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Know Your Options * Treating lower urinary tract symptoms

By: H. Pat Hezmall, MD

If you are male, chances are good that you will experience lower urinary tract symptoms (LUTS) during your adult life. Benign prostatic hyperplasia (BPH), an enlargement of the prostate gland, is considered a contributing factor to LUTS. BPH occurs in all men about 40 years of age or older. In fact, 50% of men in their fifties will experience symptoms, while up to 90% of men by the age of 80 will have significant symptoms requiring some type of therapy.

The prostate is a gland composed of glandular and stromal smooth muscle cells that surround the bladder outlet and urethra. As the prostate enlarges with age, symptoms of obstruction occur, sometimes leading to actual obstruction and an overactive bladder. Symptoms include a weak urinary stream, feeling unable to completely empty the bladder, frequent urination during the day, and increased urination at night (nocturia).

Diagnosing the Problem

Lower urinary tract symptoms are caused by a multitude of problems, sometimes in combination. Urologists use an international prostate symptom score (IPSS) and bothersome score (BOS) to help evaluate and track symptoms of bladder outlet obstruction, as well as the effect of therapy. In addition to a complete history, a physical examination is indicated to check for signs of an overly distended bladder. A rectal examination is used to determine the size and consistency of the prostate itself. Urinalysis is used to screen for infection of blood in the urine (hematuria). Blood tests are often ordered to screen for cancer of the prostate (PSA) and to rule out other medical problems, such as diabetes. Often the physician will schedule the patient for a voiding flow rate and post-void residual, a rough evaluation of bladder function that serves as a baseline for comparing the effectiveness of prescribed treatments.

Types of Treatment

Bladder outlet obstruction secondary to LUTS presents with a myriad of symptoms that can be either progressive or sporadic. The spectrum of treatment begins with simple observation but may include medical therapy with prescribed medications and some type of invasive therapy. If the symptoms are moderate and not particularly bothersome to the patient, simple observation and regular annual examinations are sufficient for controlling the condition.

Medical therapy includes alphablockers (marketed as Hytrin®, Cardura®, Flomax®, and Uroxatral®), which reduce the resistance within the prostatic capsule and/or bladder neck. This in turn reduces the amount of pressure the bladder needs for urination. Side effects of these medications may include lower blood pressure and an inability to ejaculate.

Other medications, 5alpha-reductase inhibitors (marketed as Proscar® and Avodart®), are prescribed to improve symptoms. These typically cause some shrinkage of a component of the prostate gland. Their efficacy also varies from patient to patient. These medications are now used in combination with an alpha-blocker agent for men with a much larger gland than normal.

Invasive Therapies

Transurethral resection of the prostate (TURP) is the gold standard of invasive therapies. Improvements in TURP technique and equipment — a procedure available for decades — have reduced overall morbidity, hospital stay, and recovery time. Complications can include loss of ejaculation, as well as rare problems with incontinence and/or erectile dysfunction.

Some physicians offer KTP (GreenLight), a procedure that uses a laser to vaporize the prostatic adenoma. When performed in place of a resection, this procedure results in less bleeding, a shorter hospital stay, and much less likelihood of loss of ejaculation. On the other hand, this technique produces no specimen for pathologic examination. It can also cause mild to moderate irritation that persists for some time after the operation.

Minimally Invasive Therapies

Minimally invasive BPH therapies are based on the theory that urinary symptoms will improve if enough heat is safely applied to the prostate. The body will absorb the prostate tissue just as it heals other injuries or bruising. The patient’s symptoms will then diminish.

Heat therapy can be performed with many modalities. For very small glands, the indigo laser system (ILS) is indicated. This procedure places a small laser tip into the prostate gland through a urethral scope. Oliveshaped heat defects within the prostate lobes, one on each side, causing the prostate to shrink. This therapy is not effective, however, with larger glands.

The Advantages of TUMT

For moderate to large glands (from 30 grams to 130 grams), transurethral microwave thermotherapy (TUMT) is used to manage a patient’s symptoms and decrease the size of his prostate. New heat delivery systems have recently improved TUMT outcomes. In this minimally invasive procedure, a flexible catheter is inserted into the urethra to deliver microwave energy through an antenna.

TUMT is performed in the clinic or physician’s office with local anesthesia (a periprostatic block) and normally takes about one hour. Most patients are discharged with a urinary Foley catheter for drainage over a four to seven day period to reduce swelling caused by the heating process. For six to eight weeks following TUMT, inflammation decreases gradually and the prostate shrinks, bringing considerable relief to most patients.

For patients released without a catheter, recovery time is minimal, with a return to work usually within five to seven days. Urinary urgency and frequency subside slowly over the next two months.

Whether or not a catheter is required after the procedure, TUMT usually ensures that most patients will no longer need medical therapy. And if symptoms recur in the future, TUMT can always be performed again.

Urology Associates of North Texas has performed minimally invasive BPH therapies since 1998. The practice is also involved in BPH research and development. A current NYMOX pharmaceutical trial, for example, involves a transrectal injection of a material directly into the prostate to allow shrinkage and reduce symptoms indefinitely.

For patients who qualify for this trial, the procedure and follow-up costs are covered by the research grant. Outcomes of this trial appear promising. For more information, call Urology Associates of North Texas at (817) 784-0818.

H. Pat Hezmall, MD, earned his medical degree from the University of Texas Health Science Center at San Antonio and completed a urologic residency at the University of Texas Health Science Center at Houston. Dr. Hezmall is board certified by the American Board of Urology. He is a fellow of the American College of Surgeons and a delegate to the Texas Medical Association.

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