Expert: Arthur Goldstein, M.D. - 1/10/2009

Question
My father, 83 years old.  He has three stents implanted is being advised to have Cooled Thermo Therapy. His symptoms are incontinence and waking 3 times a night with the urge to urinate.  The Dr. stated he wasn't a candidate for PVP because of the poor condition of his prostate or something in that order.  Are there conditions when PVP cannot be utilized?
Also, the Dr. has only done 3 of these procedures. Actually, he is only present during the procedure.  There are "technicians" who actually perform the procedure.  This doesn't sound right to me.  
My Dad has tried Flomax but it wasn't working.  Should he try another medicine before even considering these procedures?  
Thank you in advance for your advice.
Sincerely,
Jill
Tinley park, Illinois

Answer
Jill, the therapies you are inquiring about are used to treat benign prostatic hyperplasia (BPH) commonly referred to as a large prostate.  This is a very common disorder that occurs in men as they age.  The symptoms of incontinence, urgency and night time frequency are are typical in  BPH although there  are other causes (such as neuropathic bladder diseases, bladder stones, urinary infection, etc. that can also mimic these symptoms. To follow is a "macro" I have written on this disease.

As mentioned, benign enlargement of the prostate gland (benign prostatic hyperplasia or BPH) occurs to varying degrees in all men as they age.  The prostate surrounds the urinary canal (urethra) just after its connection to the urinary bladder.  Inward growth of the prostate either into the bladder neck (opening) or into the urethra itself can cause difficulty with urinating.  The prostate is checked by digital examination through the rectum.  This gives the doctor an idea as to the size and benignity of the gland.  However, it does not always correlate to symptoms as a small gland may have significant inward growth and a large glands enlargement may be entirely peripheral.   The ability to urinate involves the urinary bladder muscle actually becoming stronger as it works against increasing resistance from the prostate.  This delicate balance can be upset by any factor that decreases
the bladder muscles ability to contract with sufficient force to open the
prostate (such as medications, anesthesia, too much alcohol, ignoring the desire
to urinate, etc.) or those factors that might cause the prostate to
suddenly swell (ie acute prostatitis, sitting  for extended periods of time, biking,
horseback riding, etc.). The typical symptoms that occur include diurnal frequency (daytime), nocturia (night-time frequency), urgency, hesitancy, slow stream and dribbling after voiding.  This complex of symptoms is termed “prostatism”.  If the obstruction to flow progressively worsens, the bladder eventually may not be able to empty completely.  This leads to the accumulation of “residual urine” which may predispose to urinary infections and  kidney damage from back pressure.  However, relatively asymptomatic men with BPH do NOT necessarily require therapy.  Treatment is indicated to relieve symptoms and prevent complications.  In many cases medications can be used.  Alpha - blockers (ie Hytrin, Cardura, Flomax, Uroxatral etc.) work by relaxing the bladder neck and urethra so the pressure generated by a bladder contraction has less resistance to work against.  Natural herbal products such a saw palmetto and pygeum often provide symptomatic relief but the exact mechanism of action has not yet been defined.  The prescription drugs Proscar and Avodart actually shrink the prostate.  They work best in the larger glands and improvement may not be noted for up to 6 months.   Your father can consider some of these alternative treatments if his urologist thinks them reasonable.  In cases refractory to medication, interventional measures are indicated.  The “gold standard” for treatment is the time honored transurethral resection (TUR) of the prostate.  For huge glands, open surgery may be necessary.  In the past decade a number of other less invasive interventional therapies have been developed to reduce the obstructing prostate tissue utilizing various forms of energy.   These include laser prostatectomy, microwave (TUMP or transurethral microwave of the prostate), and radiofrequency (TUNA or transurethral needle ablation of the prostate).  TUMP is actually a minimally invasive, out-patient treatment that can be tried initially if the patient's gland size is appropriate.  In a patient with significant underlying medical conditions, one should try conservative treatments first, namely medications, then non-invasive office therapies, with surgery the last resort.  Obviously the pros and cons all have to be weighed in making these decisions.  

Here is an explanation of a TUR of the prostate gland. The prostate is
composed basically of three parts which from inside to out are the prostatic portion of the urethra, the prostatic glandular tissue causing the obstruction (adenoma) and the compressed capsule of the prostate.  In a TUR, the prostatic urethra and adenoma are removed leaving only the capsule. This leaves a raw bed, which, over a period of 6-8 weeks, regenerates a new urethra!  The prostate is resected into many tissue slivers which wash into the bladder and then are removed at the end of the operation by suction.  This surgery can be likened to coring out an apple from the inside leaving only the skin.  At the termination of the procedure, one can look from the far end of the prostate into the bladder without residual obstruction.  A catheter is left in for a few days to drain the bladder and to initiate the healing process.  Good luck!