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CHANGING TRENDS IN MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA

Umesh Oza
Asst. Prof., Bombay Hospital Institute of Medical Sciences, Mumbai 400 020.

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Advances in medical sciences have changed outcome of many diseases. One of them is treatment of prostate enlargement due to benign prostatic hyperplasia (BPH). The prostate problems in men are known for ages but the prostate has recently become the focus of intense medical and public interest. Over the coming years family practitioners and urologists alike will see a dramatic increase in the number of patients presenting with prostate problems. One important reason for this is the continuing rise in the proportion of the world’s population over the age of 60. In modern era, where longevity of life is increasing, even people in their sixties and seventies want to live active life and want to be treated for symptoms which negatively affect their quality of life.

The tremendous advances made in the development of new effective drugs and less invasive therapies has meant that there are now real options for treatment of prostatic disorder other than open surgery. This progress together with increase in health awareness due to magazines, newspapers and television more and more people are coming forward for health check up and prostate check up.

TABLE 1 Adverse effects of the symptoms of BPH on activities of daily living

Limits fluid intake before travel Restricts fluid intake before bedtime Cannot drive for 2 hours without a break Disruption of sleep Limits going to places without toilets Limits playing outdoor sports Avoids, for example, going to cinema, theatre or church

Every person with enlarged prostate may not require surgery. Many patients with mild symptoms remain stable (30%). Some patients may feel better temporarily (15%) whereas in 55% of the patients with time and increase in age, symptoms worsen. However proper evaluation and investigations are necessary before deciding the mode of therapy. This evaluation may also help detecting early cases of cancer of prostate. Prostate cancer is now the second commonest cause of cancer death in many countries.

Earlier symptoms of outflow obstruction in elderly people like hesitancy, poor flow and also symptoms of nocturnal frequency was thought of only due to prostate problem and many patients were subjected to surgery without success. Availability of urodynamics machine has helped us in understanding of physiology of micturition and functioning of bladder. Many times its bladder dysfunction like acontractile bladder or hyperactive bladder as in diabetes, parkinson’s disease, neurological disease which are responsible for these symptoms and prostate surgery has no role to play in the treatment. This understanding can save misery of operation to many patients if evaluated properly. Patients with mainly irritative symptoms like frequency, urgency, urge incontinences may need diagnostic cystoscopy and urodynamic evaluation before considering surgical option for BPH.

Digital rectal examination (DRE) by an experienced clinician still remains an important factor in detecting carcinoma of prostate. Estimation of prostate specific antigen (PSA) is another advance in assessing these patients with symptoms of outflow obstruction. This simple blood test is very good tumour marker and helps in detection of early cancer of prostate.

TABLE 2 Prostatism : the classical symptoms
Obstructive symptoms	Irritative symptoms
• Hesitancy	• Urgency
• Weak stream*	• Frequency
• Straining	• Nocturia
• Prolonged micturition	• Urge incontinence
• Feeling of incomplete emptying*
• Urinary retention
• Overflow incontinence

*Correlated most strongly with subsequent need for prostatectomy.

Ultrasonography has replaced intravenous pyelography in evaluation of benign prostate hyperplasia and its effect on bladder and kidney. It has become a routine screening test, USG of kidney, bladder, prostate with measurement of post void residue gives a good idea about back pressure changes on kidneys and effect on bladder due to BPH. These findings help in decision making regarding the choice of treatment for BPH. Transrectal sonography of prostate is more precise in detection of nodule or pus and detailed morphology of BPH.

It is important to note that size of the prostate do not always correlate with symptoms. Small gland can give significant obstruction and patient may require surgery and sometimes big gland can be treated conservatively. Surgery for BPH should never be decided only on USG appearance of "prostate enlargement".

When clinically prostate is hard to feel and PSA or USG are suggestive of carcinoma of prostate it may be necessary to do needle biopsy of prostate to rule out or confirm Ca Prostate before undertaking treatment of BPH with medical therapy or surgical treatment.

Treatment

The options available for management of BPH are

i. Watchful waiting

ii. Medical therapy

iii. Endoscopic management

iv. Open surgery

Watchful waiting

With increased awareness many patients come forward for prostate check up. Minimal symptoms and mention of enlarged prostate on sonography report does not mean patient needs treatment. After proper evaluation if reports are normal, patient needs only reassurance and follow up.

Medical Management

Medical treatment can be offered to patients, who have mild to moderate symptoms without any complications due to obstructive uropathy. The effect of drug therapy may be temporary or sometimes long lasting. However medical treatment is not recommended in patients who have:

1. Acute or chronic retention of urine
2. Renal insufficiency/upper tract dilatation.
3. Recurrent haematuria
4. Bladder stones/diverticuli

Medical treatment should be started only after examination and investigations.

The drugs which have been used effectively are:

a) Five alpha reductase inhibitors.

b) Alpha blockers.

Five Alpha Reductase Inhibitor

Finesteride - (e.g. Proscar) is 5 alpha reductase inhibitor. The drug tries to reduce the volume of prostate thus improving the urine flow. However, treatment has to be given for long time and the drugs are expensive. Alpha Blockers

Alpha blockers like Prazosin or Terazosin helps in blocking the receptors at bladder neck and thus allowing decrease in outflow resistance. Thus helps patient in passing urine more satisfactorily. These drugs can cause postural hypotension and has to be given under medical supervision.

In addition to standard surgical approaches that still constitute the main stay of treatment of BPH, new treatment options are being introduced at an unparalled rate. Increasingly well informed patients are now requesting information about these new treatment methods, not all of which have lived upto the hype that has surrounded their launch.

Technological interventional methods

Many attempts using a variety of new technologies, are being made to develop the ‘ideal’ interventional treatment for symptomatic BPH; there is a great enthusiasm on the part of urologists to do so. Most of these techniques are aimed at reducing the ‘static’ element of outflow obstruction - the transition zone volume. All aim to achieve a satisfactory long-term therapeutic effect with fewer complications, lower costs, and a shorter hospital stay then traditional surgery.

However, as yet, none of the new minimally invasive procedures to arise has been judged to have replaced transurethral resection of the prostate (TURP) when stringent outcome criteria have been applied. While the prospects of these techniques in the management of BPH are exciting, it is important that their longer-term clinical value and safetly are assessed at an early stage, in order that their place in order that their place in the ever - expanding therapeutic armamentarium of this disease becomes clear.

TABLE 3 Specialist treatment for BPH

Technological intervention Balloon dilatation Prostatic stents (temporary and permanent) Hyperthermia Thermotherapy Laser ablation High-intensity focused ultrasound Focused extracorporeal pyrotherapy Transurethral needle ablation (TUNA) Surgery Open prostatectomy Transurethral resection of the prostate (TURP) Transurethral incision of the prostate (TUIP)

Balance-sheet concept and patient - based decisions

Because there are insufficient efficacy, safety and outcome data to tailor any particular therapy to each individual patient, the ‘balance-sheet’ concept may be helpful. This involves explaining to the patient that treatment results in both indirect and direct health outcomes. The indirect health outcomes may be of no consequence to the patient’s mind (e.g. improvement in flow rate, PVR urine and pressure flow studies), while the direct health outcome, that is improvement in symptoms, is extremely important. In order that the patient can make a fully informed decision, the positive effects, the likelihood of successful long-term outcome and the relative incidence of complications for every treatment option must be explained fully.

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