What is the prostate?

The prostate is a gland in the lower urinary tract, at the exit of the bladder, surrounding the urethra. It is a male-specific organ and secretes a fluid found in semen.
A normal prostate is approximately the size of a large walnut, ie 15-20 ml in volume. It begins to grow slowly with age.

Benign Prostatic Hyperplasia (BPH)

Prostate diseases usually occur in advanced ages. They cause disturbing symptoms in the lower urinary tract in men over the age of 50. Symptoms are more often caused by the enlargement of the benign prostate, and we also encounter the same findings in other diseases that narrow the urinary canal.

Benign Prostatic Hyperplasia is a common disease. It develops due to hormonal changes that occur in men with aging. BPH can negatively affect our quality of life by causing difficult urination. It is one of the most frequently diagnosed diseases in urology.

It is important to know that BPH is not prostate cancer. Even if BPH is not treated, it does not turn into prostate cancer. However, benign Prostatic Hyperplasia and prostate cancer can develop with age and can be seen together. In order to get rid of our anxieties, we should have periodic urological check-ups after the age of 50.

Symptoms of benign Prostatic Hyperplasia

With Prostatic Hyperplasia, our urinary canal narrows and the patient shows signs of obstruction and irritation. Symptoms can sometimes be mild. For example, you may feel the need to urinate more frequently or it may be difficult to empty your bladder completely. Your doctor may not recommend treatment for these mild symptoms. Symptoms can sometimes be very distressing and negatively affect your quality of life. In this case, you may benefit from treatment.

Types of symptoms

Symptoms associated with benign Prostatic Hyperplasia can affect urination in different ways:

• Retention of urine in the bladder (storage)
• Urinating (peeing)
• How you feel after peeing (post urination)

Storage symptoms

• The need to urinate more often than usual
• The need to wake up at night to urinate
• The sudden need to urinate and the inability to delay this need
• Involuntary urination

Urination symptoms

• Weak stream urination
• Forked and scattered urine stream
• Interrupted urination
• Urinating by pushing
• Waiting before urinating
• Urinating for too long

Symptoms after micturition (peeing)

• Feeling that the bladder is not fully emptied (residual urine)
• Involuntary leakage of urine into underwear after urination (Dribling)

Effects on your social life

Symptoms of BPH, such as the sudden urge to urinate and the need to urinate very often, can negatively affect your social life. Some patients become very uncomfortable with these symptoms and withdraw from social activities. They are afraid of being nearby where there is no toilet. Because they wake up frequently at night to urinate and don’t get enough sleep, their energy levels drop and they have trouble doing their daily activities.

Personal relationships and sex

BPH symptoms can negatively affect your personal relationships and sex life. It can be difficult to get close with your partner because you feel interesting, confident, or not always in control of your body. Urinary incontinence and sudden urges can embarrass you and damage your pride. Side effects of drug treatments such as inability to maintain a relationship and erectile dysfunction also contribute to this condition.

Talking about your sex life with your urologist can be uncomfortable, but it’s the most effective way to deal with your fears. Together with your partner and urologist, you can determine the priorities in your sexual life and choose the most appropriate treatment method. There are many ways to ease your life with BPH, relieve symptoms and improve your sex life.

What tests are performed to diagnose benign prostate?

After examining the size, shape and stiffness of the prostate with a physical examination, your symptoms will be carefully evaluated, blood and urine tests will be performed, and urine flow rate will be measured with the uroflowmetry test.

Why is the PSA test done?

Since benign Prostatic Hyperplasia and prostate cancer can occur in the same age group, your blood PSA (prostate-specific antigen) test can be done. PSA can also be used to estimate your prostate volume and the risk of progression of your benign Prostatic Hyperplasia symptoms.

Why is urine test and urine culture done?

A urine test is done to rule out a urinary tract infection that is causing similar symptoms. If you have an infection, a urine culture is done to confirm this and to choose the best antibiotic.

What is uroflowmetry measurement for?

Uroflowmetry measures the urine flow rate. This test is done to see if the prostate is blocking the flow of urine.

Why is residual urine (PMR) measured after urination?

Measurement of the urine remaining in the bladder after voiding is done to understand whether the bladder is fully emptied. Increased PMR may be a sign of impaired bladder function or obstruction in the urinary tract. This increases the risk of urinary tract infections.

Why is Urinary Ultrasound (Kidney, Bladder and Prostate Ultrasound) done?

With the ultrasonography device, the kidney enlargement caused by BPH, the size of the prostate and the structure of the bladder and the amount of urine remaining in the bladder are examined.

Medication for Benign Prostatic Hyperplasia

Medication is recommended for patients diagnosed with benign Prostatic Hyperplasia. This treatment is recommended when symptoms are bothersome and affect quality of life.

Various drug groups are used to treat symptoms associated with BPH.

• Herbal medicine
• Alpha-blockers
• 5 Alpha-reductase inhibitors (5ARI)
• Muscarinic receptor antagonists (MRA)
• Phosphodiesterase 5 inhibitors (PDE5)
• Combinations of these medications

Each group of drugs acts in a different way and has different effects and side effects.

Herbal Medicines

Pumpkin seeds, South African star grass, African currants, Rye pollen are drugs in this group. It is also unclear how effective they are. Since there are so many herbal medicines, no specific recommendations can be made for their use. You should not use herbal medicine without the advice of your physician.

Alpha-blockers

Alpha-blockers are a group of drugs that increase symptoms and urine flow by relaxing the smooth muscles of the prostate. It is the group of drugs most commonly recommended for men with BPH.
Alfuzosin, Doxazosin, Tamsulosin, Terazosin, Silodosin are drugs in this group.

Medications usually show their full effects in a few weeks. Alpha-blockers do not reduce the size of the prostate or prevent it from growing. In patients who do not benefit from these drugs, surgical intervention will be needed to relieve their symptoms.

The side effects of alpha-blockers are mild and, despite long-term use, most patients do not experience any side effects. Patients with side effects report weakness (asthenia), dizziness and mildly low blood pressure (hypotension).

Some Alpha-blockers can cause retrograde ejaculation (ejaculation of semen into the bladder). This is an infrequent side effect and will go away when treatment is stopped.

5 Alpha-reductase inhibitors

5 alpha-reductase inhibitors (5ARI) are a group of drugs that prevent the prostate from growing and may even shrink it. These drugs are more effective in those with a prostate larger than 40 milliliters and are prescribed when an enlarged prostate causes bothersome symptoms. These drugs can reduce the risk of urinary retention and the need for surgical intervention. 5ARI is recommended for treatments longer than one year, as symptoms take a long time to resolve.

There are 2 types of 5ARIs and they all give similar results. Dutasteride and Finasteride.
The side effects of these drugs are mainly related to sexual functions. These are decreased ability to maintain intercourse, erectile dysfunction and ejaculation problems. Side effects are not very frequent and disappear with discontinuation of treatment. There is evidence that the use of 5ARI may increase the risk of prostate cancer. Because of its side effects, 5ARI is generally recommended for patients with moderate or severe symptoms.

Muscarinic receptor antagonists

Muscarinic receptor antagonists (MRAs) are a group of drugs that reduce abnormal contractions of the bladder. In men, it may benefit against squeezing symptoms caused by BPH. These medications are not usually prescribed if the bladder is not emptying completely and if there is too much urine left in the bladder after urination.

There are several types of MRAs: Darifenacin, Fesoterodine, Oxibutinin, Propiverine, Solifenacin, Tolterodine and Tropisium chloride are drugs in this group.
The side effects of MRA are generally mild. These are dry mouth and eyes, constipation, difficulty urinating, cold symptoms, blurred vision, dizziness.

Phosphodiesterase 5 inhibitors

Phosphodiesterase 5 inhibitors (PDE5I) are drugs used in the treatment of erectile dysfunction. These drugs can also improve symptoms associated with BPH.

There are 3 types of PDE5I: Sildenafil, Tadalafil and Vardenafil.

Men with erectile dysfunction, as well as men with signs of Prostatic Hyperplasia, may benefit from treatment with PDE5I, especially in patients with both BPH and concomitant erection problems.

PDE5Is can cause side effects such as headache, dizziness, and indigestion. PDE5Is should not be used with certain drugs such as alpha-blockers doxazosin or terazosin. It should be used with more caution, especially in men with heart problems.

It should not be used in men with uncontrolled blood pressure problems or kidney failure.

Consult your physician about the effects and possible side effects of PDE5Is.

Drug Combinations

Your physician may recommend a combination of drugs for you. The most commonly used combinations are:

• 5ARI with alpha-blocker
• MRA with alpha-blocker

What is a wait-and-see treatment?

If you have mild lower urinary tract symptoms, you usually do not need medication or surgery. In this case, your urologist will closely monitor your disease in the coming months or years and will start a different treatment when necessary. Your urologist will tell you about your disease, how it can develop, how you can regulate your lifestyle, how to reduce your symptoms and how to cope with them.

Some simple lifestyle changes can help improve your BPH symptoms. For example, drinking less fluids in the evening helps reduce urination at night. Consuming less alcoholic beverages, coffee or tea prevents bladder irritation.

For some men, sitting down and urinating helps the bladder to empty completely. If you still feel that it is not fully discharged, try again after 5-10 minutes.

If you feel a sudden urge to urinate, encourage yourself to hold back. This will train your bladder to hold more urine so you will need to urinate less often.

What is the purpose of surgery for BPH?

The aim of surgery is to relieve the symptoms of BPH and increase urine flow.

What is the gold standard treatment for BPH?

TUR-P: The most commonly recommended surgical treatment for BPH symptoms is transurethral resection of the prostate. The aim is to remove the prostate tissue (adenoma) that causes symptoms with a minimally invasive method. TURP provides optimal improvement in BPH symptoms. Retrograde ejaculation may develop after TUR-P.

BPH can also be treated with other surgical methods

Transurethral incision of the prostate (TUIP): During TUIP, your physician will make an incision from the bladder neck to the prostate to correct the urine flow. This procedure is rarely used in the treatment of BPH as it provides similar results with drug therapy..

Open prostatectomy: It is similar to TUR-P, but it is done by making an incision in the abdomen. It is recommended for men with very large prostates. It is an almost abandoned method.

Laser therapy: A laser called HOLEP is used to cut the prostate. Very little blood is lost during the procedure.

Prostate stents: Stents are used to keep the urethra open and increase urine flow. Recommended for men unfit for surgery.

Transurethral Needle Ablation (TUNA): It is a minimally invasive treatment that uses heat (radiofrequency energy) to harden prostate tissue. The goal is to reduce prostate volume and improve symptoms.

Transurethral microwave therapy (TUMT) is a minimally invasive treatment that uses microwave energy to harden prostate tissue. The aim is to reduce prostate volume and improve symptoms. Features It is one of the best treatment options in patients who cannot receive anesthesia.

What is retrograde ejaculation?

During orgasm, semen is no longer expelled from the urethra, but is sprayed into the bladder and then excreted from the body with urine. Retrograde ejaculation may develop after surgery for BPH. Of course, this may vary with the chosen surgical method. It is also linked to certain types of drug therapy. This rate decreases with the new techniques developed and the experience of the surgeon performing the operation.

Is there a relationship between surgical treatment and erectile dysfunction?

In general, surgical operations do not cause erectile dysfunction.

The aim of these treatments is to combine the benefits of both drugs. These drugs may be more effective when used together. However, it can often cause more side effects. The side effects of each drug are mentioned in the previous sections. Combination therapy is recommended for men with moderate or severe symptoms.