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Benign Prostatic Hyperplasia

Real Patient Cases From JAMA "Clinical Crossroads"

This information sponsored by the American Medical Association Written by Wendy Meyeroff This content has been medically reviewed by Thomas L. Delbanco, MD Chief of the Division of General Medicine and Primary Care Beth Israel Deaconess Medical Center Jennifer Daley, MD Vice President and Medical Director of the Department of Health Care Quality Beth Israel Deaconess Medical Center Richard A. Parker, MD Associate Medical Director Healthcare Associates and Instructor in Medicine Margaret A. Winker, MD Senior Editor JAMA Erin E. Hartman, MS Managing Editor for JAMA Clinical Crossroads

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Case History: Enlarged Prostate Mr. B has had an enlarged prostate gland since 1993. In 1994, he started experiencing the need to urinate frequently during the night. Despite medication, the urinary symptoms have worsened.

Personal Details Health Status: Good Age: 73 Occupation: Retired

Marital Status: Married Children: Yes (1 daughter)

Medical Background History During a routine physical check-up in 1993, Mr. B was found to have a "firm," large prostate gland, although he was not having any urinary problems. In 1994, he told the doctor that he was getting up hourly every night to urinate. Results of tests for cancer, including a blood test to determine the prostate specific antigen level, six biopsy specimens, and an ultrasound scan, were normal (see Test Results below). The doctor prescribed medication to help relieve his urinary symptoms.

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Mr. B is otherwise in good health. Although he had a history of heart disease (including surgery to bypass a coronary artery), he has recovered nicely. His last physical examination showed that his pulse rate and blood pressure were normal, lungs were clear, heart sounds were normal, and he had no other major problems. In addition to the medication for his urinary symptoms, he is taking medications for glaucoma and an elevated cholesterol level.

By 1995, Mr. B continued to have difficulty with urinary frequency. The doctor adjusted the medication for this problem, but by 1997, Mr. B was waking as often as six times during the night to urinate.

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Mr. B’s View Back in 1994, I felt my urine flow wasn't as good as it should be; it was "dribbling." My doctor put me on some medication, but then I started getting up five to six times a night to go to the bathroom. I wasn't really getting any sleep.

When I talked to my doctor, we discussed surgery as an option. I wasn't too fond of this idea. It's not that I'm afraid of surgery, because I've had heart surgery before. But I have friends who've been through this type of surgery and they all said they had a lot of bleeding. That, plus the time away from things I really want to do, made me keep putting off the surgery.

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Dr. N's View After his heart surgery, Mr. B did a terrific job of making healthy changes in his lifestyle and following instructions regarding medication. His only complaint now is that he has to get up so often to go to the bathroom.

Often, men hesitate to discuss urinary problems with their doctors, but when asked, many patients say they are bothered by urinary symptoms. This is a problem because in addition to the symptoms disrupting sleep, there is a risk of prostate cancer. In Mr. B’s case, we’ve previously excluded cancer, and I feel we've done everything we can with medication. I believe it is time to consider if surgical options may be appropriate for him.

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Test Results For Mr. B, findings from the following tests for cancer were all normal: ● Ultrasound—An instrument that emits sound waves is inserted into the rectum.

Ultrasound waves pass through fluids and soft tissues. Some of the waves are reflected back by tissue boundaries, so a series of echoes is returned. Directed at the prostate gland, the sound waves’ echo patterns are converted into electrical http://www.ama-assn.org/insight/spec_con/crossrds/rpc/bph.htm (2 of 6) [8/21/2000 1:38:57 PM]

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signals that are processed and displayed on a computer screen, providing an image of the gland.

PSA—Prostate specific antigen is a protein found only in the prostate gland. The level of PSA, which can be measured by a blood test, is increased in men who have prostate cancer (and other diseases of the prostate, such as benign prostatic hyperplasia and an infection).

Biopsies—If a suspicious mass is present that might be cancer, a small sample (or samples) of tissue is removed from the mass. The tissue sample is examined to determine if the mass is cancerous (malignant) or not (benign).

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Other Test Options A doctor might perform other tests when a man complains of urine flow problems.

These include the following: ● Urine Flow Study—During urination a measuring device is used to determine how fast or slow the urine is flowing. ● Cytoscopy—After giving a local anesthetic, a tubelike instrument (called a cystoscope) containing a viewing lens and light is passed up the urethra. Looking through this instrument the doctor can see the size and location of any blockage in the ureters (the two tubes that carry urine from the kidneys to the bladder).

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A Health Insight Writer Has Paraphrased Dr. Barry’s Discussion of the Medical Problem Q. What is the prostate gland and why does it cause urinary problems?

A. The prostate gland (about the size of a walnut) is located in front of and just below the rectum, and it surrounds the urethra. One of the prostate's main jobs it to help squeeze fluid into the urethra as sperm move through it during the climax phase of sexual intercourse. When the prostate gland enlarges, it may squeeze the urethra, causing the urine flow to slow down. An enlarged prostate can also irritate the bladder, which causes the feeling of having to urinate frequently.

Q. What is the most likely diagnosis of Mr. B's problem?

A. Mr. B most likely has a condition called benign prostatic hyperplasia (BPH)—which can cause an enlarged prostate. BPH generally progresses slowly, often over many years. Prostate cancer is discovered in 10% to 15% of men having surgery for BPH, even though the cancer itself was probably not the cause of any symptoms. If the enlarged prostate gland starts causing any kind of bothersome urinary symptoms, as in Mr. B's case, treatment is called for.

Q. Could conditions other than BPH cause Mr. B's urinary problems?

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A. Urinary problems can be caused by neurologic disorders (when certain nerves don't send the right signals to control the urine flow), bladder diseases, or infection.

Other possible causes include use of medications that impair the ability of the bladder to contract or increase obstruction of the bladder's outlet (including over-the-counter allergy and cold preparations); taking diuretics; consumption of fluids in the evening, especially caffeinated beverages; congestive heart failure; and diabetes. These other causes were unlikely in Mr. B's case.

Q. What methods might be used to confirm the diagnosis of BPH? A. Doctors can ask patients seven questions (designed by the American Urological Association). These questions are important because (as occurred in Mr. B's case) sometimes the doctor may not be sure if the patient is just ignoring urinary symptoms, if the symptoms aren't particularly bothersome, or if the patient is too embarrassed to talk about them. Using the patient's responses to the questions, the doctor can more objectively assess the severity of the patient’s symptoms and measure changes in symptoms over time and with treatment. The higher the score (the total can range from 0 to 35), the more severe the symptoms.

1. Over the past month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating?

2. Over the past month or so, how often have you had to urinate again less than 2 hours after you finished urinating?

3. Over the past month or so, how often have you found you stopped and started again several times when you urinated?

4. Over the past month or so, how often have you found it difficult to postpone urination?

5. Over the past month or so, how often have you had a weak urinary stream?

6. Over the past month or so, how often have you had to push or strain to begin urination?

7. Over the last month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

AUA Symptom Score = Sum of Questions 1-7 = ____ Adapted from the American Urological Association (AUA) Symptom Index for benign prostatic hyperplasia (range, 0-35 points), reproduced with permission. For the first 6 questions, select from the following possible answers (score for each answer is in parentheses): not at all (0), less than 1 time in 5 (1), less than half the time (2), about half the time (3), more than half the time (4), almost always (5); question 7 is answered using the following possibilities: none (0), 1 time (1), 2 times (2), 3 times (3), 4 times (4), 5 or more times (5). Total the points, and talk to your doctor for interpretation of your symptom score.

Q. What treatment options are available for men with bothersome symptoms of BPH? A. Treatment options include medications, device therapies, and surgery.

Several types of medications are used to treat patients with BPH: ●

α-Adrenergic blockers like terazosin, tamsulosin, or doxazosin (which Mr. B takes) have been used for decades. A newer medication is the 5α -reductase inhibitor, finasteride (which Mr. B also takes). These two types of medications "attack" the two components that are believed to contribute to prostate obstruction—a spasm in the muscle tissue in the prostate and the enlarged

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prostate itself.

Phytotherapy uses drugs made from plants or plant extracts. While phytotherapy has been used in Europe, there is little solid evidence on the effectiveness of these drugs. However, extracts of the saw palmetto plant appear to have some limited effectiveness in reducing lower urinary tract symptoms in men with BPH. Antibiotics are used if an infection has caused inflammation of the prostate gland.

Mr. B had treatment with antibiotics after his last biopsy, but the medication didn't help improve his urinary symptoms.

The following device therapies can be used for BPH: ● TUMT—Transurethral microwave thermotherapy involves microwaves used to heat and coagulate tissue in the prostate. At the same time, the device cools the urethra to protect it from injury. ● TUNA—Transurethral needle ablation uses a needle to deliver energy to heat and coagulate prostate tissue.

Several surgical procedures can be used to treat BPH. For a TURP (transurethral resection of the prostate), an instrument is inserted through the urethra and excess prostate tissue is removed. TURP usually requires only spinal anesthetic, and men with stable cardiac disease (like Mr. B) can undergo the procedure without special heart evaluation. The patient can leave the hospital in as little as 1 day (although it varies with each patient). After surgery, a tube (called a catheter) in the urethra is usually needed to help fluid drain (urine and any blood from the resection) for a few days.

Short-term risks include bleeding, which concerns Mr. B. Some men develop temporary urinary problems—not being able to hold urine or feeling uncomfortable—but these are a normal part of the healing process. A condition called retrograde ejaculation (semen moves backward into the bladder instead of out through the penis) may occur. Other possible complications include urinary tract infections, thrombophlebitis (inflammation, with formation of a blood clot, in part of a vein), bladder neck contracture (an abnormality caused by shrinkage of scar tissue), and narrowing of the urethra.

TUIP (which stands for transurethral incision of the prostate) involves making an incision, without the resection. It seems to have a smaller risk of bleeding, retrograde ejaculation, and other problems, but the results may be less long-lasting.

Also, different types of laser surgery vaporize unwanted tissue. So does electrical vaporization, which uses an electrode. These methods may create less bleeding than TURP. Short-term relief of symptoms is comparable with that of TURP, but long-term outcomes require more study.

Short-term results with these two device therapies have been good, but long-term outcomes are not known.

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Conclusion For Mr. B, TUMT or TUNA would probably be the easiest treatments to have.

However, their long-term effectiveness is not as good as other methods. Also, some insurers don't cover these treatments yet.

TURP surgery would probably give Mr. B the most relief of his symptoms for the longest time. The other methods are less invasive but have the potential for a less satisfactory outcome. Mr. B is the best person to weigh those trade-offs.

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At the Medicine Grand Rounds conference at the Beth Israel Deaconess Medical Center on Sept 25, 1997, a patient (Mr. B) and his physician (Dr. N) discussed the patient's enlarged prostate problem with a medical expert (Dr. Barry). A report of this conference was published in the Dec 24/31, 1997, issue of The Journal of the American Medical Association. Clinical Crossroads in The Journal of the American Medical Association is funded by the Robert Wood Johnson Foundation. A freelance writer has written this Real Patient Case based on the published report.

Updated on 4/23/1999

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