Benign prostatic hyperplasia BPH refers to noncancerous increase in the number and the size of cells in the prostate gland and it is a normal part of aging.
A prostate gland is small and is about the size of a walnut. It is located between the bladder and the penis. The bladder is a muscular pouch that collects and stores urine that it receives from the kidney. The bladder gives off a tube called the urethra that is surrounded by the prostate and the penis as it carries urine out of the body. The testes give off a tube, the ejaculatory duct also surrounded by the prostate before it joins the urethra. When a man ejaculates, the ejaculatory duct carries sperm to the prostatic urethra and then out of the penis.
The main function of the prostate is to make Prostate Specific Antigen PSA. PSA is an enzyme that is produced by the cells of the prostate and its function is to break down and to make semen more liquid so it can easily travel through the uterus for conception. PSA is produced by benign and malignant cells, so PSA level will increase in BPH and in prostate cancer.
What Are The Causes Of Benign Prostatic Hyperplasia
Men produce testosterone in their testicles. Testosterone is converted to dihydrotestosterone by an enzyme that is present in the prostate that is called alpha-reductase. Dihydrotestosterone then stimulates cells inside the prostate to multiply and to increase in size and this is referred to as BPH. BPH is not related and completely different from prostate cancer. The stimulus for prostate cancer is gene mutation and will not be discussed in this write up. However, BPH and prostate cancer can coexist because 80% of men by age 80 have BPH.
The prostate is made up of smooth muscle and fibers and an outer capsule. As the size of the prostate grows it becomes lumpier and it compresses the urethra that passes through it. This makes it more difficult for urine to pass through the tube in the prostate and to the penis and out of the body. This condition is referred to as bladder outlet obstruction. In addition, the bladder has to generate more pressure to push urine through this blocked or restricted tube, so that the bladder wall becomes thicker and abnormally stretched and this results in urgency and incontinence. This condition is referred to as an overactive bladder.
Who Gets Benign Prostatic Hyperplasia
The prevalence of BPH increases with age. So that up to 50% of 50-year-old men have BPH and 80% of 80-year-old men have BPH. Overweight men and black men are more prone to developing BPH symptoms but all men get BPH as they get older. There is a known genetic predisposition for BPH that has been shown to run in families. Some of the ways to prevent the progression of BPH include daily exercise, eating a low fat and high fiber diet, and avoiding alcohol.
What Are The Signs And Symptoms Of Benign Prostatic Hyperplasia
The obstructive symptoms of BPH occur when voiding and include slow stream, splitting or spraying, intermittency, hesitancy, straining and terminal dribble.
The overactive bladder symptoms of BPH occur when the bladder receives and stores urine and includes daytime urinary frequency, nocturia, urgency, and urinary incontinence.
The post voiding symptoms of BPH include the sensation of incomplete emptying of the bladder and post void dribble.
What Investigations Are Performed For BPH
When BPH worsens and becomes severe it can cause sudden or long standing urinary retention. BPH can also cause erectile dysfunction, ejaculatory dysfunction, and decreased sexual activity.
During a patient visit to a general practitioner, a medical history, prescribed drugs, herbal and over-the-counter medicines are reviewed.
A physical examination of the abdomen, genitals and a digital rectal examination (DRE) is performed.
Symptomatic men complete a urinary frequency volume chart. Several tests are ordered including urine dipstick tests, prostate specific antigen (PSA) test and a serum creatinine and glomerular filtration test.
When symptoms progress beyond conservative and medical management, patients are referred to a specialist. During a specialist visit, history and physical exam, urinary flow rate and post void residual volume are obtained. A cystoscopy or CT scan of the abdomen and pelvis can be ordered when there is infection, urine retention, sterile pyuria, hematuria, severe symptoms and pain.
The International Prostate Symptom Score [IPSS score] is completed by the patient before treatment is started. It is used to assess the severity of the symptoms and response to treatment. The IPSS is made up of 7 questions about voiding symptoms. A score of 0 to 7 indicates mild symptoms, 8 to 19 indicates moderate symptoms and 20 to 35 indicates severe symptoms.
What Are The Conservative Measures For BPH
Initial management of BPH is conservative. Men with post void dribble can be taught how to do urethral milking. Men with urinary incontinence can be provided pads or collecting devices. Men with overactive bladder can be offered supervised bladder training, advice on fluid intake, and containment products. Men with stress incontinence caused by prostate surgery can be offered pelvic floor training.
Men with urinary incontinence should be offered sheath appliances before placing indwelling catheterization due to the high rate of infection of permanent catheters.
Men with obstructive voiding symptoms should be offered intermittent catheterization before permanent catheterization.
Patients who fail medical management and who are not candidates for surgery, should be offered one of the minimally invasive treatments before long-term catheterization is offered. Long term indwelling catheters can cause life recurrent infections and sepsis.
Patients who present with immediate or long standing urinary retention should be offered catheterization while planning for further procedure or surgery.
What Are Drugs Used For The Treatment Of BPH
Drugs are a first line in the treatment of moderate to severe symptoms of BPH.
Alpha blocker drugs are prescribed for obstructive voiding symptoms of BPH and they relax the bladder neck, the prostate and the urethra so urine can easily flow.
5-alpha reductase inhibitors are prescribed for patients with obstructive symptoms and prostates larger than 40 ml or a PSA level greater than 1.4 ng/ml. These drugs slowly shrink the prostate by blocking the conversion of testosterone to dihydrotestosterone; a potent stimulant for BPH.
Anticholinergic drugs are used to treat overactive bladder and they relax the bladder muscle so it can efficiently receive and store urine normally without leaking urine.
What Are Some Minimally Invasive Treatment For BPH
Minimally invasive therapies are recommended for men who have severe symptoms and who have failed conservative and medical treatment.
In general, minimally invasive therapies do not involve any cutting, are same-day procedures, are performed with local anesthetic and generally do not cause sexual dysfunctions. They take a few weeks to achieve the full effect.
Prostate Artery Embolization is a minimally invasive procedure used to treat a prostate of any size including very large prostates more than 300gm.
Prostate artery embolization is performed by introducing a fine catheter into the artery of the wrist or the groin. The catheter is placed directly into the prostate artery by using live x-ray guidance, before injecting tiny beads to block the blood flow to the prostate. The prostate shrinks and loses muscle tone so that good urine flow is achieved.
The other minimally invasive options are limited to prostates less than 80gm in size and include transurethral water vapor therapy [TUVP], transurethral needle ablation [TUNA], transurethral microwave thermotherapy [TUMT], high-intensity focused ultrasound [HIFU] and transurethral ethanol ablation of the prostate [TEAP].
What Surgeries Are Available For BPH
The prefered surgery for obstructive BPH symptoms due to a large prostate that is less than 80gm in size is transurethral resection of the prostate (TURP).
Holmium laser enucleation of the prostate (HoLEP), is performed through the penis without making an incision on the body. A laser is used to free up the prostate from the outer capsule, push the prostate into the bladder before removing it out of the body with a special device. HoLEP can be used to remove very large prostates.
In open or robotic prostatectomy abdominal incisions are made. The prostate is cut out at the bladder end and the pennis end. The bladder is then attached directly to the pennis with stitches.
The advantage of surgery is that the obstructive symptoms are treated faster. The disadvantage of surgery is that the prostatic urethra and the ejeaculatory duct are damaged or removed. They potentially cause stress incontinence, sexual dysfunction and bleeding or blood transfusion at surgery.
Conclusion
BPH is a non cancer growth of the prostate that can potentially block or restrict the flow of urine out of the body. The size of the prostate and the severity of the symptoms of BPH progresses as a man ages. The severity of these symptoms and responses to treatment can be objectively evaluated. Various tests are performed to confirm the diagnosis and exclude other conditions that may cause similar symptoms. The treatments for BPH include conservative, medication, minimally invasive and surgical treatments.
There may be a role for a procedure or a surgery in a patient who progresses to severe symptoms. Treatments should be individualized to the patient’s presentation. The doctors who treat patients with BPH symptoms should be ready to discuss all the available options, perform or refer these patients for the appropriate treatment for the patient.
