Treatment of bladder and prostate problems in men

Overview

Bladder and prostate problems are very common in men and are usually thought to be due to an enlarged prostate, commonly (but erroneously) called BPHB, but that is not always the case. It is possible to have a lot of symptoms with a small prostate and no symptoms at all with a large prostate.

Normal (small) Prostate                             Large Prostate[JB1] 

Because of these consideration, we prefer to be more precise in our terminology and use the following terms:

• Benign prostatic enlargement (BPE)– diagnosed by digital rectal exam (DRE) or imaging techniques like ultrasound, MRI or CAT scan. 
  • Benign prostatic obstruction (BPO)– diagnosed by urodynamic studies 
  • Benign prostatic hypertrophy (BPH) –diagnosed by prostate biopsy

Bladder and prostate symptoms are also known as lower urinary tract symptoms (LUTS) which are subdivided into storage symptoms and voiding symptoms.

Storage symptomsare 

Voiding symptomsare those which occur when you are trying to urinate and include: difficulty starting urination, weak or slow urinary stream, the need to push or strain and the feeling that you’re not completely emptying your bladder

Treatment of LUTS depends on the underlying cause. About 2/3 of the time symptoms are caused by a blockage by the prostate (BPO),but there are many other causes including: involuntary contractions of the bladder (detrusor over-activity), a weak bladder (detrusor underactivity), drinking too much fluid (polyuria), a stiffness of the bladder wall (low bladder compliance), bladder and kidney stones tones,  bladder and prostate cancer anda very common condition in which drops of urine get trapped in the urethra after urinating and subsequently drip out when you stand up, wetting your clothing or underwear (post void dribbling).

The good news is that there are a lot of very effective treatments that range from old fashioned advice (like don’t drink so much) to medicines to surgery. Prostate sizeis important in helping with decision-making about how to treat your symptoms, but not how to diagnose what is causing the symptoms. Although many patients start with one treatment and end up with another, the overall success rate is very high.

The treatment with the highest success rate for BPO is conventional surgery like TURPand PVP (also known as green light laser), but those operations require general or spinal anesthesia and may have complications. Newer, minimally invasive surgical treatments (MIST)– like Urolift and Rezume – do not require general anesthesia and have many fewer complications. The short-term success rate appears to be high, but the long-term results and complications are not yet known and not all patients are candidates for these surgeries. Medications, too, can be effective in relieving symptoms, but the degree of improvement is not nearly so good as with surgery and the medicines themselves may have side effects and/or complications and they need to be taken for life. Nevertheless, the great majority of men with LUTSS elect to be treated with medications. Further, most doctors and patients think that it is best to start with non-invasive treatments and reserve surgery for patients who fail those treatments. 

Because the success rate for surgery is so high, the decision about whether or not to continue with non-invasive treatments is one that should be made jointly with the patient and physician based on the risk/benefit ratio for each individual patient. We call that the bottoms up approach to healthcare meaning that we obtain all of the necessary information about your particular case before making a decision about what the best treatment is. The top down’s approach means that all patients are treated the same and only those that fail the first treatment go on to the next treatment.

 Treatment Options depend on:

• your symptoms
• the underlying cause of your symptoms which is determined by
  • your medical history 
  • a physical exam 
  • a urine test 
  • a bladder diary 
  • two non-invasive tests done in the office:
    •  uroflow
    • measurement of post void residual urine
  • sometimes:
    • cystoscopy – shows what the bladder, prostate and urethra look like from the inside (looking inside the bladder with a camera lens inserted through the tip of penis)
    • urodynamics – shows how the bladder, prostate and urethra work (function). It is done by passing a catheter (tube) into the bladder through the tip of the penis and another into the rectum. 
• your own preferences

Medical Treatmentsinclude:

• Alpha Blockers are pills that relieve your symptoms by relaxing the muscles of the prostate, reducing prostate blockage and improving urine flow. Alpha blockers include alfuzosin (Uroxatral), terazosin (Hytrin), doxazosin (Cardura) and tamsulosin (Flomax).Alpha blockers usually work right away. Side effects include dizziness, lightheadedness, fatigue and difficulty ejaculating. Tams 22 > 12; teraz 22 > 13 IPSS
• 5-Alpha Reductase Inhibitorsare pills that shrink the prostate.These drugs include finasteride (Proscar)and dutasteride (Avodart).Side effects include difficulty with erections and reduced libido (sex drive).
• Antimuscarinicsare medications that relax the bladder muscles and are primarily used to treat overactive bladder symptoms.Anti-muscarinic medications include oxybutynin IR/ER/patch, tolterodine IR/ER (Detrol), Trospium (Sanctura), Solifenacin (Vesicare), Darifenacin (Enablex), Fesoterodine (Toviaz)Side effect include dry mouth, constipation, __________
• Beta 3 agonistsare another class of medications that relax the bladder and are used to treat overactive bladder symptoms.Mirebegron (Myribetriq) is the only beta three agonists that is currently available. Beta 3 agonists may worsen hypertension or cause an increase in heart rate.  

Surgical treatments 

Surgical treatmentsare intended to relieve the prostate blockage that is the cause of your symptoms. There are two main types of surgical treatments – minimally invasive surgeries and conventional surgeries. Minimally invasive surgeriesare outpatient procedures that require local or minimal anesthesia and enable you to return to your normal activities within a day or so. Conventional surgeriesare done under general or spinal anesthesia and may require a hospital stay.

            Surgeryis usually elective but, under certain circumstances, can be highly recommended. These include:

• Urinary retention (inability to urinate at all, requiring a catheter)

• Kidney damage
• Frequent urinary tract infections
• Recurrent gross hematuria (excessive bleeding in the urine)
• Bladder stones

Minimally Invasive Surgeries – a number of minimally invasive surgeries have been developed over the last few decades including prostatic stent, high Intensity focused ultrasound (HIFU), transurethral microwave thermotherapy (TUMT), balloon dilation of the prostate, transurethral needle ablation (TUNA), Resume and UroLift. In our judgment, though, most of these have not met the test of time and we do not recommend them, or, only recommend them in special circumstances. The only minimally invasive surgeries that we routinely recommend are the Urolift and Rezume. 

• Urolift – The UroLift System is an outpatient procedure that uses tiny metal implants delivered through a cystoscope to spread apart the prostate tissue that is blocking the urethra. There is no cutting, heating or removal of prostate tissue. The procedure is usually done with light anesthesia and takes about a half hour to perform[JB2] [gv3] . Urolift is appropriate for most men who are considering prostate surgery unless the prostate is too large or if there is an enlarged median lobe.  IPSS 23 > 13 @ 4 years

• Rezūm– high temperature steam (water heated by a microwave) is injected into prostate through a proprietary cystoscope under light anesthesia. The high temperature causes the prostate cells to die, seals the blood vessels and destroys the nerves that cause the obstruction. Preserves sexual function. IPSS decreased by 12.5 @ 1yr.

Conventional Surgery

• Transurethral Resection of the Prostate (TURP)has long been considered the gold standard operation for BPH. It has been in common use for over 60 years and has an excellent track record. It is done under spinal or general anesthesia. The surgeon inserts an instrument called a resectoscope through the tip of the penis into the urethra. A “U” shaped loop comes out the end of the resectoscope. The loop is part of an electric circuit that gets very hot and cuts out the prostate tissue that is blocking the urethra. The loop is also used to seal blood vessels. The operation usually takes 1 – 2 hours to complete and hospital stay is 1 -2 days. Blood loss, retrograde ejaculation. IPSS 19 > 6 @ 4 years

Video of surgery:https://www.youtube.com/watch?v=gVkX96mgWck

• Transurethral Incision of the Prostate (TUIP) is also performed with a resectoscope, but instead of removing prostate tissue, an incision is made into the prostate with an electric knife.  IPSS 19 > 6 @ 4 years
• Photoselective Vaporization (PVP) also known as Green Light Laser and KTP laser, PVP is another modification of TURP. Like the TURP, the procedure is done under general or spinal anesthesia. During laser PVP surgery, the surgeon passes a KTP laser fiber through the cystoscope and vaporizes the obstructing prostatic tissue that is blocking urine flow. Unlike traditional prostate surgery, laser PVP surgery does not remove any tissue and there is generally much less blood loss during the operation. This is particularly good news for men on blood thinners because the operation can be done without needing to stop them. The downside is the fact that, since no tissue is removed, there is no biopsy specimen. IPSS 18 > 5 @ 1 year 
• Holmium Laser Enucleation of Prostate (HoLEP) – This procedure uses a holmium laser to remove prosthetic tissue procedure and is done under general or spinal anesthesia through a cystoscope. It actually cuts the prostatic tissue into large pieces which float into the bladder. Then, another instrument is used to cut the prostate tissue into smaller fragments for removal. HoLEP is similar to open prostate surgery but, like the TURP, it is done through the urethra and requires no incisions. Another advantage is that it provides a lot of tissue for biopsy. IPSS  decreased by 17 @  

 Transurethral Electroevaporation of The Prostate TUVP –Transurethral electro-vaporization of the prostate (TUEVAP) is a newer modification of transurethral resection of the prostate (TURP).  It is done in the hospital under general or spinal anesthesia. Instead of using an electrical current loop as is done in the TURP procedure, a TUEVAP uses a roller ball to heat the prostate tissue so that it is reduced to vapor. During the process, the small blood vessels in the prostate are sealed off. There is less bleeding during and after this procedure than there is with the TURP. 

Catheters:

A catheter isflexible tube, like a miniature garden hose, that is passed through the urethra or abdomen into the bladder to drain the urine. It is necessary in men who cannot urinate at all or in those who do not empty their bladder sufficiently of urine after they urinate.  Unlike the other treatments, catheters do not cure or improve the underlying condition; rather, they bypass the blockage. If the blockage is a temporary problem, the catheter is an ideal way to monitor symptoms until the condition is reversed. For a more permanent solution, medications and surgery are far preferable for the vast majority of men. 

There are two different ways that catheters are used:

Intermittent Catheterization – Instead of urinating, you or your caregiver passes the catheter into the bladder, empties the urine and removes the catheter. This is repeated about 4 – 6 times per day. Believe it or not, this is the safest way to manage your bladder when a catheter is necessary. The great majority of patients far prefer intermittent catheterization to an indwelling catheter.  

Indwelling catheter– An indwelling catheter remains in the bladder continuously for as long as is needed. For most people, it is intended as a temporary measure until effective treatment can be instituted. The catheter is connected to a drainage bag by a tube. The urine drains into the bag that needs to be emptied into the toilet about 4 – 6 times per day. Indwelling catheters require special attention to be sure that they are draining properly and that they do not become twisted or clogged, because if that happens severe and sometimes life-threatening infection can occur. The biggest risk of having a catheter in place for long periods of time is infection. Bacteria can stick to the surface of the catheter. This makes it hard for the immune system or antibiotics to work. In addition, indwelling catheters can cause bleeding and bladder stones. When used continuouslyfor few years, there is a higher risk of bladder cancer. For all of these reasons, we recommend clean intermittent catheterization (for long-term treatment), whenever possible. In our judgment, it has a much lower risk of serious infection, bladder stones and no additional risk of bladder cancer. If the catheter needs to stay in for a prolonged period of time, it should be changed at least monthly. 

There are two kinds of indwelling catheters:            

• Transurethral (Foley) catheter – the catheter is passed through the penis into the bladder and held in place with a balloon at the end that is inflated with water. The catheter can be inserted under sterile conditions by the patient himself, a doctor, physician assistant, nurse or a trained caregiver. 
• Suprapubic catheter – Suprapubic catheter is placed through the skin of the lower abdomen into the bladder. It can be done in the office with local anesthesia or in the operating room with light anesthesia. 

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 [JB1]Need to label bladder, prostate, urethra and penis

 [JB2]Check how long Urolift takes

 [gv3]I cannot find this information online, but after reading about the procedure I would estimate about 10-30 minutes