- Causes & Risk Factors
- Symptoms & Signs
- Watchful Waiting
- Other Prostate Problems
What is benign prostatic hyperplasia (BPH)?
What is the prostate?
The prostate is a small organ about the size of a walnut. It lies below the bladder (where urine is stored) and surrounds the urethra (the tube that carries urine from the bladder). The prostate makes a fluid that helps to nourish sperm as part of the semen (ejaculatory fluid).
Prostate problems are common in men 50 and older. Most can be treated successfully without harming sexual function.
What is BPH?
Benign prostatic hyperplasia (BPH) is nonmalignant (noncancerous) enlargement of the prostate gland, a common occurrence in older men. It is also known as benign prostatic hyperplasia and abbreviated as BPH and benign prostatic enlargement (BPE). It's also referred to as an enlarged prostate gland.
BPH must be differentiated from prostate cancer. Prostate cancer can cause symptoms like BPH but is more commonly associated with an increase in PSA and an abnormal prostate on rectal examination or ultrasound evaluation.
Is BPH a type of cancer?
What are causes and risk factors for BPH?
Medical professionals do not have a good understanding of what causes an enlarged prostate.
BPH generally begins around age 30, evolves slowly, and most commonly only causes symptoms after 50.
BPH is extremely common. Advanced age is a risk factor for an enlarged prostate. BPH affects 40%-50% of men aged 51-60 years, but only 10% need medical or surgical intervention.
What are BPH symptoms and signs?
In benign prostatic hyperplasia, the prostate gland grows in size. It may compress the urethra, which courses through the center of the prostate. This can impede the flow of urine from the bladder through the urethra to the outside. Lower urinary tract symptoms from BPH can be due to one of the factors: (1) dynamic, (2) static, and (3) compensatory.
Dynamic factors are related to the tone of the muscle surrounding the prostate and the outlet of the bladder whereas static factors are related to the enlargement of the prostate tissue. Dynamic and static symptoms are prostate-related symptoms. Compensatory factors are the result of changes that occur in the bladder as a result of the bladder working harder to push urine past the bladder neck and prostate.
Signs and symptoms of BPH include lower urinary tract symptoms (LUT) of weak urine stream, difficulty starting the urine stream (hesitancy), straining to urinate, inability to completely empty the bladder, inability to urinate (urinary retention), blood in the urine (hematuria), leakage of urine (urinary incontinence), decreased urine flow (slow urine stream), and post-void dribbling of urine.
How is BPH diagnosed?
A doctor or other health care professional usually can detect an enlarged prostate by rectal examination. Medical professionals may perform a rectal examination to ensure that there are no "nodules," which are hard, irregular areas in the prostate suspicious for prostate cancer, as well as to assess the size of the prostate. Assessment of prostate size and shape is better assessed with abdominal or transrectal ultrasound or cystoscopy. A cystoscope is a long, thin telescope-like instrument that has a light source and lens allowing one to look at the urethra, the prostate, and the bladder when inserted through the opening at the tip of the penis. Cystoscopy and/or ultrasound are recommended prior to surgical treatment of BPH.
Other tests that medical professionals may perform include: (1) bladder scanner postvoid residual determination (this is often performed in the office after urination to determine the amount of urine left behind in the bladder after urination and determines if one is emptying completely) and (2) uroflowmetry (a test in which the patient urinates into a special urine collection device that can measure the rate and pattern of urine flow).
Lastly, a PSA is often obtained and if abnormal may require further evaluation to rule out prostate cancer.
The American Urological Association (AUA) recommends that men with BPH complete the AUA-symptom index (AUA-SI), which assesses the degree to which symptoms bother. It is a useful way to assess changes in bothersome symptoms with treatment.
What happens if BPH goes untreated?
Watchful waiting often is chosen by men who are not bothered by signs or symptoms of BPH. They have no treatment except to get regular checkups with an assessment of lower urinary tract symptoms and signs and wait to see whether the condition gets worse.
Several over-the-counter products and phytotherapy have been tried to treat BPH. Beta-sitosterol is a phytosterol found in vegetable oil, nuts, and avocados. There are limited studies evaluating its effect on BPH. Other studied therapies include pygeum africannum, cernilton, and serenoa repens (saw palmetto). Although these therapies do not require a prescription, it is important that you discuss the use with your primary care physician, as interactions with other medications or medical problems may exist.
Dietary and lifestyle changes may help with symptoms and signs. Strategies to help improve symptoms include limiting the amount of alcohol and caffeine consumed, decreasing fluid intake 2 hours before bedtime, going to the bathroom before sleep, and minimizing long trips or other activities where a restroom is not readily available. Double voiding, voiding once then waiting 1 minute, and trying to void again may help with bladder emptying. Constipation can aggravate symptoms and thus eating more fiber and exercising can help prevent constipation.
Talk with your doctor about medications prescribed and over-the-counter medications that you use, as commonly used medications such as antihistamines and decongestants can aggravate symptoms and signs. Studies suggest that diets high in meat or dairy products may increase the risk of prostate enlargement thus increasing the intake of fruits, vegetables, and healthy fats may be helpful.
What is the main treatment for BPH?
There are several different ways to treat BPH, and the treatment may vary with the different factors. Alpha-blockers and PDE-5 inhibitors commonly treat the dynamic factors associated with BPH, whereas 5-alpha reductase inhibitors and surgical interventions treat the static factors, and anticholinergics and beta 3-adrenoceptor agonists treat the compensatory factors.
Men should carefully weigh the risks and benefits of each of these options. Although surgical intervention tends to produce the most significant impact on symptoms, it is associated with greater risk and is typically reserved for individuals who fail medical therapy, either by lack of adequate symptom improvement or side effects of the medication.
Medical treatment of BPH is usually reserved for men who have an elevated AUA-SI (bothersome symptoms):
- Alpha-blockers treat the dynamic part of BPH by relaxing the smooth muscles of the prostate and the bladder neck, which helps to relieve urinary obstruction caused by an enlarged prostate in BPH. Several alpha-blockers treat BPH, some of which are more selective for the prostate and bladder neck smooth muscles. Medication side effects can include headaches, fatigue, problems ejaculating, decreased semen volume, or lightheadedness. Commonly used alpha-blockers in BPH include tamsulosin (Flomax), alfuzosin (Uroxatral), silodosin (Rapaflo), and older medications such as terazosin (Hytrin) or doxazosin (Cardura). Silodosin is a more selective alpha-blocker, which is specific to the lower urinary tract. It has similar efficacy as other alpha-blockers but may have a higher risk of sexual side effects. Naftopidil is an alpha-blocker that is like tamsulosin. It is approved in several countries throughout the world but not currently in the U.S. These medicines generally lead to improvement in symptoms within several weeks and have no effect on prostate size and do not produce any permanent changes.
- Phosphodiesterase type 5 inhibitors (PDE5 inhibitors) treat the dynamic part of BPH by decreasing the tone of the smooth muscle in the bladder, prostate, and urethra. They appear to be less effective in improving maximal urine flow rate than alpha-blockers. PDE5 inhibitors have been used cautiously in combination with alpha-blocker therapy. Tadalafil (Cialis) is the only FDA-approved PDE5 inhibitor for the treatment of BPH. PDE5 inhibitors are more commonly used for erectile dysfunction. Side effects of PDE5 inhibitors include facial flushing, headaches, upset stomach, nasal congestion, dizziness, and backache.
- 5-alpha reductase inhibitors treat the static component of BPH by blocking the conversion of the male hormone testosterone into its active form in the prostate (DHT). The prostate enlargement in BPH is directly dependent on DHT, so these drugs lead to an approximate 25% reduction in prostate size over 6 to 12 months. For this reason, improvement in urinary symptoms most commonly takes this long to occur. Examples of 5-alpha reductase inhibitors include the drugs finasteride (Proscar) and dutasteride (Avodart). Side effects of finasteride may include declining interest in sex, problems getting an erection, and problems with ejaculation. The reduction in DHT is the cause of the decrease in libido and erectile troubles, but these symptoms appear to decrease over time on the medication.
- Combination therapy with alpha-blocker and 5-alpha reductase inhibitors has been demonstrated to result in greater improvements in lower urinary tract symptoms compared to monotherapy as well as decrease the risk of urinary retention or need for BPH-related surgery, but there is an increased risk of adverse events such as sexual dysfunction (erectile dysfunction, decreased libido, and ejaculatory dysfunction).
- Anticholinergic and beta 3 adrenoceptor agonists treat the compensatory factors. Both anticholinergic agents and beta 3 adrenoceptor agonists are FDA approved for the treatment of overactive bladder (OAB) with symptoms of frequency and urgency with or without urgency incontinence. Men with BPH may develop changes in the bladder that result in OAB symptoms. These medications are not used alone to treat men with BPH and LUT, rather they may be used in men on alpha-blocker therapy with improvement in their obstructive symptoms (decreased urine stream, straining to void, incomplete emptying) but who still have storage-related symptoms (frequency and urgency). It is important that one is monitored on combination therapy to ensure adequate bladder emptying. Anticholinergic agents decrease the overactivity of the bladder muscle. Several anticholinergics are available, differing in the mode of administration, the duration of action, and muscarinic receptor affinity, and side effects. Such agents include oxybutynin (Ditropan, Ditropan XL, Oxytrol, Gelnique), tolterodine (Detrol, Detrol LA), trospium chloride (Sanctura, Sanctura XR), darifenacin (Enablex), fesoterodine (Toviaz), and solifenacin (Vesicare). Side effects of anticholinergic agents include dry mouth, facial flushing, constipation, blurred vision, urinary retention, and cognitive problems. Beta 3 adrenoceptor agonists work to relax the bladder muscle. Currently, there is only one FDA-approved beta-3 adrenoceptor agonist, mirabegron (Myrbetriq). Beta 3 adrenoceptor agonists have comparable efficacy to anticholinergic agents. Side effects of beta 3-adrenoceptor agonists include increased blood pressure, urinary retention, sinus pain, dry mouth, and constipation.
Surgery or office procedures may also be used to treat BPH, most commonly in men who have not responded satisfactorily to medicine or those who have more severe problems, such as a complete inability to urinate, kidney problems due to the BPH, recurrent urinary tract infections, recurrent bladder stones, or gross hematuria (bloody urine).
- Transurethral resection of the prostate (TURP): Physicians have used TURP for the longest period and consider it the gold standard procedure. After giving a patient anesthesia, the doctor inserts a special instrument (a resectoscope) into the urethra through the penis. The resectoscope is similar to a cystoscope but has a small instrument that is connected to an electrical current, which allows the urologist to resect (cut away) the prostate tissue that is bulging into the urethra under direct visualization. Risks of TURP include hematuria (blood in urine), injury to the bladder, electrolyte abnormalities, painful or difficult urination, retrograde ejaculation (the ejaculate going backward into the bladder), and rarely erectile dysfunction and urinary incontinence.
Transurethral incision of the prostate: Doctors perform this procedure using a resectoscope, but instead of removing the prostate tissue, deep incisions are made into the prostate. This procedure has fewer side effects than a TURP, however, is only useful for small prostate glands.
- Laser procedures: A number of different laser procedures are available to treat BPH. These include transurethral vaporization of the prostate (TUVP), photo selective vaporization of the prostate (PVP), and laser enucleation of the prostate by holmium laser (HOLEP) or by thulium (THuLEP). Laser procedures have less risk of bleeding, however, require specific equipment and skills. HOLEP, PVP, and THuLEP are procedures that should be considered in men who are at higher risk of bleeding such as those taking blood thinners (anticoagulants).
- Transurethral microwave therapy (TUMT): Medical professionals generally perform this procedure in the office, and it involves the use of microwave energy delivered to the prostate to kill some of the cells leading eventually to shrinkage of the prostate. TUMT is associated with a higher need for retreatment than TURP.
- Prostate urethral lift (PUL): This is a minimally invasive procedure in which four to five sutures are placed to hold back prostate tissue on both sides of the urethra. The procedure is performed by guiding a device into the urethra through the tip of the penis. The device moves the prostate tissue away from the urethra and uses a needle to the sutures to hold the prostate tissue back. A medical professional often performs a cystoscopy to ensure that the prostate is not too large and that there is no "middle lobe," an enlargement of the prostate in the middle of the urethra. The improvements in urine flow rate and LUT are less than with a TURP, however, it is not associated with the sexual side effects of TURP.
- Water vapor thermal therapy: This can be used if the prostate is not too large. It is not as efficacious as TURP and is associated with an increased retreatment rate compared to TURP.
- Aquablation: This is a new procedure that is more restricted to prostate size, and there are currently limited long-term results available regarding its efficacy and retreatment rates. Further clinical trials are needed to determine its role in the management of BPH.
- Simple prostatectomy: This is a more invasive procedure typically reserved for men with very large prostate glands. It can be performed through an incision on the lower abdomen, laparoscopically, or robotic-assisted. Due to its more invasive nature, simple prostatectomy has a higher risk of complications than minimally invasive treatments and takes longer to recover. Simple prostatectomy does not remove the entire prostate and is not a procedure performed for prostate cancer and thus differs from radical prostatectomy, a cancer-related procedure.
Are there other non-cancerous prostate problems?
Yes, aside from BPH, there are a number of prostate problems that also have nothing at all to do with prostate cancer. Among these benign disorders of the prostate are acute prostatitis and chronic prostatitis and, rarely, prostatic infarct (a localized area of dead prostate tissue as a result of inadequate blood supply).
- Acute prostatitis is a bacterial infection of the prostate. It can occur in men at any age. Symptoms include fever, chills, and pain in the lower back and between the legs. This problem also can make it hard or painful to urinate. Doctors prescribe antibiotic medicines for acute prostatitis and recommend that the patient drink more liquids. Treatment is usually successful.
- Chronic prostatitis is a prostate inflammation that tends to recur over time. It is usually not associated with true bacterial infection but causes similar symptoms of pain and discomfort, without fevers or chills. Chronic prostatitis is difficult to treat, and the exact cause is not well understood. Antibiotics may be used in some cases as well as anti-inflammatory medicines such as ibuprofen. In many cases, symptoms will resolve on their own.
- A prostate infarct is a localized area of dead prostate tissue as a result of inadequate blood supply. Prostate infarct is uncommon and may cause sudden increases in the PSA test.
Is it possible to prevent prostate problems?
The best protection against prostate problems is to have regular medical checkups that include a careful prostate exam. See a doctor promptly if the following symptoms occur:
Regular checkups are important even for men who have had surgery for BPH. Surgery does not protect against prostate cancer because only part of the prostate is removed. In all cases, the sooner a doctor finds a problem, the better the chances that treatment will work.
Deters, L.A. "Benign Prostatic Hyperplasia." Medscape. Jan. 15, 2019. <http://emedicine.medscape.com/article/437359-overview>.
Jiwrajka, M., et al. "Drugs for benign prostatic hypertrophy." Aust Prescr 41.5 Oct. 2018: 150-153.
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