By Lawrence Volz, MD
Voiding complaints are found in both sexes and all age groups, and can have a multitude of causes, or a combination of causes. Classic urinary complaints include “irritative” symptoms of frequency (urgency, urge incontinence, nocturia or nighttime urination) and “obstructive” symptoms (incomplete bladder emptying, slow stream, postvoid dribbling, and hesitancy.) Entire books have been written describing the pathophysiology, diagnosis, and treatment of urinary complaints.
One of the most common reasons for worsening urinary symptoms in men as they age is BPH (benign prostatic hyperplasia), more commonly known to the layman as “enlarged prostate.” That term can be somewhat misleading, however. Although it’s universally true that as most men age, their prostates enlarge, there’s more to the story. It is certainly the case that in general, the larger the prostate is, the more compression it will have on the outlet from the bladder. However, it’s not uncommon for some men with large prostates to have little or no urinary complaints, while others with smaller prostates may suffer greatly. The reason has been thought to be because some men may have smaller but more constrictive prostates, while other prostates may grow outward rather than inward as they enlarge, therefore minimally constricting the central channel.
The cause of the obstructive symptoms is self-explanatory. As the urethral channel narrows and the stream slows, it may take longer to initiate urination, and men may be unable to empty the bladder fully. The irritative symptoms are thought to possibly result from the bladder having to generate higher pressures to empty. As with any muscle having to work harder, the bladder wall thickens over time, becomes less “stretchable”, and therefore holds a lower volume of urine before needing to empty, causing frequency and urgency.
All treatments for BPH-related voiding complaints ultimately focus on reversing the obstruction of the urethra from the prostate. In general, a stepwise progression of treatments should be pursued, moving from least aggressive to most aggressive. These include the medication class of alpha blockers such as tamsulosin (Flomax) which relax constriction of the prostate channel. These medications work on both large and small prostates, and symptom improvement is quick, typically as early as two-to-four weeks.
The other class of medication, “5 alpha reductase inhibitors,” is used to shrink the enlarged prostate. However, it may take 4-6 months to see the beginning of symptom improvement. These medications also tend not to have significant effect on smaller constricted prostates, but have been shown to reduce a man’s long-term risk of urinary retention and the need for future prostate surgery.
Lastly, there are many surgical options, all of which aim to open the prostate channel. This includes the very effective transurethral resection of the prostate or “TURP” that has been performed for years, now with recently improved equipment and technique. Prostate vaporization and laser treatments are available, along with a recently FDA-approved minimally invasive procedure that “pulls” the prostate channel open without removing or destroying tissue.
Patients should be reassured that effective treatment options exist, from well-tolerated daily medication to minimally invasive and more permanent treatments.
Lawrence Volz, MD has returned to Williamsburg. He is seeing patients in the new Urology of Virginia Williamsburg location. He earned his medical degree from the University of Pennsylvania. He completed his urologic residency at the Hospital of the University of Pennsylvania after two years of general surgery training at that institution. urologyofva.net