Benign Prostatic Hyperplasia

  • What Is Benign Prostatic Hyperplasia?

    Benign prostatic hyperplasia (BPH) is a nodular, irregular enlargement of the prostate, a walnut-size gland located just below the bladder in men, which produces about 30 percent of the fluid portion of semen. Because the prostate surrounds the urethra (the passageway through which urine empties from the bladder), enlargement of the prostate may eventually constrict the urethra and thus interfere with urination.

    An enlarged prostate may also cause the muscular bladder wall to thicken, as stronger contractions are necessary to push urine through a narrowed urethra. Increased thickness of the wall of the bladder can reduce its ability to store urine and can result in frequent need for urination and sudden strong urges to urinate (urgency).

    BPH is common, and its incidence increases with age: evidence of BPH is present in over 50 percent of men by age 60. There is no evidence that BPH leads to prostate cancer; however, symptoms of both disorders are similar, and it is possible to have BPH and prostate cancer at the same time. BPH responds well to treatment.

    Who Gets Benign Prostatic Hyperplasia? 

    It is difficult to determine the exact incidence and prevalence of BPH because research groups often use different criteria to define the condition. According to the National Institutes of Health (NIH), BPH affects more than 50 percent of men over age 60 and as many as 90 percent of men over the age of 70.

    Symptoms 

    • Frequent or urgent need to urinate; delayed, weak, or interrupted urine stream; dribbling.
    • Pain upon urination.

    • Urge to urinate several times a night.
    • Blood in the urine.

    Causes/Risk Factors 

    • The cause of BPH is unknown.
    • Male sex hormones play a role.

    What If You Do Nothing?

    Because urinary discomfort is largely subjective, how aggressively to deal with BPH is largely up to the patient. For men with mild symptoms, “watchful waiting” is usually the best course, since mild symptoms sometimes clear up or remain stable without treatment. Studies show that about 40 percent of men with mild symptoms improve without treatment, 45 percent continue with no change, and only 15 percent deteriorate. You should nonetheless get regular checkups to monitor the condition. Your physician may monitor your urinary flow rate or the amount of urine that remains in the bladder after urinating. Worsening of these parameters may prompt treatment.

    Diagnosis 

    A physical examination, patient history, evaluation of symptoms, laboratory tests, and other tests provide the basis for a diagnosis of benign prostatic enlargement (BPE). The following help to determine the diagnosis:

    • Digital rectal examination (DRE). In DRE the doctor inserts a gloved finger into the rectum and presses on the prostate gland to check for enlargement. 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) Prostate Symptom Index is a questionnaire designed to evaluate urinary problems in men and to help diagnose BPH. The patient answers seven questions related to common symptoms of BPH with the frequency of each symptom rated on a scale of 1 to 5. The final score is used to evaluate the condition.
    • Urodynamic Testing. Urodynamic tests are used to measure the volume and pressure of urine in the bladder and to evaluate the flow of urine.
    • Uroflowmetry is a simple test performed to record urine flow, to determine how quickly the bladder can be emptied. 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. A reduced flow rate may indicate BPH.
    • Pressure flow study is a test that 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. Another catheter is placed into the rectum to measure if you are straining during urination. The procedure is uncomfortable, but most patients can tolerate it. Rarely, it may cause urinary tract infection.
    • 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. PVR less than 50 mL generally indicates adequate bladder emptying and measurements of 100 to 200 mL or higher often indicate blockage.
    • A blood test may be used to check the level of prostate specific antigen (PSA) in a patient who may have benign prostatic hyperplasia. The PSA test can help the physician rule out prostate cancer.

    Treatment 

    There are several treatment options for men with BPH, depending on the severity of symptoms. In general, no treatment is needed for men who have only a few symptoms and are not bothered by them. The main treatment options are:

    Watchful waiting (close monitoring but no immediate treatment)

    Men with mild symptoms may choose to return for annual examinations. The physician will perform an examination that includes a DRE, PSA tests, urinary flow rate, and PVR. The patient will be asked to describe symptoms in order to determine if the condition is worsening

    Medication

     Your doctor may prescribe medication such as finasteride (Proscar) or dutasteride (Avodart) to shrink the prostate or drugs that relax smooth muscle tone in the prostate (alpha- blockers).

    The FDA has also approved tadalafil (Cialis) to treat BPH symptoms. This drug is used to treat erectile dysfunction (ED). It may be ideal for men with both symptoms of BPH and ED. Cialis should not be used by men who are taking nitrates (e.g., nitroglycerin) or in those who are also taking alpha blockers for BPH, because the combination of these drugs can cause a dangerously low blood pressure.

    Minimally invasive procedures 

    There are several different types of minimally invasive procedures for BPH.

    TUNA (transurethral needle ablation of the prostate) utilizes the application of heat to prostate tissue to alleviate symptoms of BPH. An advantage of this approach is that it can be administered on an outpatient basis using minimally invasive radio-frequency energy.

    Laser treatment

    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.

    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.

    Microwave Treatment

    Cooled ThermoTherapy/TUMT reduces BPH symptoms, preserves sexual function, and provides durable results using the Targis system or the Prostatron system.

    CoreTherm is an outpatient, microwave-generated heat treatment that destroys excess prostate tissue.

    TherMatrx is a minimally invasive procedure performed in a urologist's office that uses heat delivered through a microwave antenna.

    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.

    Other Minimally Invasive Treatments

    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.

    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.

    Surgery

    Transurethral resection of the prostate (TURP). This is the most common surgical treatment. A thin, lighted viewing tube is passed through the penis into the urethra, and a minuscule cutting tool at the end of the tube is used to excise prostate tissue that is pressing upon the urethra.

    Open Prostatectomy. An open prostatectomy is the surgery of choice when a man's prostate is so large that TURP can't be performed safely.

    • Prostatic stents. 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. In some cases, a temporary prostatic stent, such as the Spanner™ Temporary Prostatic Stent, may be used following minimally invasive BPH treatment.
    • UroLift implants. This procedure, approved by the FDA in 2013, involves the placement of tiny permanent implants that push the enlarged tissue away from the urethra, widening the channel. It can be done in the office with local anesthesia.

    Alternative Treatments

    Alternative treatments include nutritional supplements, herbal remedies, and hydrotherapy. Probably the best-known herbal remedy is saw palmetto, derived from berries of the saw palm tree (Serenoa repens, Serenoa serrulata, and other species). Saw palmetto appears to have a similar action to that of finasteride—that is, it may shrink the prostate. Some studies tend to support its effectiveness, though the evidence is fairly sparse. Unfortunately, there is still a lack of real scientific information based on well-designed clinical trials of saw palmetto and other herbal remedies.

    Lifestyle Changes

    The following lifestyle changes can help manage mild BPH:

    Avoid certain medications. Avoid tranquilizers, as well as over-the-counter cold remedies containing decongestants and antihistamines. These can worsen urinary symptoms.

    Cut down on fluids—especially alcoholic beverages—in the evening. This will decrease the need to urinate during the night.


     Go easy on caffeinated drinks. These are diuretics, which don’t help and can be harmful.

    Prevention 

    There is as yet no way to prevent BPH.

    When To Call Your Doctor 

    Call a doctor if you develop symptoms of BPH.

    Reviewed by Sovrin M. Shah, M.D., F.A.C.S., Assistant Professor of Urology, Icahn School of Medicine at Mount Sinai, Pelvic Medicine and Reconstructive Surgery, Sol and Margaret Berger Department of Urology, Mount Sinai Beth Israel, and Phillips Ambulatory Care Center, New York, NY. Review provided by VeriMed Healthcare Network.

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