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Prostate Hyperplasia, Benign

Last Updated: November 18, 2004 Rate this Article Email to a Colleague Synonyms and related keywords: benign prostatic hyperplasia, BPH, prostatism, prostatic hypertrophy, enlarged prostate, bladder outlet obstruction, BOO, testosterone, dihydrotestosterone, DHT, obstructioninduced bladder dysfunction, acute urinary retention, AUR, frequent urination, nocturia, nycturia, lower urinary tract symptoms, LUTS, prostatectomy, transurethral resection of the prostate, TURP, transurethral incision of the prostate, TUIP, transurethral microwave therapy, TUMT, transurethral needle ablation of the prostate, TUNA, water-induced thermotherapy, WIT, digital rectal examination, DRE, prostate-specific antigen, PSA AUTHOR INFORMATION Section 1 of 11 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Author: Raymond J Leveillee, MD, Associate Professor, Department of Urology, University of Miami School of Medicine; Chief, Division of Endourology/Laparoscopy and Minimally Invasive Surgery, Department of Urology, Jackson Memorial Hospital Coauthor(s): Vipul Patel, MD, Director of Robotics, Department of Surgery, St Vincent's Hospital; Vincent G Bird, MD, Assistant Professor of Urology, University of Miami School of Medicine; Consulting Staff, Division of Endourology/Laparoscopy and Minimally Invasive Surgery, Department of Urology, Jackson Memorial Hospital Raymond J Leveillee, MD, is a member of the following medical societies: American College of Physicians, American Medical Association, American Urological Association, Endourological Society, Sigma Xi, and Society of Laparoendoscopic Surgeons Editor(s): Edward David Kim, MD, Associate Professor, Department of Urology, University of Tennessee School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Martin I Resnick, MD, Lester Persky Professor and Chair, Department of Urology; Professor, Department of Oncology, Case Western Reserve University School of Medicine; J Stuart Wolf, Jr, MD, Director of Michigan Center for Minimally Invasive Urology, Associate Professor, Department of Urology, University of Michigan Medical Center; and Stephen W Leslie, MD, FACS, Founder and Medical Director, Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio INTRODUCTION Section 2 of 11 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Background: Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland that may restrict the flow of urine from the bladder. BPH is a proliferative process of the cellular elements of the prostate (ie, an enlarged prostate). Cellular accumulation and gland enlargement may be due to epithelial and stromal proliferation, impaired preprogrammed cell death (apoptosis), or both. More recently, the voiding dysfunction that ensues from prostate gland enlargement and bladder outlet obstruction (BOO) has been generically termed lower urinary tract symptoms (LUTS). It has also been commonly referred to as prostatism, although this term has decreased in popularity. These entities overlap; not all men with BPH have LUTS, and, likewise, not all men with LUTS have BPH. The same can be said for BOO. BPH involves both the stromal and epithelial elements of the prostate arising in the periurethral and transition zones of the gland; the condition is considered a normal part of the aging process in men and is hormonally dependent on testosterone and dihydrotestosterone (DHT) production. Pathophysiology: The prostate is a walnut-sized gland that forms part of the male reproductive system. The gland is composed of several regions or lobes that are enclosed by an outer layer of tissue (capsule). The different zones are the peripheral, central, anterior fibromuscular stroma, and transition. The transition zone, which surrounds the urethra, enlarges with age in a hormonally dependent manner. Castrated males do not develop BPH. The prostate is located in front of the rectum and just below the urinary bladder. It can be examined or felt by inserting a gloved finger into the rectum. Only the posterior superficial surface of the gland can be examined this way. For a short distance, the prostate surrounds the urethra, the tube that carries urine from the bladder to the outside of the body. Its main function is primarily secretory; it produces alkaline fluid that comprises approximately 70% of the seminal volume. It is a conduit for semen to pass, and it prevents retrograde ejaculation (ejaculation resulting in semen being forced backwards into the bladder) by closing off the bladder neck during sexual climax. The fluid (semen) helps to neutralize the acidic vaginal environment and provides carbohydrates and nutrients for the sperm. Ejaculation involves a coordinated contraction of many different components, including the smooth muscles of the seminal vesicles, vasa deferentia, ejaculatory ducts, and the ischiocavernosus and bulbocavernosus muscles. The traditional theory is that as the prostate enlarges, the surrounding capsule prevents it from readily expanding, and this subsequently results in urethral compression. The notion that clinical symptoms are simply due to mass-related increases in urethral resistance is too simplistic. Current thinking holds that obstruction-induced bladder dysfunction contributes significantly to symptoms. The bladder wall becomes thickened, trabeculated, and irritable when it is forced to hypertrophy and increase its own contractile force. This increased sensitivity (detrusor instability), even with small volumes of urine in the bladder, is believed to cause ensuing urinary frequency and LUTS. The bladder may gradually weaken and lose the ability to empty completely, thus leading to increased residual urine volume and, sometimes, acute or chronic urinary retention. Frequency: In the US: As many as 14 million men in the United States have symptoms related to this benign enlargement.

Internationally: Worldwide, approximately 30 million men have symptoms related to this benign enlargement. Mortality/Morbidity: In the past, chronic end-stage BOO often led to renal failure and uremia. While this complication is much less common now, chronic BOO secondary to BPH may lead to urinary retention, renal insufficiency, recurrent urinary tract infections, gross hematuria, and bladder calculi. Age: BPH is a common problem affecting the quality of life (QOL) for approximately one third of men older than 50 years. Histologic evidence of BPH occurs in up to 90% of men by age 80 years. CLINICAL Section 3 of 11 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

History: As with many disease states, the diagnosis can often be suggested based on history findings alone. Special attention to the onset and duration of symptoms, general health issues (including sexual history), fitness for any possible surgical intervention, severity of symptoms and how they are affecting QOL, medications, and previously attempted treatments is essential to making the correct diagnosis. Symptoms often attributed to BPH can be caused by neurogenic bladder, carcinoma in situ of the bladder, urethral stricture from trauma or sexually transmitted disease, cystitis, and prostatitis. Excluding these entities based on findings from a thorough history and appropriately directed diagnostic studies is essential. The prostate is a chestnut- or walnut-sized gland that produces lubrication and nutrition for sperm. It also adds alkaline fluid to the ejaculate, resulting in liquefaction. The prostate rests just below the bladder, as a collar around the urethra. When the prostate enlarges, it may act similar to a clamp on a hose, constricting the flow of urine. Nerves within the prostate also may have a role in causing the following common symptoms: Urinary frequency The need to urinate frequently during the day or night (nocturia), usually voiding only small amounts of urine with each episode Interrupted sleep to urinate at night Urinary urgency The sudden urgent need to urinate quickly The sensation of imminent loss of urine without control Hesitancy Hesitant, interrupted, weak urinary stream Difficulty initiating the urinary stream Having to stand at or sit on the toilet for some time prior to producing a urinary stream Incomplete bladder emptying The sensation of incomplete evacuation of urine from the bladder The feeling of persistent residual urine regardless of the frequency of urination Straining - The need strain or push (Valsalva maneuver) to initiate and maintain urination in order to more fully evacuate the bladder Decreased force of stream - The subjective loss of force of the urinary stream over time Dribbling - Dribbling small amounts of urine due to a poor urinary stream Physical:

Conduct a focused physical examination to assess the suprapubic area for signs of bladder distention and a cursory neurological examination for overall sensory and motor deficits. The digital rectal examination (DRE) is an integral part of the evaluation for men with presumed BPH. During this portion of the examination, prostate size and contour can be assessed, nodules can be evaluated, and areas suggestive of malignancy can be detected. The normal prostate volume in a young adult is approximately 20 g. A more precise volumetric determination can be made using transrectal ultrasound (TRUS). In general, an estimation of the number of index finger pads that one can sweep over the rectal surface of the prostate during a DRE is a useful way for nonurologists to communicate estimated gland size. Anecdotally, each fingerbreadth correlates to approximately 15-20 g of tissue. For example, one can report the prostate size as 2-3 fingerbreadths wide when charting in the medical record or communicating with a colleague. Most asymptomatic men have glands less than or equal to 2 fingerbreadths. In addition, pelvic floor tone, the presence or absence of fluctuance (ie, prostate abscess), and pain sensitivity of the gland (prostatodynia) can be assessed. The prostate is examined using the index finger of the dominant hand. The finger is placed through the anus after relaxation of the anal sphincter, and the prostate is palpated circumferentially (analogous to a windshield wiper movement). DIFFERENTIALS Section 4 of 11 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Bladder Cancer Bladder Stones Bladder Trauma Chronic Pelvic Pain Interstitial Cystitis Neurogenic Bladder Prostatitis, Bacterial Prostatitis, Tuberculous Prostatodynia Radiation Cystitis Urethral Strictures Urinary Tract Infection, Males

Other Problems to be Considered: The differential diagnosis of BPH, in which BOO must be differentiated from LUTS, includes prostate cancer, prostatic abscess, acute and chronic prostatitis, pelvic floor dysfunction, detrusor hyperreflexia, and detrusor sphincter dyssynergia.

Lab Studies: Urinalysis: Examine the urine using dipstick methods and/or via centrifuged sediment evaluation to assess for the presence of blood, leukocytes, bacteria, protein, or glucose. Prostate-specific antigen (PSA): Although BPH does not cause prostate cancer, men in the age range for BPH are at risk for cancer and should be screened accordingly. Men with larger prostates may have slightly higher PSA levels. Discuss the risks and benefits of screening PSA levels with the patient. Urine culture: This may be useful to exclude infectious causes of irritative voiding and is usually performed if the initial urinalysis findings indicate an abnormality.

Electrolytes, BUN, and creatinine: These evaluations are useful screening tools for chronic renal insufficiency if patients have high postvoid residual urine volumes. Imaging Studies: Ultrasound (abdominal, renal, transrectal) and intravenous urography are useful for helping determine bladder and prostate size and the degree of hydronephrosis (if any) in patients with urinary retention or signs of renal insufficiency. Generally, they are not indicated for the initial evaluation of a patient with uncomplicated LUTS. Imaging of the prostate using TRUS is recommended in selected patients. The success of certain minimally invasive treatments (see Surgical Care) may depend on the anatomical characteristics of the gland. For patients with elevated PSA levels, a TRUS-guided biopsy may be indicated. Imaging of the upper tracts is indicated if patients present with concomitant hematuria, history of urolithiasis, elevated creatinine level, high postvoid residual volume, or history of upper urinary tract infection. Other diagnostic studies, such as CT scanning or MRI, have no role in the evaluation and treatment of patients with uncomplicated BPH. Other Tests: A consensus panel (ie, the International Consultation on Benign Prostatic Hyperplasia, in conjunction with the World Health Organization and the International Union Against Cancer) has convened in Paris every 3 years since 1991 to make uniform recommendations that can be used worldwide. These panels have established the following categories to classify diagnostic tests and studies. A recommended test is one that should be performed on every patient, whereas an optional test is of proven value in selected patients. The following tests are recommended: International Prostate Symptom Score (IPSS): Developed to quantitate and validate responses to the questions asked, this set of 7 questions has been adopted worldwide and yields reproducible and quantifiable information regarding symptoms and response to treatment. Each question allows the patient to chose 1 of 6 answers indicating increasing severity of symptoms on a scale of 0-5; the total score ranges from 0-35. Questions concern incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia. The eighth question is known as the bother score and pertains to the patient's perceived QOL. Scores can range from 0 (delighted) to 6 (terrible). After calculating the total score for all 8 eight questions, patients are classified as 0-7 (mildly symptomatic), 8-19 (moderately symptomatic), or 2035 (severely symptomatic). Specific IPSS questions are as follows (adapted from the recommendations of the International Scientific Committee, 2000): Incomplete emptying: Over the past month, how often have you had the sensation of not emptying your bladder completely after you have finished urinating? (Not at all = 0, less than 1 time in 5 = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5) Frequency: Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? (Not at all = 0, less than 1 time in 5 = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5) Intermittency: Over the past month, how often have you stopped and started again several times when urinating? (Not at all = 0, less than 1 time in 5 = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5) Urgency: Over the past month, how often have you found it difficult to postpone urination? (Not at all = 0, less than 1 time in 5 = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5) Weak stream: Over the past month, how often have you had a weak urinary stream? (Not at all = 0, less than 1 time in 5 = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5)

Straining: Over the past month, how often have you had to push or strain to begin urination? (Never = 0, once = 1, twice = 2, thrice = 3, 4 times or more = 4, 5 times or more = 5) Nocturia: Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? (Not at all = 0, less than 1 time in 5 = 1, less than half the time = 2, about half the time = 3, more than half the time = 4, almost always = 5) Bother score: This helps assess perceived QOL due to urinary symptoms, and the score ranges from 0 (delighted) to 6 (terrible). How would you feel if you were to spend the rest of your life with your urinary condition just the way it is now? (Delighted = 0, pleased = 1, mostly satisfied = 2, mixed = 3, mostly dissatisfied = 4, unhappy = 5, terrible = 6) Voiding diary (frequency voiding chart): When these are filled out for several 24-hour periods, the information helps quantify the degree of frequency and volume output. The information also may help identify patients with polyuria and or distinguish these patients from those with polydipsia. The following tests are optional: Flow rate Flow rate is useful in the initial assessment and to help determine the response to treatment. It should be performed prior to embarking on any active treatments, including medical treatment. A maximal flow rate (Qmax) is the single best measurement, but a low Qmax does not help differentiate between obstruction and poor bladder contractility. For more detailed analysis, a pressure flow study is required. A Qmax value of greater than 15 mL/s is considered by many to be normal. A value of less than 7 mL/s is widely accepted as low. The results of flow rate measurements are somewhat effort- and volume-dependent; therefore, the best plan to make a reasonable determination of significance is to obtain at least 2 tracings with at least 150 mL of voided volume each time. Residual urine Obtain this value as soon after voiding as possible to gauge the severity of bladder decompensation. It can be obtained invasively with a catheter but is best determined noninvasively with a transabdominal ultrasonic scanner. Pressure flow studies Although these tests are somewhat invasive, requiring catheterization of the urethra and placement of a transrectal pressure transducer, the findings are invaluable for determining the presence of BOO, especially prior to any invasive therapy. Urodynamic studies are the only way to help distinguish patients with poor bladder contraction ability (detrusor underactivity) from those with outlet obstruction. BOO is characterized by high intravesical voiding pressures (>60 cm water) accompanied by low urine flow rates (Qmax <15 mL/s). Endoscopy of the lower urinary tract Procedures: Endoscopy of the lower urinary tract (cystoscopy) Reserve this invasive test for patients in whom an invasive treatment is scheduled. Conversely, endoscopy may be indicated for patients with a history of sexually transmitted disease (eg, gonococcal urethritis), prolonged catheterization, or trauma; findings may suggest urethral stricture as the cause of BOO, instead of BPH.

Flexible cystoscopy can be easily performed in several minutes in an office-based setting using topical gelbased intraurethral anesthesia without sedation. Histologic Findings: With regard to the prostate, BPH is characterized by a varying combination of epithelial and stromal hyperplasia. Some patients demonstrate an almost pure smooth muscle proliferation, although most demonstrate a fibroadenomyomatous pattern of hyperplasia. With regard to the bladder, obstruction leads to smooth muscle cell hypertrophy. Biopsy specimens of trabeculated bladders demonstrate evidence of scarce smooth muscle fibers with an increase in collagen. The collagen fibers limit compliance, leading to higher bladder pressures with filling. In addition, their presence limits shortening of adjacent smooth muscle cells, leading to impaired emptying and the development of residual urine. TREATMENT Section 6 of 11 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Medical Care: Transurethral resection of the prostate (TURP) has long been accepted as the criterion standard for relieving BOO secondary to BPH. The indications for surgical intervention include acute urinary retention, failed voiding trials, recurrent gross hematuria, urinary tract infection, and renal insufficiency secondary to obstruction. In addition, failure of medical therapy, a desire to terminate medical therapy, and/or financial constraints associated with medical therapy may be indications to proceed with a surgical intervention. However, TURP has a significant risk of morbidity (18%) and mortality (0.23%). In current clinical practice, most patients do not present with obvious surgical indications; instead, they often have milder LUTS and, therefore, are initially treated with medical therapy. The era of medical therapy dawned in the mid 1970s with the use of nonselective alpha-blockers such as phenoxybenzamine. The medical therapeutic options for BPH have evolved significantly over the last 3 decades, giving rise to the receptor-specific alpha-blockers that comprise the first line of therapy. Hormonally inspired medical management emerged from the discovery of a congenital form of pseudohermaphroditism secondary to DHT deficiency (due to a lack of 5-alpha reductase activity). This deficiency produced a hypoplastic prostate. Type II 5-alpha reductase is an enzyme responsible for the conversion of testosterone to DHT. DHT promotes growth of prostatic tissue. The 5-alpha reductase inhibitors block the conversion of testosterone to DHT, causing lower intraprostatic levels of DHT. This leads to inhibition of prostatic growth, apoptosis, and involution. Rationale for alpha1-receptor blockade in BPH A significant component of the BPH complex and its associated symptoms is believed to be related to the smooth muscle tension in the prostate stroma, urethra, and bladder neck. The smooth muscle tension in these areas is mediated by the alpha1-adrenergic receptors; therefore, alpha-adrenergic receptor-blocking agents should theoretically decrease resistance along the bladder neck, prostate, and urethra by relaxing the smooth muscle and allowing passage of urine. BPH is predominantly a stromal proliferative process, and a significant component of prostatic enlargement is due to smooth muscle proliferation. The stromal-to-epithelial ratio is significantly greater in males with symptomatic BPH relative to those with asymptomatic BPH. The 3 subtypes of the alpha-1 receptor are 1a, 1b, and 1c. Of these, the alpha-1a receptor is most specifically concentrated in the bladder neck and prostate. Provided that the alpha-1a subtype is predominant in the prostate, bladder neck, and urethra, but not in other tissues, drugs that are selective for

this receptor (eg, tamsulosin) may have a potential therapeutic advantage. Tamsulosin is considered the most pharmacologically uroselective of the commercially available agents because of its highest relative affinity for the alpha1a-receptor subtype. Alpha-adrenergic receptor blockers The alpha-blocking agents administered in BPH studies can be subgrouped according to receptor subtype selectivity and the duration of serum elimination half-lives. Nonselective alpha-blockers include phenoxybenzamine. Selective short-acting alpha-1 blockers include prazosin, alfuzosin, and indoramin. Selective long-acting alpha-1 blockers include terazosin and doxazosin. Partially subtype (alpha-1a)selective agents include tamsulosin. Nonselective alpha-blockers Phenoxybenzamine was the first alpha-blocker studied for BPH. Its nonselective nature causes it to antagonize both the alpha1- and alpha2-adrenergic receptors, resulting in a higher incidence of adverse effects. Because of the availability of more alpha1-receptorspecific agents, it currently is not often used for the treatment of BPH. Phytotherapeutic agents Pharmaceuticals derived from plant extracts are widely used throughout the world for the treatment of various medical ailments. In 1998, Americans spent a total of $3.65 billion on all herbal remedies. In France and Germany, plant extracts have a market share of up to 50% of all drugs prescribed for symptomatic BPH. In the United States, these agents are also popular and readily available. The attraction to phytotherapeutic agents appears to be related to the perception of therapeutic healing powers of natural herbs, the ready availability, and the lack of adverse effects. Most of the phytotherapeutic agents used in the treatment of LUTS secondary to BPH are extracted from the roots, seeds, bark, or fruits of plants listed below. Some suggested active components include phytosterols, fatty acids, lectins, flavonoids, plant oils, and polysaccharides. Some preparations derive from a single plant; others contain extracts from 2 or more sources. Each agent has one or more proposed modes of action. The following modes of action are suggested: Antiandrogenic effect Antiestrogenic effect Inhibition of 5-alpha reductase Blockage of alpha receptors Antiedematous effect Anti-inflammatory effect Inhibition of prostatic cell proliferation Interference with prostaglandin metabolism

Protection and strengthening of detrusor The origins of phytotherapeutic agents are as follows: Saw palmetto, ie, American dwarf palm (Serenoa repens, Sabal serrulata) fruit South African star grass (Hypoxis rooperi) roots African plum tree (Pygeum africanum) bark Stinging nettle (Urtica dioica) roots Rye (Secale cereale) pollen Pumpkin (Cucurbita pepo) seeds The mechanisms of action of some selected phytotherapeutic agents are as follows: Saw palmetto (American dwarf palm): Extracts of the berries are the most popular botanical products for BPH. The active components are believed to be a mixture of fatty acids, phytosterols, and alcohols. The proposed mechanisms of action are antiandrogenic effects, 5alpha-reductase inhibition, and antiinflammatory effects. The recommended dosage is 160 mg orally twice daily. Studies show significant subjective improvement in symptomatology without objective improvements in urodynamic parameters. Minimal adverse effects include occasional GI discomfort. African plum tree (P africanum): Suggested mechanisms of action include inhibition of fibroblast proliferation and anti-inflammatory and antiestrogenic effects. This extract is not well studied. Rye (S cereale): This extract is made from pollen taken from rye plants growing in southern Sweden. Suggested mechanisms of action involve alpha-blockade, prostatic zinc level increase, and 5alphareductase activity inhibition. Significant symptomatic improvement versus placebo has been reported. The 5alpha-reductase inhibitors The inhibition of 5-alpha reductase selectively blocks androgen action in tissues whose function is dependent on continuing production of DHT, including prostate and hair follicles. Finasteride, a 4-aza-steroid, has demonstrated type II 5alpha-reductase blocking activity resulting in the inhibition of DHT-receptor complex formation. This effect causes a profound decrease in the concentration of DHT in plasma, which, in turn, results in a consistent decrease in prostate size. A third of men treated with this agent exhibit improvements in urine flow and symptomatology. A newer agent recently introduced, dutasteride, has affinity for both type I and type II 5alpha-reductase receptors. Both agents actively reduce serum DHT levels by more than 80%, improve symptoms, reduce the incidence of urinary retention, and decrease the likelihood of surgery for BPH. These agents may not work in all men and may take several months before activity is noted. However, for those in whom they are effective, the impact may be profound. Surgical Care: Open prostatectomy This procedure is now reserved for patients with very large prostates (>75 g), patients with concomitant bladder stones or bladder diverticula, and patients who cannot be positioned for transurethral surgery. The procedure requires hospitalization and involves the use of general/regional anesthesia and a lower abdominal incision. The inner core of the prostate (adenoma), which represents the transition zone, is shelled out, thus leaving the peripheral zone behind. It may involve significant blood loss resulting in

transfusion. Open prostatectomy usually has an excellent outcome in terms of improvement of urinary flow and urinary symptoms. Transurethral resection of the prostate TURP has long been the most common method by which obstructing prostate tissue is removed through the urethra. This procedure is performed with regional or general anesthesia and involves the placement of a working sheath in the urethra through which a hand-held device with an attached wire loop is placed. High-energy electrical cutting current is run through the loop so that the loop can be used to shave away prostate tissue. The entire device is usually attached to a video camera to provide vision for the surgeon. Although TURP is often successful, it has significant drawbacks. When prostate tissue is cut away, significant bleeding may occur, which may result in termination of the procedure, blood transfusion, and a prolonged hospital stay. Irrigating fluid may also be absorbed in significant quantities through veins that are cut open, with possible serious sequelae termed transurethral resection syndrome (ie, TUR syndrome). A urinary catheter must be left in place until the bleeding has mostly cleared. The large working sheath combined with the use of electrical energy may also result in stricturing of the urethra. The cutting of the prostate also results in a partial resection of the urinary sphincteric mechanism, causing the muscle along the bladder outlet to become weak or incompetent. As a result, when the individual ejaculates, this sphincteric mechanism cannot keep the bladder adequately closed. The ejaculate consequently goes backwards into the bladder (ie, retrograde ejaculation), rather than from the end of the penis. TURP usually requires hospitalization. Also, the nerves associated with erection run along the outer rim of the prostate, and the high-energy current and/or heat generated by such may damage these nerves, resulting in impotence. Minimally invasive treatment for BPH Urologists have been trying to develop other therapies to decrease the amount of obstructing prostate tissue while avoiding the above-mentioned adverse effects associated with TURP. These therapies are collectively called minimally invasive therapies. Most minimally invasive therapies rely on heat to cause destruction of prostatic tissue; however, this heat is delivered in a limited and controlled fashion with the hope that the complications associated with TURP may be avoided. They also allow for the use of milder forms of anesthesia, which translates into less anesthetic risk for the patient. Heat may be delivered in the form of laser energy, microwaves, radiofrequency energy, high-intensity ultrasound waves, and high-voltage electrical energy. Delivery devices are usually similarly passed through a working sheath placed in the urethra, although they are usually of a smaller size than that needed for TURP. Devices may also simply be attached or incorporated into a urinary catheter or passed through the rectum, from which the prostate may also be accessed. Keep in mind that many of these minimally invasive therapies are undergoing constant improvements and refinements resulting in increased efficacy and safety. Ask urologists about the specifics of the minimally invasive therapies that they use and what results they have experienced. Transurethral incision of the prostate (TUIP) has actually been in use for many years and, for a long time, was the only alternative to TURP. It may be performed with local anesthesia and sedation. TUIP is suitable for patients with small prostates and for patients unlikely to tolerate TURP well because of other medical conditions.

TUIP is associated with less bleeding and fluid absorption compared to TURP. It is also associated with a lower incidence of retrograde ejaculation and impotence compared to TURP. Lasers deliver heat to the prostate in a variety of ways. They may be used to directly evaporate, ie, melt away prostate tissue. They may also be used in a manner in which the laser is not actually in direct contact with the prostate but delivers heat energy into the prostate, resulting in cell death of the prostate tissue. Laser fibers may first be placed directly into the prostate tissue and then turned on, releasing energy into the tissue. All these laser treatments essentially cause thermal destruction of prostate tissue (coagulation necrosis). Over time, this destroyed tissue then contracts, with resultant decreased prostatic volume. Lasers may be used in a knifelike fashion to directly cut away prostate tissue, similar to a TURP procedure. Laser treatment usually results in decreased bleeding, fluid absorption, length of hospital stay, and incidence of impotence and retrograde ejaculation when compared to standard TURP; however, in patients in whom lasers are used for thermal destruction (coagulation necrosis), they may cause significant swelling of the prostate, resulting in prolonged catheterization after the procedure. Additionally, because treating tissue with a laser involves a time interval during which dead cells slough and healing follows, patients may experience urinary urgency or an irritation, resulting in frequent or uncomfortable urination for some weeks. The results of laser therapy are variable in that many lasers are being used in many different ways. They usually bring about more relief of urinary symptoms than treatment with medicines, but not quite as much as provided by a TURP procedure. A laser treatment in which the laser is used to excise prostate tissue like a knife (in a fashion similar to TURP) has recently been shown to be as effective as TURP. The use of microwave energy, termed transurethral microwave therapy (TUMT), delivers heat to the prostate via a urethral catheter or a transrectal route. The surface closest to the probe (the rectal or urethral surface) is cooled to prevent injury. The heat causes cell death, with subsequent tissue contraction, thereby decreasing prostatic volume. TUMT can be performed in the outpatient setting with local anesthesia. Microwave treatment appears to be associated with significant prostatic swelling; a considerable number of patients require replacement of a urinary catheter until the swelling somewhat subsides. In terms of efficacy, TUMT places between medical therapy and TURP. Transurethral needle ablation of the prostate (TUNA) involves using high-frequency radio waves to produce heat, resulting in a similar process of thermal injury to the prostate as previously described. A specially designed transurethral device with needles is used to deliver the energy. TUNA can be performed under local anesthesia, allowing the patient to go home the same day. Similar to microwave treatment, radiofrequency treatment is quite popular, and a number of urologists have experience with its use. Radiofrequency treatment appears to reliably result in significant relief of symptoms and better urine flow, although not quite to the extent achieved with TURP. High-intensity ultrasound energy therapy delivers heat to prostate tissue, with the subsequent process of thermal injury.

High-intensity ultrasound waves may be delivered rectally or extracorporeally and can be used with the patient on intravenous sedation. Urinary retention appears to be common with its use. High-intensity ultrasound energy also produces moderate results in terms of improvement of the urinary flow rate and urinary symptoms, although its use is now relatively limited compared to the more popular TUNA and TUMT. Water-induced thermotherapy is a relatively new procedure in which heated water is circulated through a balloon in the prostatic urethra, thus initiating a process of thermal destruction of prostate tissue. Only local anesthesia is needed. Further analysis of outcomes of patients treated with this procedure is needed before an assessment of its efficacy and its place in the treatment of BPH can be determined. Optimal results may not be apparent for 3-4 months after the procedure. Mechanical approaches are used less commonly and are usually reserved for patients who cannot have a formal surgical procedure. Mechanical approaches do not involve the use of energy to treat the prostate. Prostatic stents are flexible devices that can expand when put in place to improve the flow of urine past the prostate. Their use has been associated with encrustation, pain, incontinence, and overgrowth of tissue through the stent, possibly making their removal quite difficult. To date, their full role and long-term effects are not fully known. Balloon dilation involves transurethral placement of a balloon, which is then inflated with the intent of expanding the prostatic urethra. Balloon dilation has largely been abandoned. Efficacy has not been demonstrated with this procedure. MEDICATION Section 7 of 11 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Drug Category: Alpha-adrenergic blockers -- Block effects of postganglionic synapses at the smooth muscle and exocrine glands.Drug Name Phenoxybenzamine (Dibenzyline) -- Nonselective alpha-adrenergic receptor blocker that antagonizes both alpha-1 and alpha-2 receptors. The nonselectivity leads to higher incidence of adverse effects, causing a decrease in use in clinical settings. Induces subjective improvement in urinary flow rates when compared to placebo. May improve daytime and nighttime urinary frequency. Improves symptoms in 75% of patients. Adult Dose 10 mg PO bid Pediatric Dose Not established Contraindications Documented hypersensitivity; patients in whom a fall in blood pressure would be undesirable Interactions Used concurrently, alpha-adrenergic agonists decrease effects; beta-blockers increase toxicity Pregnancy C - Safety for use during pregnancy has not been established. Precautions Caution in cerebral or coronary arteriosclerosis and renal impairment; can worsen symptoms of respiratory tract infections; fatigue, dizziness, impaired ejaculation, nasal stuffiness, and difficulty with visual accommodation may occur Drug Name

Prazosin (Minipress) -- Treats prostatic hypertrophy. Improves urine flow rates by relaxing smooth muscle. Relaxation is produced by blocking alpha-1 adrenoreceptors in the bladder neck and prostate. Advantage over nonselective alpha-adrenergic blockers includes lower incidence of adverse effects. Because of availability of longer-acting, once-daily selective agents, clinical utility for BPH has been reduced. Improves urinary flow rate and frequency of micturition. Subjective improvement observed in 82% of patients treated. When increasing dosages, administer first dose of each increment at bedtime to reduce syncopal episodes. Although doses >20 mg/d do not usually increase efficacy, some patients may benefit from up to 40 mg/d. Adult Dose 2 mg PO bid Pediatric Dose Not established Contraindications Documented hypersensitivity Interactions Acute postural hypotensive reaction from beta-blockers may worsen; indomethacin may decrease antihypertensive activity; verapamil may increase serum levels and may increase patients' sensitivity to prazosin-induced postural hypotension; may decrease antihypertensive effects of clonidine Pregnancy C - Safety for use during pregnancy has not been established. Precautions Caution in renal insufficiency; adverse effects include dizziness, asthenia, peripheral edema, hypotension, reflex tachycardia, miosis, sedation, nasal stuffiness, and erectile dysfunction Drug Name Alfuzosin (UroXatral) -- Alpha-1 blocker of adrenoreceptors in prostate. Blockade of adrenoreceptors may cause smooth muscles in bladder neck and prostate to relax, resulting in improvement in urine flow rate and reduction in symptoms of BPH. Adult Dose 2.5 mg PO tid Pediatric Dose Not established Contraindications Documented hypersensitivity Interactions Effects may increase with coadministration of diuretics and antihypertensive medications Pregnancy B - Usually safe but benefits must outweigh the risks. Precautions Dizziness, fatigue, and headache may occur; patients should avoid situations in which injury could result if syncope occurs; exclude presence of carcinoma of prostate before beginning therapy Drug Name Indoramin -- Not available in the United States. Helps treat prostatic hypertrophy. Improves urine flow rates by relaxing smooth muscle. Relaxation produced by blocking alpha-1 adrenoreceptors in the bladder neck and prostate. Advantage over nonselective alpha-adrenergic blockers includes lower incidence of adverse effects. Because of availability of longer-acting, once-daily selective agents, clinical utility for BPH has been reduced. Improves urinary flow rate and frequency of micturition. Adult Dose 20 mg PO bid Pediatric Dose Not established Contraindications Documented hypersensitivity Interactions Acute postural hypotensive reaction from beta-blockers may worsen; indomethacin may decrease antihypertensive activity; verapamil may increase serum levels and may increase patients' sensitivity to indoramin-induced postural hypotension; may decrease antihypertensive effects of clonidine Pregnancy C - Safety for use during pregnancy has not been established. Precautions Caution in renal insufficiency; adverse effects include dizziness, asthenia, peripheral edema, hypotension, reflex tachycardia, miosis, sedation, nasal stuffiness, and erectile dysfunction Drug Name Terazosin (Hytrin) -- Quinazoline compound that counteracts alpha1-induced adrenergic contractions of bladder neck, facilitating urinary flow in presence of BPH. Effect on voiding symptoms and flow rates is dose-dependent. Improves irritative and obstructive voiding symptoms. Improvement in flow rate is objective. Hytrin starter pack available for easy dosing progression to 5 mg. Adult Dose 1-5 mg PO qhs; may titrate to maximal dose of 10 mg based on tolerability and symptomatic improvement Pediatric Dose Not established Contraindications Documented hypersensitivity Interactions Effects decrease with coadministration of NSAIDs; effects increase with coadministration of diuretics and antihypertensive medications Pregnancy B - Usually safe but benefits must outweigh the risks.

Precautions Caution in renal impairment; may cause marked hypotension following first dose and coadministration with beta-blockers; adverse effects include dizziness, headache, asthenia, peripheral edema, hypotension, reflex tachycardia, miosis, sedation, nasal stuffiness, and erectile dysfunction; incidence of erectile dysfunction is lower compared to other antihypertensive agents Drug Name Doxazosin (Cardura) -- Inhibits postsynaptic alpha-adrenergic receptors, resulting in vasodilation of veins and arterioles and decrease in total peripheral resistance and blood pressure. Long-acting alpha1-blocking agent with similar profile to terazosin. Improves irritative and obstructive voiding symptoms. Adult Dose 1 mg PO qhs; may titrate to maximal dose of 8 mg based on tolerability and symptomatic improvement Pediatric Dose Not established Contraindications Documented hypersensitivity Interactions Effects decrease with coadministration of NSAIDs; effects increase with coadministration of diuretics and antihypertensive medications Pregnancy B - Usually safe but benefits must outweigh the risks. Precautions Caution in renal impairment; may cause marked hypotension following first dose and with coadministration of beta-blockers; adverse effects include dizziness, headache, asthenia, peripheral edema, hypotension, reflex tachycardia, miosis, sedation, nasal stuffiness, and erectile dysfunction; incidence of erectile dysfunction is lower compared to other antihypertensive agents Drug Name Tamsulosin (Flomax) -- Alpha-adrenergic blocker specifically targeted to alpha-1 receptors. Has advantage of relatively less orthostatic hypotension and requires no gradual up-titration from initial introductory dosage. Inhibits postsynaptic alpha-adrenergic receptors, resulting in vasodilation of veins and arterioles and decrease in total peripheral resistance and blood pressure. Improves irritative and obstructive voiding symptoms. Adult Dose 0.4 mg PO qd initially; may increase to 0.8 mg PO qd; no dose titration needed Pediatric Dose Not established Contraindications Documented hypersensitivity Interactions Cimetidine may significantly increase plasma concentrations; may increase toxicity of warfarin Pregnancy B - Usually safe but benefits must outweigh the risks. Precautions Not for use as antihypertensive drug; may cause orthostasis; avoid situations that may result in injuries if syncope occurs; exclude presence of carcinoma or cancer before initiating treatment; adverse effects include increased rate of retrograde ejaculation and rhinitis Drug Category: 5Alpha-reductase inhibitors -- Inhibit the conversion of testosterone to DHT, causing DHT levels to drop, which, in turn, may decrease prostate size.Drug Name Finasteride (Proscar) -- Inhibits conversion of testosterone to DHT, causing serum DHT levels to decrease. Beneficial in men with prostates >40 g. Improves symptoms and reduces prostatic size by 20-30%. Reduction in prostate size sustained 5 y following treatment. Improves urinary flow rate by 2 mL/s. Adult Dose 5 mg PO qd; minimum of 6 mo treatment necessary to determine response Pediatric Dose Not established Contraindications Documented hypersensitivity; lactation, children Interactions None reported Pregnancy X - Contraindicated in pregnancy Precautions Caution in liver function abnormalities; monitor patients with severely diminished urinary flow for obstructive uropathy (may not be candidates for this therapy); generally well tolerated with few adverse effects; rare headache, loss of libido, and impotence may occur; lowers serum PSA level by 50% after 6 mo of therapy Drug Name Dutasteride (Avodart) -- Used to treat symptomatic BPH in men with an enlarged prostate. Improves symptoms, reduces urinary retention, and may decrease need for BPH-related surgery. Inhibits 5alphareductase isoenzymes types I and II. Suppresses >95% conversion of testosterone to DHT, causing serum DHT levels to decrease. Adult Dose 0.5 mg PO qd Pediatric Dose Contraindicated Contraindications Documented hypersensitivity; pregnancy or lactation; women or children

Interactions CYP450 3A4 substrate; data limited, caution with potent CYP450 3A4 inhibitors (eg, ketoconazole, ritonavir, erythromycin) or inducers (eg, rifampin, phenytoin) Pregnancy X - Contraindicated in pregnancy Precautions Unknown whether excreted in breast milk; caution with hepatic disease; establish new baseline PSA level 3 mo after therapy initiation FOLLOW-UP Section 8 of 11 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Further Outpatient Care: Patients with BPH who have symptoms significant enough to be placed on medication should be evaluated during biannual (at least) office visits to discuss the efficacy of the medication and potential dose adjustment. Patients should receive a DRE and PSA test at least annually. Complications: Complications related to BOO secondary to BPH Urinary retention Renal insufficiency Recurrent urinary tract infections Gross hematuria Bladder calculi Renal failure or uremia (rare in current practice) Patient Education: For excellent patient education resources, visit eMedicine's Prostate Health Center and Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Enlarged Prostate, Bladder Control Problems, and Inability to Urinate. MISCELLANEOUS Section 9 of 11 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Medical/Legal Pitfalls: Failure to pay special attention to the onset and duration of symptoms, general health issues (including sexual history), fitness for any possible surgical intervention, severity of symptoms and how they are affecting QOL, medications, and previously attempted treatments could lead to medicolegal liability. Symptoms often attributed to BPH can be caused by neurogenic bladder, carcinoma in situ of the bladder, urethral stricture from trauma or sexually transmitted disease, cystitis, and prostatitis. Failure to exclude these entities based on findings from a thorough history and appropriately directed diagnostic studies could lead to medicolegal liability. PICTURES Section 10 of 11 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Caption: Picture 1. Benign prostatic hyperplasia. The prostate is located at the apex of the bladder and surrounds the proximal urethra. View Full Size Image eMedicine Zoom View (Interactive!) Picture Type: Image BIBLIOGRAPHY Section 11 of 11 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Arai Y, Fukuzawa S, Terai A, Yoshida O: Transurethral microwave thermotherapy for benign prostatic hyperplasia: relation between clinical response and prostate histology. Prostate 1996 Feb; 28(2): 848[Medline]. Barry MJ, Cockett AT, Holtgrewe HL, et al: Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia. J Urol 1993 Aug; 150(2 Pt 1): 351-8[Medline]. Barry MJ, O'Leary MP: Advances in benign prostatic hyperplasia. The developmental and clinical utility of symptom scores. Urol Clin North Am 1995 May; 22(2): 299-307[Medline]. Berry SJ, Coffey DS, Walsh PC, Ewing LL: The development of human benign prostatic hyperplasia with age. J Urol 1984 Sep; 132(3): 474-9[Medline]. Bihrle R, Foster RS, Sanghvi NT, et al: High intensity focused ultrasound for the treatment of benign prostatic hyperplasia: early United States clinical experience. J Urol 1994 May; 151(5): 1271-5[Medline]. Bolmsjo M, Wagrell L, Hallin A, et al: The heat is on--but how? A comparison of TUMT devices. Br J Urol 1996 Oct; 78(4): 564-72[Medline]. Cohen MS, Steiner MS: Interstitial laser coagulation techniques: local anesthesia techniques. World J Urol 2000 Apr; 18 Suppl 1: S18-21[Medline]. Danielli L, Kaver I, Fintsi Y, et al: Water induced thermotherapy (WIT) for benign prostatic hypertrophy (BPH), one year clinical experience and histopathological studies. Eur Urol 1996; 30(S2): 222. Girman CJ, Jacobsen SJ, Guess HA, et al: Natural history of prostatism: relationship among symptoms, prostate volume and peak urinary flow rate. J Urol 1995 May; 153(5): 1510-5[Medline]. Girman CJ, Epstein RS, Jacobsen SJ, et al: Natural history of prostatism: impact of urinary symptoms on quality of life in 2115 randomly selected community men. Urology 1994 Dec; 44(6): 825-31[Medline]. International Scientific Committee: The evaluation and treatment of lower urinary tract symptoms (LUTS) in older men. Proceedings of the 5th International Consultation on BPH; Paris, France; 2000; 519-32. Issa MM: Transurethral needle ablation of the prostate: report of initial United States clinical trial. J Urol 1996 Aug; 156(2 Pt 1): 413-9[Medline]. Jacobsen SJ, Jacobson DJ, Girman CJ, et al: Natural history of prostatism: risk factors for acute urinary retention. J Urol 1997 Aug; 158(2): 481-7[Medline]. Kaplan SA, Chiou RK, Morton WJ, Katz PG: Long-term experience utilizing a new balloon expandable prostatic endoprosthesis: the Titan stent. North American Titan Stent Study Group. Urology 1995 Feb; 45(2): 234-40[Medline]. Le Duc A, Gilling PJ: Holmium laser resection of the prostate. Eur Urol 1999 Feb; 35(2): 155-60[Medline]. Lepor H, Sypherd D, Machi G, Derus J: Randomized double-blind study comparing the effectiveness of balloon dilation of the prostate and cystoscopy for the treatment of symptomatic benign prostatic hyperplasia. J Urol 1992 Mar; 147(3): 639-42; discussion 642-4[Medline]. McConnell JD: Epidemiology, etiology, pathophysiology and diagnosis of benign prostatic hyperplasia. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998: 1429-52.

McConnell JD, Bruskewitz R, Walsh P, et al: The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group. N Engl J Med 1998 Feb 26; 338(9): 557-63[Medline]. McConnell JD, Barry MJ, Bruskewitz RC, et al: Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline. No. 8, AHCPR Publication No. 94-0582. Rockville, Md: Agency for Healthcare Policy and Research, Public Health Service, US Department of Health and Human Services, 1994. McCullough DL: Minimally invasive treatment of benign prostatic hyperplasia. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998: 14791509. McNeal JE: Origin and evolution of benign prostatic enlargement. Invest Urol 1978 Jan; 15(4): 3405[Medline]. McNeal JE: The prostate gland: Morphology and pathobiology. Monogr Urol 1983; 4: 3-33. Mebust WK: Transurethral Surgery. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998: 1511-28. Muschter R, Hofstetter A: Interstitial laser therapy outcomes in benign prostatic hyperplasia. J Endourol 1995 Apr; 9(2): 129-35[Medline]. Narayan P, Tewari A, Aboseif S, Evans C: A randomized study comparing visual laser ablation and transurethral evaporation of prostate in the management of benign prostatic hyperplasia. J Urol 1995 Dec; 154(6): 2083-8[Medline]. Narayan P, Starling J: Minimally invasive therapies for the treatment of symptomatic benign prostatic hyperplasia: the University of Florida experience. J Clin Laser Med Surg 1998 Feb; 16(1): 29-32[Medline]. Oesterling JE: Retropubic and Suprapubic Prostatectomy. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998: 1529-41. Oesterling JE, Kaplan SA, Epstein HB: The North American experience with the UroLume endoprosthesis as a treatment for benign prostatic hyperplasia: long-term results. The North American UroLume Study Group. Urology 1994 Sep; 44(3): 353-62[Medline]. Steele GS, Sleep DJ: Transurethral needle ablation of the prostate: a urodynamic based study with 2-year followup. J Urol 1997 Nov; 158(5): 1834-8[Medline]. Stein BS, Bihrle RB, Issa M, et al: Minimally Invasive Surgeries for BPH. 009826 PG. Presented at AUA 93rd Annual Meeting; San Diego, California, USA. Baltimore, Md: AUA Office of Education; 1998. Steiner MS, Cohen MS, Conn RL, et al: The armamentarium for BPH. Physicians Dialogue 1998; 1: 5-11. Tewari A, Oleksa J, Johnson C, et al: Minimally invasive therapy of benign prostatic hypertrophy. Hospital Physician 1999; May: 29-68. Watson G, Anson K, Janetschek G, et al: An in-depth evaluation of contact laser vaporization of prostate. J Urol 1994; 151: 231A. NOTE: Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER Prostate Hyperplasia, Benign excerpt Copyright 2004, eMedicine.com, Inc. About Us | Privacy | Terms of Use | Contact Us | Advertise | Institutional Subscribers

http://health.yahoo.com/health/ency/adam/000381 Benign prostatic hyperplasia (BPH) Provided by A.D.A.M., Inc. Overview | Treatment | Images Definition BPH is a condition where benign (non-cancerous) nodules enlarge the prostate gland (the gland that produces the liquid in which sperm are expelled from the penis). Alternative Names BPH; Benign prostatic hypertrophy; Enlarged prostate; Prostate - enlarged Causes, incidence, and risk factors The actual cause of benign prostatic hyperplasia (BPH) is unknown. However, men who have had their testicles removed do not develop BPH and, after castration, BPH has been observed to regress. In other words, the presence of normally functioning testicles appears to be necessary for the development of BPH. Abnormally growing prostate tissue may use male hormones differently than normal prostate tissue. Although this tissue growth is non-cancerous, as the tumor grows larger it can obstruct the urethra and interfere with the normal flow of urine. The incidence of BPH increases with advancing age. BPH is so common that it has been said, "All men will have benign prostatic hyperplasia if they live long enough!" A small amount of BPH is present in 80% of men over 40 years old and over 95% of men 80 years old. No risk factors have been identified other than having normally functioning testicles. Prevention The benign enlargement of the prostate is a normal process of aging. Although the castration of men prior to puberty would most certainly prevent the development of benign prostatic hyperplasia, virtually no one would choose to end their fertility and reduce or eliminate sexual desire and capacity for this reason. Symptoms Less than half of all men with BPH have symptoms of the disease. Symptoms from BPH include: urinary hesitancy (slowed or delayed start of the urinary stream) weak urine stream nocturia (needing to urinate 2 to 3 times or more per night) pain with urination bloody urine urinary retention (difficulty urinating) increased urinary frequency strong and sudden urge to urinate (urinary urgency) incontinence Signs and tests A digital rectal exam (where health care provider inserts a finger into the rectum to feel the size of the prostate gland) may reveal an enlarged, firm prostate. Urine flow rate may be measured. (Men with BPH usually have a rate less than 15 ml per second.) The amount of urine left in bladder after urination may be measured. (This is called post-void residual urine.) Pressure flow studies will measure the pressure in the bladder as you urinate. An IVP (an x-ray study) may be done to confirm the diagnosis or look for blockage. Urinalysis may be done to check for blood or infection. Urine culture may be used to evaluate for infection. Voiding cystourethrogram (another x-ray study) may be performed. A prostate-specific antigen (PSA) blood test may be performed in patients over 50 years of age or those at increased risk of prostate cancer. Cystoscopy may be performed to visualize the prostate and bladder if surgery is required.

Additionally, you may be asked to complete a self-screening form to evaluate the severity of your symptoms and the impact on your daily life. Your score on the screening tool may be compared to past records to evaluate progression of the disease. Last Reviewed: 10/29/2002 by Steven Angelo, M.D., Assistant Professor of Medicine, Yale School of Medicine, New Haven, CT. Review provided by VeriMed Healthcare Network. Read about Treatment Treatment The choice of an appropriate treatment is based on the severity of your symptoms, the extent to which they affect your lifestyle, and the presence of any other medical conditions. Treatment options include "watchful waiting," various drug therapies, and several surgical methods. MEDICATIONS Alpha 1-Blockers: Your therapy may involve a trial use of alpha 1-blockers (doxazosin, prazosin, tamsulosin, and terazosin), which are also used to treat high blood pressure. These medications are used to treat BPH because they relax the muscles of the bladder neck, allowing easier urination. Two thirds of the people treated with alpha 1-blocker medications report an improvement in symptoms. Finasteride: This drug lowers prostate hormone levels, thus reducing the size of the prostate. Finasteride has been shown to increase urine flow rate and decrease the symptoms of BPH. It may take up to 6 months before you notice a significant improvement in your symptoms. Potential side effects related to use of finasteride include decreased sex drive (3.3%) and impotence (2.5 - 3.7%). Other medications: Antibiotics may also be prescribed to treat chronic prostatitis, which commonly accompanies BPH. Some men note symptom relief after a course of antibiotics. SURGERY Surgery is usually recommended for men with symptoms of incontinence, recurrent blood in the urine, urinary retention, and recurrent urinary tract infections. The choice of a specific surgical procedure is usually based on the severity of symptoms and the size and shape of the prostate gland. Surgical treatment options include transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), and open prostatectomy. Various studies are underway to evaluate the effectiveness of other treatments, such as hyperthermia, laser therapy, and prostatic stents. TURP: Transurethral resection of the prostate (TURP) is the most common surgical treatment for BPH. The TURP is performed by inserting a scope through the penis. The primary advantage of this procedure is that it does not involve an incision, thus reducing the risk of infection. Other surgical approaches include the retropubic (behind the pubic structures) and suprapubic (above the pubic structures) open prostatectomies, which are done through an abdominal incision. The perineal surgical approach (through the region from the scrotum to the anus) is rarely used because the impotence rate after surgery may be as high as 50%. Among men who have had a TURP, 88% reported an improvement in symptoms lasting from 10 to 15 years. Impotence occurred in 13.6% and one percent of the men reported urinary incontinence after a TURP. TUIP: Transurethral incision of the prostate (TUIP) is similar to TURP, but is usually performed in men who have a relatively small prostate. This procedure is usually performed on an outpatient basis and does not require a hospital stay. The procedure is done through the penis without an incision. A small incision is made in the prostatic tissue to enlarge the lumen (opening) of the urethra and bladder outlet, thus improving the urine flow rate and reducing the symptoms of BPH. Eighty percent of the men who had this procedure reported some improvement in their symptoms. Possible complications include bleeding, infection, urethral stricture, and impotence. Open Prostatectomy: An open prostatectomy is usually performed using general or spinal anesthesia. An incision is made through the abdomen or perineal area (i.e., through the pelvic floor, including the region from the scrotum to the anus). This is a lengthy procedure, and it usually requires a hospital stay of 5 to 10 days. Most of the men (98%) who had open prostatectomy surgery reported some improvement in their symptoms. Possible complications include impotence (16 to 32% depending on surgical approach) and urinary incontinence (less than 1%). LIFESTYLE

Self-help measures may prove beneficial if the degree of obstruction is minimal. These include hot baths, urinating upon the earliest urge to do so, sexual activity or ejaculation on a regular basis, and avoiding alcohol or excessive fluid intake (especially at night). Herbalists suggest that saw palmetto berries and extracts may potentially ease prostate symptoms. You can reduce the frequency of nighttime trips to the bathroom by eliminating fluids a few hours before you go to sleep. Symptoms of urinary incontinence may be improved by spreading out your fluid intake over the course of the day. You should avoid drinking large amounts of fluids at one time and only take sips of fluids with meals. Men with BPH should avoid taking over-the-counter cold and sinus medications that contain decongestants, because these medications can increase the symptoms of BPH. "WATCHFUL WAITING" Less than half of all men with BPH have symptoms of the disease, or their symptoms are minor and do not severely restrict their lives. These patients can simply be monitored over time for an increase in their symptoms. Studies show that of the men who receive no treatment for BPH, 31 - 55% show an improvement, and only 1 - 5% ever develop complications. Men who choose "watchful waiting" should receive yearly exams to monitor progression of the disease. MONITORING All men who have BPH should receive a yearly exam to monitor the progression of symptoms. Support Groups Several national groups provide information on BPH. See support groups - BPH. Complications Men who have had long-standing BPH with a gradual increase in symptoms may develop an acute (sudden) inability to urinate, urinary tract infections, urinary stones, damage to the kidneys, and blood in the urine. Even after surgical treatment, a recurrence of BPH may develop over time. Calling your health care provider Call for an appointment with the health care provider if symptoms of BPH occur. Last Reviewed: 10/29/2002 by Steven Angelo, M.D., Assistant Professor of Medicine, Yale School of Medicine, New Haven, CT. Review provided by VeriMed Healthcare Netwo

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Benign Prostatic Hyperplasia

(Benign Prostatic Hypertrophy)
Benign adenomatous hyperplasia of the periurethral prostate gland, causing variable degrees of bladder outlet obstruction. A major difficulty in establishing prevalence of benign prostatic hyperplasia (BPH) has been the lack of a common definition. Based on autopsy studies, the prevalence of histologically diagnosed BPH increases from 8% in men aged 31 to 40 yr to 40 to 50% in men aged 51 to 60 yr and > 80% in men older than 80 yr. However, based on clinical criteria in men aged 55 to 74 yr without prostate cancer, the prevalence of BPH is 19% using the criteria of a prostate volume > 30 mL and a high International Prostate Symptom score. However, the prevalence is only 4% if the criteria are a prostate volume > 30 mL, a high score, a maximal urinary flow rate < 10 mL/sec, and a postvoid residual urine volume > 50 mL.

Etiology and Pathophysiology

The etiology is unknown but may involve hormonal changes associated with aging. Multiple fibroadenomatous nodules occur in the periurethral region of the prostate gland, probably originating within the periurethral glands rather than in the true fibromuscular prostate (surgical capsule), which is

displaced peripherally by progressive growth of the nodules. The hyperplasia may involve the lateral walls of the prostate (lateral lobe hyperplasia) or tissue at the inferior margin of the vesical neck (middle lobe hyperplasia). Histologically, the tissue is glandular, with varying proportions of fibrous stroma interposed. As the lumen of the prostatic urethra becomes compromised, urine outflow is progressively obstructed, accompanied by hypertrophy of the bladder detrusor, trabeculation, cellule formation, and diverticula. Incomplete bladder emptying causes stasis and predisposes to infection with secondary inflammatory changes in the bladder (chronic prostatitis, see below) and the upper urinary tract. Urinary stasis predisposes to calculus formation (see Ch. 221). Prolonged obstruction, although incomplete, can produce hydronephrosis and compromise renal function.

Symptoms, Signs, and Diagnosis

Progressive urinary frequency, urgency, and nocturia are due to incomplete emptying and rapid refilling of the bladder. Decreased size and force of the urinary stream produce hesitancy and intermittency. Sensations of incomplete emptying, terminal dribbling, almost continuous overflow incontinence, or complete urinary retention may ensue. Straining to void can cause congestion of superficial veins of the prostatic urethra and trigone, which may rupture and produce hematuria. Acute complete urinary retention may be precipitated by prolonged attempts to retain urine, immobilization, exposure to cold, anesthetics, anticholinergic and sympathomimetic drugs, or ingestion of alcohol. Symptoms may be quantitated by the seven-question American Urological Association Symptom Score (see Table 218-1). On rectal examination, the prostate usually is enlarged, has a rubbery consistency, and, frequently, has lost the median furrow. However, digital rectal examination of prostate size may be misleading. A small prostate on rectal examination may be sufficiently large to cause obstruction. The distended urinary bladder may be palpable or percussible on physical examination. Serum prostate-specific antigen (PSA) is moderately elevated in 30 to 50% of patients with BPH, depending on prostate size and degree of obstruction (see also Prostate Cancer in Ch. 233). Men with mild or moderate BPH symptoms usually do not need further testing. More severe symptoms or the presence of hematuria or UTI warrants further evaluation by a urologist. IVU may disclose upward displacement of the terminal portions of the ureters (fishhooking) and a defect at the base of the bladder compatible with prostatic enlargement. With prolonged obstruction, the ureters dilate and hydronephrosis occurs. Urethral catheterization cystoscopy or ultrasonography after voiding measures residual urine, and catheterization permits preliminary drainage to stabilize renal function and adequately control UTI. If indicated because of an elevated serum PSA, transrectal ultrasonography permits estimation of gland size, may aid selection of the appropriate surgical approach, and differentiates vesical neck contracture, chronic prostatitis, and other obstructive phenomena. Instrumentation should be avoided until definitive therapy has been decided, because manipulation may increase obstruction, trauma, and infection. An indurated and tender prostate suggests prostatitis, whereas a stony, hard, nodular prostate usually indicates carcinoma or, occasionally, prostatic calculi.

Treatment
When BPH is associated with UTI or azotemia due to bladder outlet obstruction, initial therapy should be medical, directed toward stabilizing renal function, discontinuing anticholinergic and sympathomimetic drugs, and eradicating infection. Urethral or suprapubic catheter drainage may be desirable in advanced bladder outlet obstruction. The chronically obstructed, distended bladder should be slowly decompressed to help avoid postobstructive diuresis. For some patients with mild to moderate obstructive symptoms, -adrenergic blockers such as terazosin may improve voiding. The 5-reductase inhibitor finasteride may

reduce prostate size, improving voiding over time (months), especially in patients with large (> 40 mL) glands. All such patients should avoid anticholinergic and narcotic drugs, which may induce obstruction. Definitive therapy is surgical. Although sexual potency and continence are usually retained, about 5 to 10% of patients will experience some postsurgical problems. Transurethral resection of the prostate (TURP) is preferred. Larger prostates (usually > 75 g) may require open surgery using the suprapubic or retropubic approach, permitting enucleation of the adenomatous tissue from within the surgical capsule. The incidence of impotence and incontinence is much higher than after TURP. All surgical methods require postoperative catheter drainage for 1 to 5 days. Alternative surgical approaches include intraurethral stents, microwave thermotherapy, high-intensity focused ultrasound thermotherapy, laser ablation, electrovaporization, and radiofrequency vaporization; their roles are not established.

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Open Prostatectomy http://www.emedicine.com/med/topic3041.htm

Last Updated: July 8, 2004 Rate this Article Email to a Colleague Synonyms and related keywords: retropubic prostatectomy, Millin prostatectomy, enucleation of a hyperplastic prostatic adenoma, suprapubic prostatectomy, simple perineal prostatectomy, benign prostatic hyperplasia, radical retropubic prostatectomy for malignant prostatic disease, transurethral resection of the prostate, TURP AUTHOR INFORMATION Section 1 of 9 Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Bibliography

Author: Brian J Miles, MD, Medical Director, Chief of Urology Service, St Luke's Episcopal Hospital; Program Director, Director of Education, Associate Professor, Department of Urology, Baylor College of Medicine Coauthor(s): Robert J Cornell, MD, Staff Physician, Department of Urology, Baylor College of Medicine Brian J Miles, MD, is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Clinical Oncology, American Urological Association, Association of Military Surgeons of the US, Society of Urologic Oncology, and Texas Medical Association Editor(s): Michael Grasso, MD, Chairman, Saint Vincents Medical Center, Manhattan, New York, Professor and Vice Chairman, Department of Urology, New York Medical College; Francisco Talavera,

PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Allen Frank Morey, MD, Chief, Urology Service, Brooke Army Medical Center; Clinical Assistant Professor, Department of Surgery, Uniformed Services University of the Health Sciences; J Stuart Wolf, Jr, MD, Director of Michigan Center for Minimally Invasive Urology, Associate Professor, Department of Urology, University of Michigan Medical Center; and Stephen W Leslie, MD, FACS, Founder and Medical Director, Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio INTRODUCTION Section 2 of 9 Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Bibliography

History Retropubic prostatectomy is the enucleation of a hyperplastic prostatic adenoma through a direct incision of the anterior prostatic capsule. The procedure dates to 1945, when Terrence Millin first reported his experience with 20 patients. Suprapubic prostatectomy is the enucleation of the hyperplastic prostatic adenoma through an extraperitoneal incision of the lower anterior bladder wall. Eugene Fuller first performed this procedure in 1894. By 1912, Peter Freyer, who reported his results with 1000 patients, had popularized the procedure. Simple perineal prostatectomy for the treatment of lower urinary tract obstruction secondary to benign prostatic hypertrophy illustrates the developments in the approach to this common pathology. More than 2000 years ago, surgeons devised and employed a median perineal incision for the removal of bladder calculi. In the first century CE, surgeons used a semielliptical incision in the perineum for partial removal of the prostate. Few records document the use of this procedure for several hundred years to follow. Problem: A number of treatment options exist for benign prostatic hyperplasia. Medications that act at the level of the prostate and bladder neck include tamsulosin (Flomax), terazosin (Hytrin), doxazosin (Cardura), and finasteride (Proscar). Each can decrease outlet resistance related to prostatic hyperplasia and improve symptoms of lower urinary tract obstruction. In patients with recalcitrant or more advanced degrees of outlet obstruction, minimally invasive procedures exist, including visual laser prostatic ablation, transurethral incision of the prostate (TUIP), and electrovaporization of the prostate. Other patients present with acute urinary retention, persistent or recurrent urinary tract infections, significant hemorrhage from an enlarged and friable prostate, or renal insufficiency from chronic bladder outlet obstruction. In many of these patients, prostatectomy is indicated (either transurethral resection of the prostate (TURP) or open prostatectomy). This article reviews the indications for open prostatectomy, discusses the various approaches for this procedure, weighs the advantages and disadvantages of each approach, and provides a brief outline of standard surgical technique. Finally, the indications for anatomic radical retropubic prostatectomy for malignant prostatic disease are discussed, with a thorough presentation of surgical technique. Clinical: Consider open prostatectomy, using either the retropubic or suprapubic approach, when the prostate is larger than 50-70 g or larger than the surgeon can resect reliably by TURP in 60-90 minutes. In patients with concomitant bladder pathology complicating their outlet obstruction (eg, a large or hard bladder calculus, symptomatic bladder diverticulum), open prostatectomy remains the procedure of choice. Additionally, patients with musculoskeletal disease precluding proper patient positioning in the dorsal lithotomy position for TURP may benefit from an open prostatectomy. INDICATIONS Section 3 of 9 Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Bibliography

Retropubic prostatectomy Advantages of the retropubic technique over the suprapubic approach Superb anatomic prostatic exposure Direct visualization of the adenoma during enucleation to ensure complete removal Precise division of the prostatic urethra optimizing preservation of urinary continence Direct visualization of the prostatic fossa after enucleation for hemorrhage control and minimal trauma to the urinary bladder Suprapubic prostatectomy The major advantage of the suprapubic approach over the retropubic approach is that it permits better visualization of the bladder neck and ureteral orifices and, therefore, is better suited for patients with the following conditions: Enlarged, protuberant, median prostatic lobe Concomitant symptomatic bladder diverticulum Large bladder calculus Obesity (to a degree that makes access to the retropubic space more difficult) Simple perineal prostatectomy The principal indication for simple perineal prostatectomy is in the treatment of lower urinary tract obstructive symptoms secondary to benign prostatic hypertrophy, which is resistant to medical therapy. The main contraindications to perineal enucleation prostatectomy are in young patients, for whom sexual potency remains important. This approach invades the perineal neurovascular anatomy more extensively than other available open techniques that are used more often. Other instances in which simple perineal prostatectomy is feasible include treatment of clinically significant prostatic abscess and prostatic cysts. RELEVANT ANATOMY AND CONTRAINDICATIONS Section 4 of 9 Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Bibliography

Contraindications: Compared to suprapubic prostatectomy, the disadvantages of retropubic prostatectomy relate largely to the limited access to the bladder, which is an important consideration if a bladder diverticulum requiring excision coexists or when a large bladder calculus must be removed directly. Additionally, if cystoscopy suggests that the obstructing adenoma primarily involves the median lobe, the suprapubic approach may be preferred because this technique optimizes anatomic exposure.

The disadvantage of the suprapubic approach relates to reduced visualization of the apical prostatic adenoma and the potential complication of postoperative urinary incontinence and intraoperative bleeding. Quick Find Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Bibliography Click for related images. Continuing Education CME available for this topic. Click here to take this CME. Patient Education Prostate Health Center Men's Health Center Enlarged Prostate Overview Enlarged Prostate Causes Enlarged Prostate Symptoms Enlarged Prostate Treatment Understanding the Male Anatomy

WORKUP Section 5 of 9 Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Bibliography

Lab Studies: Exclude prostate cancer before performing a prostatectomy in patients with symptomatic bladder outlet obstruction. All men should undergo preoperative prostate-specific antigen (PSA) determination and routine digital rectal examination (DRE). Suspicions evoked by either screening modality should prompt a

transrectal ultrasound-guided needle biopsy of the prostate to exclude the presence of carcinoma before open prostatectomy is performed. Preoperative lower urinary tract studies may include a urinary flow rate with documentation of postvoid residual and, possibly, a cystometrogram and pressure or flow evaluation in patients with more complex conditions who may have coexisting bladder instability or detrusor function abnormalities. Patients who present for open prostatectomy typically are aged 60 years or older. The comorbidities common to this patient population involve not only routine preoperative history, physical examination, and standard serum chemistries, but also chest radiography and ECG to investigate potential complications of these possible preexisting conditions. Imaging Studies: Although transrectal ultrasound may help document large prostatic size, it is not indicated preoperatively and does not assist in the preoperative screening for prostatic malignancy. Imagery of the upper urinary tract is not performed routinely in patients with outlet obstruction unless it is indicated for other reasons (eg, evaluation of hematuria). Chest radiography is indicated to investigate potential complications of possible preexisting conditions in patients older than 60 years. Other Tests: ECG is indicated to investigate potential complications of possible preexisting conditions in patients older than 60 years. Diagnostic Procedures: Cystoscopy, although useful for identifying the presence of urethral stricture disease, bladder calculi, and diverticula, is not routinely performed preoperatively once the decision has been made to perform the procedure by an open surgical technique. In questionable cases, cystoscopy may help determine prostate size or shape that precludes other surgical options. TREATMENT Section 6 of 9 Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Bibliography

Medical therapy: A number of treatment options exist for benign prostatic hyperplasia. Consider medications that act at the level of the prostate and bladder neck, including tamsulosin (Flomax), terazosin (Hytrin), doxazosin (Cardura), and finasteride (Proscar). Each can decrease outlet resistance related to prostatic hyperplasia and improve symptoms of lower urinary tract obstruction. In patients with recalcitrant or more advanced degrees of outlet obstruction, minimally invasive procedures exist, including visual laser prostatic ablation, TUIP, and electrovaporization of the prostate. Other patients present with acute urinary retention, persistent or recurrent urinary tract infections, significant hemorrhage from an enlarged and friable prostate, or renal insufficiency from chronic bladder outlet obstruction. In many of these patients, prostatectomyeither TURP or open prostatectomyis indicated. Surgical therapy: The advantages of open prostatectomy over TURP include the complete removal of the prostatic adenoma under direct visualization in the suprapubic or retropubic approaches. These procedures do not obviate the need for further prostate cancer surveillance because the posterior zone of the prostate remains as a potential source of carcinoma formation. The transurethral resection syndrome of dilution hyponatremia is unique to TURP and does not occur with open prostatectomy. Thus, in patients with a greater risk of congestive heart failure caused by underlying cardiopulmonary disease, open prostatectomy has a much smaller risk of intraoperative fluid challenge.

Disadvantages of open prostatectomy when compared to TURP exist, however, and include the morbidity and longer hospitalization associated with the open procedure and the potential for greater intraoperative hemorrhage. Patients with a prostate size smaller than 50 g, history of previous pelvic surgery in the retropubic space preventing access to the prostate, and evidence of prostate cancer are not candidates for an open, simple prostatectomy. Preoperative details: Exclude prostate cancer before prostatectomy is performed in patients with symptomatic bladder outlet obstruction. All men should undergo preoperative PSA determination and routine DRE. Suspicions evoked by either screening modality should prompt a transrectal ultrasound-guided needle biopsy of the prostate before open prostatectomy is performed. Additionally, preoperative lower urinary tract studies likely include a urinary flow rate with documentation of postvoid residual and, possibly, a cystometrogram and pressure or flow evaluation in patients with more complex conditions who may have coexisting bladder instability or detrusor function abnormalities. Patients who present for open prostatectomy typically are aged 60 years or older. The comorbidities common to this patient population involve not only routine preoperative history, physical examination, and standard serum chemistries, but also chest radiography and ECG to investigate potential complications of these potential preexisting conditions. If anticoagulants (eg, aspirin, other nonsteroidal anti-inflammatory drugs [NSAIDs], warfarin [Coumadin]) are required preoperatively, coordinate their discontinuation with the ordering physician, and correct any significant coagulopathy before surgery. Discuss potential risks of open prostatectomy with the patient preoperatively, including urinary incontinence, erectile dysfunction, retrograde ejaculation, urinary tract infection, and the need for a blood transfusion. Additionally, as with all open pelvic procedures, the risk of deep vein thrombosis and pulmonary embolus always exists. Intraoperative details: The retropubic (Millin) prostatectomy The Millin (transverse capsular) prostatectomy is initiated by locating the vesicle neck by palpation of the Foley balloon. Place a 1-0 absorbable suture deeply in the capsule of the prostate, just below the vesicle neck. Repeat this technique until a 4-cornered area is created, through which a transverse incision is made into the adenoma across the entire anterior surface while the bladder is retracted cephalad. Place the proximal capsule under tension and achieve hemostasis actively with full suction. Next, identify the plane between the adenoma and the capsule and dissect sharply. Once developed, explore this plane manually while the adenoma is enucleated under direct visualization. Carefully identify the apex of the prostate and divide the urethra sharply under direct visualization. Hemostasis is achieved before placement of figure-of-8, 2-0 absorbable sutures at the 5- and 7-o'clock positions through the vesical neck and proximal capsule. Clearly identify the ureteral orifices before resecting a wedge of posterior vesical neck. Using a running 2-0 absorbable suture, evert and approximate the edges. Introduce a large catheter per urethra, and inflate the balloon.

Finally, close the capsule from both ends with 2 continuous 2-0 absorbable sutures. Foley traction may be used as needed for hemostasis. An external drain should be placed into the space of Retzius until drainage stops. The wound then is irrigated and closed. Suprapubic prostatectomy With the suprapubic approach, place the patient in a supine position on the operative table, with the umbilicus over the break of the table. Then, hyperextend the table slightly, placing the patient in a mild Trendelenburg position. After preparing and draping the patient in the standard fashion, introduce a urethral catheter into the bladder, through which the bladder is filled to approximately 250 cc with sterile water or saline before the catheter is removed. Make a vertical midline incision from below the umbilicus to the pubic symphysis. Dissect between the laterally retracted rectus abdominus, developing the prevesical space extraperitoneally. Neither the retropubic nor the lateral vesical spaces are necessarily entered. Below the peritoneal resection, place 2 stay-sutures in the anterior abdominal wall, make a vertical cystotomy, and carry it within 1 cm of the bladder neck, allowing visualization of the bladder neck and prostate. Retract the superior bladder edge cranially and retract the inferior portion distal to the trigone in a caudal direction to display the posterior bladder neck. The urethral orifices are now well visualized and protected as the bladder neck mucosa is incised just distal to the trigone. Using sharp dissection, develop the plane between the adenoma and the prostatic capsule. Perform gentle blunt digital dissection, completing the remaining dissection both posteriorly and circumferentially around the prostatic apex and urethra. Sharply transect the urethra close to the apex of the prostate, carefully avoiding the external urethral sphincter. Following gross enucleation of the adenoma, manually inspect the prostatic fossa, and remove any remaining nodular adenoma. Ligate the prostatic arteries at the 5- and 7-o'clock positions to provide adequate hemostasis and vascular control. Pass a 22F, 30-cc, 3-way catheter per urethra (and in select patients an additional suprapubic tube through a separate anterior cystostomy). Close the bladder in full-thickness through the serosa using a double layer of interrupted 2-0 chromic or Vicryl suture. Inflate the catheter balloon to prevent retraction into the prostatic fossa, and drain the space of Retzius. Postoperative details: Postoperative care of patients who have had an open prostatectomy parallels that of patients who have had most major open surgical procedures. Since the need for postoperative blood transfusions is minimized through improvements in understanding of the relevant surgical anatomy and advancements in operative technique, most patients are discharged comfortably on the second day after surgery. For the surgeon, the most significant concern is to observe drain output and fluid status immediately after surgery, since patients generally are ambulating and tolerating a regular advancement of their diet by the first day after surgery.

Follow-up care: Follow up in the clinic after surgery. If the Foley catheter was not removed during the hospitalization, a voiding trial can be performed on an outpatient basis. Remove pathology and schedule follow-up examinations to exclude carcinoma. For excellent patient education resources, visit eMedicine's Prostate Health Center and Men's Health Center. Also, see eMedicine's patient education articles Understanding the Male Anatomy and Enlarged Prostate. COMPLICATIONS Section 7 of 9 Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Bibliography

Postoperative complications following both suprapubic and retropubic prostatectomy include hemorrhage, urinary extravasation, and associated urinoma. Infectious processes, including cystitis and epididymo-orchitis, also may occur, but only rarely when prophylactic antibiotics are administered. Because risk of injury to the external urinary sphincter is minimal with these procedures, stress and/or total urinary incontinence are rare. Coincident erectile dysfunction and bladder neck contracture also have been reported postoperatively in approximately 2-3% of patients following suprapubic prostatectomy. Retrograde ejaculation has been reported in up to 80-90% of patients after surgery and is a common phenomenon after these procedures. Finally, as with any significant pelvic surgery, the risk of nonurologic complications exists, including deep vein thrombosis, pulmonary embolus, myocardial infarction, and cerebral vascular accident. The incidence of these complications, however, is low and reflects the comorbidities of the patient population being treated. OUTCOME AND PROGNOSIS Section 8 of 9 Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Bibliography

Open (simple) prostatectomy is an invasive surgical approach for the treatment of medically resistant or advanced lower urinary tract obstruction secondary to benign prostatic hyperplasia. Patients with an exceedingly large prostate or with concomitant bladder calculi or diverticula are ideal candidates for this approach, since these techniques optimize exposure to both the entire prostate and intravesical bladder. These procedures differ from radical prostatectomy in which the entire prostate, seminal vesicles and vas deferens are removed en bloc. With simple prostatectomy, the risk of prostate cancer in the future remains and patients must be followed with DRE and PSA studies. BIBLIOGRAPHY Section 9 of 9 Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Bibliography

Elder JS, Gibbons RP, Correa RJ Jr: Morbidity of radical perineal prostatectomy following transurethral resection of the prostate. J Urol 1984 Jul; 132(1): 55-7[Medline]. Freyer P: One thousand cases of total enucleation of the prostate for radical cure of enlargement of that organ. Br Med J 1912; 2: 868. Gibbons R: Radical perineal prostatectomy. In: Campbell's Urology, 7th ed., Philadelphia, W.B. Saunders Co. 1998; vol. 2: 2589-2604. Hinman F: Atlas of Urologic Surgery. 2nd ed. Philadelphia, W.B. Saunders Co.; 1998: 414-425. Hudson P: Perineal prostatectomy. In: Campbell's Urology. 4th ed. Philadelphia, W.B. Saunders Co.; vol.3: 2327-2360. Millin R: Retropubic prostatectomy: New extravesical technique. Report on 20 cases. Lancet 1945; II: 693. Oesterling J: Retropubic and suprapubic prostatectomy. In: Campbell's Urology. Vol 2. 7th ed. WB Saunders; 1998: 1529-1540. Partin AW, Yoo J, Carter HB: The use of prostate specific antigen, clinical stage and Gleason score to predict pathological stage in men with localized prostate cancer. J Urol 1993 Jul; 150(1): 110-4[Medline]. Reiner WG, Walsh PC: An anatomical approach to the surgical management of the dorsal vein and Santorini's plexus during radical retropubic surgery. J Urol 1979 Feb; 121(2): 198-200[Medline]. Szutzman R: Textbook of Operative Urology. WB Saunders 1998; 532-536. Walsh PC, Oesterling JE: Improved hemostasis during simple retropubic prostatectomy. J Urol 1990 Jun; 143(6): 1203-4[Medline]. Weldon VE, Tavel FR, Neuwirth H: Patterns of positive specimen margins and detectable prostate specific antigen after radical perineal prostatectomy [published erratum appears in J Urol 1995 Aug;154(2 Pt 1):538]. J Urol 1995 May; 153(5): 1565-9[Medline]. NOTE: Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER Open Prostatectomy excerpt Copyright 2004, eMedicine.com, Inc. About Us | Privacy | Terms of Use | Contact Us | Advertise | Institutional Subscribers