http://hcd2.bupa.co.uk/fact_sheets/Mosby_factsheets/BPH.

html

Enlarged prostate (BPH)

Published by BUPA's Health Information Team
December 2002, revised June 2004

An enlarged prostate – known as benign prostatic hyperplasia or BPH – is caused by an

overgrowth of prostate cells. This enlargement constricts the urethra so the flow of urine
is reduced, making it increasingly difficult to empty the bladder.

The prostate gland

The prostate is a gland about the size of a walnut that is only present in men. It is located
just below the bladder and surrounds the urethra, the tube through which urine flows
from the bladder and out through the penis. Please see the diagram, overleaf.

One of the main functions of the prostate is to produce an important liquefying

component of semen, which allows the sperm to move freely. The gland is divided into
three zones, peripheral, transitional and central. With BPH, it is the central part where
overgrowth of cells takes place.

BPH is very common, affecting about one third of men over 50. Although it is not
prostate cancer, the symptoms of BPH are similar to those of prostate cancer so you
should see your doctor if you start to experience problems passing urine. A separate
BUPA factsheet on prostate cancer covers that topic in more detail.

Location of the prostate gland

Symptoms
You should seek medical advice if you notice any of the following symptoms:

 hesitancy (difficulty in starting to pass urine,

 a weak stream,
  the need to strain to pass urine,
 the feeling that your bladder isn't empty after urination,
 the need to pass urine urgently,
 frequent trips to the toilet, including having to get up several times in the night,
 feeling a burning sensation or pain when passing urine.

Diagnosis
Your doctor will ask you questions about your symptoms and your general health. You
may be asked to fill in a urination questionnaire to help work out the severity of your
symptoms.

A digital rectal examination (DRE) will be performed to examine the size and
consistency of your prostate by inserting a finger into the rectum. Although this can be
uncomfortable, it is not painful. Many men find the prospect of a DRE embarrassing, but
should bear in mind that it's a simple procedure, performed routinely by GPs.

Your doctor will also feel your abdomen to find out if the bladder is distended. A
distended bladder may indicate that you are not completely emptying it (chronic urinary
retention, which is painless).

Other tests will be carried out to make sure that your urinary problems are due to BPH
and not other conditions. A urine test will be done to check for infection or blood. Blood
tests, including a prostate specific antigen (PSA) test may be carried out. This measures
the amount of an enzyme produced by the prostate. High levels of the enzyme can
indicate prostate cancer. Other blood tests include one to assess your kidney function and
another for blood sugar to check for diabetes. Both of these problems can cause urinary
symptoms.

Other tests
Less common tests may include: urine flow tests; ultrasound to measure urine left in the
bladder and to check for bladder stones; urodynamic measurements using a catheter
inserted into the bladder to measure the pressure of urine there; and transrectal
ultrasonography (TRUS) where an ultrasound probe is passed into the rectum to give a
view of the prostate.

A biopsy (samples of the prostate) may be collected using a needle to check for cancerous
cells.

Treatment
The mainstays of treatment for BPH are drugs and surgery. However, as any treatment
can have unwanted effects, some men with mild symptoms opt for "watchful waiting",
where no treatment is undertaken. Instead the situation is monitored closely with routine
check-ups. If symptoms deteriorate, it is then possible to opt for treatment.

Drug treatment
There are two main classes of drugs that are prescribed for BPH: alpha-blockers and 5-
alpha-reductase inhibitors.

Alpha-blockers

Work by relaxing the muscles at the neck of the bladder and in the prostate. In this way
they reduce the pressure on the urethra and so help increase the flow of urine. They do
not cure BPH but help to alleviate some of the symptoms.

Around 60% of men find symptoms improve significantly within the first 2-3 weeks of
treatment with an alpha-blocker. There are several different alpha blockers. Currently,
these are alfuzosin (Xatral), doxazosin (Cardura), indoramin (Doralese), prazosin
(Hypovase), terazosin (Hytrin BPH), and tamsulosin (Flomax MR). Some of these drugs
can also be used to treat high blood pressure. The most common side-effects of alpha-
blockers are tiredness, dizziness and headaches.

5-alpha-reductase inhibitors

These drugs work by inhibiting the production of a hormone called DHT, which
contributes to prostate enlargement. Finasteride (Proscar) is the most commonly used
drug of this type for BPH. Unlike alpha blockers, 5-alpha- reductase inhibitors are able to
reverse BPH to some extent and so may delay your need for surgery.

Potential side-effects of finasteride include a reduced sex drive and difficulty in

maintaining an erection. Several months of treatment may be needed before the benefit is
noticed.

Plant extracts

A number of plant extracts are popularly used to alleviate BPH, although formal evidence
that they are effective is often scanty. However, there is some scientific evidence that an
extract of saw palmetto (called Serenoa repens) can be beneficial. If you decide to try a
plant remedy, it's always best to discuss this first with your doctor or pharmacist as
interactions with conventional medicines are possible.

Surgery
There are three main surgical options for BPH:

TURP
Transurethral resection of the prostate (TURP) is the most common operation for BPH.
The procedure is usually done under a general anaesthetic. A long thin instrument called a
resectoscope is passed into the urethra. With a light source and lens on the end it acts as a
telescope, allowing the surgeon to view the prostate either directly or on a video monitor.
A precisely controlled electric current, applied by a loop of wire at the end of the
resectoscope, is used to shave off sections of the enlarged prostate. See the separate
BUPA fact sheet on TURP for further details.

TURP is an effective procedure with over 90% of men reporting an improvement after
the operation. However, as with any surgical procedure there is a risk of side-effects and
complications. A common side-effect of this procedure is retrograde ejaculation - where
semen passes into the bladder during orgasm instead of out of the penis. This is
sometimes called a "dry orgasm". Retrograde ejaculation is usually not a problem,
although it may reduce fertility. Complications of the operation can include urinary
incontinence or damage to the urethra, resulting in a "stricture" that can itself cause
difficulty passing urine.

TUIP

Transurethral incision of the prostate (TUIP) may be appropriate for men who have a less
enlarged prostate. It is a quicker operation than a TURP and involves removing less
tissue. It is performed under general or spinal anaesthetic. As with a TURP an instrument
is passed up through the penis, but instead of removing a portion of the prostate, small
cuts are made in the neck of the bladder and the prostate. This reduces the obstruction of
the flow of urine.

Open prostatectomy

Open prostatectomy is only recommended for men whose prostate is very large. It is a
major operation and carried out under a general anaesthetic. An incision is made in the
lower abdomen in order to remove the central part of the prostate.

Other treatments

Laser therapy (using a laser probe to cut away prostate tissue) and transurethral
microwave thermotherapy (using heat to remove some of the prostate tissue via a probe)
are becoming more common in the treatment of BPH.

Prevention
Although it is not known why only some men develop BPH, it is clear that advancing age
is the prime risk factor. Eating a diet that is low in fat and rich in fruit and vegetables
(five portions per day) may well help to reduce the risk of prostate cancer and has been
proven to bring other health benefits. You should visit your doctor promptly if you
develop urinary problems as early treatment is likely to be more simple.
http://www.nlm.nih.gov/medlineplus/ency/article/000381.htm

Alternative names Return to top

BPH; Benign prostatic hypertrophy (hyperplasia); Prostate - enlarged

Definition Return to top

The prostate is a male reproductive gland that produces the fluid that carries sperm during
ejaculation. It surrounds the urethra, the tube through which urine passes out of the body.

An enlarged prostate means the gland has grown bigger. Prostate enlargement happens to
almost all men as they get older. As the gland grows, it can press on the urethra and
cause urination and bladder problems.

An enlarged prostate is often called benign prostatic hyperplasia (BPH) or benign

prostatic hypertrophy. It is not cancer, and it does not raise your risk for prostate cancer.

Causes, incidence, and risk factors Return to top

The actual cause of prostate enlargement is unknown. It is believed that factors linked to
aging and the testicles themselves may play a role in the growth of the gland. Men who
have had their testicles removed at a young age (for example, as a result of testicular
cancer) do not develop BPH.

Similarly, if the testicles are removed after a man develops BPH, the prostate begins to
shrink in size.

Some facts about prostate enlargement:

 The likelihood of developing an enlarged prostate increases with age.

 BPH is so common that it has been said, "All men will have an enlarged prostate
if they live long enough."
 A small amount of prostate enlargement is present in many men over age 40 and
more than 90% of men over age 80.
 No risk factors have been identified other than having normally functioning
testicles.

Symptoms Return to top

Less than half of all men with BPH have symptoms of the disease, which include:

 Slowed or delayed start of the urinary stream

 Weak urine stream
  Dribbling after urinating
 Straining to urinate
 Strong and sudden urge to urinate
 Incomplete emptying of your bladder
 Needing to urinate two or more times per night
 Urinary retention (complete inability to urinate)
 Incontinence
 Pain with urination or bloody urine (these may indicate infection)

Signs and tests Return to top

After taking a complete medical history, your doctor will perform a digital rectal exam
to feel the prostate gland. The following tests may also be performed:

 Urine flow rate

 Post-void residual urine test to see how much urine is left in your bladder after
urination
 Pressure flow studies to measure the pressure in the bladder as you urinate
 An IVP (an x-ray study) to confirm BPH or look for blockage
 Urinalysis to check for blood or infection
 Urine culture to check for infection
 Voiding cystourethrogram
 A prostate-specific antigen (PSA) blood test to screen for prostate cancer
 Cystoscopy

In addition, you may be asked to complete a form to evaluate the severity of your
symptoms and their impact on your daily life. Your score may be compared to past
records to determine if the condition is getting worse.

Treatment Return to top

The choice of a treatment is based on the severity of your symptoms, the extent to which
they affect your daily life, and the presence of any other medical conditions. Treatment
options include "watchful waiting," lifestyle changes, medication, or surgery.

If you are over 60, you are more likely to have symptoms. But many men with an
enlarged prostate have only minor symptoms. Self-care steps are often enough to make
you feel better.

If you have BPH, you should have a yearly exam to monitor the progression of your
symptoms and determine if any changes in treatment are necessary.

SELF-CARE

For mild symptoms:

  Urinate when you first get the urge. Also, go to the bathroom when you have the
chance, even if you don't feel a need to urinate.
 Avoid alcohol and caffeine, especially after dinner.
 Don't drink a lot of fluid all at once. Spread out fluids throughout the day. Avoid
drinking fluids within 2 hours of bedtime.
 Try NOT to take over-the-counter cold and sinus medications that contain
decongestants or antihistamines. These medications can increase BPH symptoms.
 Keep warm and exercise regularly. Cold weather and lack of physical activity
may worsen symptoms.
 Learn and perform Kegel exercises (pelvic strengthening exercises).
 Reduce stress. Nervousness and tension can lead to more frequent urination.

MEDICATIONS

 Finasteride lowers levels of hormones produced by the prostate, reduces the size
of the prostate gland, increases urine flow rate, and decreases symptoms of BPH.
It may take 3 to 6 months before you notice a significant improvement in your
symptoms. Potential side effects related to use of finasteride include decreased
sex drive and impotence.
 Alpha 1-Blockers (doxazosin, prazosin, tamsulosin, and terazosin) are a class of
medications also used to treat high blood pressure. These medications relax the
muscles of the bladder neck, allowing easier urination. Two thirds of the people
treated with alpha 1-blocker medications report an improvement in symptoms.
 Antibiotics may be prescribed to treat chronic prostatitis (inflammation of the
prostate), which may accompany BPH. Some men note relief of their BPH
symptoms after a course of antibiotics.

SAW PALMETTO

Saw palmetto has been used by millions of men to ease BPH symptoms and is often
recommended as an alternative to medication. Experts suggest a fat-soluble saw palmetto
extract with 85-95% fatty acids and sterols. However, a well-conducted study published
in the February 9, 2006 edition of the New England Journal of Medicine found that the
popular herb was no better than a dummy pill in relieving the signs and symptoms of
BPH. Further studies are needed. If you use saw palmetto and think it works, ask your
doctor if you should still take it.

SURGERY

Prostate surgery may be recommended if you have:

 Incontinence
 Recurrent blood in the urine
 Urinary retention
 Recurrent urinary tract infections
The choice of a specific surgical procedure is usually based on the severity of your
symptoms and the size and shape of your prostate gland.

 Transurethral resection of the prostate (TURP): This is the most common

surgical treatment for BPH. The TURP is performed by inserting a scope through
the penis and removing the prostate piece by piece.
 Transurethral incision of the prostate (TUIP): This procedure is similar to
TURP, but is usually performed in men who have a relatively small prostate. This
procedure is usually performed as an outpatient without need for a hospital stay.
Like the TURP, a scope is inserted through the penis until the prostate is reached.
Then, rather than removal of the prostate, a small incision is made in the prostatic
tissue to enlarge the opening of the urethra and bladder outlet.
 Open Prostatectomy: An open prostatectomy is usually performed using general
or spinal anesthesia. An incision is made through the abdomen or perineal area
(i.e., through the pelvic floor, including the region from the scrotum to the anus).
Then, the prostate is removed. This is a lengthy procedure, and it usually requires
a hospital stay of 5 to 10 days.

The majority of men who have prostate surgery have improvement in urine flow rates and
symptoms. Possible complications include impotence, urinary incontinence, retrograde
ejaculation (semen flowing back into the bladder rather than out the penis), infertility, and
urethral stricture (narrowing). Rates of these complications vary, depending on the
surgical procedure that you and your doctor decide is best.

Various other procedures are available, such as those that destroy prostate tissue with heat
generated by microwaves or lasers. Photoselective vaporization of the prostate (PVP),
one of the newer laser technologies, is typically done as an outpatient procedure. The
patient goes home on the same day. However, there is no long-term data for this
procedure. Another form of treatment is prostatic stents.

For more information, see prostate surgery.

Support Groups Return to top

Several national groups provide information on BPH. See BPH support groups.

Complications Return to top

Men who have had long-standing BPH with a gradual increase in symptoms may
develop:

 Sudden inability to urinate

 Urinary tract infections
 Urinary stones
 Damage to the kidneys
 Blood in the urine
Even after surgical treatment, a recurrence of BPH may develop over time.

Calling your health care provider Return to top

Call your doctor right away if you have:

 Less urine than usual

 Fever or chills
 Back, side, or abdominal pain
 Blood or pus in your urine

Also call your doctor if:

 Your bladder does not feel completely empty after you urinate
 You take medications that may cause urinary problems, like diuretics,
antihistamines, antidepressants, or sedatives. DO NOT stop or adjust your
medications on your own without talking to your doctor
 You have taken self-care measures for 2 months without relief

References Return to top

Hormone Foundation. Hormones & you. Patient information page. Benign prostatic
hyperplasia (enlarged prostate). J Clin Endocrinol Metab. 2005; 90(10):2.

AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic

hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. J Urol. 2003
Aug; 170:530-47.

Bent S, Kane C, Shinohara K, et. al. Saw Palmetto for Benign Prostatic Hyperplasia.
NEJM. 2006; 354:557-566.

Update Date: 2/9/2006

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http://www.urologychannel.com/prostate/bph/treatment_surg.shtml
Risk Factor

BPH is a condition of aging. Nearly all men over the age of 50 have an enlarged
prostate.

Causes

The cause of benign prostatic hyperplasia is unknown. It is possible that the

condition is associated with hormonal changes that occur as men age. The testes
produce the hormone testosterone, which is converted to dihydrotestosterone (DHT)
and estradiol (estrogen) in certain tissues. High levels of dihydrotestosterone, a
testosterone derivative involved in prostate growth, may accumulate and cause
hyperplasia. How and why levels of DHT increase remains a subject of research.

Signs and Symptoms

Common symptoms of benign prostatic hyperplasia include the following:

 Blood in the urine (i.e., hematuria), caused by straining to void

 Dribbling after voiding
 Feeling that the bladder has not emptied completely after urination
 Frequent urination, particularly at night (i.e., nocturia)
 Hesitant, interrupted, or weak urine stream caused by decreased force
 Leakage of urine (i.e., overflow incontinence)
 Pushing or straining to begin urination
 Recurrent, sudden, urgent need to urinate

In severe cases of BPH, another symptom, acute urinary retention (the inability to
urinate), can result from holding urine for a long time, alcohol consumption, long
period of inactivity, cold temperatures, allergy or cold medications containing
decongestants or antihistamines, and some prescription drugs (e.g., ipratropium
bromide, albuterol, epinephrine). Any of these factors can prevent the urinary
sphincter from relaxing and allowing urine to flow out of the bladder. Acute urinary
retention causes severe pain and discomfort. Catheterization may be necessary to
drain urine from the bladder and obtain relief.

Diagnosis

A physical examination, patient history, and evaluation of symptoms provide the

basis for a diagnosis of benign prostatic hyperplasia. The physical examination
includes a digital rectal examination (DRE), and symptom evaluation is obtained
from the results of the AUA Symptom Index.

Digital rectal examination (DRE)

DRE typically takes less than a minute to perform. The doctor inserts a lubricated,
gloved finger into the patient's rectum to feel the surface of the prostate gland
through the rectal wall to assess its size, shape, and consistency. Healthy prostate
tissue is soft, like the fleshy tissue of the hand where the thumb joins the palm.
Malignant tissue is firm, hard, and often asymmetrical or stony, like the bridge of the
nose. If the examination reveals the presence of unhealthy tissue, additional tests
are performed to determine the nature of the abnormality.

AUA Symptom Index

The AUA (American Urological Association) Symptom Index is a questionnaire
designed to determine the seriousness of a man's urinary problems and to help
diagnose BPH. The patient answers seven questions related to common symptoms of
benign prostatic hyperplasia. How frequently the patient experiences each symptom
is rated on a scale of 1 to 5. These numbers added together provide a score that is
used to evaluate the condition. An AUA score of 0 to 7 means the condition is mild; 8
to 19, moderate; and 20 to 35, severe.

Back to top

PSA and PAP Tests

Blood tests taken to check the levels of prostate specific antigen (PSA) and prostatic
acid phosphatase (PAP) in a patient who may have benign prostatic hyperplasia
helps the physician eliminate a diagnosis of prostate cancer.

Prostate-specific antigen (PSA) is a specific antigen produced by the cells of the

prostate capsule (membrane covering the prostate) and periurethral glands. Patients
with benign prostatic hyperplasia (BPH) or prostatitis produce larger amounts of PSA.
The PSA level also is determined in part by the size and weight of the prostate.

The test measures the amount of PSA in the blood in nanograms per milliliter
(ng/mL). A PSA of 4 ng/mL or lower is normal; 4–10 ng/mL is slightly elevated; 10–
20 is moderately elevated; and 20–35 is highly elevated. Most men with slightly
elevated PSA levels do not have prostate cancer, and many men with prostate
cancer have normal PSA levels. A highly elevated level may indicate the presence of
cancer.

The PSA test can produce false results. A false positive result occurs when the PSA
level is elevated and there is no cancer. A false negative result occurs when the PSA
level is normal and there is cancer. Because of this, a biopsy is usually performed to
confirm or rule out cancer when the PSA level is high.

Free and total PSA (also known as PSA II) PSA in the blood may be bound
molecularly to one of several proteins or may exist in a free, or unbound, state. Total
PSA is the sum of the levels of both forms; free PSA measures the level of unbound
PSA only. Studies suggest that malignant prostate cells produce more bound PSA;
therefore, a low level of free PSA in relation to total PSA might indicate a cancerous
prostate, and a high level of free PSA compared to total PSA might indicate a normal
prostate, BPH, or prostatitis.

Age-specific PSA Evidence suggests that the PSA level increases with age. A PSA of
up to 2.5 ng/mL for men age 40–49 is considered normal, as is 3.5 ng/mL for men
age 50–59, 4.5 ng/mL for men age 60–69, and 6.5 ng/mL for men 70 and older. The
use of age-specific PSA levels is not endorsed by all medical professionals.
Use the PSA Age/Race Quiz or the PSA Velocity Quiz to deterimine your risk of
prostate cancer.

Urodynamic Testing

Urodynamic tests, usually performed in a physician's office, are used to measure the
volume and pressure of urine in the bladder and to evaluate the flow of urine. They
are particularly useful for the diagnosis of Intrinsic sphincter deficiency and uncertain
cases of mixed, overflow, urgency, or total incontinence. Additional tests may be
conducted if symptoms indicate that blockage is caused by a condition other than
BPH.

Uroflowmetry is a simple test performed to record urine flow, to determine how

quickly and completely the bladder can be emptied, and to evaluate obstruction.
With a full bladder, the patient urinates into a device that measures the amount of
urine, the time it takes for urination, and the rate of urine flow. Patients with stress
or urge incontinence usually have a normal or increased urinary flow rate, unless
there is an obstruction in the urinary tract. A reduced flow rate may indicate BPH.

A pressure flow study measures pressure in the bladder during urination and is
designed to detect a blockage of flow. It is the most accurate way to evaluate
urinary blockage. This test requires the insertion of a catheter through the urethra in
the penis and into the bladder. The procedure is uncomfortable and rarely may cause
urinary tract infection (UTI).

Post-void residual (PVR) test measures the amount of urine that remains in the
bladder after urination. The patient is asked to urinate immediately prior to the test
and the residual urine is determined by ultrasound or catheterization. PRV less than
50 mL generally indicates adequate bladder emptying and measurements of 100 to
200 mL or higher often indicate blockage. Nervousness and other types of stress
may affect the result; therefore, the test is often repeated.

Minimally Invasive Treatment

Minimally invasive BPH treatments use state-of-the-art tools and techniques to

reduce or eliminate symptoms. Men are treated on an outpatient basis in a
urologist's office or the hospital. Other advantages of minimally invasive treatments
are

 less pain,
 faster recovery,
 lower costs, and
 local anesthesia and mild sedative.

Usually, heat is used to destroy excess prostate tissue. Techniques differ in heat
source, heat delivery method, side effects, and number of treatments. Delivery
methods include:

Laser
 o Indigo®
o PVP
o HoLAP

Microwave

o CoreTherm®
o Cooled ThermoTherapy™/TUMT™
o TherMatrx®
o Prolieve™

Other

o AquaTherm™ System
o TUNA

Laser Treatments

Interstitial Laser Coagulation

Interstitial laser coagulation is often performed under local anesthesia on an
outpatient basis. The Indigo LaserOptic Treatment® System uses a cystoscope
through which a fiberoptic probe is directly introduced into the prostate. Heat energy
is conducted through the probe for 3 minutes and quickly coagulates the obstructing
prostate tissue. The process can be repeated to treat another area in the prostate, as
determined by the physician. The procedure lasts approximately 30 to 60 minutes.
Symptoms resolve over 6 to 12 weeks, as tissue is absorbed.

After the device is removed, a Foley catheter is inserted to drain urine for several
days, until bladder function returns. Blood in the urine is a common side effect of the
procedure and resolves within a week or so. Erectile dysfunction (impotence),
retrograde ejaculation, and incontinence are rare complications.

PVP
Photoselective vaporization of the prostate (PVP) is a minimally invasive procedure
that uses a special high-energy laser (e.g., GreenLight PVP™ Laser) to vaporize
excess prostate tissue and seal the treated area. The procedure is performed on an
outpatient basis in a hospital or surgical center and may be performed under local,
spinal, or general anesthesia. PVP takes between 10 and 30 minutes to perform,
depending on the size of the prostate and patients are usually discharged within a
few hours.

The type of laser used in PVP is delivered to the prostate through an endoscope
(device that consists of a tube and an optical system) that is inserted into the
urethra. The procedure prevents damage to surrounding tissue and minimizes side
effects such as pain, blood in the urine (hematuria), and swelling.

Many patients do not require a catheter after PVP, and those who do typically are
catheterized for less than 24 hours. Patients are advised to avoid strenuous exercise
for 2 weeks following the procedure and can usually resume regular activities the
next day. PVP provides immediate and long-lasting results comparable with other
minimally invasive procedures.
HoLAP
HoLAP (holmium laser ablation of the prostate) involves using a laser to vaporize
obstructive prostatic tissue. The decision whether to use HoLAP or HoLEP (holmium
enucleation of the prostate) is based primarily on the size of the prostate. Ablation
usually is performed when the prostate is smaller than 60 cc (cubic centimeters).

HoLAP offers many of the same advantages as HoLEP when compared to traditional
surgery (e.g., TURP). These potential benefits include a shorter hospital stay, less
bleeding and shorter catheterization and recovery times.

Patients who undergo HoLAP usually do not require overnight hospitalization and in
most cases, the catheter is removed the same day or the morning following the
procedure.

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Microwave Treatments

Cooled ThermoTherapy™/TUMT™
Cooled ThermoTherapy™/TUMT™ reduces BPH symptoms, preserves sexual function,
and provides durable results using the Targis® system or the Prostatron® system.
Treatment can be completed within 30 minutes, usually does not require anesthesia,
and is performed in a physician's office or an outpatient setting.

In this treatment, a specially designed antenna inside a catheter is inserted into the
prostate through the urethra. This antenna is used to direct microwave energy into
the prostate to heat and destroy enlarged tissue. During the procedure, cool water is
circulated through the catheter to minimize patient discomfort, protect adjacent
urethral tissues from excessive temperatures, and reduce the risk for serious side
effects.

Medication is often administered to reduce discomfort and help patients relax during
the procedure. Many patients are able to read, watch television, or listen to music
during treatment and some may experience the following:

 Bladder spasms
 Pressure in the rectum
 Sensation of needing to empty the bladder or have a bowel movement
 Warm or burning sensation in the abdomen or penis

Following treatment, anti-inflammatory medication and antibiotics may be

prescribed. Most patients can resume normal activity immediately after treatment.
Destroyed prostatic tissue is reabsorbed by the body or discharged in the urine over
the course of 6 to 12 weeks and BPH symptoms gradually improve during this time.

Side effects usually resolve without intervention within a few weeks of treatment
and include the following:

 Frequent urination
 Pink discharge in the urine or around the catheter
 Soreness in the lower abdomen
  Urethral inflammation and swelling (most patients require catheterization for
2–5 days)
 Urgency (even after removal of the catheter)

To find a urologist who is familiar with this procedure click here.

CoreTherm®
An outpatient, microwave-generated heat treatment that destroys excess prostate
tissue. CoreTherm uses a transurethral catheter containing a microwave antenna and
an intraprostatic probe with three temperature sensors. This system takes into
account the fact that different patients have differently sized prostates and different
intraprostatic blood flows.

Continuous monitoring of intraprostatic temperatures, intraprostatic blood flow rate,

progressive destruction of targeted tissue, and adjustable microwave power enable
the physician to tailor treatment to the individual. These data are calculated and
displayed in real time on a computer screen throughout the session, which helps the
physician determine when to stop treatment.

Before the procedure, the bladder and bowel are emptied, and the patient is given a
sedative, local anesthesia, and antibiotics. Urinary retention is a common temporary
side effect. A urinary catheter is placed after treatment and removed within a couple
of weeks.

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TherMatrx®
TherMatrx® is a minimally invasive procedure performed in a urologist's office that
uses heat delivered through a microwave antenna. This outpatient procedure
requires local anesthesia. A mild sedative or pain reliever may be given to help the
patient relax and make him as comfortable as possible during the procedure.

A urethral catheter containing the microwave antenna is passed through the urethra
and prostate gland and is secured by a balloon at the tip of the catheter that passes
through the uretheral sphincter. Localized microwave energy is delivered at a
temperature high enough to relieve BPH symptoms, including difficult, frequent, or
urgent urination. The procedure lasts approximately 1 hour.

Following the procedure, a catheter is inserted to drain urine from the bladder for a
few days. Once the catheter is removed, the patient can resume normal activity.
Symptoms improve in 4 to 6 weeks. Healing takes 6 weeks to 3 months.

Possible complications include incontinence, pain during urination, and urinary

retention. Most complications resolve during the healing period without intervention.

Prolieve™
Prolieve™ Thermodilatation System is a transurethral microwave thermotherapy
(TUMT) device that also uses a special balloon catheter to open up (dilate) the
urethra, as well as microwave energy to heat and destroy enlarged prostatic tissue.
In this procedure, the balloon catheter is filled with warm water. After the
temperature of the tissue returns to normal, the urethra remains open. Prolieve™,
which takes about 45 minutes, is performed in a physician's office under local
anesthesia. In a recent study, about 5% of patients required catheterization
following the procedure.

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Other Minimally Invasive Treatments

AquaTherm™
The AquaTherm™ System uses water-induced thermotherapy (WIT) to destroy
obstructive prostatic tissue and reopen the urethra. WIT can be performed in
ambulatory surgery, outpatient surgery, or a physician's office. It takes only 45
minutes and does not require general anesthesia.

A catheter made up of four contiguous sections - the urinary drainage lumen, the
positioning balloon, the treatment balloon, and the insulated shaft - is attached to a
computer console that heats water to 60° C (140° F). Throughout the procedure, the
computer console precisely maintains the water temperature at 60° C, and urine is
allowed to pass by means of the urinary drainage lumen.

The urologist inserts the catheter through the urethra and into the bladder. Once the
urinary drainage lumen and the positioning balloon reach the bladder, the positioning
balloon inflates and secures the catheter. The treatment balloon, resting in the
prostatic urethra (located directly below the bladder), inflates and fills with water.
Temperature-controlled water circulates through the insulated shaft into the
treatment balloon. The catheter conducts heat through the insulated shaft to the
prostate gland, raises the temperature of the gland, and destroys the obstructive
tissue. Destroyed tissue is either sloughed off or absorbed by the body over time.
After 45 minutes of treatment, the catheter is removed.

Following the procedure, a urethral catheter remains in place for approximately 4 to

17 days, or until normal urinary flow is restored. Temporary hematuria, or blood in
the urine, is usually present after the procedure, and treatable urinary tract infection
or urinary urgency also may occur.

Transurethral Needle Ablation (TUNA)

Transurethral needle ablation of the prostate (TUNA), procedure delivers low level
radio frequency (RF) energy to the prostate, relieving obstruction without causing
damage to the urethra. A small probe is inserted through the urethra and into the
prostate. Two small electrodes are deployed into the prostate and a low level of radio
frequency energy is applied. The energy heats the prostate tissue and shrinks it,
relieving the obstruction while protecting the urethra and surrounding areas.

The TUNA procedure can be performed in an office or hospital outpatient center in

less than 1 hour using minimal anesthesia. Clinical studies have demonstrated that
TUNA provides significant improvements in urine flow and other symptoms of BPH.
Its long-term side effects are minor compared with those of such conventional
procedures as TURP. Most patients are able to return to their normal activities within
24 hours.
Possible complications include blood in the urine, discomfort or pain during urination,
urinary retention, and sexual dysfunction. Most complications resolve without
intervention during the healing period.

FAQs

To locate a urologist in your area who is familiar with this procedure click here.

TUVP
Transurethral vaporization of the prostate (TUVP), also called vaportrode, involves
direct application of heat (under 100° F) to the prostate tissue with a grooved roller-
bar that vaporizes tissue. The immediate tissue loss leads to quick improvement of
symptoms. The procedure takes from 20 to 65 minutes. The catheter is usually
removed within 24 hours and most patients go home within 2 days.

High Intensity Focused Ultrasound (HIFU)

High intensity focused ultrasound (HIFU) is currently undergoing clinical trials in the
United States. HIFU is a noninvasive treatment that uses precision-focused
ultrasound waves to heat and destroy (ablate) targeted prostatic tissue without
affecting healthy surrounding tissue. It has been shown to effectively treat BPH as
well as localized prostate cancer. The Food and Drug Administration (FDA) has not
yet approved this treatment in the United States.

In clinical trials, HIFU is performed on an outpatient basis, under anesthesia. HIFU

can be repeated as necessary, and each treatment takes 1–3 hours. Following
treatment, a catheter is necessary for about 1 week and most patients are able to
resume regular activities within days. Impotence occurs in 1–7% of patients.

o
o TUVP
o HIFU

Patients who want to stop taking medication or whose medication no longer

improves symptoms may elect to have one of these procedures. However, patients
with severely enlarged prostates and whose bladders do not work properly may not
be good candidates.

Prior to diagnosis and treatment of BPH, a prostate-specific antigen (PSA) test and
digital rectal examination (DRE) are performed to rule out prostate cancer. A
transrectal ultrasound and cystoscopy also may be performed to determine if
prostatectomy or TURP is indicated.

Medical Treatment

There are several treatment options for men with benign prostate hyperplasia,
depending on the severity of symptoms. If symptoms do not threaten the man's
health, he may choose not to be treated. If symptoms are severe enough to cause
discomfort, interfere with daily activities, or threaten health, treatment is usually
recommended.
Watchful waiting
Men with mild symptoms may choose to return for annual examinations. The
physician will perform an examination that includes a DRE, PSA tests, and a urinary
flow rate. The patient will be asked to describe symptoms in order to determine if the
condition is worsening.

Medication
5-Alpha reductase inhibitors such as finasteride (Proscar®) and dutasteride
(Avodart®) prevent the conversion of testosterone to the hormone
dihydrotestosterone (DHT). In many cases, a treatment period of 6-month is
necessary to see if the therapy is going to work. These drugs are taken orally, once a
day. Finasteride is available in tablet form and dutasteride is available as soft gelatin
capsules. Patients should see their physician regularly to monitor side effects and
adjust the dosage, if necessary.

Side effects include reduced libido, impotence, breast tenderness and enlargement,
and reduced sperm count. Long-term risks and benefits have not been studied.

Women who may be pregnant must avoid handling dutasteride capsules and broken
or crushed finasteride tablets because exposure to the drugs may cause serious side
effects to the fetus. Intact tablets are coated to prevent absorption through the skin
during normal handling. Patients should wait at least 6 months after dutasteride
treatment to donate blood to prevent pregnant women from being exposed to the
drug through blood transfusion.

Alpha blockers relax smooth muscle tissue in the bladder neck and prostate, which
increases urinary flow. They typically are taken orally, once or twice a day.

Commonly prescribed alpha blockers include the following:

 alfuzosin (UroXatral®), extended-release tablet taken once daily

 doxazosin (Cardura®), tablet taken once daily
 prazosin (Minipress®), capsule taken 2 or 3 times daily
 tamsulosin hydrochloride (Flowmax®), capsule taken once daily
 terazosin (Hytrin®), capsule taken once daily

Patients taking an alpha blocker require follow-up during the first 3 or 4 weeks to
evaluate the effect on symptoms and adjust the dosage, if necessary. Side effects
include headache, dizziness, low blood pressure, fatigue, weakness, and difficulty
breathing. Long-term risks and benefits have not been studied.

Prostatic stents
Although a prostatic stent is not a medical treatment, neither does it fall under the
classification of a surgical procedure. Prostatic stents are used most often for
patients with significant medical problems that prohibit medication or surgery. It is a
tiny, springlike device inserted into the urethra. When expanded, it pushes back the
surrounding tissue and widens the urethra. Prostatic stents have several
advantages:

 They can be placed in less than 15 minutes under regional anesthesia.

 Bleeding during and after surgery is minimal.
  The patient can be discharged the same day or the next morning.

There are also several disadvantages:

 Prepositioning can be difficult.
 They may cause irritation and frequent urination.
 They may cause pain or incontinence.
 Removing them (necessary in one-third of cases) can be difficult.

Naturopathic Treatment

The goal of benign prostatic hyperplasia (BPH) treatment is to reduce excessive cell
growth by inhibiting the conversion of testosterone into the more potent hormone
dihydrotestosterone (DHT) and by preventing estrogen from attaching to receptors in
prostate tissue. From a naturopathic viewpoint, this is accomplished through
nutrition and the use of supplements and herbs.

Nutrition

 Eat whole, fresh, unrefined, and unprocessed foods. Include fruits,

vegetables, whole grains, soy, beans, seeds, nuts, olive oil, and cold-water
fish (salmon, tuna, sardines, halibut, and mackerel). Eating organic food
helps reduce exposure to hormones, pesticides, and herbicides.
 Avoid refined sugar and flour, dairy products, refined foods, fried foods, junk
foods, hydrogenated oils, alcohol (particularly beer), and caffeine.
 Eliminate food sensitivities. Use an elimination and challenge diet to
determine food sensitivities.
 Drink 50% of your body weight in ounces of water daily (e.g., if you weigh
150 lbs, drink 75 oz of water daily).

Supplements
Supplements are intended to provide nutritional support. Because a supplement or a
recommended dose may not be appropriate for all persons, a physician (i.e., a
licensed naturopathic physician or holistic MD or DO) should be consulted before
using any product. Recommended doses follow:

 Amino acids – The combination of glycine, alinine, and glutamic acid (200
mg of each daily) reduces urinary urgency, urinary frequency, and delayed
micturition (initiation of flow).
 Beta-sitosterol – 120 mg daily in 3 divided doses may help reduce
symptoms. Beta-sitosterol also lowers cholesterol (a higher dose of 500 mg 3
times daily is required), which is important since high cholesterol levels can
cause prostatic hyperplasia.
 Flaxseed meal – Grind and eat 2-4 tbsp daily. An alternative is to take 1
tbsp of flaxseed oil daily. Flaxseed oil is a good source of the essential fatty
acid (EFA) alpha-linolenic acid (an omega-3 fatty acid).
 Flower pollen – Follow product directions. It has been used in Europe for
over 25 years to treat BPH. Flower pollen is not the same as bee pollen.
 Zinc picolinate – 30–50 mg daily. Zinc competes with copper for absorption;
therefore, when supplementing long term with zinc, copper should also be
 supplemented. There are supplements available that contain both zinc and
copper.

Herbal Medicine
Herbal medicines usually do not have side effects when used appropriately and at
suggested doses. Occasionally, an herb at the prescribed dose causes stomach upset
or headache. This may reflect the purity of the preparation or added ingredients,
such as synthetic binders or fillers. For this reason, it is recommended that only
high-quality products be used. As with all medications, more is not better and
overdosing can lead to serious illness and death.

These herbs may be used to treat BPH:

 Saw palmetto (Serenoa repens) – Inhibits the conversion of testosterone to

DHT in the prostate, has an antiestrogenic effect, and helps improve all
symptoms of BPH. Recommended dosage is 320 mg of extract (standardized
to contain approximately 85% fatty acids and sterols) daily.
 Pygeum (Pygeum africanum) – Reduces BPH symptoms. Recommended
dosage is 100-200 mg of extract (standardized to 14% triterpenes) 2 times
daily.
 Stinging nettles (Urtica dioica) – The concentrated extract reduces
symptoms. Recommended dosage is 120 mg daily.

Surgical Treatment

Surgery involves removing the enlarged part of the prostate that constricts the
urethra. It is recommended for patients who experience serious complications, such
as the following:

 Bleeding through the urethra as a result of BPH

 Damage to the kidneys caused by urine backing up
 Frequent urinary tract infections
 Inability to urinate
 Stones in the bladder

TURP
Transurethral resection of the prostate (TURP) is the gold standard to which other
surgeries for BPH are compared. This procedure is performed under general or
regional anesthesia and takes less than 90 minutes.

The surgeon inserts an instrument called a resectoscope into the penis through the
urethra. The resectoscope is about 12 inches long and one-half an inch in diameter.
It contains a light, valves for controlling irrigating fluid, and an electrical loop to
remove the obstructing tissue and seal blood vessels. The surgeon removes the
obstructing tissue and the irrigating fluids carry the tissue to the bladder. This debris
is removed by irrigation and any remaining debris is eliminated in the urine over
time.
Patients usually stay in the hospital for about 3 days, during which time a catheter is
used to drain urine. Most men are able to return to work within a month. During the
recovery period, patients are advised to

 avoid heavy lifting, driving, or operating machinery;

 drink plenty of water to flush the bladder;
 eat a balanced diet;
 use a laxative if necessary to prevent constipation and straining during bowel
movements.

Complications !!!!!!!!!!!!!!!!!!!!!!!!!
Blood in the urine (hematuria) is common after TURP surgery and usually resolves by
the time the patient is discharged. Bleeding also may result from straining or
activity. Postsurgical bleeding should be reported to the urologist
immediately. !!!!!!!!!!!!!!!!

Some patients have initial discomfort, a sense of urgency to urinate, or short-term

difficulty controlling urination. These conditions slowly improve as recovery
progresses, but it is important to remember that the longer the urinary problems
existed before surgery, the longer it takes to regain full and normal bladder function
after surgery.

Up to 30% of men who undergo TURP experience problems with sexual function.
Complete recovery of sexual function may take up to 1 year. The most common,
long-term side effect of prostate surgery is retrograde ejaculation (dry climax),
which results when the muscle that closes the bladder neck during ejaculation is
removed along with the obstructing prostate tissue. Semen enters the wider opening
to the bladder instead of being expelled through the penis, causing sterility but not
affecting the man's ability to experience sexual pleasure. This complication is not an
issue for most men requiring prostate surgery.

HoLEP
Holmium laser enucleation of the prostate (HoLEP) produces results that are similar
to TURP with fewer complications (e.g., less intraoperative bleeding). In this
procedure, a holmium laser is used to remove obstructive prostatic tissue and seal
blood vessels. HoLEP is usually performed as a day procedure in the hospital.
Benefits of HoLEP over traditional surgery include the following:

 Shorter hospital stay

 Shorter catheterization time
 Shorter recovery time

Approximately 10–15% of patients with large prostates (>100 gm) experience stress
incontinence after undergoing HoLEP. In most cases, incontinence resolves within 6
weeks.

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Prostatectomy
If the prostate is greatly enlarged, if the bladder has been damaged, or if the patient
has complications prohibiting transurethral surgery, prostatectomy (removal of the
obstructing prostate) may be necessary. This procedure is sometimes the best and
safest approach.

Prostatectomy is performed under general or regional anesthesia. The surgeon

makes an external incision in the lower abdomen or in the perineum (area between
the rectum and the scrotum). If the surgeon accesses the prostate from the
abdomen, the procedure is called suprapubic or retropubic prostatectomy; surgery
through the perineum is called perineal prostatectomy. Once access is gained, the
prostate is removed.

After prostate surgery, a urinary catheter is inserted to ensure bladder emptying.

Urine output and color and continuous bladder irrigation (CBI), if present, are
monitored. Blood in the urine is an expected side effect of prostate surgery. CBI is
used to maintain the effectiveness of the urinary catheter, remove blood clots, and
cleanse the surgical area. If bladder spasms occur, the surgeon should be notified.

Once they have been discharged from the hospital, patients should abstain from
sexual intercourse for 6 weeks after surgery. Strenuous activity and lifting is to be
avoided throughout the recovery period, which can take up to 8 weeks.

Potential complications include incontinence and impotence. Depending on the

procedure, stress urinary incontinence may result when pressure is put on abdominal
muscles. Urge incontinence and involuntary passing of urine while asleep also may
occur. Patients are encouraged to use Kegel exercies to strengthen pelvic floor
muscles and to increase their water intake. Ejaculatory and erectile dysfunction
(impotence) may occur, depending on the procedure.

TUIP
Transurethral incision of the prostate (TUIP) may be recommended to treat a
prostate that is not greatly enlarged. The surgeon makes one or more cuts in the
bladder neck where the urethra joins the bladder, extending into the prostate. This
reduces the prostate's pressure on the urethra and makes urination easier. TUIP may
provide relief with a lower incidence of retrograde ejaculation than TURP. However,
its long-term benefits and risks compared to TURP have not been established.

TULIP
Transurethral ultrasound-guided laser incision of the prostate (TULIP) is a new
procedure that is similar to TUIP, except that the cuts are made with a laser.

Nefrolithiasis
Overview

Kidney stones (calculi) are hardened mineral deposits that form in the kidney. They
originate as microscopic particles and develop into stones over time. The medical
term for this condition is nephrolithiasis, or renal stone disease.

The kidneys filter waste products from the blood and add them to the urine that the
kidneys produce. When waste materials in the urine do not dissolve completely,
crystals and kidney stones are likely to form.
Small stones can cause some discomfort as they pass out of the body. Regardless of
size, stones may pass out of the kidney, become lodged in the tube that carries urine
from the kidney to the bladder (ureter), and cause severe pain that begins in the
lower back and radiates to the side or groin. A lodged stone can block the flow of
urine, causing pressure to build in the affected ureter and kidney. Increased pressure
results in stretching and spasm, which cause severe pain.

Stone Formation

Kidney stones form when there is a high level of calcium (hypercalciuria), oxalate
(hyperoxaluria), or uric acid (hyperuricosuria) in the urine; a lack of citrate in the
urine; or insufficient water in the kidneys to dissolve waste products. The kidneys
must maintain an adequate amount of water in the body to remove waste products.
If dehydration occurs, high levels of substances that do not dissolve completely
(e.g., calcium, oxalate, uric acid) may form crystals that slowly build up into kidney
stones.

Urine normally contains chemicals—citrate, magnesium, pyrophosphate—that

prevent the formation of crystals. Low levels of these inhibitors can contribute to the
formation of kidney stones. Of these, citrate is thought to be the most important.

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Types

The chemical composition of stones depends on the chemical imbalance in the urine.
The four most common types of stones are comprised of calcium, uric acid, struvite,
and cystine.

Calcium Stones Approximately 85% of stones are composed predominantly of

calcium compounds. The most common cause of calcium stone production is excess
calcium in the urine (hypercalciuria). Excess calcium is normally removed from the
blood by the kidneys and excreted in the urine. In hypercalciuria, excess calcium
builds up in the kidneys and urine, where it combines with other waste products to
form stones. Low levels of citrate, high levels of oxalate and uric acid, and
inadequate urinary volume may also cause calcium stone formation.

Calcium stones are composed of calcium that is chemically bound to oxalate (calcium
oxalate) or phosphate (calcium phosphate). Of these, calcium oxalate is more
common. Calcium phosphate stones typically occur in patients with metabolic or
hormonal disorders such as hyperparathyroidism and renal tubular acidosis.

Increased intestinal absorption of calcium (absorptive hypercalciuria), excessive

hormone levels (hyperparathyroidism), and renal calcium leak (kidney defect that
causes excessive calcium to enter the urine) can cause hypercalciuria. Prolonged
inactivity also increases urinary calcium and may cause stones.

Renal tubular acidosis (inherited condition in which the kidneys are unable to excrete
acid) significantly reduces urinary citrate and total acid levels and can lead to stone
formation, usually calcium phosphate.
Uric Acid Stones Digestion produces uric acid. If the acid level in the urine is high or
too much acid is excreted, the uric acid may not dissolve and uric acid stones may
form. Genetics may play a role in the development of uric acid stones, which are
more common in men. Approximately 10% of patients with kidney stone disease
develop this type of stone.

Struvite Stones This type of stone, also called an infection stone, develops when a
urinary tract infection (e.g., cystitis) affects the chemical balance of the urine.
Bacteria in the urinary tract release chemicals that neutralize acid in the urine, which
enables bacteria to grow more quickly and promotes struvite stone development.

Struvite stones are more common in women because they have urinary tract
infections more often. The stones usually develop as jagged structures called
"staghorns" and can grow to be quite large.

Cystine Stones Cystine is an amino acid in protein that does not dissolve well.
Some people inherit a rare, congenital (i.e., present at birth) condition that results in
large amounts of cystine in the urine. This condition (called cystinuria) causes
cystine stones that are difficult to treat and requires life-long therapy.

Incidence and Prevalence

People who live near large bodies of water (e.g., Great Lakes, Gulf of Mexico), those
who live in "soft" water areas, and those who have a sibling or parent with the
condition experience a higher incidence of renal stone disease. According to the U.S.
National Institutes of Health, 1 person in 10 develops kidney stones during their
lifetime and renal stone disease accounts for 7–10 of every 1000 hospital
admissions. Kidney stones are most prevalent in patients between the ages of 30
and 45, and the incidence declines after age 50.

Causes and Risk Factors

Several factors increase the risk for developing kidney stones, including inadequate
fluid intake and dehydration, reduced urinary flow and volume, certain chemical
levels in the urine that are too high (e.g., calcium, oxalate, uric acid) or too low
(e.g., citrate), and several medical conditions. Anything that blocks or reduces the
flow of urine (e.g., urinary obstruction, genetic abnormality) also increases the risk.

Chemical risk factors include high levels of the following in the urine:

 Calcium (hypercalciuria)
 Cystine (cystinuria; caused by a genetic disorder)
 Oxalate (hyperoxaluria)
 Uric acid (hyperuricosuria)
 Sodium (hypernatremia)

A low level of citrate is a risk factor for hypocitraturia.

The following medical conditions are also risk factors:

 Congenital kidney defect that may increase urinary calcium loss and stone
formation (medullary sponge kidney)
  Excessive parathyroid hormone, which causes calcium loss
(hyperparathyroidism)
 Gout (caused by excessive uric acid in the blood)
 High blood pressure (hypertension)
 Inflammation of the colon that causes chronic diarrhea, dehydration, and
chemical imbalances (colitis)
 Inherited condition in which the kidneys are unable to excrete acid (renal
tubular acidosis)
 Intestinal disorder that causes chronic diarrhea, dehydration, and low citrate
(Crohn's disease)
 Painful joint inflammation (arthritis)
 Urinary tract infections (affect kidney function)

Diet plays an important role in the development of kidney stones, especially in

patients who are predisposed to the condition. A diet high in sodium, fats, meat, and
sugar, and low in fiber, vegetable protein, and unrefined carbohydrates increases the
risk for renal stone disease. Recurrent kidney stones may form in patients who are
sensitive to the chemical byproducts of animal protein and who consume large
amounts of meat.

High doses of vitamin C (i.e., more than 500 mg per day) can result in high levels of
oxalate in the urine (hyperoxaluria) and increase the risk for kidney stones. Oxalate
is found in berries, vegetables (e.g., green beans, beets, spinach, squash,
tomatoes), nuts, chocolate, and tea. Stone formers should limit their intake of
cranberries, which contain a moderate amount of oxalate.

Signs and Symptoms

Small, smooth kidney stones may remain in the kidney or pass without causing pain
(called "silent" stones). Stones that lodge in the tube that carries urine from the
kidneys to the bladder (ureter) cause the urinary system to spasm and produce pain.
The pain is unrelated to the size of the stone and often radiates from the lower back
to the side or groin.

A "small" stone (usually 4 mm in diameter or less) has a 90% chance of spontaneous

passage. Stones that are 8 mm in diameter or larger usually require medical
intervention.

Other symptoms of kidney stones may include the following:

 Blood in the urine (hematuria)

 Increased frequency of urination
 Nausea and vomiting
 Pain during urination (stinging, burning)
 Tenderness in the abdomen and kidney region
  Urinary tract infection (fever, chills, loss of appetite)

Diagnosis

Diagnosis of renal stone disease involves a medical history, physical examination,

laboratory evaluation, and imaging tests. The physician determines if the patient has
a history of kidney stones, documents past medical conditions, and evaluates
present symptoms. Physical examination may be difficult if the patient is
experiencing severe pain and is unable to remain still. Lightly tapping on the kidney
region often worsens the pain. Fever may indicate a urinary tract infection that
requires antibiotics.

Laboratory tests include urinalysis to detect the presence of blood (hematuria) and
bacteria (bacteriuria) in the urine. Other tests include blood tests for creatinine (to
evaluate kidney function), BUN and electrolytes (to detect dehydration), calcium (to
detect hyperparathyroidism), and a complete blood count (CBC; to detect infection).

Imaging tests
Imaging tests used to diagnose kidney stones include ultrasound, intravenous
pyelogram (IVP), retrograde pyelogram, and computed tomography (CT) scan.

Ultrasound This test uses high-frequency sound waves to produce pictures of

internal structures (e.g., organs, kidney stones). Ultrasound can detect a dilated
(stretched) upper urinary tract and kidney caused by a stone lodged in the ureter,
but usually cannot detect small stones, especially those located outside the kidney. It
is the preferred imaging method for kidney stone patients who are pregnant.

Intravenous Pyelogram (IVP) This test involves taking a series of x-rays after
injecting a contrast agent (dye) into a vein. The contrast agent flows through the
veins, is excreted by the kidneys, and improves the x-ray images of the kidneys and
ureters. If a kidney stone is blocking a ureter, the contrast agent builds up in the
affected kidney and is excreted more slowly. Most kidney stones (e.g., calcium
stones) can be precisely located using this procedure. There is a slight risk for an
allergic reaction to the contrast agent during this procedure and overall kidney
function must be normal. IVP can take a very long time if the blockage to the kidney
is severe.

Retrograde Pyelogram A cystoscopy (i.e., a procedure in which a telescopic

instrument is inserted into the urethra) is performed to locate the opening from the
ureter to the bladder. The contrast agent is injected directly into this opening and an
x-ray is taken to locate the kidney stone.

This procedure eliminates the risk for an allergic reaction to the contrast agent
because the dye does not reach the bloodstream, but it may require anesthesia.
While retrograde pyelogram is the most reliable method for visualizing the urinary
system and detecting stones, it is generally used only when other imaging methods
are inadequate or unsuccessful.

Computerized tomography (CT Scan) This test uses a scanner and a computer to
create images of the urinary system. It is performed quickly but may have difficulty
detecting small stones located near the bladder. CT scan can also help identify
medical conditions (e.g., ruptured appendix, bowel obstruction) that cause
symptoms similar to kidney stones.

Newer scanners do not require a contrast agent. The non-contrast CT scan is the
most common imaging test used to evaluate a possible kidney stone attack. If any
stones are found, a plain abdominal x-ray is also taken to determine their size,
shape, and orientation. X-rays are used for follow-up studies to monitor the stones'
progress.

Treatment

Treatment depends on the size and type of stone, the underlying cause, the
presence of urinary infection, and whether the condition recurs. Stones 4 mm and
smaller (less than 1/4 inch in diameter) pass without intervention in 90% of cases;
those 5–7 mm do so in 50% of cases; and those larger than 7 mm rarely pass
without intervention. Patients are advised to avoid becoming sedentary, because
physical activity, especially walking, can help move a stone.

If possible, the kidney stone is allowed to pass naturally and is collected for analysis.
The patient is instructed to strain their urine to obtain the stone(s) for analysis. It
is important to analyze the chemical composition of kidney stones to determine how
to prevent recurrent stone formation. The urine may be strained using an aquarium
net or another device. Each voiding should be strained until the physician instructs
the patient otherwise.

Dietary changes may be required and fluid intake should be increased. Patients
with stones must increase their urinary output. Generally, 2000 cc of urine per day
(slightly more than 1/2 gallon) is recommended and patients should drink enough
water to produce this amount of urine daily. In some cases (e.g., some cystine stone
formers), even higher levels of fluid intake are required.

Dietary calcium usually should not be severely restricted. Reducing calcium intake
often causes problems with other minerals (e.g., oxalate) and may result in a higher
risk for calcium stone disease.

Hypercalciuria
Thiazides, water pills (diuretics), are sometimes prescribed to reduce high levels of
urinary calcium (hypercalciuria) and to increase urinary volume. Patients with
hypercalciuria who do not respond to thiazide therapy may be prescribed
orthophosphates to reduce calcium absorption and may be given dietary calcium
restrictions. Patients should not reduce their calcium intake unless their physicians
advise them to do so.

Hyperuricosuria
Patients with elevated uric acid levels (hyperuricosuria) are advised to drink 3 liters
of water a day and reduce excessive dietary protein. Potassium citrate (medication
that maintains the antacid level in urine) or allopurinol (medication that stops the
production of uric acid) may also be prescribed.
Hyperoxaluria
Hyperoxaluria (high levels of urinary oxalate) may be mild, enteric, or primary. Mild
hyperoxaluria is usually caused by an excess of dietary oxalate (found in tea,
chocolate, cola, nuts, and green leafy vegetables). Prevention consists of daily doses
of pyridoxine (vitamin B-6), which reduces oxalate excretion, increased fluids,
phosphate therapy, and sometimes, calcium citrate supplementation.

A low-oxalate, low-fat diet, increased fluid intake, and calcium supplementation is

prescribed for enteric hyperoxaluria. This rare condition is often severe and is
usually caused by an intestinal disorder (e.g., Crohn's disease, colitis). Calcium
citrate, magnesium, iron, and cholestyramine may be given to reduce oxalate levels.

Primary hyperoxaluria is rare, severe, and caused by an inherited liver disorder.

Primary hyperoxaluria requires aggressive treatment to prevent severe renal stone
disease and kidney failure. High doses of vitamin B-6, orthophosphates, magnesium
supplements, and increased fluid intake (to produce 2 liters of urine/day) are
prescribed. Rarely, kidney and liver transplants are necessary.

Hypocitraturia
Hypocitraturia (low level of urinary citrate) usually requires a prescribed supplement,
such as potassium citrate. The dosage depends on the level of urinary citrate, which
is determined by the 24-hour urine test. Patients with renal tubular acidosis usually
respond well to treatment with potassium citrate supplements. Citrus fruits and
lemon juice also can be used as supplements.

Cystinuria
Treatment for high cystine levels in the urine (cystinura) includes increasing fluid
intake and raising the pH of the urine (usually with bicarbonate). Penicillamine
(Cuprimine®) and tiopronine (Thiola®) may also be prescribed.

Medication
Over-the-counter pain relievers (e.g., aspirin, Tylenol®, Advil®) usually are not
effective for severe pain caused by kidney stones. Oral analgesics such as
acetaminophen/codeine (Tylenol with Codeine&174), propoxyphene HCL (Darvon®),
and oxycodone/acetaminophen (Percocet®) may be prescribed to minimize
moderate pain associated with stones.

Injectable medications such as morphine sulfate (Duramorph PF®), meperidine HCL

(Demerol®), and tramadol HCL (Ultram®) may be administered intravenously (IV)
or intramuscularly (by injection) for severe pain. There is a risk for dependency with
oral narcotic analgesics and a risk for accidental overdose if injectable medications
are given directly into a vein. Side effects of these medications include the
following:

 Constipation
 Drowsiness
 Nausea
 Slowed breathing (respiration)
 Vomiting

Nausea and vomiting can be reduced using medications such as prochlorperazine

edisylate (Compazine®), promethazine HCL (Phenergan®), and metoclopramide HCL
(Reglan®). Pentosan polysulfate sodium (Elmiron®) may be prescribed in severe
cases to prevent stone formation by blocking crystal formation.
Surgery

If a kidney stone does not move through the ureter within 30 days, surgery is
considered. Urologists use several procedures to break up, remove, or bypass
kidney stones.

Ureteroscopy This procedure can be used to remove or break up (fragment)

stones located in the lower third of the ureter. A fiberoptic instrument resembling a
long, thin telescope (ureteroscope) is inserted through the urethra and passed
through the bladder to the stone. Once the stone is located, the urologist either
removes it with a small basket inserted through the ureteroscope (called basket
extraction) or breaks the stone with a laser or similar device. The fragments are then
passed by the patient. Ureteroscopy is performed under general or local anesthesia
on an outpatient basis.

Lithotripsy This procedure is effective for stones in the kidney or upper ureter. It
uses an instrument, machine, or probe to break the stone into tiny particles that can
pass naturally. Lithotripsy is not appropriate for patients with very large stones or
other medical conditions.

 Ultrasonic lithotripsy uses high frequency sound waves delivered through

an electronic probe inserted into the ureter to break up the kidney stone. The
fragments are passed by the patient or removed surgically.
 Electrohydraulic lithotripsy (EHL) uses a flexible probe to break up small
stones with shock waves generated by electricity. The probe is positioned
close to the stone through a flexible ureteroscope. Fragments can be passed
by the patient or extracted. EHL requires general anesthesia and can be used
to break stones anywhere in the urinary system.
 Extracorporeal shock wave lithotripsy (ESWL) uses highly focused
impulses projected from outside the body to pulverize kidney stones
anywhere in the urinary system. The stone usually is reduced to sand-like
granules that can be passed in the patient's urine. Large stones may require
several ESWL treatments. The procedure should not be used for struvite
stones, stones over 1 inch in diameter, or in pregnant women.

Patients undergoing lithotripsy are given a sedative and general or local anesthesia,
and the procedure takes over an hour. More than one treatment may be required.

Percutaneous Nephrostolithotomy (PCN) This surgical procedure is performed

under local anesthesia and intravenous sedation. Percutaneous (i.e., through the
skin) removal of kidney stones (lithotomy) is accomplished through the most direct
route to stones through the kidney. A needle and guidewire are used to access the
stones. The surgeon then threads various catheters over the guidewire and into the
kidney and manipulates surgical instruments through the catheters to fragment and
remove kidney stones. This procedure achieves a better stone-free outcome in the
treatment of medium and large stones than shock wave lithrotripsy. This procedure
usually requires hospitalization, and most patients resume normal activity within 2
weeks.
Ureteroscopic Stone Removal This procedure is performed under general
anesthesia to treat stones located in the middle and lower ureter. A small, fiberoptic
instrument (ureteroscope) is passed through the urethra and bladder and into the
ureter. Small stones are removed and large stones are fragmented using a laser or
similar device. A small tube (or stent) may be left in the ureter for a few days after
treatment to promote healing and prevent blockage from swelling or spasm.

Open Surgery This procedure requires general anesthesia. An incision is made in

the patient's back and the stone is extracted through an incision in the ureter or
kidney. Most patients require prolonged hospitalization and recovery takes several
weeks. This procedure is now rarely used for kidney stones.

Prevention

Prevention of renal stone disease depends on the type of stone produced, underlying
urinary chemical risk factors, and the patient's willingness to undergo a long-term
prevention plan. The patient may be asked to make lifestyle modifications such as
increased fluid intake and changes in diet.

Lemonade with real lemon juice is a good source of citrate and may be
recommended as an alternative to water. Limiting meat, salt, and foods high in
oxalate (e.g., green leafy vegetables, chocolate, nuts) in the diet may also be
recommended. Medication may be prescribed and treatment for an underlying
condition that causes renal stone disease may be necessary.

24-Hour Urine Test Effective preventative measures are based on the patient's
chemical risk factors, which can often be uncovered with a 24-hour urine test and a
blood test.

1. The patient strains their urine to collect stones for chemical analysis.
2. The physician performs a blood test to evaluate the serum calcium, uric acid,
phosphate, electrolytes, and bicarbonate content.
3. Urine is collected during a 24-hour period and analyzed for calcium, citrate,
uric acid, magnesium, phosphate, sodium, oxalate, pH (acid level), and total
volume.

The physician evaluates the data and recommends dietary modifications,

supplements, and medications to minimize the risk for developing kidney stones. The
24-hour urine test may be repeated several months after treatment has begun to
determine the success of the therapy and any adjustments that should be made.
Long-term strict compliance and periodic retesting may substantially reduce the risk
for future stone formation.

Prevention

Prevention of renal stone disease depends on the type of stone produced, underlying
urinary chemical risk factors, and the patient's willingness to undergo a long-term
prevention plan. The patient may be asked to make lifestyle modifications such as
increased fluid intake and changes in diet.
Lemonade with real lemon juice is a good source of citrate and may be
recommended as an alternative to water. Limiting meat, salt, and foods high in
oxalate (e.g., green leafy vegetables, chocolate, nuts) in the diet may also be
recommended. Medication may be prescribed and treatment for an underlying
condition that causes renal stone disease may be necessary.

24-Hour Urine Test Effective preventative measures are based on the patient's
chemical risk factors, which can often be uncovered with a 24-hour urine test and a
blood test.

1. The patient strains their urine to collect stones for chemical analysis.
2. The physician performs a blood test to evaluate the serum calcium, uric acid,
phosphate, electrolytes, and bicarbonate content.
3. Urine is collected during a 24-hour period and analyzed for calcium, citrate,
uric acid, magnesium, phosphate, sodium, oxalate, pH (acid level), and total
volume.

The physician evaluates the data and recommends dietary modifications,

supplements, and medications to minimize the risk for developing kidney stones. The
24-hour urine test may be repeated several months after treatment has begun to
determine the success of the therapy and any adjustments that should be made.
Long-term strict compliance and periodic retesting may substantially reduce the risk
for future stone formation.
Naturopathic Treatment

From a naturopathic perspective, kidney stones that do not occur as a result of a

genetic or metabolic disorder are considered to be a diet-related condition. Proper
nutrition can support healthy kidney function and may discourage stone formation,
and natural therapies may help ease the pain and spasm that accompanies stone
passage. Kidney stone treatment should be undertaken only after a physician has
made a definitive diagnosis.

Nutrition

The following nutritional recommendations may help to prevent stone formation or

recurrence:

 Eat a whole foods diet that contains leafy green vegetables, fruits,
vegetables, whole grains, legumes, and fish and poultry in small portions.
Include foods that have a high ratio of magnesium to calcium such as brown
rice, bananas, oats, barley, and soy, and that are high in fiber such as oat
bran, psyllium seed husk, and flaxseed meal.
 Drink a minimum of 50% of body weight in ounces of water daily (e.g., a 150
lb person would drink 75 oz of water). Proper hydration helps prevent the
urine from becoming concentrated with crystals, which can lead to stone
formation; and reduces the risk for urinary tract infections, which may lessen
the risk for struvite stones. Urine color can indicate the level of concentration:
dark or bright yellow urine indicates highly concentrated urine; pale or
colorless urine indicates dilute urine.
 Avoid sugar (check ingredients for hidden sources of sugar), alcohol,
antacids, excessive protein, dairy products (especially milk), salt, carbonated
 beverages, caffeine, and refined white flour products such as pasta, white
bread, and baked goods.

Supplements
 Magnesium citrate–Take 500 mg daily. Low magnesium intake has been
linked to stone formation. Magnesium supplementation may decrease the size
of an existing stone and prevent further formations. Citrate supplementation
may prevent further stone formation.
 Vitamin B-6–Take 25 mg daily. A B-6 deficiency increases urinary oxalate,
which may lead to kidney stones.

Herbal Medicine

Herbal medicines usually do not have side effects when used appropriately and at
suggested doses. Occasionally, an herb at the prescribed dose causes stomach upset
or headache. This may reflect the purity of the preparation or added ingredients,
such as synthetic binders or fillers. For this reason, it is recommended that only
high-quality products be used. As with all medications, overdosing can lead to
serious illness and death.

These herbs are sometimes used to ease the discomfort associated with stone
passage:

 Bearberry (Arctostaphylos uva-ursi)–Acts as a diuretic and antiseptic for

the urinary tract.
 Cleavers (Galium aparine)–Has a history of use in treatment of congestive
kidney disorders, stones, and urinary infections.
 Corn silk (Zea mays)–A soothing demulcent with mild diuretic properties.
 Crampbark (Viburnum opulus)–Relaxes smooth muscle and is an
antispasmodic.
 Gravel root (Eupatorium purpureum)–Named for its traditional use as a
treatment for stones and gravel of the kidneys.
 Kava kava (Piper methysticum)–Has antianxiety and sedative qualities.
 Khella (Ammi visnagi)–Has a long tradition in the treatment of kidney
stones. Scientific research has demonstrated that the herb may work as a
calcium channel blocker-type antispasmodic, which targets and relaxes ureter
tissue. This may allow easier passage of small stones.
 Seven barks (Hydrangea aborescens)–Has a sedative effect on the
urinary system; used in the treatment of kidney stones.
 Stone root (Collinsonia canadensis)–Strong diuretic with a history of use
in acute and preventative treatment of kidney stones.

Homeopathy

Homeopathic medicines may be utilized by naturopathic physicians to treat the pain

and spasm associated with kidney stones. When treating the passage of a kidney
stone with homeopathy, it is important to remember that the size of the stone must
be small enough to pass without surgical intervention and that administration of the
homeopathic medicine usually changes the clinical picture, which will then require a
different remedy. Other therapies, such as herbal medicines, hot packs, and
supplements, are sometimes used with homeopathy.
The following homeopathic remedies have been utilized by naturopathic physicians in
treating a kidney stone:

 Berberis vulgaris–Indicated for sharp, stitching pains that radiate to the

groin area and right-sided kidney stones.
 Cantharis–Indicated for urine that burns and is passed drop by drop.
 Colocynthis–Indicated for pain over the whole abdomen while urinating.
 Ocimum canum–Indicated for pain accompanied by nausea and vomiting.
 Pennyroyal–Indicated for frequent urination and left-sided ureter spasm or
stone.

The standard dosage for acute symptom relief is 3 pellets of 30C every 4 hours until
symptoms resolve. Lower potencies, such as 6X, 6C, 30X, may be given every 2 to 4
hours. Symptoms may improve shortly after the second dose. If there is no
improvement after 3 doses, a different remedy is given. Note: Most homeopathic
remedies are delivered in a pellet that has a lactose (milk sugar) base. Homeopathic
liquid may be a better choice for those who are lactose intolerant.

Hydrotherapy

 Castor oil pack–Castor oil has antiinflammatory properties and may be used
to relieve painful cramping or spasms.
 Hot pack–Placed over the affected area, hot packs can relax muscles that are
tense from pain and spasm, allowing for easier passage of the stone. Use
caution in the elderly and diabetics, as they are less sensitive to heat and
may be burned.
 Hot vinegar pack–Indicated for severe pain: use a 50:50 vinegar-water
solution and place over affected area.

This hypertext document gives basic information about the prostate gland and the
condition called prostate enlargement, or benign prostatic hyperplasia (BPH). It describes
the symptoms, diagnosis, and treatment for BPH and lists sources of further reading. A
glossary of terms explaining medical words may be found at the back. The purpose of
this hypertext document is to help you discuss prostate problems with your doctor and
make choices about your medical care.

The Prostate Gland

The prostate is a walnut-sized gland that forms part of the male reproductive system
(def). The gland is made of two lobes, or regions, enclosed by an outer layer of tissue. As
the diagrams show, the prostate is located in front of the rectum (def) and just below the
bladder (def), where urine is stored. The prostate also surrounds the urethra (def), the
canal through which urine passes out of the body.
Scientists do not know all the prostate's functions. One of
its main roles, though, is to squeeze fluid into the urethra
as sperm move through during sexual climax. This fluid,
which helps make up semen (def), energizes the sperm
and makes the vaginal canal less acidic.

One of the gland's main roles is to squeeze fluid into the

urethra as sperm move through during sexual climax.

www.mdadvice.com/images/turp.gif

Normal Urinary Flow

Urine Flow with BPH

BPH: A Common Part of Aging

It is common for the prostate gland to become enlarged as a man ages. Doctors call the
condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy.

As a male matures, the prostate goes through two main periods of growth. The first
occurs early in puberty, when the prostate doubles in size. At around age 25, the gland
begins to grow again. It is this second growth phase that often results, years later, in BPH.

Though the prostate continues to grow during most of a man's life, the enlargement
doesn't usually cause problems until late in life. BPH rarely causes symptoms before age
40, but more than half of men in their sixties and as many as 90 percent in their seventies
and eighties have some symptoms of BPH.

As the prostate enlarges, the surrounding capsule stops it from expanding, causing the
gland to press against the urethra (def) like a clamp on a garden hose. The bladder (def)
wall becomes thicker and irritable. The bladder begins to contract even when it contains
small amounts of urine, causing more frequent urination (def). As the bladder weakens, it
loses the ability to empty itself, and urine remains behind. This narrowing of the urethra
and partial emptying of the bladder cause many of the problems associated with BPH.

Many people feel uncomfortable talking about the prostate, since the gland plays a role in
both sex and urination. Still, prostate enlargement is as common a part of aging as gray
hair. As life expectancy rises, so does the occurrence of BPH. In the United States alone,
350,000 operations take place each year for BPH.

It is not clear whether certain groups face a greater risk of getting BPH. Studies done
over the years suggest that BPH occurs more often among married men than single men
and is more common in the United States and Europe than in other parts of the world.
However, these findings have been debated, and no definite information on risk factors
exists.

Why BPH Occurs

The cause of BPH is not well understood. For centuries, it has been known that BPH
occurs mainly in older men and that it doesn't develop in males whose testes (def) were
removed before puberty. For this reason, some researchers believe that factors related to
aging and the testes may spur the development of BPH.

Throughout their lives, men produce both testosterone, an important male hormone (def),
and small amounts of estrogen, a female hormone. As men age, the amount of active
testosterone in the blood decreases, leaving a higher proportion of estrogen. Studies done
with animals have suggested that BPH may occur because the higher amount of estrogen
within the gland increases the activity of substances that promote cell growth.

Another theory focuses on dihydrotestosterone (DHT), a substance derived from

testosterone in the prostate, which may help control its growth. Most animals lose their
ability to produce DHT as they age. However, some research has indicated that even with
a drop in the blood's testosterone level, older men continue to produce and accumulate
high levels of DHT in the prostate. This accumulation of DHT may encourage the growth
of cells. Scientists have also noted that men who do not produce DHT do not develop
BPH.

Some researchers suggest that BPH may develop as a result of "instructions" given to
cells early in life. According to this theory, BPH occurs because cells in one section of the
gland follow these instructions and "reawaken" later in life. These "reawakened" cells
then deliver signals to other cells in the gland, instructing them to grow or making them
more sensitive to hormones that influence growth.

Symptoms

Many symptoms of BPH stem from obstruction of the urethra (def) and gradual loss of
bladder (def) function, which results in incomplete emptying of the bladder. The
symptoms of BPH vary, but the most common ones involve changes or problems with
urination (def), such as:
 a hesitant, interrupted, weak stream
 urgency and leaking or dribbling
 more frequent urination, especially at night.

The size of the prostate does not always determine how severe the obstruction or the
symptoms will be. Some men with greatly enlarged glands have little obstruction and few
symptoms while others, whose glands are less enlarged, have more blockage and greater
problems.

Sometimes a man may not know he has any obstruction until he suddenly finds himself
unable to urinate at all. This condition, called acute urinary retention, may be triggered by
taking over-the-counter cold or allergy medicines. Such medicines contain a decongestant
drug, known as a sympathomimetic, which may, as a side effect, prevent the bladder
opening from relaxing and allowing urine to empty. When partial obstruction is present,
urinary retention also can be brought on by alcohol, cold temperatures, or a long period
of immobility.

It is important to tell your doctor about urinary problems such as those described above.
In 8 out of 10 cases, these symptoms suggest BPH, but they also can signal other, more
serious conditions that require prompt treatment. These conditions can be ruled out only
by a doctor's exam.

Severe BPH can cause serious problems over time. Urine retention and strain on the
bladder can lead to urinary tract (def) infections, bladder or kidney damage, bladder
stones, and incontinence (def). If the bladder is permanently damaged, treatment for BPH
may be ineffective. When BPH is found in its earlier stages, there is a lower risk of
developing such complications.

Diagnosis

You may first notice symptoms of BPH yourself, or your doctor may find that your
prostate is enlarged during a routine checkup. When BPH is suspected, you may be
referred to a urologist, a doctor who specializes in problems of the urinary tract (def) and
the male reproductive system (def). Several tests help the doctor identify the problem and
decide whether surgery is needed. The tests vary from patient to patient, but the following
are the most common:

Rectal Exam

This exam is usually the first test done The doctor inserts a gloved finger into the
rectum (def) and feels the part of the prostate next to the rectum. This exam gives
the doctor a general idea of the size and condition of the gland.

Ultrasound

If there is a suspicion of prostate cancer, your doctor may recommend a test with
rectal ultrasound (def). In this procedure, a probe inserted in the rectum directs
sound waves at the prostate. The echo patterns of the sound waves form an image
of the prostate gland on a display screen.

Urine Flow Study

Sometimes the doctor will ask a patient to urinate into a special device which
measures how quickly the urine is flowing. A reduced flow often suggests BPH.

Intravenous Pyelogram (IVP)

IVP is an x-ray of the urinary tract (def). In this test, a dye is injected into a vein,
and the x-ray is taken. The dye makes the urine visible on the x-ray and shows
any obstruction or blockage in the urinary tract.

Cystoscopy

In this exam, the doctor inserts a small tube through the opening of the urethra
(def) in the penis. This procedure is done after a solution numbs the inside of the
penis so all sensation is lost. The tube, called a cystoscope, contains a lens and a
light system, which help the doctor see the inside of the urethra and the bladder
(def). This test allows the doctor to determine the size of the gland and identify
the location and degree of the obstruction.

Treatment

Men who have BPH with symptoms usually need some kind of treatment at some time.
However, a number of recent studies have questioned the need for early treatment when
the gland is just mildly enlarged. These studies report that early treatment may not be
needed because the symptoms of BPH clear up without treatment in as many as one-third
of all mild cases. Instead of immediate treatment, they suggest regular checkups to watch
for early problems. If the condition begins to pose a danger to the patient's health or
causes a major inconvenience to him, treatment is usually recommended.

Since BPH may cause urinary tract (def) infections, a doctor will usually clear up any
infection with antibiotics before treating the BPH itself. Although the need for treatment
is not usually urgent, doctors generally advise going ahead with treatment once the
problems become bothersome or present a health risk. The following section describes
the types of treatment that are most commonly used for BPH.

Surgical Treatment

Most doctors recommend removal of the enlarged part of the prostate as the best long-
range solution for patients with BPH. With surgery for BPH, only the enlarged tissue that
is pressing against the urethra (def) is removed; the rest of the inside tissue and the
outside capsule are left intact. Surgery usually relieves the obstruction and incomplete
emptying caused by BPH. The following section describes the types of surgery that are
used.

Transurethral Surgery. In this type of surgery, no external incision is needed. After

giving anesthesia (def), the surgeon reaches the prostate by inserting an instrument
through the urethra.

A procedure called TURP (transurethral resection of the prostate) is used for 90 percent
of all prostate surgeries done for BPH. With TURP, an instrument called a resectoscope is
inserted through the penis. The resectoscope, which is about 12 inches long and 1/2 inch
in diameter, contains a light, valves for controlling irrigating fluid, and an electrical loop
that cuts tissue and seals blood vessels.
 Transurethral Resection of the Prostate

During the 90-minute operation, the surgeon uses the resectoscope's wire loop to remove
the obstructing tissue one piece at a time. The pieces of tissue are carried by the fluid into
the bladder (def) and then flushed out at the end of the operation.

Although this procedure is delicate and requires a skilled surgeon, most doctors suggest
using TURP whenever possible. Transurethral procedures are less traumatic than open
forms of surgery and require a shorter recovery period.

Another surgical procedure is called transurethral incision of the prostate (TUIP). Instead
of removing tissue, as with TURP, this procedure widens the urethra (def) by making a
few small cuts in the bladder neck, where the urethra joins the bladder, and in the prostate
gland itself. Although some people believe that TUIP gives the same relief as TURP with
less risk of side effects such as retrograde ejaculation (def), its advantages and long-term
side effects have not been clearly established.

Open Surgery. In the few cases when a transurethral procedure cannot be used, open
surgery, which requires an external incision, may be used. Open surgery is often done
when the gland is greatly enlarged, when there are complicating factors, or when the
bladder has been damaged and needs to be repaired. The location of the enlargement
within the gland and the patient's general health help the surgeon decide which of the
three open procedures to use.

With all the open procedures, anesthesia (def) is given and an incision is made. Once the
surgeon reaches the prostate capsule, he scoops out the enlarged tissue from inside the
gland.

Laser Surgery. Some researchers are exploring the use of lasers to vaporize obstructing
prostate tissue. Early studies suggest that this method may be as effective as conventional
surgery.

Your Recovery After Surgery In the Hospital

Following surgery, you'll probably stay in the hospital from 3 to 10 days depending on
the type of surgery you had and how quickly you recover.

At the end of surgery, a special catheter (def) is

inserted through the opening of the penis to drain urine
from the bladder (def) into a collection bag. Called a
Foley catheter, this device has a water-filled balloon
on the end that is placed in the bladder, which keeps it
in place.

This catheter is usually left in place for several days.

Sometimes, the catheter causes recurring painful

Foley Catheter
bladder spasms the day after surgery. These may be difficult to control, but they will
eventually disappear.

You may also be given antibiotics while you are in the hospital. Many doctors start giving
this medicine before or soon after surgery to prevent infection. However, some recent
studies suggest that antibiotics may not be needed in every case, and

Kidney cancer
Diagnosis

If the physician suspects RCC, a series of examinations, procedures, and laboratory

tests are performed to confirm the diagnosis. A thorough physical examination is
performed to assess the patient's health and obtain information about symptoms and
a medical history is taken to determine if there are risk factors for RCC.

Imaging Tests
One or more imaging tests are performed to obtain pictures of the kidney(s) and
locate abnormalities. Some imaging tests require the injection of a special "tracer"
material (dye or low-level radioactive isotope) into the patient's bloodstream.

Computed tomography (CT scan)

CT scan is a type of x-ray that produces a series of cross-sectional, three-
dimensional images of internal organs and glands. It can detect tumors and, in some
cases, lymph nodes enlarged by cancer.

Magnetic resonance imaging (MRI scan)

An MRI scan uses large magnets to project magnetic waves through the body and
create computer-generated, cross-sectional images of internal organs.

Ultrasound
Ultrasound uses sound waves projected into the body to produce an image of
internal organs, structures, and tumors. In this procedure, a gel is applied to the
patient's pelvic and kidney areas, and a small device that emits ultrasonic pulses is
slowly passed over the area. The sonic image produced is viewed on a monitor.

Intravenous pyelogram (IVP)

An intravenous pyelogram (IVP) involves injecting a dye containing iodine through a
vein in the arm into the bloodstream. The dye eventually collects in the urinary
system, where it improves the contrast for x-rays and produces a well-defined image
of the kidneys, ureters, and bladder. By showing up as white on the dark x-ray film,
the IVP can detect tumors or damage caused by a tumor in the kidney.
In some cases, the physician may request an arteriogram or venacavagram (IVP of
the blood vessels that supply the kidneys) to look for tumors in the connecting
arteries and veins.

Chest x-ray
A standard chest x-ray may be used to detect RCC that has has spread
(metastasized) to the lungs or bones in the chest.

Bone scan
This nuclear imaging procedure is used to detect the spread (metastasis) of cancer
to bones, when aggressive tumors and metastasis are suspected. In a bone scan, a
small amount of low-level radioactive material is injected into a vein in the arm. This
material discloses metastatic cancer, as well as some noncancerous diseases, in
bones.

Laboratory tests
One or more laboratory tests are performed to confirm the presence of RCC.

Urinalysis
More than half of all patients with RCC have blood in the urine (hematuria). Often
this blood is present in small amounts or diffused in the urine so that it cannot be
seen with the naked eye (called microscopic hematuria). To detect hematuria, a
chemical test of the urine is performed. On occasion, cells found in the urine are
examined under a microscope for abnormalities. This procedure is called urine
cytology.

Blood tests
Another laboratory procedure typically used in the diagnosis of RCC involves
microscopic examination and/or chemical analysis of the patient's blood. These tests
screen for the following conditions which may indicate the presence of cancer:

 Anemia (too few red blood cells; caused by internal bleeding, a common
cancer symptom)
 Polycythemia (too many red blood cells; sometimes caused by cancerous
tumors in the kidney that trigger the release of erythropoitin [EPO], a
hormone that increases red blood cell production in bone marrow)
 Hypercalcemia (high blood calcium levels) and elevated liver enzymes

Cystoscopy
Blood in the urine can result from other health problems, such as kidney stones or
traumatic kidney injury, so the doctor may order a cystoscopy to determine precisely
where the internal bleeding is occurring. In cystoscopy, a long, thin, rigid or flexible
optical scope is inserted through the urethra and into the bladder. The practitioner
then makes a visual examination of the urethra, bladder, and kidneys to locate the
site of bleeding.

Fine needle aspiration

RCC tumors are made up of cancerous (malignant) cells that grow into a mass. If a
tumor is found through imaging or other procedures, a cell sample may be taken for
microscopic examination.
Physicians usually avoid performing needle biopsies of suspected kidney tumors
because of the risk for bleeding or other complications. Some tumors contain a fluid-
filled cyst. A small amount of this fluid can be drawn out of the cyst for examination
by a pathologist, who will look for and identify the cancer cells. This can help the
physician determine an appropriate treatment plan. While no longer common, a
similar technique can be used to collect a sample of solid tissue from a noncystic
tumor.

Pathology
Cells that make up RCC tumors fall into four categories based on their appearance
under microscopic examination:

 Clear cell
 Granular cell
 Mixed clear and granular
 Sarcomatoid or spindle type

Most studies suggest that the type of cancer cell indicates the relative
aggressiveness of the disease.

Under a microscope, clear cell cancers are the least abnormal. They are round or
polygon-shaped and contain an abundance of fat and sugar. The tumors they
produce are yellow to orange in color. Clear cell cancers are thought to be the least
likely to spread (aggressive) and usually respond more favorably to treatment.

Few tumors contain only clear cells, however. Darker granular cells usually are
present to some degree. These have a larger, darker nucleus and are full of tiny pink
granules called mitochondria. The tumors they produce tend to be gray to white in
color. Mitochondria are small, oval bodies that provide energy for cell growth. Their
presence indicates a more aggressive form of cancer.

Tumors that contain both clear and granular cells are considered mixed. This is the
most common form of RCC and indicates the most aggressive form of kidney cancer.

Mixed tumors that contain spindle shaped, sarcomatoid cells have the least
favorable prognosis. Although tumors composed exclusively of spindle cells are
uncommon, the presence of sarcomatoid cells indicates a form of cancer that grows
and spreads quickly.

The grade of a cancer cell is an assessment of its appearance compared to that of a

normal, healthy cell. Grading is done on a scale of 1 to 4: Grade 1 RCC cells differ
little from normal kidney cells, typically spread slowly, and have a good prognosis for
treatment. Grade 4 RCC cells look extremely different and indicate an aggressive
cancer with poor prognosis.

Staging

Although grading and the identification of cancer cell types help determine a
patient's prognosis, most doctors believe that the cancer's stage is a better indicator
of a patient's survivability.
Staging allows a physician to gauge the size and location of tumors by using
information gathered from imaging studies such as CT scans and MRIs, and from
pathology tests and physical examinations.

Staging factors that influence a patient's prognosis are:

 Spread to tissues surrounding the kidney

 Spread to contiguous organs
 Spread to nearby lymph nodes (the small, bean-shaped structures found
throughout the body that produce and store infection-fighting cells)
 Distant metastasis

There are two staging systems for RCC, Robson and TNM.

The Robson system classifies tumors as stages.

Stage The tumor is confined to the kidney and does

I not involve the capsule of tissue that surrounds
the kidney
Stage The tumor extends through the capsule of the
II kidney
Stage The tumor involves lymph node(s) or extends
III into the renal vein (the main blood vessel that
carries blood from the kidney) or inferior vena
cava (the large vein that drains blood back to
the heart)
Stage The tumor has invaded organs adjacent to the
IV kidney (e.g., pancreas or bowel) or shows
evidence of distant spread to organs such as
the lungs

The TNM (tumor-node-metastasis) system uses stages generally similar to those

of the Robson system. This staging system is becoming more widely accepted
because it provides a more detailed description of the tumor(s).

The TNM system stages RCC tumors at four intervals:

Stage Small tumors (less than 1 inch) without

I evidence of local invasion; no lymph node
involvement and absence of distant disease
Stage Tumors larger than 1 inch without evidence of
II local invasion; no lymph node involvement and
absence of distant disease
Stage Tumors of any size that involve one lymph node
III (less than 1 inch); tumors that invade the
adrenal gland or surrounding renal tissues;
tumors that invade the renal vein or the inferior
vena cava
Stage A mixed group including tumors that invade
IV adjacent structures; any tumor that has
evidence of distant spread; any tumor in which
 more than one lymph node is involved

The TNM system also uses alphanumeric subcategories to define areas and degrees
of invasion. These are as follows:

Primary tumor (T); all sizes measured in greatest dimension:

TX Primary tumor cannot be assessed.

T0 No evidence of primary tumor.
T1 Tumor 7 centimeters (cm) or less, limited to the kidney.
T2 Tumor more than 7 cm, limited to the kidney.
T3 Tumor extends into major veins or invades the adrenal gland or
surrounding tissue, but not beyond the Gerota's fascia (the fibrous tissue
surrounding the kidney that separates it from adjacent musculature).
T3a - Tumor invades the adrenal gland or surrounding tissue, but not
beyond the Gerota's fascia.
T3b - Tumor grossly extends into the renal vein or veins (the main blood
vessels that carry blood from the kidney) or the vena cava (the large
vein that drains blood back to the heart).
T4 Tumor invades beyond the Gerota's fascia.

Regional lymph nodes (N):

NX Regional lymph nodes cannot be assessed.

N0 No regional node metastasis.
N1 - Metastasis in a single regional lymph node.
N2 Metastasis in more than one regional lymph node.

Distant metastasis (M):

MX Presence of metastasis cannot be assessed.

M0 No distant metastasis present.
M1 Distant metastasis present.

Stephan L. Werner, MD F.A.C.S.

Benign Prostatic Hypertrophy, also known as BPH, is a virtually universal

overgrowth of the prostate gland in men as they age. Various factors affecting
BPH are age, genetic makeup, testosterone levels, and environment. It can
start in men's 20's but usually does not cause problems until middle age. It is
not related to either Prostate Cancer, (PCa), or prostatitis.

What is BPH? The prostate gland lies below the bladder and
surrounds the urethra, or urine tube. The prostate has little
function in humans other than supporting the urethra and some
of the sperm ducts.
<click to enlarge

What are the symptoms of BPH? As the prostate enlarges it compresses

the urethra causing obstruction to urine flow. The urinary stream becomes
smaller, there may be difficulty in initiating the stream, (hesitancy), dribbling,
intermittent flow, frequency of urination, getting up at night to void,
(nocturia), inability to empty, or even inability to void at all, (retention). BPH
can also be the cause of urinary tract infections.

How is BPH Evaluated? The Urologist will take a history, frequently asking
the patient to fill out an AUA Symptom Score, do a physical examination
including a digital rectal examination, (DRE), and then perform some of the
following tests:

Urinalysis to determine the presence of infection or bleeding

PSA a blood test to help determine the need for cancer evaluation
Uroflow to measure the rate and volume of flow
Bladder residual urine by catheter or sonogram to see if the bladder
empties completely.
Cystoscopy to look inside the bladder, urethra and prostate with a
telescope.

How is BPH Treated? Once the diagnosis of BPH has been made, and
infection or prostatitis treated, there are several options for treatment. If the
symptoms are mild and there is no significant retention, the patient may be
observed with reevaluation every 6 to 12 months. However, when the flow is
very slow, the symptoms are great, and especially when retention reaches 100
cc, (3-4 oz.), treatment becomes necessary.
When a patient cannot void at all, acute urinary retention, a catheter is
inserted for several days, treatment may be instituted, and the a trial of
voiding given. If the patient is able to void, and empty well no treatment or
continuing medical treatment is appropriate. When greater symptoms and/or
retention exist, medical or surgical therapy is indicated. Some patients may
have had blockage for so long that they have caused kidney damage, and may
require a catheter for several weeks to allow the kidneys to regain whatever
function remains before definitive surgical therapy.

Medical Treatment of BPH There are two forms of medical treatment for
BPH: a series of drugs called alpha blockers relaxes the muscles within the
prostate and bladder neck, allowing the flow of urine to improve; a second
family of medication, 5-alpha reductase inhibitors, will cause some large
prostates to shrink and thereby improve flow , although the action is slow and
maximum response may take 6-12 months to achieve. The herbal saw palmetto
is a biologic 5-alpha reductase inhibitor.
There are four drugs in the alpha blocker family: terazocin/Hytrin™,
doxasacine/Cardura™ , tamulosin/Flomax™ and alfuzacin/Uroxatrol™. The first
two are also antihypertensives, so they can be used to treat two conditions,
they require dose titration, may take several weeks to reach maximum dose
effectiveness and are available as generics. Flomax and Uroxatrol are
selective, working predominantly on the prostate and bladder neck muscles,
and work in several days. Side effects for all four may include dizziness,
decreased erections and retrograde ejaculations, (dry orgasms). In some
patients the prostate will continue to grow and some patients will require
increasing doses of medication, addition of other drugs or surgical intervention
over time.
Finasteride/Proscar™ and dutasteride/Avodart™ are the 5-alpha
reductase inhibitors available and will slowly shrink prostates. They take about
3 to 6 weeks to begin to have an effect , and may take 3-6 months to reach
maximum effect. They will only have an effect on larger prostates, and are
effective in about a third of patients. The herbal, saw palmetto works in a
similar fashion, but as an herbal is less well controlled. Decreased sexual
functioning and increased hair growth, (Rogaine™ is finasteride), may affect a
minority of patients on 5-alpha reductase inhibitors. 5-alpha reductase
inhibitors artificially lowers PSA, the prostate cancer blood test. So if you
are taking one of these you must let your doctors know, so that they can
take it into account when doing your prostate cancer check!

Surgical Treatment of BPH There are three forms of surgical treatment

for BPH: TURP/PVP Laser, minimally invasive procedures and open surgery.
Over the past several years there has been a boom in treatment modalities for
BPH.

TURP or transurethral resection of the prostate, (known euphemistically as

"roto-rooter"), remains the gold standard for treatment of significant BPH. A
specialized telescope, called a resectoscope, is inserted under anesthesia, into
the urethra, and the overgrown prostate tissue is cut away from the inside
using electric current. The urethral lining is removed during this process, but
will regrow over several months. Results in terms of rate of urine flow, and
long term effectiveness is the best of all the procedures available. It
frequently requires a short hospital stay. Results are seen immediately, and
complications can include bleeding, infection, incontinence, scarring and
stricture and infrequently a decrease in potency. Dry ejaculations are
common. It is uncommon to require a repeat TURP during ones lifetime.
The new (2003) high power Laserscope, PVP Green Light laser is very
similar to a TURP, but by using laser there is virtually no bleeding and patients
frequently go home the same day, most without a catheter. It is the only
procedure approved for patients on anticoagulants or blood thinners. The
procedure is usually not done in the doctor's office, but in the hospital
outpatient department or surgicenter. Laserscope, Dr. Werner is a national
instructor for the PVP laser.

Minimally invasive procedures include a family of procedures that destroy

islands of tissue within the prostate using different forms of energy: laser,
microwave, radio-frequency waves, or ultrasound. The procedures go under
the various names of Indigo Laser, TUNA, TUMT, Prostatron, etc. An energy
source is inserted through a cystoscope into the prostate, and when the energy
is turned on, it coagulates an olive shaped volume of tissue. This may be done
to multiple areas in the prostate. The coagulated tissue is slowly absorbed by
the body, opening up the urinary channel. The procedures are usually done as
outpatient procedures. A catheter must remain in for several days to a month
or two, as the prostate swells up after the procedure, and the tissue is
absorbed slowly. Maximum effectiveness is seen in 3 to 6 months. The
improvement in flow rates is less than with TURP or PVP Laser. The durability
of the results has not yet been fully determined but repeat procedures after
several years are not uncommon. Bleeding, infection and scarring can occur.
Dry or retrograde ejaculation or decreased potency is not common, but does
occur.
A newer minimally invasive procedure,
Thermodilation or Prolieve™ combines TUMT
with balloon dilation of the prostate, an older
technology that afforded a rapid but short lived
improvement in voiding. This procedure is
usually done in the urologist's office under sedation, takes about an hour. Most
patients are able to void right after the procedure, though a few require a
short term catheter. The long term results are equivalent to the other
minimally invasive procedures. As the balloon dilation slowly fails over several
months, the TUMT is improving flow, so there does not appear to be a change
during the healing process. At the present time this is our preferred minimally
invasive technique. Thermodilation/Prolieve

Cryotherapy or freezing is another minimally invasive procedure for

obstructive BPH. Similar to the heat induced treatments, an iceball is formed
within the prostate, and the destroyed tissues slowly sloughs. A catheter is
frequently needed, and rates of impotence are high.
Open surgery for BPH is relatively rare but is sometimes needed for
very large prostate glands. The procedure requires a hospital stay. Results are
usually good an seen shortly after surgery. Complications include, bleeding,
infection, scarring, retrograde ejaculation, incontinence and occasionally,
impotence among others. However for most patients requiring an open
prostatectomy, there is no good alternative.
Rev: 07/05 Stephan Werner, M.D., F.A.C.S.

www.vrp.com/art/1057.asp
Benign Prostatic Hypertrophy
'
Ward Dean, MD

Few men ever consider the walnut-sized fibrous gland located just below the bladder,
until it starts to give them trouble. In fact, a 1995 survey in the London Times found that
89 percent of the men surveyed did not know where the prostate was located. After the
age of 50, the prostate begins to hypertrophy, or increase in size. This is known as benign
prostatic hypertrophy (BPH). The urethra (the tube that carries urine from the bladder)
runs through the middle of the prostate. Consequently, when the prostate enlarges the
urethra is compressed. (Fig. 1) This causes difficulty in urinating and requires many men
to get up three or four times during the night to urinate. Other symptoms of BPH include
hesitancy, dribbling, reduced force of the urinary stream, and occasional bleeding or
infection. This condition may even proceed to the point of complete urinary obstruction.
Fifty to sixty percent of men between 40-60 years of age suffer from BPH, escalating to
75 percent of men by age 60 (Fig. 2).1 The projected annual cost of hospital care and
surgical treatment for BPH in the United States is over $1 billion. In fact, this condition is
so common that physicians routinely ask their over-50 male patients, not “whether” but
“How many times do you have to get up at night to go to the bathroom?” I wonder how
many men have seen the cartoon character “Calvin” on the back of a truck windshield
urinating from one side of the vehicle to the other and said secretly to themselves, “I wish
I could still do that?”
Causes of Prostatic Enlargement
Prostate hypertrophy and inflammation are believed to be due to the consequences of a
number of age-related changes in the metabolism and levels of male steroid hormones.2
After the age of fifty, the level of free testosterone decreases, while levels of prolactin,
estradiol, and sex hormone-binding globulin (SHBG) increase. Concentrations of
dihydrotestosterone (DHT)— the active metabolite of testosterone—in the prostate
increase, and binding of DHT to prostate tissue increases. DHT stimulates the prostate
cells to enlarge, resulting in the swollen gland.

5-alpha reductase is the enzyme that converts testosterone into DHT. Consequently, one
approach to preventing BPH has been to use substances that inhibit this enzyme, thereby
blocking the formation of DHT, and its prostate-enlarging effect. Estrogen also seems to
play a role in BPH by inhibiting the breakdown and removal of testosterone and DHT.
The increased ratio of plasma estrogen/testosterone is due to the increased formation of
estrogens formed by the conversion of androstenedione to estrone and estradiol by the
enzyme, aromatase. Another approach to preventing or treating BPH is, therefore, to use
aromatase inhibitors to prevent this estrogenic conversion.

Therapeutic Options for BPH

Until recently, outside of “watchful waiting,” surgery was about the only solution for this
troublesome condition. Fortunately, less invasive and more physiological approaches to
prevent and treat BPH are now available, based on our increased understanding of its
causes. Clearly, a rational approach should include: (1) normalization of prostate nutrient
levels; (2) restoration of steroid hormones to normal levels; (3) inhibition of excessive
conversion of testosterone to DHT (dihydrotestosterone); (4) reduction of DHT receptor
binding; and (5) reduction of prostatic inflammatory promoters such as prolactin.

Proscar® is a prescription drug which inhibits 5-alpha reductase. This drug has recently
been introduced into the physician’s armamentarium for treatment of BPH. Use of
Proscar results in a 20 percent decrease in prostate size in 50 percent of the men who are
treated. Unfortunately, Proscar is fairly expensive, with the significant side effect of
sexual dysfunction.2 Fortunately, however, there are nutritional alternatives which
provide, without adverse effects, equivalent or greater benefits at reduced cost.

Saw Palmetto (Serenoa repens)

Extracts of saw palmetto berry are being used extensively throughout the world for the
relief of BPH. Both the French and German governments approve lipo-philic extracts of
saw palmetto berries for this purpose. Saw palmetto reduces prostate hypertrophy by
blocking the conversion of testosterone to dihydrotestosterone by inhibiting 5-alpha
reductase—just like its expensive prescription “cousin”—and by preventing the binding
of DHT to androgen receptor cell sites. These actions increase the breakdown and
excretion of DHT. Saw palmetto also interferes with the actions of inflammatory
substances that contribute to prostate inflammation and reduces the pro-hypertrophic
effects of estrogen and progesterone on the prostate.3-6

Positive results with saw palmetto have been confirmed in numerous open8-14 as well as
double-blind, placebo-controlled clinical trials.15-19 All of these studies demonstrated
statistically significant improvements in the symptoms of BPH, which included increased
volume and rate of urine flow, alleviation of pain and night time urination, and reduced
number of voidings per day. Overall, these studies showed a consistent benefit of saw
palmetto extract, with virtually no side effects of any consequence. A striking
characteristic of these studies is that most subjects experienced relief within days of
beginning the therapy, with benefits continuing to improve over time — in many cases, as
much as one year of continuing improvement! Most studies however, were terminated
after 30, 60 or 90 days. “A striking characteristic of these studies is that most subjects
experienced relief within days of beginning the therapy, with benefits continuing to
improve over time, in many cases, as much as one year of continuing improvement!”

Most recently, University of Chicago researchers studied the effects of saw palmetto
extract versus placebo on 85 men, 45 years of age or older.20 The researchers evaluated
the subjects based upon three measurements: the International Prostate Symptom Score, a
sexual function questionnaire, and the urinary flow rate. At the end of the study, the
subjects treated with saw palmetto experienced significant improvement and reduction of
symptoms such as frequent urination both during the night and day and interruptions in
urination. The researchers stated that their study provides the most conclusive evidence to
date that saw palmetto can benefit men with prostate problems.

Of particular interest was a study that compared Proscar with saw palmetto extract that
found that saw palmetto had fewer side effects, provided an equivalent or greater benefit,
and was a more affordable form of treatment.21,22 The optimum dose of saw palmetto in
most clinical studies was 320 mg per day.

Pygeum Africanum
Extracts of the African herb Pygeum africanum have also shown impressive results in
relieving symptoms of BPH. The action of pygeum extract in counteracting prostate
hypertrophy is believed to be due to a number of mechanisms, which include its ability
to: (1) inhibit the basic fibroblast growth factor induced cellular proliferation;23 (2)
inhibit aromatase;24 (3) restore secretory activity of the prostatic epithelium;25 and (4)
increase prostatic secretions.26

In one study, 18 patients with BPH or chronic prostatitis, many of whom also had sexual
disturbances, received an extract of pygeum. After 60 days, all urinary parameters that
were investigated were improved, and sexual disturbances were relieved.27 In a placebo-
controlled French trial of 120 patients, the pygeum group experienced significant
reductions in the number of urinations and more complete bladder emptying than the
placebo group.28

An international, multi-center, double-blind, controlled trial of pygeum extract in 263

patients with BPH over a 60 day period showed improved urinary symptoms in 66
percent of the patients.29 Italian placebo-controlled studies confirmed these benefits.23-
25 Most of the clinical studies with pygeum used dosages ranging from 75-150 mg per
day.

Stinging Nettle (Urtica dioica)

Extracts of stinging nettle are used routinely in Europe to treat BPH. Stinging nettle
shares several mechanisms with Pygeum and saw palmetto, but has several actions that
are unique. The known mechanisms of stinging nettles on the prostate include its ability
to: (1) inhibit aromatase;30 (2) reduce the binding activity of SHBG;31,32 (3) inhibit
prostate membrane Na+, K+-ATPase activity;33 (4) block epidermal growth factor
receptors;34 and (5) block 5-alpha reductase.35
Stinging nettle has been tested and found to be effective in BPH as a single nutrient,36-39
or in combination with Pygeum.40 Extracts of stinging nettle when used alone were
superior to placebo, but efficacy was enhanced when combined with Pygeum. The
dosages of stinging nettle in the clinical studies was 300 mg per day.

Beta Sitosterol
Beta-sitosterol, one of the main subcomponents of a group of plant sterols known as
phytosterols, is a white, waxy substance with a chemical structure very similar to that of
cholesterol. Research into beta-sitosterol has shown beneficial effects against a wide
variety of human ailments, including BPH. Beta sitosterol is the key ingredient in a
prescription formulation in Europe, Azuprostat-beta-sitosterol, which has been
demonstrated to improve prostate symptom scores and quality of life, and reduce urine
volume and residual urine levels. The research team reported that “beta-sitosterol itself is
an effective option in the treatment of BPH.”41 Beta-sitosterol was also found to reduce
the growth of human prostate cancer cells,42 and appears to be one of the key compounds
in soybeans that suppresses carcinogenesis.43

Lycopene
More than 500 types of carotenoids exist in nature. The most common carotenoids
include alpha carotene, beta carotene, lycopene, lutein, and beta cryptoxanthin.
In one study, a group of scientists evaluated prostate cancer risk in comparison to dietary
intake of specific carotenoids. They found that of 43 fruits and vegetables examined, only
tomato-based products (tomato sauce, tomatoes, and pizza—but not tomato juice) and
strawberries were found to be protective against prostate cancer. The researchers
attributed the protective effect of these tomato-based foods to their high lycopene content.

Lycopene is highly lipophilic (fat soluble) and requires fat for proper intestinal
absorption. This is probably the reason for the lack of efficacy of tomato juice.
Strawberries are not a good source of lycopene, and the reason for the protective effect of
strawberries was not known. Thus, it would seem reasonable to include a high
concentration of tomato-based foods (or a lycopene supplement) and strawberries in a
prostate cancer preventive nutritional program.

Although researchers believed that tomato-based products may help prevent prostate
cancer, they now have evidence that lycopene may also benefit patients already suffering
from the disease. A study in the December 19, 2001 Journal of the National Cancer
Institute, reported on 32 men with prostate cancer who were about to undergo radical
prostatectomy.44 They began a three-week diet of pasta with tomato sauce–the equivalent
of roughly 30 mg of lycopene daily–prior to their surgery. This resulted in markedly
increased prostate lycopene concentrations, accompanied by a 21.3 percent reduction in
leukocyte oxidative DNA damage. In addition, serum PSA levels (a marker for prostate
cancer) dropped 17.5 percent, from a mean of 10.9 ng/mL before the diet to 8.7 ng/mL
after the diet. Another impressive result of the study was the rate that DNA damage
declined in the patients consuming diets high in lycopene. Oxidative DNA damage in
prostate tissue from the men consuming high-lycopene diets was 28.3 percent less than in
tissue samples from seven randomly selected prostate cancer patients not consuming a
high-lycopene diet.

Most recently, Giovanucci reviewed eight epidemiological studies which reported that
those with the highest tomato or lycopene consumption had a 30 percent to 40 percent
reduction in prostate cancer risk.45 The largest study, in male health professionals, found
that consumption of two to four servings of tomato sauce per week was associated with
about a 35 percent reduction of total prostate cancer and a 50 percent reduction of
advanced (extraprostatic) prostate cancer. In the largest study of blood lycopene levels,
very similar risk reductions were observed for total and advanced prostate cancer. Those
with the highest lycopene levels had the lowest incidence of prostate cancer.

Conclusion
Beta Sitosterol, and extracts from Saw palmetto, Pygeum africanum, and Stinging nettle
have all demonstrated efficacy when used in the treatment and prevention of benign
prostatic hypertrophy (BPH). Because of their multiplicity of actions, it should be no
surprise that when these phytonutrients are combined, they are even more effective than
when used individually. Combined with the prostate cancer-protecting carotenoid
lycopene (and beta sitosterol), men no longer need to consider the years over 50 as “The
Prostatic Age.”
http://www.surgical-tutor.org.uk/default-home.htm?
system/abdomen/jaundice.htm~right
Obstructive jaundice

Aetiology of obstructive jaundice

 Common
o Common bile duct stones
o Carcinoma of the head of pancreas
o Malignant porta hepatis lymph nodes
 Infrequent
o Ampullary carcinoma
o Pancreatitis
o Liver secondaries
 Rare
o Benign strictures - iatrogenic, trauma
o Recurrent cholangitis
o Mirrizi's syndrome
o Sclerosing cholangitis
o Cholangiocarcinoma
o Biliary atresia
o Choledochal cysts

Investigation of obstructive jaundice

Investigation will differentiate hepatocellular and obstructive jaundice in 90%

cases

Blood results
 Conjugated bilirubin >35 mmol/l
 Increase in ALP / GGT >> AST / ALT
 Albumin may be reduced
 Prolonged PTT

Urinalysis findings

Obstruction Hepatocellular
Haemolysis
Conjugated
normal increased normal
bilirubin
Urobilinogen increased nil normal

Ultrasound
 Normal CBD <8 mm diameter
 CBD diameter increase with age and after previous biliary surgery
 For obstructive jaundice ultrasound has a sensitivity 70 - 95% and
specificity 80 - 100%
 In future endoscopic ultrasound may become more widely available

CT Scanning
 Sensitivity and specificity similar to good quality ultrasound
 Useful in obese or excessive bowel gas
 Better at imaging lower end of common bile duct
 Stages and assesses operability of tumours

Radionuclide scanning
99
 technetium iminodiacetic acid (HIDA)
 Taken up by hepatocytes and actively excreted into bile
 Allows imaging of biliary tree
 Failure to fill gallbladder = acute cholecystitis
 Delay of flow into duodenum = biliary obstruction

Endoscopic retrograde cholangiogram (ERCP)

 Allows biopsy or brush cytology
 Stone extraction or stenting

Percutaneous transhepatic cholangiogram (PTC)

  Rarely required today
 Performed with 22G Chiba Needle
 Also allows biliary drainage and stenting

Complications of obstructive jaundice

 Ascending cholangitis
o Charcot's triad is classical clinical picture
o Intermittent pain, jaundice and fever
o Cholangitis can lead to hepatic abscesses
 o Need parenteral antibiotics and biliary decompression
o Operative mortality in elderly of up to 20%
 Clotting disorders
o Vitamin K required for gamma-carboxylation of Factors II, VII,
IX, XI
o Vitamin K is fat soluble. No absorbed.
o Needs to be given parenterally
o Urgent correction will need Fresh Frozen Plasma
o Also endotoxin activation of complement system
 Hepato-renal syndrome
o Poorly understood
o Renal failure post intervention
o Due to gram negative endotoxinaemia from gut
o Preoperative lactulose may improve outcome
o Improves altered systemic and renal haemodynamics
 Drug Metabolism
o Half life of some drugs prolonged. (e.g. morphine)
 Impaired wound healing

Perioperative management of obstructive jaundice

 Preoperative biliary decompression improves postoperative morbidity

 Broad spectrum antibiotic prophylaxis
 Parenteral vitamin K +/- fresh frozen plasma
 IVI and catheter
 Pre operative fluid expansion
 Need careful post operative fluid balance to correct depleted ECF
compartment
 Consider 250 ml 10% mannitol. No proven benefit in RCT

Common bile duct stones

 Accurate prediction of the presence of common bile duct stones can be

difficult
o If elevated bilirubin, ALP and CBD > 12 mm risk of CBD stones
is 90%
o If normal bilirubin, ALP and CBD diameter risk of CBD stones
0.2%
 ERCP and endoscopic sphincterotomy is investigation of choice
 Stones extracted with balloons or Dormia basket
o 90% successful
o Complication rate 8%
o Mortality
 If fails to clear stones will require on of:
o Open cholecystectomy + exploration of CBD
o Laparoscopic exploration of CBD
o Mechanical lithotripsy
 80% successful after failure of ERCP
o Extra-corporeal shockwave lithotripsy
o Chemical dissolution with cholesterol solvents
 Methyl terbutyl ether or mono-octanoin
 Administered via T Tube or nasobiliary catheter
 25% complete response and 30% partial response
 If retained stones after CBD exploration need to consider:
o Early ERCP
 o Exploration via T tube tract at 6 weeks

Bibliography

Huang J. Decision making in surgery: the management of obstructive jaundice.

Br J Hosp Med 1997; 57: 40 - 42.

Diamond T, Parks R W. Perioperative management of obstructive jaundice. Br J

Surg 1997; 82: 147 - 148.

Hulse P A, Nicholson D A. Investigation of biliary obstruction. Br J Hosp Med

1994; 52: 103-107.

Hatfield A R W. Palliation of malignant obstructive jaundice - surgery or stent.

Gut 1990; 31: 1339-1340.

Hunter J G, Bordelon B M. Laparoscopic and endoscopic management of

common bile duct stones. Current Practice in Surgery 1993; 5: 105 - 111.

http://www.netdoctor.co.uk/diseases/facts/jaundice.htm

Jaundice

Written by Dr John ET Pillinger, GP

What is jaundice?
Jaundice means the yellow appearance of the skin and whites
of the eyes that occurs when the blood contains an excess of
the pigment called bilirubin.
Bilirubin is a natural product arising from the normal
breakdown of red blood cells in the body and is excreted in
the bile, through the actions of the liver.
Although jaundice is most often the result of a disorder
affecting the liver it can be caused by a variety of other
conditions affecting for example the blood or spleen. It should
be thoroughly investigated so that the underlying cause can be
identified and treated.
How does a person get jaundice?
The red blood cells in our circulation carry oxygen to all parts
of the body and have a life span of about 120 days. At the end
of their life they are broken down and removed from the
circulation by special cells called phagocytes, which are
found within the bone marrow, spleen and liver.
New red cells are of course continually manufactured and this
also takes place within the bone marrow.
Following breakdown of the red cells some of their
component parts such as amino acids and iron can be re-used
by the body. Other components such as bilirubin need to be
removed.
Knowing how this removal pathway works is the key to
understanding how jaundice occurs.
Most waste products of the body are excreted in the urine via
the kidneys but the liver and bile system is the other main
physical route out of the body for these substances.
By 'waste products' we mean the many compounds that arise
in the course of the body's metabolism but almost all forms of
drugs must also be eliminated either via the urine or bile
routes.
In the case of bilirubin released from old red cells, it passes
through the bloodstream to the liver, where the liver cells
process it.
These cells carry out many complex chemical functions and
also produce the liquid bile, which is the 'vehicle' by which
the cells discharge their output to the bile duct system. This is
a branching network of tiny tubes throughout the liver, which
merge in the same way as the branches of a tree.
Ultimately a single main bile duct comes out of the liver and
joins the first part of the small intestine (duodenum). Bile
(and therefore bilirubin) then passes out through the small and
large intestines and is excreted in the stool (faeces).
Bile is green in colour, but bacteria in the large bowel act to
change the bilirubin to substances that are brown, which gives
stool its characteristic colour.
Some of the bilirubin is reabsorbed back into the body
through the bowel wall, eventually appearing in the urine as a
substance called urobilinogen (although the typical
yellow/orange colour of urine is in fact due a different
pigment called urochrome).
Therefore, any failure of the bilirubin removal pathway will
lead to a build-up of bilirubin in the blood. When this happens
the individual's skin turns yellow, causing jaundice.
What conditions can be associated with jaundice?

An excessive breakdown of red blood cells

The balance between manufacture and breakdown of
red cells is normally precisely balanced and equal but
there are several conditions in which the rate of
breakdown increases. If the amount of bilirubin thus
released exceeds the liver's capacity to remove it, then
jaundice will develop.
The medical term for excessive red cell breakdown is
'haemolysis', and within the developed world it is a
fairly rare condition. Malaria is however a major cause
in tropical climates as the malaria parasites live within
the red cells and shorten their life.
Similarly the condition in which a foetus develops
haemolysis due to incompatibility of its Rhesus blood
group with that of its mother is now rarely seen in the
UK where we routinely check for 'Rhesus antibodies'
in the mother's blood. In parts of the world where
antenatal care is not as good haemolytic disease of the
newborn is much more common.
A temporary jaundice of newborn babies is however
quite common, due to the relative immaturity of the
baby's liver cells and the higher than normal rate of
cell breakdown that occurs in the first few weeks of
life. It improves rapidly without treatment although
when too high it can be speeded up by exposing the
baby to ultraviolet light. Jaundice of the newborn is
commoner in premature babies as their liver is even
more immature than a baby born at term.
Autoimmune haemolytic anaemia is a rare disease in
which the body's immune system seems to attack the
 red cells. It usually affects adults. Haemolysis can also
be a side effect of some drugs, eg dapsone.

Impairment of liver cell function

The commonest cause is a viral infection of the liver
cells (hepatitis). Many different types of infection
including glandular fever (mononucleosis) can also be
responsible for this.
Alcohol abuse and subsequent scarring of the liver
(cirrhosis) can cause significant cell damage leading to
jaundice. Other less common conditions causing liver
cell damage include haemochromatosis, alpha-1
antitrypsin deficiency and primary biliary cirrhosis.
Tumours of the liver - either primary liver cancers
(arising from the liver tissue itself) or more
commonly, the secondary spread of a tumour from
elsewhere in the body into the liver can lead to cell
failure and jaundice.

Blockage of the bile ducts

This can occur as a result of abnormality inside or
outside the ducts. The commonest example of an
internal blockage is a gallstone. Tumours of the bile
duct are rare but if large enough, or situated just where
the bile duct meets the duodenum, then they can block
the flow of bile. At this junction point, known as the
ampulla of Vater, the tube from the pancreas gland
also joins to the duodenum. Cancer of the pancreas
tends to arise in the part of the pancreas nearest to the
ampulla of Vater, so is another potential cause of
'obstructive' jaundice.
Any external organ or mass lying nearby that becomes
large enough to press on the bile duct could be
responsible. Examples include swollen internal lymph
glands, a cyst (perhaps of the pancreas) or scar tissue
following a previous infection or surgery.

What are the symptoms?

The symptoms, other than that of the jaundice itself, will
relate to the underlying cause. For example someone with
haemolysis might also be anaemic and tired. If a gallstone
were responsible there would probably have been a preceding
history of pain in the abdomen. A cancer might be
accompanied by weight loss, and so on.
When jaundice is due to obstruction of the bile duct the
person will often notice that their urine becomes dark and
stools become pale, as the excess bilirubin 'spills over' into the
urine and no longer colours the stool. Obstructive jaundice is
also often accompanied by intense itching.
How is jaundice diagnosed?
The diagnosis is made by recognition of the patient's
appearance and accompanying symptoms. A blood test will
confirm the raised bilirubin level and other tests such as those
for hepatitis and haemolysis are also done on the blood.
Ultrasound is a good way to inspect the liver and bile ducts
for signs of obstruction, and often can give useful information
on the pancreas gland. CT scanning also helps diagnose
obstructive jaundice accurately.
What can your doctor do?
If you or one of your friends or relatives suspect that you may
have jaundice, it is essential that you arrange to see your
doctor in order that the underlying cause is identified and any
possible treatment initiated as soon as possible.
Treatment will depend upon the diagnosis behind the
symptom of jaundice. For example, if the problem is one of
gallstones, then removal of the gallbladder may be required.

Last updated 04.08.2005