Diagnosis and Treatment of Benign Prostatic Hyperplasia

What is the prostate?

The prostate is a gland weighing 18–20 grams, located at the outlet of the bladder in men. Its main function is to produce part of the seminal fluid and help expel this fluid during sexual intercourse.

Benign Prostatic Enlargement (Benign Prostatic Hyperplasia = BPH)

Although the cause and mechanism of BPH are not fully understood, changing hormones in aging men are thought to play a role. An imbalance between testosterone and estrogen after the age of 40 is considered one of the leading causes of benign prostatic enlargement. Genetic predisposition is important.

What Are the Symptoms of BPH?

The signs and symptoms of benign prostatic enlargement are divided into 2 groups: storage (irritative) and voiding (obstructive) symptoms.

Storage symptoms

• Getting up at night to urinate
• Frequent urination during the day
• Burning during urination
• Sudden urgency to urinate
• Involuntary leakage of urine

Voiding symptoms

• Straining to urinate
• Weak urine stream
• Intermittent urine stream
• Waiting before urination begins
• Urination taking a very long time

HOW IS BPH DIAGNOSED?

Benign prostatic enlargement is the most common cause of urinary symptoms, but there are other causes of the same symptoms. For diagnosis, the patient's complaints are first assessed. In addition, the patient fills out the International Prostate Symptom Score (IPSS) form. This test is an assessment method that helps determine the degree of obstruction. This is followed by a general physical examination and a digital rectal examination of the prostate. In the prostate examination, the size and consistency of the prostate are assessed. The digital rectal examination is also an important screening method in the diagnosis of prostate cancer.

TESTS USED IN DIAGNOSIS

PSA Test
Since benign prostatic enlargement and prostate cancer can occur in the same age group, the blood PSA (prostate-specific antigen) test is an important test. It should be checked routinely after the age of 50. In those with a family history of prostate cancer, it should be checked after the age of 40.

Urinalysis and urine culture
Urine tests are performed to rule out urinary tract infections, which cause similar symptoms.
Because BPH slows the flow of urine and causes urine to accumulate in the bladder, urinary tract
infections are more likely. That is why urine tests are important.

Uroflowmetry (urine flow test)
Uroflowmetry measures your urine flow rate. This test is performed to determine whether the prostate is obstructing the flow of urine. It guides treatment planning.

Why is post-void residual urine (PVR) measured?
Measuring the urine remaining in the bladder after urination is done to determine whether the bladder empties completely.

An increased PVR is a sign that the bladder is not functioning well, that is, it is not contracting properly, or that there is an obstruction at the bladder outlet. In this case, the risk of urinary tract infection increases.

Bladder and prostate ultrasound
Bladder ultrasound is used to investigate other possible causes of these symptoms.

TREATMENT

Medication
Medication is recommended for patients with mild symptoms.

Herbal Medicines
Their effectiveness is not clear. There are many herbal medicines for this condition. They should be used under a doctor's supervision.

Alpha-blockers
These are drugs that relax the smooth muscles of the prostate, reducing symptoms and improving urine flow. They are the most commonly used drug group in BPH. Terazosin, silodosin, alfuzosin, doxazosin and tamsulosin are among the drugs in this group. They take effect in about 2 weeks. They do not shrink the prostate or prevent
it from growing.

5-alpha reductase inhibitors
These are drugs that prevent the prostate from growing and cause it to shrink. They are more effective in patients with a prostate volume of 40 g or more. Dutasteride and finasteride are the active ingredients of these drugs.

Phosphodiesterase-5 inhibitors
Phosphodiesterase-5 inhibitors (PDE5i) are drugs used to treat erectile dysfunction. These drugs have also been proven to improve BPH symptoms. Sildenafil, tadalafil and vardenafil are the active ingredients.

SURGICAL TREATMENT
THE GOLD STANDARD TREATMENT IS TRANSURETHRAL RESECTION OF THE PROSTATE (TURP).

In this method, a camera system is inserted endoscopically through the tip of the penis, and prostate tissue is removed by both cutting and vaporizing it. The latest and most successful method is PLASMAKINETIC TECHNOLOGY.

PLASMAKINETIC TURP
The MOST COMMON method used in the surgical treatment of BPH is transurethral resection of the prostate (TURP). In this method, the enlarged central-inner part of the prostate that causes the symptoms is removed.

ADVANTAGES OF PLASMAKINETIC TURP
Cutting and bleeding control are performed with plasmakinetic energy using BIPOLAR CURRENT (WHICH DOES NOT PASS THROUGH THE PATIENT'S BODY). As with classic TURP, tissue can be removed for pathology, and it has the advantage of bleeding control as in laser prostatectomy. Because isotonic saline is used instead of sterile water, TUR syndrome (electrolyte imbalance due to water intoxication) is very rare. The hospital stay and catheterization period are 1–2 days.

OPEN PROSTATECTOMY
The technique for removing the prostate tissue is similar to TURP. Open prostatectomy is recommended for men with a very large prostate. The operation is performed through an incision below the navel. The hospital stay is 3 days, and the catheterization period is approximately 7–10 days.

TRANSURETHRAL MICROWAVE THERAPY (TUMT)
This is a minimally invasive treatment that uses microwave energy to shrink and harden prostate tissue. The aim is to relieve symptoms by reducing the size of the prostate. It is preferred for very elderly patients and/or those at high risk for surgery. The procedure is performed under local anesthesia in about 45–60 minutes.