Introduction
Prostate enlargement (benign prostatic hyperplasia) is a change in the tissue of the prostate (prostate gland) that leads to an increase in the size of the organ. A prostate enlargement can be present without any problems. If it leads to problems with urination and continence, it is known as benign prostate syndrome (BPS).
The goals of therapy should be to improve the quality of life, reduce symptoms and, in the long term, prevent complications or slow the progression of the disease. The therapy should be individually tailored to each patient and be decided jointly by doctor and patient. In addition, the success of the therapy should be monitored and checked by means of a questionnaire on complaints and by measuring parameters such as urine flow.
A prostate enlargement can be treated conservatively or surgically. Conservative treatment includes controlled waiting, treatment with plant extracts (phytotherapy) and with medication. In surgical therapy, the prostate is reduced in size using various techniques and dilated stents can be placed in the narrowed urethra (urethral stricture).
Radiologically, an MRI of the prostate is recommended. With controlled waiting, the symptoms are observed and not treated. This procedure is based on the knowledge that there can be an improvement even if left untreated.
In addition, the course of prostate enlargement can be positively influenced by changes in behavior: Fluid intake should be controlled and evenly distributed throughout the day and should not exceed 1500 ml per day. Alcohol, coffee and hot spices should be avoided because of their draining or urinary tract irritating effect. Dehydrating medication (especially diuretics) should not be taken in the evening.
Bladder and pelvic floor exercises can reduce symptoms. Controlled waiting is particularly suitable for patients with a low level of distress, who have a low risk of further deterioration and are willing to change their lifestyle. However, regular check-ups are extremely important.
As a “gentle” method, plant extracts are widely used as a treatment (phytotherapy). However, the costs are not reimbursed by most health insurance companies. The mechanism of action of most preparations has not been clearly clarified.
A further problem is that the plant extracts are composed of many substances in a highly complex way. It is often not known which substance is responsible for the effect. Preparations from different manufacturers are difficult to compare with each other due to different manufacturing processes.
There are individual proofs of effect of the manufacturers with regard to the acute symptoms of BPH, but an effect on the long-term course of the disease has not yet been proven. The side effects are very rare and mild. The fruits of the sawtooth palm and the roots of pine trees have many free fatty acids and should therefore reduce the production of the active testosterone (dihydrotestosterone, DHT) responsible for prostate enlargement.
Stinging nettle extracts are rich in vitamins A, C, E, D and K, many minerals and unsaturated fatty acids. It is not clear which substances are supposed to be responsible for the effect. Pumpkin seeds and extracts from the bark of the African plum tree are said to have an anti-inflammatory effect on the prostate.
Pollen extracts (e.g. from rye) are also sold in Europe. Combination preparations are also available. In drug therapy, one can fall back on various groups of drugs that are approved for the treatment of prostate enlargement.
Alpha-blockers (e.g. alfuzosin) relax the muscles of the prostate and urethra. This leads to a rapid improvement in symptoms within days. In the long term, there is a slight delay in the development of the disease, but without actually preventing the enlargement of the prostate.
The larger the prostate is at the start of therapy, the smaller the effectiveness of alpha-blockers. Since α blockers were originally used to treat high blood pressure, side effects include circulatory problems (dizziness, fatigue and collapse) and headaches. Preparations with delayed release in the intestine are better tolerated.
They must not be taken in heart failure. 5α reductase inhibitors (e.g. finasteride) inhibit the production of active testosterone (DHT). The improvement in symptoms only occurs after several months.
They should be taken as long-term therapy (over 1 year) and can then delay the progression of the symptoms.The side effects mainly affect the sexual functions. Ejaculation disorders, loss of libido, erectile dysfunction and enlargement of the mammary glands may occur. The side effects decrease over the duration of the treatment.
Muscarinic receptor antagonists (e.g. Darifenacin) as the third group are mainly effective against the sudden and frequent urge to urinate. They are not recommended as the sole therapy for other complaints and in cases of obstruction of the urinary tract. Dry mouth is the most common side effect.
The latest drugs in the treatment of prostate enlargement are phosphodiesterase inhibitors. They have been used until now for erectile dysfunction. The best known representative of this group is sildenafil (Viagra).
Tadalafil, which works according to the same mechanism, received additional approval for the treatment of prostate enlargement in 2012. The subjective complaints are reduced by treatment and also the measurable urine flow improves after some time. However, there are still no data on whether the course of the disease is positively influenced in the long term.
Side effects include digestive disorders in the upper abdomen, headaches and hot flushes. They must not be taken in case of heart failure or coronary heart disease. In addition to treatment with one medication, there is the possibility of treatment with a combination.
The effects may complement each other, but the side effects add up as well. In the long term, a combination of α blocker and 5α reductase inhibitor is recommended for patients with moderate to severe symptoms and a high risk of worsening. A α blocker and muscarinic receptor antagonist are acutely effective against urinary symptoms.
In brief:
- Wait (“watch and wait”)
- Phytotherapy (Greek phytos = plant)
The goals of an operative therapy are on the one hand the fast and strong reduction of the symptoms and the prevention of late effects, and on the other hand the least possible stress from the operation itself. The more complete the removal of the prostate, the greater the improvement of the symptoms. At the same time, however, the stress caused by the operation itself increases.
With a mortality rate of less than 1%, the operation is comparatively harmless. However, a middle course adapted to the patient must be found. There are certain conditions in which conservative treatment is strongly discouraged and surgery is considered absolutely necessary (absolute indications for surgery).
These include recurrent urinary retention, recurrent urinary tract infections or blood admixtures in the urine, bladder stones and dilatation of the upper urinary tract with kidney dysfunction caused by urinary retention. The surgical procedures can be divided into groups. In primary ablative procedures, post-static tissue is removed directly; in secondary ablative procedures, the body itself removes the tissue after treatment.
There is also the possibility of implanting a stent that keeps the urethra open. In addition, urine can be drained directly from the bladder through a catheter over the pubic bone (suprapubic catheter). If there is one of the above-mentioned reasons for an unconditional operation (absolute indication for surgery), a primary ablative procedure should be chosen first.
If this is not possible or too dangerous, a secondary ablative procedure can be attempted and then a stent implantation. The final solution is a bladder catheter. Complications of the surgical procedures include incidents during the surgery itself, urination difficulties during the healing phase, incontinence after treatment and recurrence of the disease.
In addition, so-called dry (retrograde) ejaculation can occur after surgery: The sperm is directed backwards into the bladder instead of into the penis. However, this has no effect on sexual sensation, lust and orgasm. One of the primary ablative procedures is TUR-P (transurethral resection of the prostate).
In this procedure, prostate tissue is removed with a loop inserted through the urethra. TUR-P is the standard procedure and the most common surgery in urology. It achieves very good immediate results and the risk of complications is low.
Newer procedures must be measured against it. There is also the open prostate surgery (adenoma nucleation). Prostate tissue is removed through the abdominal wall or the bladder.
It is the oldest operation for prostate enlargement and causes the most tissue damage. As a result, the length of time spent in hospital is higher. The operation is suitable for very large prostates (>70ml).
Results and complications are comparable with TUR-P.Primary ablative procedures using a laser are also practiced. HoLEP (holmium laser enucleation of the prostate) uses the laser for cutting and is suitable for treating a very large prostate. PVP (photoselective laser vaporization) is recommended for patients with many concomitant diseases, the laser is used to vaporize the tissue.
Both procedures effectively stop bleeding during the operation. They are therefore also suitable for patients with thin blood. With TUIP (Transurethral Incision of the Prostate) no post-operative tissue is removed, but only the lower opening of the bladder to the urethra is notched.
The operation is particularly recommended for sexually active patients with a low prostate volume (<30 ml), as receding ejaculation is less frequent afterwards. The strain and hospital stay are also lower, but there is more frequent recurrence of the symptoms. Secondary ablative procedures include the following: In TUMT (transurethral microwave thermotherapy) the prostate tissue is heated with microwave radiation, in TUNA (transurethral needle ablation) with electricity.
Both procedures can be performed on an outpatient basis without anesthesia and there is practically no risk of bleeding. They are therefore recommended especially for patients in poor general condition. At the same time, however, the results do not match those of TUR-P, and in some cases a longer-term drainage of the urine through a catheter is necessary during the healing phase.
Stent implantation aims to keep the section of the urethra running in the postata open. On the one hand, successes comparable to those of the standard TUR-P procedure have been recorded. On the other hand, in half of the patients the stents have to be removed again within 10 years due to complications.
Therefore, stents should only be used in patients with a limited life expectancy who have a very high risk of complications of BPH (such as acute urinary retention). For these patients, they can replace a catheter. According to the current state of research, some surgical procedures are also not recommended.
These are transrectal microwave hyperthermia, cryosurgery, balloon dilatation and HIFU (“high frequency ultrasound“). Surgery is unavoidable in cases of repeated or chronic urinary retention, high residual urine levels, dilation of the upper urinary tract, blood in the urine or repeated urinary tract infections. In brief:
- Electroresection of the prostate (TUR-P)This procedure is often performed on patients in stage 2 or 3.
- Transurethral incision of the prostate (TUIP)This operation is particularly useful when the prostate volume is still small (< 20g).
- Suprapubic transvesical or retropubic prostatectomy
