Despite the advances in research, the origins of benign prostatic hyperplasia are still not clear. Numerous studies have recently shown that it may be the result of hormone changes caused as a result of the aging process. Another theory links benign prostatic hyperplasia to the fact that as men age, the quantity of testosterone in the blood decreases constantly, leaving behind a greater concentration of estrogens in the blood. The higher concentration of estrogens in the blood can influence the proliferation of cells inside the prostrate.
Symptoms of prostatic hyperplasia
The increase in the volume of the prostate causes symptoms which persist over time.
The most frequent disturbances are as follows:
- Reduction in the urinary flow rate (assessed using urinary flow test)
- Urinary frequency: i.e. the need to urinate frequently during the day and night (nocturia)
- Urinary urgency: i.e. urgent urinary stimulus
Over time prostatic hypertrophy results in an ever increasing effort required to empty the bladder to overcome the resistance caused by enlarging of the prostate. This can cause thickening and the formation of protrusions on the walls of the bladder (diverticulitis of the bladder). The obstruction caused by enlarging of the prostate often causes incomplete emptying of the bladder: urine residues in the bladder can cause urinary infections and the formation of stones inside the bladder. Sometimes the obstruction preventing emptying of the bladder can impede urinary function completely; in this case the patient is unable to urinate and a catheter must be applied to empty the bladder.
The significant frequency of prostate pathologies results in the recommendation that all men over the age of 45 should have an annual urological check-up even if no disturbance has been identified.
Treatment of prostatic hypertrophy
The purpose of prostatic hypertrophy treatment is to enable the patient to urinate better. Good urinary frequency means that the urinary system is functioning correctly. Reducing or removing the obstruction caused by prostatic hypertrophy means a better quality of life for patients by eliminating the disturbances caused by the hyperplasia so that the kidneys and bladder are able to eliminate urine satisfactorily.
Treatment mainly involves drugs and surgical procedures.
Depending on the diagnosis of the urologist, treatment involving drugs may be prescribed.
Two types of drug are involved in the treatment of prostatic hyperplasia: some drugs act to reduce the volume of the prostate and others act on the muscles of the bladder neck to increase dilatation to improve the urinary flow. Sometimes a combination of these drugs is used. If this treatment does not eliminate the disturbances caused by the hyperplasia, the urologist may decide that a surgical procedure is required.
The surgical procedure for prostatic hypertrophy involves removal of that part of the enlarged prostate (prostate adenoma) obstructing the neck of the bladder and preventing regular urination. The operation can be one of two types: the procedure can be performed traditionally or endoscopically. The volume of the prostate and the presence of any complications (bladder stones, protrusions) are the criteria used to select the type of procedure. The final result is identical for both types of surgery. Generally speaking the traditional surgical operation is performed when the prostate is particularly large, whereas the endoscopic procedure is used with smaller increases in the volume of the prostate. The dimensions of the prostate are accurately assessed using transrectal prostatic ultrasound.
Traditional surgical procedure
Trans-urinary adenomectomy for benign prostate hyperplasia can be performed using spinal anaesthesia or general anaesthesia. The prostate is reached by making an incision in the abdomen and then opening the bladder. The adenoma is then removed. A catheter and two temporary drains are then inserted in the bladder. The procedure is completed by closing the wall of the abdomen. The catheter and drains are removed after a few days. Patients remain in hospital for a total of 6-7 days.
Endoscopic surgical procedure
Transurethral resection of the prostate (TURP)
This is the most common type of procedure to treat prostatic hypertrophy and is generally performed under spinal anaesthesia. An optical instrument connected to a camera and monitor (enabling the patient to watch the operation) is inserted in the urethra. This device uses an electrical system, preferably bipolar, which utilises heat energy to remove part of the enlarged prostate and coagulate the bleeding vessels. A catheter is again inserted at the end of the operation and is removed after a few days. Patients remain in hospital for approximately 4 days.
Photoselective vaporisation of the prostate (PVP)
Latest-generation laser systems for PVP provide a single effective cure for the symptoms of prostatic hyperplasia. This minimally invasive treatment uses a very powerful laser system to vaporise and remove the tissues of the enlarged prostate. During the procedure a minute laser fibre is inserted in the urethra using a cystoscope and laser beams are used to remove the obstructing hyperplasic tissue. The result is an unobstructed urinary channel, restoration of normal urinary flow and the disappearance of the symptoms.
See video 2A removal; 2B vaporisation; combined technique 2C.
Most patients are able to return home just a few hours after the operation.
As with other forms of physical activity, a period of abstinence from sexual activity of approximately one month is recommended following the operation. Regardless of the type of procedure used to perform the operation, sexual performance remains unchanged in that the vascular and nerve structures used to achieve an erection are not involved.
The operation modifies the ejaculation mechanism to cause retrograde ejaculation. Instead of being expelled directly through the urethra, sperm flows back into the bladder and is then expelled during urination. This method of ejaculation is a consequence of the inevitable surgical removal of the muscle fibres which close the bladder neck. Retrograde ejaculation has no effect on sexual pleasure.
If you are a man of approximately 55 years of age and you have reduced or interrupted urinary flow, unpleasant leaks when you have urinated, urinary frequency or urinary urgency, you probably have an enlarged prostate obstructing the flow of urine.