Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH) - What it is

Benign Prostatic Hyperplasia BPH Conditions and Treatments

What is the Prostate?

The prostate is a walnut-sized gland in men that sits between the bladder and the urethra. It is a sexual organ that is involved in semen production. Because of its location at the bladder outlet, enlargement or irregularity of the prostate may impede the flow of urine, causing bothersome symptoms.

What is Benign Prostatic Hyperplasia (BPH)?

Benign Prostatic Hyperplasia, or BPH, is a non-cancerous enlargement of the prostate gland which may or may not result in urinary symptoms. It is one of the most common conditions affecting older men, as high as 50% of men aged 60 years and above.

Benign Prostatic Hyperplasia (BPH) - Symptoms

Prostate enlargement in BPH is often non uniform, causing irregularity and compression of the urinary tract. This results in obstruction, or blockages, to the path of urine flow which in turn results in problems with emptying urine in the bladder.

Symptoms can vary depending on the degree of obstruction. There may be no bothersome symptoms in very mild cases. With more serious obstruction, affected men may experience symptoms such as:

Slow urine flow
Difficulty in passing urine, at times having to strain to expel urine
Sensation of incomplete bladder emptying
Frequent urination
Waking up many times to pass urine at night

In the most severe of cases, BPH can cause complications such as urinary tract infections, blood in urine, bladder stones, inability to pass urine and damage to the kidneys.

It is important to note that these symptoms can also be caused by other urinary tract conditions, including cancerous and non-cancerous ones. If you experience any of these symptoms, you should consult your family physician who may refer you to see a Urologist.

Benign Prostatic Hyperplasia (BPH) - Diagnosis

What can I expect when I see a Urologist?

In the clinic, your doctor will speak to you to find out more about the symptoms you are experiencing. Your doctor will then do a set of routine physical examinations and tests, which may include:

Bedside ultrasound

This is a scan used to assess your bladder, prostate, and kidneys. Measurements of your prostate will be taken. There is no radiation in an ultrasound scan.

Digital rectal examination

A physical examination that involves the doctor inserting a gloved finger into your rectum to feel the prostate, giving him/her a general idea of the condition of the gland.

Uroflowmetry

You may be brought into a private cubicle and asked to urinate into a device to measure your flow of urine.

Prostate specific antigen (PSA)

This is a blood test to measure the level of serum PSA, which is a prostate cancer marker. Your doctor will discuss with you what the test result means, and if you need further tests to rule out prostate cancer.

At the end of the consultation, your doctor will discuss the treatment options for BPH and tailor one that is suitable for you.

Benign Prostatic Hyperplasia (BPH) - Treatments

The treatment options will depend on how serious your BPH condition is and how badly your symptoms are affecting you. Your choice of treatment is also determined by your lifestyle priorities, such as how important it is to maintain your sexual functions.

A simplistic way to guide your treatment is as follows:

Severity of BPH
Mild	Moderate	Severe
Lifestyle improvements Medications	Medications Surgery	Surgery

Lifestyle changes may be sufficient for very mild BPH. Such lifestyle improvements include managing your intake of fluids and reducing caffeine and salt intake. If you require medications, you may be prescribed one of the following groups, or both:

Alpha blocker

This group includes Terazosin, Tamsulosin, Alfuzosin and others. They work by relaxing the smooth muscles around your prostate and urethra, allowing urine to pass through more easily. Common side effects include blocked nose, giddiness related to posture and abnormal ejaculation.

5-alpha-reductase inhibitor

Dutasteride and finasteride are medications that belong to this group. They work by gradually reducing the size of the prostate over a longer period (more than 6 months). Common side effects include erectile dysfunction and reduced libido.

Other medications may be prescribed depending on your symptoms. Your doctor may discuss surgery with you if your BPH condition is more serious or medications are not effective or suitable.

When do I need surgery?

Your doctor may discuss BPH surgery if your symptoms are moderate to severe, if you have urinary complications from prostate enlargement, if medications are not suitable for you, or should you make a personal choice to have surgery upfront. There are various reasons that medications may not be suitable for you, such as being no longer effective, side effects being too bothersome, or interactions with other medical conditions. Longstanding and untreated severe BPH can cause urinary complications such as urinary tract infections, blood in urine, bladder stones, inability to pass urine and damage to the kidneys.

What are the options for surgery?

The optimal choice of surgical procedure depends on the severity of your BPH condition and your lifestyle preferences.

Transurethral resection of prostate (TURP)
TURP is considered the most effective surgery used to treat urinary problems from prostate enlargement or BPH. This is the surgery of choice for large and highly obstructing prostates, or for men with severe BPH symptoms or BPH complications. There are variations of TURP, which achieve similar end-results with added benefits. Such techniques include TUERP, HoLEP and laser vaporisation.
Minimally Invasive Surgical Treatments (MIST)
The options for MIST procedure for BPH are diverse, and most are still under investigation. With the progress of medical technology, newer techniques are expected appear in the future.

MIST is less invasive than TURP, and the main benefits of MIST include preservation of sexual functions, improved recovery experience and better safety profile, as compared to TURP. At this point in time, the improvements in urine flow are not as good, and the effects do not last as long, as TURP. You may choose a MIST procedure if your BPH symptoms are mild to moderate and your wish to maintain certain aspects of your lifestyle.

The MIST options currently offered at SGH include:

Prostatic Urethra Lift (UroLift®)
Convective Water Vapour Thermal Therapy (Rezum™)

What is TURP?

Transurethral resection of prostate (TURP) is considered the most effective surgery used to treat urinary problems from prostate enlargement, also known as benign prostate hyperplasia (BPH). A severe and longstanding blockage to urine flow can cause complications such as urinary tract infections, blood in urine, bladder stones, inability to pass urine (urine retention) and damage to the kidneys. Your doctor may recommend a TURP if you have severe urinary symptoms or complications from prostate enlargement, or if BPH medications are not working or suitable for you.

TURP is carried out under half- or full-body anaesthesia. During the procedure, an instrument called a resectoscope is inserted through the urethra (the urine passage from the tip of penis to the bladder), and the prostate gland is shaved away with a cutting device. The procedure ends when as much of the prostate tissue as possible has been removed, and a urinary catheter is placed in your bladder. The bladder catheter will be removed at the end of your hospital stay in a few days’ time.

What is the MIST procedure for BPH?

Minimally Invasive Surgical Treatment (MIST) for BPH is a term used for newer surgical methods of treating BPH that are considered less invasive than TURP.

The main benefits of MIST include preservation of sexual functions, improved recovery experience and better safety profile, as compared to TURP. You may choose a MIST procedure if your BPH symptoms are mild to moderate and your wish to maintain certain aspects of your lifestyle.

The options for MIST procedure for BPH are diverse, some examples include:

Prostatic Urethra Lift (UroLift®)
Convective Water Vapour Thermal Therapy (Rezum™)
Prostatic Artery Embolisation (PAE)
Various prostatic urethra stents
and many others

While some of these have good medium-term results from clinical studies, many are still considered techniques under investigation. With the progress of medical technology, newer techniques are expected appear in the future.

In SGH, we review the various MIST options and offer those that have been rigorously tested in clinical studies and found to be safe and effective. Currently, the MIST options available in SGH are:

Prostatic Urethra Lift (UroLift®)
Convective Water Vapour Thermal Therapy (Rezum™)

What is Prostatic Urethra Lift, or UroLift®?

UroLift® works by creating an open channel through the prostate to reinstate the normal flow of urine out of the bladder. This is achieved by placing tiny implants into the prostate tissues to stretch the obstructing lobes away from the urinary passage. The aim is to improve urine flow and relieve the symptoms caused by BPH.

UroLift® procedure can be performed under sedation or general anaesthesia. The applicator device is passed through the urethra into the prostate channel to tiny implant into the prostate tissue, compressing it away to create an open passage for urine. The number of implants needed depends on your prostate size, typically between 4-6 implants on average, or more for larger prostates. These implants are biologically inert and will remain in the prostate tissue permanently.

The risks for erectile dysfunction and ejaculatory problems have been reported to be 0% in clinical studies. Short-term side effects are generally mild and resolve within 2 weeks after procedure. No long-term complications have been reported.

This procedure is performed as day surgery, and a urinary catheter is not routinely needed. Most men undergoing this treatment can return to regular activity within a few days. The relief of symptoms and improvement in urine flows can be noticed shortly after surgery, but may take up to one month for full results.

If you are interested in UroLift®, your doctor will discuss with you in more details and assess if you are suitable for the procedure.

What is Convective Water Vapour Thermal Therapy, or Rezum™?

The Rezum™ System works by creating an open channel through the prostate to reinstate the normal flow of urine out of the bladder. This is achieved by water vapour or steam injections, each delivered in small amounts for several seconds, into targeted areas of the prostate tissue. The treatment kills the cells of the treated prostate tissue, which is resorbed by the body over several weeks, resulting in the widening of prostate channel and reduction in prostate size. This improves urine flow and relieves the symptoms caused by BPH.

Rezum™ procedure can be performed under sedation or general anaesthesia. The device is inserted through the urethra into the prostate channel, to inject small amounts of steam into the prostate tissue at multiple points. The number of steam injections depends on your prostate size, with more injections needed for larger prostates. There are no permanent implants inserted into the prostate.

Clinical studies have reported the risks for erectile dysfunction to be 0% and ejaculatory problems to be minimal. Short-term side effects are generally mild and resolve within 2 weeks after procedure. No long-term complications have been reported.

This is day surgery procedure. A urinary catheter will be inserted and removed after 1 week, or longer for larger prostates. The relief of symptoms and improvement in urine flows are usually noticeable within 1 month of treatment, but full results may take 3 to 6 months to be apparent.

If you are interested in Rezum™, your doctor will discuss with you in more details and assess if you are suitable for the procedure.