What is benign prostatic hyperplasia?

Benign prostatic hyperplasia (also called BPH) is a condition that affects the prostate gland in men. The prostate is a gland found between the bladder (where urine is stored) and the urethra (the tube urine passes through). As men age, the prostate gland slowly grows bigger (or enlarges). As the prostate gets bigger, it may press on the urethra and cause the flow of urine to be slower and less forceful. "Benign" means the enlargement isn't caused by cancer or infection. "Hyperplasia" means enlargement. What are the symptoms of BPH? Most symptoms of BPH start gradually. One symptom is the need to get up more often at night to urinate. Another symptom is the need to empty the bladder often during the day. Other symptoms include difficulty in starting the urine flow and dribbling after urination ends. The size and strength of the urine stream may decrease. These symptoms can be caused by other things besides BPH. They may be signs of more serious diseases, such as a bladder infection or bladder cancer. Tell your doctor if you have any of these symptoms, so he or she can decide which tests to use to find the possible cause. How will my doctor know if I have BPH? After your doctor takes a complete history of your symptoms, a rectal exam is the next step. In a rectal exam, your doctor checks your prostate by putting a gloved, lubricated finger into your rectum to fee the back of your prostate gland. This exam allows your doctor to feel the size of the prostate gland. To make sure that your prostate problem is benign, your doctor may need to look at a sample of your urine for signs of infection. Your doctor may also do a blood test. An ultrasound exam or a biopsy of the prostate may help your doctor make the diagnosis. How will my doctor treat my BPH? Once your doctor is sure that your symptoms are caused by benign growth of the prostate gland, treatment can be recommended. However, your doctor may suggest that you wait to see if your symptoms get better. Sometimes mild symptoms get better on their own. If your symptoms get worse, your doctor may suggest another treatment option. Surgery is considered the most effective treatment and is used in men with strong symptoms that persist after other treatments are tried. This is also the best way to diagnose and cure early cancer of the prostate. Surgery is usually done through the urethra, leaving no scars. Surgery does have risks, such as bleeding, infection or impotence. These risks are generally small. Are there any drugs I can take?

Drug treatments are available. Finasteride (brand name: Proscar) and dutasteride (brand name: Avodart) blocks a natural hormone that makes the prostate enlarge, but it does not help all patients. The side effects of finasteride are rare and mild, but they usually have to do with sexual function. They go away when the medicine is stopped. The prostate may enlarge again when the medicine is stopped, so your doctor may suggest another treatment. Another kind of medicine, called alpha-blockers, also can help the symptoms of BPH. Alpha-blockers have been used for a long time to treat high blood pressure, but they can also help the symptoms of BPH, even in men with normal blood pressure. Some of these drugs are terazosin (brand name: Hytrin), doxazosin (brand name: Cardura), tamsulosin (brand name: Flomax) and alfuzosin (brand name: Uroxatral). These medicines may not work in all men. The side effects of alpha-blockers include dizziness, fatigue and lightheadedness. The side effects go away if you stop taking the medicine. Written by familydoctor.org editorial staff. Source
American Academy of Family Physicians
Reviewed/Updated: 12/06 Created: 09/00 Copyright © 2000-2007 American Academy of Family Physicians This article provides a general overview on this topic and may not apply to everyone. To find out if this article applies to you and to get more information on this subject, talk to your family doctor.

What is the prostate gland? 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 becomes part of semen. Semen is the white fluid that contains sperm.

Prostate problems are common in men 50 and older. Most can be treated successfully without harming sexual function. A urologist is a specialist in diseases of the urinary system, including diagnosing and treating problems of the prostate gland. How does the doctor detect prostate enlargement? A doctor usually can detect an enlarged prostate by rectal exam. The doctor also may examine the urethra, prostate, and bladder using a cytoscope, an instrument that is inserted through the penis. What is benign prostatic hyperplasia? Benign prostatic hyperplasia is nonmalignant (noncancerous) enlargement of the prostate gland, a common occurrence in older men. It is also known as benign prostatic hypertrophy and abbreviated as BPH and as nodular hyperplasia of the prostate.

Benign Prostatic Hyperplasia and Benign Prostatic Hypertrophy are both non-cancerous conditions that cause a constriction of the urethra, due to the increase in the size of the prostate. BPH commonly affects middle aged to elderly men. About 43% of men with BPH are over 65.

Although the two conditions are scientifically quite distinct from each other they are both called BPH by doctors, and have the same methods of diagnosis and treatment. This fact sheet is about the causes, symptoms, diagnosis and treatment of BPH.

What is BPH
Benign Prostatic Hyperplasia describes the abnormal increase in the number of non-cancerous cells within the transition zone of the prostate. Most cancers of the prostate start in the peripheral zone, whilst the central zone tends to be free from changes.

Benign Prostatic Hypertrophy is the abnormal increase in the size of non-cancerous cells within the transition zone of the prostate.

What causes BPH?
As men get older, there is a surplus in the amount of testosterone produced by the testicles. This excess testosterone is absorbed by the prostate. Testosterone causes an increase in the growth of prostate cells, and how long those cells live. The result of this is growth of the prostate. Since the prostate surrounds the urethra this growth slowly begins to strangle the urethra as it exits the bladder. This can cause obstruction and reduce the flow of urine from the bladder.

Signs & Symptoms
The degree of ‘bother’ symptoms cause will differ from man to man as will the type of symptoms experienced and length of time they last. The signs and symptoms experienced are often referred to by health professionals as Lower Urinary Tract Symptoms (LUTS).

Symptom Poor stream Frequency Urgency Hesitancy Nocturia Dribbling

Description Urine flow is weak and slow Peeing more than 10 times a day The sudden almost uncontrollable need to pee Difficulty and delay starting to pee Waking up more than twice a night to pee Being unable to stop completely the flow of urine Incomplete emptying of the bladder Burning/pain on peeing

Effects of BPH
How and when you decide to seek advice for your symptoms will usually depend on the ‘bother’ factor of symptoms and their impact upon you and your partners work and social life. Some men find that their activities are limited due to the need to be near toilet facilities. Work, driving, outdoor activities and attending social events can become difficult. If left unchecked problems that are more serious can develop: Some men find that they have a sudden and painful inability to pass urine. This is Acute Retention of Urine. This requires urgent medical treatment by means of draining the bladder with a urinary catheter and probably a short period of hospitalisation. Other men find it becomes increasingly more difficult, though usually painless, to empty the bladder and they retain more urine than they pass. This is Chronic Retention of Urine. Chronic retention will cause an overstretching of the bladder as it tries to cope with the increase in capacity and pressure. The increase in pressure can lead to back pressure which left unchecked can result in kidney failure as the kidneys become ‘waterlogged’. As the lining and muscles of the bladder become fatigued through the constant stretch of chronic retention small tears and pockets may develop and give rise to urinary tract infections as well as the formation of bladder stones. Bladder stones are collections of crystallised urine that form into semi-soft ‘putty like’ and hard ‘rock like’ stones. Although not life threatening bladder stones can be painful and contribute to a worsening of symptoms.


An initial diagnosis can be made by your GP who may perform the following tests. If not completed by your GP they will be done by an Urologist or Specialist Nurse at your local hospital. You will be asked about your symptoms. A scorecard may be used to rate your symptoms.

• • • • • •

You may be asked to record your drinking and urination over a series of days to assess the frequency and amount of urine you pass. A rectal examination will indicate if the prostate is enlarged. The prostate can be felt through the wall of the rectum. Usually your urine will be tested to find any possible infection. A blood test to check kidney function should be performed. You may be given a PSA test. More specialist tests will be required and these are usually carried out in a more specialist setting:

Flow rate
Assesses the force of urination by recording the speed and energy of flow of urine when passed into a recording device.

Ultrasound scan
This records the amount of urine that the bladder retains following urination. A scan to check the size and shape of the urinary system may also be performed.

Depending on symptoms, other x-ray examinations such as dye tests (Intravenous Urogram IVU) may be performed to ascertain the effects upon the kidneys and the bladder.

Treatment Options
The type of treatment you require will be based upon the severity of your symptoms, the presence of any complications and your general health. All treatments have advantages and disadvantages. You should discuss the most appropriate treatment with your specialist. Treatment options are: • • • • •

Watchful Waiting and lifestyle changes Permanent catheterisation Drug treatments and alternative medicines Non surgical interventions Surgery

Watchful Waiting
If there are no complications and minimal inconvenience from the symptoms it may be more appropriate to wait and see how your condition develops over a period of time. You should have regular checks on your symptoms.

Lifestyle Changes

If you who wish to avoid surgery and drug therapies relief from symptoms may be increased by some simple changes to your lifestyle: • • • •

• •

Avoid drinks that are high in caffeine Avoid alcohol or reduce your alcohol intake Decrease the amount you drink in the evening Avoid cold and allergy medicines such as anti-histamines and decongestants, which can affect the muscles in the bladder (this should be done in consultation with your GP) Drink Green tea, it contains flavonoids that may be of benefit to the prostate Increase the amount of fibre and fruit you eat to avoid constipation

Urinary Catheterisation
Urinary catheterisation may be used for some men for medicines are not suitable as a treatment choice or those who cannot endure surgery. The catheter may be placed via the urethra or via the abdominal wall. This will allow urine to drain continually with minimal inconvenience. Catheterisation is not without its disadvantages. Men with a catheter are more susceptible to infection and may find it interferes with their sex life.

Drug Treatments & Alternative Medicines
The continual development in conventional drug therapies, and the greater awareness of ‘alternative medicines’, has reduced the number of men undergoing surgery for BPH. They have also had a part in delaying the eventual need for surgery in those with symptoms that are more aggressive. Conventional drug therapies fall into two type of drugs: • •

Alpha-blockers 5 a-reductase inhibitors.

Alpha-blockers A drug that relaxes smooth muscles, alpha-blockers have previously been used to treat high blood pressure. They are effective in treating the symptoms of BPH in men who don’t have significantly enlarged prostates. By relaxing the smooth muscles surrounding the prostate alphablockers increase the flow of urine and improve symptoms.

Drug Alfuzosin Doxazosin Indoramin Prazosin Tamsulosin Terazosin

Types of alpha-blockers Brand Name Xatral SR & Xatral XL Cardura Doralese Hypovase Flomax MR Hytrin BPH

Advantages of alpha-blockers • • •

Improve urinary flow Quick to work No adverse effect upon sexual drive

Disadvantages of alpha-blockers • • • • • • •

Short acting Usually only delays the need for surgery, no evidence for preventing the progression of BPH Only effective on moderately enlarged prostates Lower blood pressure and dizziness Short acting Can cause fatigue, nasal congestion, headache Can decrease ejaculate

5 Alpha-reductase Inhibitors
5 a-reductase inhibitors block the conversion of testosterone within the prostate cells. 5 areductase inhibitors are more effective in men with larger prostate glands than alpha-blockers and have been found to reduce prostate volume by 20% resulting in an improvement in symptoms. Types of 5 a–reductase inhibitors

Drug Finasteride
Advantages of Finasteride • • • •

Brand Name Proscar

More effective on larger prostates Longer acting Less side effects than alpha blockers Can reverse male pattern balding

Disadvantages of Finasteride • • • • •

Not effective on slight and moderately enlarged prostates Slow to act - can take up to six months to work Can affect sexual function Can cause breast swelling Can be transmitted in semen and cause birth defects, users should have protected sex

Alternative Therapies
Although there are as yet no conclusive studies to the true value of herbal and non-traditional therapies many men have found relief from the symptoms of BPH. If you intend trying any alternate treatments it is advisable to discuss this with your doctor before you start. The more widely available alternative therapies include Saw palmetto, Beta-sitosterol plant extracts and Rye Grass pollen extract.

For the majority of men with BPH whose symptoms are becoming unbearable or who develop complications surgery is the recommended treatment.

Transurethral Resection of Prostate (TURP)
This is the most widely available surgery. TURP involves stripping away the enlarged prostate via the urethra, under anaesthetic. This procedure is ideal for most degrees of enlargement. TURP is performed under anaesthetic and via the urethra, so no incision is required. Using fibre-optic equipment small scrapings of the enlarged prostate tissue are made until a clear passage is be made. A catheter can then be inserted to help drain the bladder and evacuate any debris. Smaller prostates can be removed in a similar fashion. This is often called Bladder Neck Incision or Transurethral Incision. Larger prostates may require an open prostatectomy where the enlarged prostate is removed via an incision in the abdomen. It is common for the symptoms of BPH to persist for several weeks after TURP, they should settle with time and if required performing pelvic floor exercises to strengthen the muscles of the pelvis. Most men are discharged within five days of admission and return to the clinic within three months of the operation for a check up.

Open Prostatectomy
Open Prostatectomy is only carried out on men with very large prostate glands. The gland is removed through an incision in the lower abdomen. Open Prostatectomy is a major operation and requires a hospital stay of 7 days or more. A catheter will be inserted at the time of the operation that will stay in place for about two weeks. Recovery following this surgery is slower than TURP because of the wound, and men are advised to avoid strenuous activity for several months. The complications are similar to TURP with 10% requiring further surgery within 8 years. Different hospitals and specialists have different ways of achieving the same results so always check their treatment plan for your procedure.

Advantages of surgery
• •

TURP is widely available 90% probability of symptom improvement

Disadvantages of surgery

• • • • • • • •

Blood Loss 20% of men will need a second TURP within 8 years (5) Disruption of sexual function Risk of scarring (stricture) in the urethra Hospital stay of five – seven days Temporary incontinence Infection Wound (open prostatectomy)

Non Surgical Interventions
Non Surgical Techniques are not widely available in the UK and many are still under study to see if they are effective compared to TURP. It will be several years before any conclusive evidence of their value is available.

Non surgical interventions
• • • • •

Transurethral Microwave Therapy (TUMT) Transurethral Needle Ablation (TUNA) Transurethral Electrovaporisation (TUEVP) Laser Surgery Prostatic Stenting

Transurethral Microwave Therapy (TUMT)
TUMT, or thermotherapy, is the destruction of enlarged prostatic tissue by heating it to around 45 – 55 C. Microwave heat is delivered via a probe inserted via the urethra with a temperature regulator placed in the rectum. Advantages of TUMT • • •

Little or no bleeding Reasonable urinary flow improvement Less effect on sexual function compared to standard surgery

Disadvantages of TUMT • • • • •

May need repeated sessions Requires general anaesthetic High risk of retention of urine after treatment Cannot be performed if you have a pacemaker, or other metal implant Not widely available

Transurethral Needle Ablation (TUNA)
Destruction of enlarged prostatic tissue is achieved by using radio-frequency energy applied to the centre of the prostate gland at temperatures of 120 C. It is applied to the core of the prostate

to avoid damage to the urethra and is reported to be more effective on moderately enlarged prostates. Advantages of tuna • • • •

Can be performed under local anaesthetic Little bleeding Low risk of incontinence Urine flow improvement comparable to surgery

Disadvantages of tuna • • • • •

Not effective on large prostates High risk of retention of urine after treatment Disruption to sexual function Painful urination after procedure Not widely available

Transurethral Electrovaporisation of Prostate (TUEVP)
A modification of the standard surgery TURP. The prostate tissue is vaporised by a high electrical current rather than cut away. The electrical current also seals any bleeding.

Advantages of TUEVP
• •

Similar results to surgery Minimal blood loss compared to surgery

Disadvantages of TUEVP • • •

Not widely available Effectiveness of surgery can be delayed Hospital stay of around 5 days

Laser Surgery
There are various methods of laser-based surgery being used and studied at present. All require the insertion of a laser probe or wire into the urethra to rest on the surface of the prostate. Treatments tend to be short in duration compared to conventional surgery. Men receiving laser surgery usually see an immediate improvement in their symptoms and urine flow, whereas those treated by the laser coagulation method find the response is delayed. Advantages of laser surgery Minimal bleeding compared to standard surgery •

Symptoms may improve immediately

Disadvantages of laser surgery • • •

High risk of retention of urine following treatment Symptom improvement may be slow Not Widely available

Prostatic Stenting
For men whom surgery, medicines and catheterisation is not advisable prostatic stenting may be an option. The obstruction caused by the enlarged prostate can be held back by the insertion, usually under a local anaesthetic, of a cylinder shaped mesh structure, called a stent. This is made from flexible metals such as titanium alloy. Stents are advantageous in the reducing the symptoms of BPH by having the instant effect of improving symptoms without any

Sign up to vote on this title
UsefulNot useful