Benign prostatic hyperplasia (BPH) is a condition in which the prostate, a walnut-sized body part made of glandular and muscular tissue, grows in size. The prostate surrounds part of the urethra, which is the tube that carries urine and sperm out of the body. The benign (noncancerous) condition is also called benign prostatic enlargement (BPE).
The prostate is located directly beneath the bladder and in front of the rectum. The urethra passes through the prostate, so if the prostate becomes enlarged, it can keep urine or semen from passing through the urethra. The main function of the prostate is to produce fluid for the semen, the milky fluid in which sperm swims. Sperm is produced in the testicles, which also make the main male hormone testosterone. During puberty, testosterone stimulates the growth and function of the prostate, and helps with the production of fluid for semen.
Pathophysiology of Benign Prostatic Hyperplasia
Multiple fibroadenomatous nodules develop in the periurethral region of the prostate, probably originating within the periurethral glands rather than in the true fibromuscular prostate (surgical capsule), which is displaced peripherally by progressive growth of the nodules.
As the lumen of the prostatic urethra narrows and lengthens, urine outflow is progressively obstructed. Increased pressure associated with micturition and bladder distention can progress to hypertrophy of the bladder detrusor, trabeculation, cellule formation, and diverticula. Incomplete bladder emptying causes stasis and predisposes to calculus formation and infection. Prolonged urinary tract obstruction, even if incomplete, can cause hydronephrosis and compromise renal function.
Causes of Benign Prostatic Hyperplasia
The actual cause of benign prostatic hyperplasia is unknown. Factors linked to aging and changes in the cells of the testicles may have a role in the growth of the gland, as well as testosterone levels. Men who have had their testicles removed at a young age (for example, as a result of testicular cancer) do not develop BPH.
Also, if the testicles are removed after a man develops BPH, the prostate begins to shrink in size. However, this is not a standard treatment for an enlarged prostate.
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. More than 90% of men over age 80 have the condition.
- No risk factors have been identified, other than having normally-functioning testicles.
Risk factors of Benign Prostatic Hyperplasia
Risk factors for prostate gland enlargement include:
- Prostate gland enlargement rarely causes signs and symptoms in men younger than age 40. About one-third of men experience moderate to severe symptoms by age 60, and about half do so by age 80.
- Family history. Having a blood relative, such as a father or a brother, with prostate problems means you’re more likely to have problems.
- Diabetes and heart disease. Studies show that diabetes, as well as heart disease and use of beta blockers, might increase the risk of BPH.
- Obesity increases the risk of BPH, while exercise can lower your risk.
Signs and Symptoms
BPH symptoms can be divided into those caused directly by urethral obstruction and those due to secondary changes in the bladder.
Typical obstructive symptoms are:
- Difficulty starting to urinate despite pushing and straining
- A weak stream of urine; several interruptions in the stream
- Dribbling at the end of urination
Bladder changes cause:
- A sudden strong desire to urinate (urgency)
- Frequent urination
- The sensation that the bladder is not empty after urination is completed
- Frequent awakening at night to urinate (nocturia)
As the bladder becomes more sensitive to retained urine, a man may become incontinent (unable to control the bladder, causing bed wetting at night or inability to respond quickly enough to urinary urgency).
Burning or pain during urination can occur if a bladder tumor, infection or stone is present. Blood in the urine (hematuria) may herald BPH, but most men with BPH do not have hematuria.
Complications of benign prostate enlargement
Benign prostate enlargement can sometimes lead to complications, such as:
- A urinary tract infection (UTI)
- Acute urinary retention
Acute urinary retention (AUR) is the sudden inability to pass any urine. Symptoms of AUR include:
- Suddenly not being able to pee at all
- Severe lower tummy pain
- Swelling of the bladder that you can feel with your hands
Diagnosis of Benign Prostatic Hyperplasia
See your doctor if you have symptoms that might be related to BPH. See your doctor right away if you have blood in your urine, pain or burning when you pass urine or if you cannot pass urine.
There are many tests for BPH. The following tests are used to diagnose and track BPH.
Symptom Score Index
The American Urological Association (AUA) has built a BPH Symptom Score Index. It is a series of questions about how often urinary symptoms happen. The score rates BPH from mild to severe. Take the test and talk with your doctor about your results.
A digital rectal exam (DRE) is often the next step. During a DRE, you would lie on your side or bend over. The doctor inserts a gloved, lubricated finger into your rectum to feel the back wall of the prostate gland.
The health care provider is looking for enlargement, tenderness, lumps or hard spots. This 10-15 second exam is an important way to find problems.
These tests are done to measure how well you release urine. This shows the doctor if the urethra is blocked or obstructed. There are several types:
- Urinalysis tests your urine sample to check for important things such as blood, signs of infection, glucose (sugar), protein and other factors that can tell your urologist the cause of your symptoms. Urine tests are also used to screen for bladder cancer. If you have blood in your urine, pain or burning when you pass urine, or you cannot pass urine, it is important to see your doctor right away.
- Post-void residual volume (PVR) measures urine left in the bladder after passing urine. This is done to diagnose the problem. IT may also be done before surgery.
- Uroflowmetry measures how fast urine flows. This is done to diagnose the problem. It may also be done before surgery.
- Urodynamic pressure flow study tests pressure in the bladder during urination.
These tests are done to see the size and shape of the prostate. Some BPH scans include:
- Ultrasounds look inside the body to see the size and shape of the prostate.
- Cystoscopy is an exam used to look at the urethra or bladder with a scope.
- Magnetic resonance imaging (MRI) and computed tomography (CT) for more detailed scans. These are done if surgery is necessary to reopen the flow of urine. These scans provide a very clear image of the prostate and surrounding area. It shows exactly how and where the prostate is enlarged.
Prostate-specific antigen (PSA) blood test is used to screen for prostate cancer. The PSA blood test checks the level of PSA, a protein made only by the prostate gland. This blood test can be done in a lab, hospital or a provider’s office. Avoid sexual activity several days prior to the test, as this may artificially increase the PSA reading.
When the prostate is healthy, very little PSA is found in the blood. A rapid rise in PSA may be a sign something’s wrong. A benign (non-cancer) enlargement of the prostate can cause a rise in PSA levels, as can inflammation of the prostate (prostatitis). The most serious cause of a rise in PSA is cancer.
Treatment for Benign Prostatic Hyperplasia
Currently, the main options to address BPH are:
- Watchful waiting
- Surgery (prostatic urethral lift, transurethral resection of the prostate, photovaporization of the prostate, open prostatectomy)
If medications are ineffective in a man who is unable to withstand the rigors of surgery, urethral obstruction and incontinence may be managed by intermittent catheterization or an indwelling Foley catheter (which has an inflated balloon at the end to hold it in place in the bladder). The catheter can remain indefinitely (it is usually changed monthly).
Because the progress and complications of BPH are unpredictable, a strategy of watchful waiting — no immediate treatment is attempted — is best for those with minimal symptoms that are not especially bothersome. Physician visits are needed about once per year to review the progress of symptoms, perform an examination and do a few simple laboratory tests. During watchful waiting, the man should avoid tranquilizers and over-the-counter cold and sinus remedies that contain decongestants. These drugs can worsen obstructive symptoms. Avoiding fluids at night may lessen nocturia.
Medication for Benign Prostatic Hyperplasia
Data is still being gathered on the benefits and possible adverse effects of long-term medical therapy. Currently, two types of drugs — 5-alpha-reductase inhibitors and alpha-adrenergic blockers — are used to treat BPH.
Finasteride (Proscar) blocks the conversion of testosterone to dihydrotestosterone, the major male sex hormone found in cells of the prostate. In some men, finasteride can relieve BPH symptoms, increase urinary flow rate and shrink the prostate, though it must be used indefinitely to prevent recurrence of symptoms, and it may take as long as six months to achieve maximum benefits.
These drugs, originally used to treat high blood pressure, reduce the tension of smooth muscles in blood vessel walls and relax smooth muscle tissue in the prostate. As a result, daily use of an alpha-adrenergic drug may increase urinary flow and relieve symptoms of urinary frequency and nocturia. Some alpha-l-adrenergic drugs — for example, doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin) and tamsulosin (selective alpha 1-A receptor blocker — Flomax) — have been used for this purpose.
Phosphodiesterase-5 inhibitors, such as Cialis, are commonly used for erectile dysfunction, but when used daily, they also can relax the smooth muscle of the prostate and overactivity of the bladder muscle. Studies examining the impact of daily Cialis use compared to placebo demonstrated a reduction in International Prostate Symptom Score by four to five points, and Cialis was superior to placebo in reducing urinary frequency, urgency and urinary incontinence episodes. Studies examining Cialis’ impact on urine flow, however, have not shown meaningful change.
Surgical treatment of the prostate involves displacement or removal of the obstructing adenoma of the prostate. Surgical therapies have historically been reserved for men who failed medical therapy and those who developed urinary retention secondary to BPH, recurrent urinary tract infections, bladder stones or bleeding from the prostate. However, a large number of men are poorly compliant with medical therapy due to side effects. Surgical therapy can be considered for these men to prevent long-term deterioration of bladder function.
Current surgical options include monopolar and bipolar transurethral resection of the prostate (TURP), robotic simple prostatectomy (retropubic, suprapubic and laparoscopic), transurethral incision of the prostate, bipolar transurethral vaporization of the prostate (TUVP), photoselective vaporization of the prostate (PVP), prostatic urethral lift (PUL), thermal ablation using transurethral microwave therapy (TUMT), water vapor thermal therapy, transurethral needle ablation (TUNA) of the prostate and enucleation using holmium (HoLEP) or thulium (ThuLEP) laser.
Thermal procedures alleviate symptoms by using convective heat transfer from a radiofrequency generator. Transurethral needle ablation (TUNA) of the prostate uses low-energy radio waves, delivered by tiny needles at the tip of a catheter, to heat prostatic tissue.
A new form of thermal therapy, called water vapor thermal therapy or Rezum, involves conversion of thermal energy into water vapor to cause cell death in the prostate. Studies examining the six-month prostate size after water vapor thermal therapy demonstrated a 29% reduction in prostate size by MRI.
With thermal therapies, several treatment sessions may be necessary, and most men need more treatment for BPH symptoms within five years after their initial thermal treatment.
Transurethral Incision of the Prostate (TUIP)
This procedure was first used in the U.S. in the early 1970s. Like transurethral resection of the prostate (TURP), it is done with an instrument that is passed through the urethra. But instead of removing excess tissue, the surgeon only makes one or two small cuts in the prostate with an electrical knife or laser, relieving pressure on the urethra. TUIP can only be done for men with smaller prostates.
Prostatic Urethral Lift (UroLift)
In contrast to the other therapies that ablate or resect prostate tissue, the prostatic urethral lift procedure involves placing UroLift implants into the prostate under direct visualization to compress the prostate lobes and unobstruct the prostatic urethra. The implants are placed using a needle that passes through the prostate to deliver a small metallic tab anchoring it to the prostate capsule. Once the capsular tab is placed, a suture connected to the capsular tab is tensioned and a second stainless steel tab is placed on the suture to lock it into place. The suture is severed.
Transurethral Prostatectomy (TURP)
This procedure is considered the “gold standard” of BPH treatment — the one against which other therapeutic measures are compared. It involves removal of the core of the prostate with a resectoscope — an instrument passed through the urethra into the bladder. A wire attached to the resectoscope removes prostate tissue and seals blood vessels with an electric current. A catheter remains in place for one to three days, and a hospital stay of one or two days is generally required. TURP causes little or no pain, and full recovery can be expected by three weeks after surgery.
Prostatectomy is a very common operation. About 200,000 of these procedures are carried out annually in the U.S. A prostatectomy for benign disease (BPH) involves removal of only the inner portion of the prostate (simple prostatectomy). This operation differs from a radical prostatectomy for cancer, in which all prostate tissue is removed. Simple prostatectomy offers the best and fastest chance to improve Benign Prostatic Hyperplasia (BPH) symptoms, but it may not totally alleviate discomfort. For example, surgery may relieve the obstruction, but symptoms may persist due to bladder abnormalities.
Prevention of Benign Prostatic Hyperplasia
Although you cannot prevent the prostate from enlarging, you can take measures to reduce your symptoms:
Limit your intake of liquids in the evening, especially drinks containing alcohol and caffeine. Cutting back helps to minimize the number of times you have to urinate during the night. (Also, drinking too much alcohol may irritate the bladder or prostate. Most experts recommend that men avoid more than two alcoholic drinks a day.)
Ask your doctor whether you can change or eliminate mediations that may be aggravating the problem. These medications include antihistamines, diuretics, decongestants, antispasmodics, tranquilizers and certain types of antidepressants. These can weaken the bladder muscle or narrow the opening of the prostate.
Take every opportunity to use the bathroom and allow yourself enough time to empty your bladder completely.
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