until the swelling resides. As with
the laser procedure, no prostate tissue is removed for pathologic diagnosis.
This procedure is so new that few reports are available to judge its
effectiveness. The FDA has not yet approved the use of the HIFU or similar
devices in the United States.
Injections of dehydrated alcohol into the prostate
In this technique highly concentrated dehydrated alcohol is injected directly
into the prostate gland. The alcohol comes either as a liquid or a gel. Through
a telescope special needles are placed deep into the prostate tissue. Alcohol is
injected from the end of the needle. This causes destruction of prostate tissue.
The prostate tissue is destroyed and initially swells but then shrinks. Most men
require a catheter for a period of time afterwards until the swelling resides.
As with other procedures, no prostate is removed for pathologic diagnosis. The
FDA has not yet approved the use of the alcohol procedures in the United States.
Summary
Not every man needs treatment for early BPH. It is normal for a man's
urinary flow to reduce as he ages. Mandatory reasons to proceed with some form
of treatment include recurring infections, repeated bleeding episodes, bladder
or kidney damage and the presence of cancer. When any of the above problems
occur, or one's lifestyle is changed by the presence of prostate obstruction,
consideration to treat the prostate enlargement should be given.
As time goes on, additional medications and surgical procedures will be
developed to treat prostatic enlargement. There are many excellent treatments
available now. Each patient must be considered individually as to what therapy
gives him the best chance for successful treatment.