Benign Prostatic Hyperplasia (BPH)

Table of Contents

1. Introduction to Benign Prostatic Hyperplasia (BPH)
2. Symptoms
3. Causes
4. Diagnosis
5. Treatment

Introduction to Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH) refers to an increase in the size of the prostate. This enlargement may cause urinary symptoms like blockage of urine flow and increased frequency of urination. It is a fairly common condition that affects most men above the age of 60. BPH is a non-cancerous and harmless enlargement, and should not be a cause of extreme worry.

Nevertheless, the urinary problems that accompany this condition can be unpleasant and may significantly alter the quality of a person’s life. In such a scenario, it is advisable to seek medical care.

What is the Prostate?

As a part of the male reproductive system, the prostate gland lies directly below the bladder. It completely encircles a part of the urethra, the tube that carries urine from the bladder to an external opening in the penis and in which the secretions of the prostate are released. The secretions from the prostate make a normal part of semen.

The Underlying Pathology:

When this normally walnut-sized gland enlarges, it presses against the urethra and narrows its diameter. The bladder has to exert additional effort to force urine into a narrowed urethra. To compensate, the bladder walls thicken and eventually become weak and ineffective. With time, the bladder loses the ability to empty fully; the narrowed urethra worsens this obstruction, leading to urinary retention.

Key Statistics Regarding BPH

• Data collected in recent surveys suggests that BPH is one of the most common conditions that affect older men. In this population, it is also the primary cause of lower urinary tract symptoms like poor urination, retention, and urinary urgency. ¹
• 5% of prostate glands from men in their 40s, and 50% and 80% of prostate glands from men in their 6^th and 9^th decades respectively showed changes characteristic of BPH on microscopic examination. ¹
• Moreover, it has been reported that Asian men are less likely to develop the condition than Western populations, which suggests that environmental factors like diet and lifestyle are at play in the development of this disease. ¹

Symptoms of Benign Prostatic Hyperplasia (BPH)

An enlarged prostate can block urine flow or cause irritation in the lower urinary tract. The primary symptoms of BPH include:

• A feeling of bladder fullness even after urinating
• Having to use the bathroom frequently; often every 1-2 hour, especially at night
• Feeling an “urgency” that urination cannot wait or that you cannot control your need to use the toilet
• A weak flow of urine (a trickle instead of a uniform stream)
• Hesitancy – finding it difficult to start urinating
• Needing to push or strain to urinate as if against some obstruction
• Dribbling of urine after urination

In addition to these primary symptoms of BPH, you can also develop some complications. These can include urinary tract infection (UTI), which may present with fever, blood or pus in urine and pain and a burning sensation with urination. Another complication that may arise because of incomplete bladder emptying characteristic of BPH is bladder stones. Long-term complications like bladder and kidney damage can develop in older men as the condition generally worsens with age. ²

If you are completely unable to pass urine, please seek immediate medical attention, as this is a complication that requires emergency treatment.

Causes of Benign Prostatic Hyperplasia (BPH)

The prostate normally goes through two phases of growth in a man’s life. One is during puberty. The other one starts at around 25 years and continues for the rest of life. BPH happens as part of the second growth phase. ³

Research suggests several theories for the development of this condition.

Normally, men produce a significantly large quantity of the male hormone testosterone and a small quantity of the female hormone estrogen. With age, however, testosterone production starts to drop off, and a relatively larger fraction of estrogen remains maintained in the blood. Many studies have suggested that BPH may develop as a result of this change in the ratio of the two hormones as estrogen may interact with substances in the prostate that induce its cells to start growing.

Another male hormone called Dihydrotestosterone or DHT has also been implicated in the development of BPH. Studies have suggested that even as testosterone levels fall with increasing age, DHT levels continue to affect the prostate and promote its growth. ⁴

Who is at Increased Risk of Developing BPH?

Aging and family history are believed to be the most common risk factors for BPH. If your father, brother, or a close male relative have the condition, your chances of having it are also increased. Similarly, the incidence of BPH increases markedly after you cross the age of 40 and has been estimated to be as high as 70% in men of ages 60-69. ⁵

A minor increase in risk is also associated with obesity, inactive lifestyles, and erectile dysfunction. Here, maintaining a healthy diet rich in fruits and vegetables and exercising regularly may impart some protection against developing BPH.

Diagnosis of Benign Prostatic Hyperplasia (BPH)

Medical History:

As with the clinical assessment of any condition, your doctor will begin by taking a comprehensive medical history. For the scoring of BPH-associated symptoms, your doctor may ask you a series of questions as per the BPH Symptom Score Index devised by American Urological Association. ⁶ This will allow an estimation of the severity of your BPH; classified as mild, moderate or severe.

Physical Examination:

Your healthcare provider will then proceed to do a physical examination, including a Digital Rectal Examination or DRE. This is a great clinical tool that allows the doctor to gather some much-needed information about the extent and nature of prostate enlargement by palpating it manually.

Lab Tests:

Lastly, the doctor may order some blood and urine tests to rule out other conditions. These can include:

• Urinalysis – to check for infection and stones. 
• PSA blood test – to screen for prostate pathologies. PSA, or Prostate Specific Antigen, is a marker for prostate health. Levels of PSA can be measured through a blood sample. Low levels of PSA signify good prostate health, whereas levels may be increased in conditions like BPH or prostatitis. Abnormal increase in PSA can also point to a more serious pathology like prostate cancer.
• Post-void residual volume – specific tests may additionally be done to measure the volume of urine left in the bladder after urinating.
• Uroflowmetry (rate of flow of urine) – to assess bladder and sphincter function. The Uroflow test.

Your doctor may also advise cystoscopy and an ultrasound scan of the prostate, depending on their assessment.

Treatment of Benign Prostatic Hyperplasia (BPH)

There are many treatment methods that are currently employed in the treatment of BPH. Depending on the severity of symptoms, size of the prostate, and the disturbance caused by these factors, one or more options can be used.

Age, general health of the patient, as well as personal preferences also significantly affect the choice of treatment. You and your physician can best work out a method that is suited to your individual needs and is also bound to give adequate relief.

Treatment options include:

• Watchful waiting/active surveillance
• Pharmacological therapy
• Minimally invasive surgical procedures
• Surgery

Watchful Waiting/Active Surveillance

This is advised for patients with mild or moderate symptoms that do not cause a noticeable disturbance in everyday life. Your BPH symptoms will be regularly monitored, and you will have annual exams. If symptoms worsen, you may be moved up to active medical treatment.

Pharmacological Therapy

Pharmaceutical mainstays of treatment of BPH include alpha-blockers and 5-alpha-reductase inhibitors.

• Alpha-blockers: These are drugs that relax the muscles of the prostate and the urinary bladder, thus relieving obstruction and causing improvement of urinary flow. Men with moderate to severe BPH whose quality of life is affected by urinary symptoms may benefit from this treatment. These drugs do not change the size of the prostate but cause an immediate improvement in symptoms. Drugs in this category include alfuzosin (Uroxatral), terazosin (Hytrin), doxazosin (Cardura). You may experience slight dizziness, fatigue, and trouble with ejaculation as a side-effect to their use.

• 5-Alpha Reductase Inhibitors: These drugs directly reduce the size of the prostate as they inhibit the production of DHT, the hormone that causes accelerated prostate growth in old age. As the prostate shrinks, obstructive urinary symptoms are eased. Dutasteride (Avodart) and finasteride (Proscar) are two of the drugs included in this category. They are especially helpful in men with very large prostates and older men who are at an increased risk of complications. The need for surgery may also be significantly reduced with the use of these drugs. Some side-effects include erectile dysfunction and reduced sex drive.

The two drugs may be used in a combination therapy method as research has shown that combining the two drugs may be more helpful in uplifting quality of life than either drug alone. ⁷ Not only does combination therapy reduce current symptoms, but it also helps slow down disease progression to a great degree.

Minimally Invasive Surgical Procedures:

As the name suggests, these are quick procedures done under minimal anesthesia on an outpatient basis. Recovery times for such surgeries are noted to be very short.

If you have urinary troubles like slow urination, incomplete bladder emptying, blood in the urine, or have failed to benefit from medication therapy, minimally invasive surgeries may just be the treatment option for you.

Depending on your health status and preference, your doctor can prescribe any of the following options:

• Prostatic Urethral Lift (PUL) or UroLift: In this surgery, tiny implants are used to lift and hold the prostate so that it no longer obstructs the urethra. This leads to an improvement in symptoms within two weeks. The procedure uses no heat or destructive methods to cut or remove prostatic tissue. Side-effects concerning sexual function are lesser than those in other surgical options. Patients who have concurrent medical conditions or are high-risk for other types of surgeries make ideal candidates for this method.

• Convective Water Vapor (Steam) Ablation (CWVA, Rezum): This method uses the stored thermal energy of water vapor to destroy prostatic tissue. The thermal energy dose is delivered through a small needle. Symptom improvement with this method may last up to 4 years, but more research is needed.

• Transurethral Microwave Thermotherapy (TUMT): Here, an electrode entered through a catheter placed in the urethra is made to emit microwaves and destroy selected parts of the prostate. Advantages include a lack of need for anesthesia and minimal blood loss. However, relief of symptoms through this method may only be partial, and it takes time to show effect.

• Catheterization: This is a temporary relief measure employed in people who are awaiting surgery or for medication to take effect. A hollow plastic tube is inserted into the bladder through the urethra or through a suprapubic incision to allow urine to drain. There is a high risk of infection with this method.

• Surgery: People in whom medication has failed to show effect, or those who are suffering from kidney damage, frequent UTIs, complications, bleeding, or a complete inability to pass urine, can benefit from surgery as the chosen treatment of BPH.

• Transurethral Resection of the Prostate (TURP): This is the most common surgical procedure performed for BPH with well-documented benefits. ^8,9  Its positive outcomes can last for up to more than ten years. ^10,11 The surgery requires no incision, and the associated hospital stay is usually 1-2 days. Moreover, it shows immediate relief in symptoms. Under anesthesia, the surgeon passes a thin tube with a light source and camera attached to it through the urethra, and cuts away the obstruction-causing part of the prostate tissue using electric current.

• Photoselective Vaporization of the Prostate (PVP): This is another common surgery in which a tube is passed into the urethra, and prostatic tissue is destroyed using GreenLight laser.

• Transurethral Incision of the Prostate (TUIP): This surgery is ideal for patients who do not have very enlarged prostates but still suffer from urethral blockage. Small cuts are made in the urethra using an electric current or laser beam. This relieves the pressure on the urethra and improves urine flow.

• Holmium Laser Enucleation of Prostate (HoLEP), Thulium Laser Enucleation of the Prostate (ThuLEP): These surgeries include the use of different types of lasers to remove prostatic tissue. No incisions are needed, and the risk of bleeding is minimal.

• Transurethral Water Jet Ablation (TWJA, Aquablation): This is a newer technique that uses high-pressure water jets to destroy prostate tissue.

Other less popular surgeries include Transurethral Needle Ablation (TUNA), Prostate Artery Embolization (PAE), and prostatectomy.

To conclude, while BPH itself is not a worrisome condition, the disturbances and reduced quality of life associated with it may be quite bothersome to affected patients. Additionally, complications can result from longstanding and untreated cases. As such, it’s best to seek prompt medical care if you have any of the symptoms detailed above.

References:

1. Lim, K. B. (2017). Epidemiology of clinical benign prostatic hyperplasia. Asian journal of urology, 4(3), 148-151.  
2. Speakman, M. J., & Cheng, X. (2014). Management of the complications of BPH/BOO. Indian journal of urology: IJU: journal of the Urological Society of India, 30(2), 208.
3. Berry, S. J., Coffey, D. S., Walsh, P. C., & Ewing, L. L. (1984). The development of human benign prostatic hyperplasia with age. The Journal of urology, 132(3), 474-479.
4. Carson III, C., & Rittmaster, R. (2003). The role of dihydrotestosterone in benign prostatic hyperplasia. Urology, 61(4), 2-7.
5. 3. Parsons, J. K. (2010). Benign prostatic hyperplasia and male lower urinary tract symptoms: epidemiology and risk factors. Current bladder dysfunction reports, 5(4), 212-218.
6. International Prostate Symptom Score (I-PSS). http://www.urospec.com/uro/Forms/ipss.pdf
7. Roehrborn, C. G., Siami, P., Barkin, J., Damiao, R., Major-Walker, K., Nandy, I., … & CombAT Study Group. (2010). The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes in men with symptomatic benign prostatic hyperplasia: 4-year results from the CombAT study. European urology, 57(1), 123-131.
8. Mayer, E. K., Kroeze, S. G., Chopra, S., Bottle, A., & Patel, A. (2012). Examining the ‘gold standard’: a comparative critical analysis of three consecutive decades of monopolar transurethral resection of the prostate (TURP) outcomes. BJU international, 110(11), 1595-1601.
9. Gupta, N. P., & Anand, A. (2009). Comparison of TURP, TUVRP, and HoLEP. Current urology reports, 10(4), 276-278.
10. Reich, O., Gratzke, C., & Stief, C. G. (2006). Techniques and long-term results of surgical procedures for BPH. European urology, 49(6), 970-978.
11. Mishriki, S. F., Grimsley, S. J., Nabi, G., Martindale, A., & Cohen, N. P. (2008). Improved quality of life and enhanced satisfaction after TURP: prospective 12-year follow-up study. Urology, 72(2), 322-326.