Running head: BENIGN PROSTATE HYPERPLASIA (BPH) 1

Benign Prostate Hyperplasia (BPH)

Megan Schleigh

King University
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Benign Prostate Hyperplasia (BPH)

Introduction of Disease

Benign prostatic hyperplasia, or BPH, is a condition that occurs when the prostate gland

enlarges, potentially slowing or blocking the urine stream from increased proliferation

(Cunningham & Kadmon, 2018). The increased proliferation results in an enlarged prostate with

possible voiding dysfunction and bladder outlet obstruction from compression on the urethra

(Lepor, 2005). BPH typically present as lower urinary tract symptoms, infections, and retention

(Patel & Parsons, 2014).

Pathophysiology

BPH is an uncontrolled proliferative process that leads to an increase in the cell number

and size of the cells in the connective tissue, smooth muscle, and glandular elements of the

prostate gland (Patel & Parsons, 2014). The proliferative process in the prostate begins in the

transition zone in the periurethral region of the prostate (Lee & Kuo, 2017). As the

hyperproliferation occurs, prostatic intrusion into the urethral lumen or bladder neck can result in

bladder outlet resistance causing mechanical obstruction (Patel & Parsons, 2014).

Prevalence, Incidence of Occurrence and Statistical data

The prevalence of BPH rises significantly with aging (Lee & Kuo, 2017). It is estimated

that approximately 50% of all men by the age of 60 will have BPH (Lee & Kuo, 2017), and 90%

of men will develop the disease by 80 years old (Lepor, 2005).

BPH has a significant impact on the health of older men and health-care costs (Patel &

Parsons, 2014). Complications of BPH include urinary infections, urinary retention, bladder

calculi, and acute renal failure (Patel & Parsons, 2014). In 2000, BPH accounted for 4.4 million

office visits, 117,000 emergency room visits, and 105,000 hospitalizations (Patel & Parsons,
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2014). It is estimated that the annual cost of BPH treatment in the United States is at least $3.9

billion dollars (Patel & Parsons, 2014).

Risk factors

The exact etiology of BPH is complicated and poorly understood (Lee & Kuo, 2017).

However, several risk factors for the development of BPH have been identified (Lee & Kuo,

2017). There are two broad categories of risk factors associated with BPH: non-modifiable and

modifiable (Patel & Parsons, 2014). Non-modifiable risk factors include age, geography, and

genetics (Patel & Parsons, 2014). Modifiable risk factors include sex steroid hormones, the

metabolic syndrome, cardiovascular disease, obesity, diabetes, physical activity, diet, and

inflammation (Patel & Parsons, 2014).

Diagnosis of Disease

The prostate normally enlarges to some degree in all men with advancing age, although

not all men require treatment and not all men with BPH have symptoms (Cunningham &

Kadmon, 2018). In men with symptoms, the most common include needing to urinate frequently

(during the day and night), a weak urine stream, and leaking or dribbling of urine (Cunningham

& Kadmon, 2018). To know if BPH or another problem is causing these symptoms, a doctor or

nurse practitioner must ask questions, perform a rectal exam, and do urine and blood tests

(Cunningham & Kadmon, 2018).

A blood test to check the prostate-specific antigen (PSA) level is recommended

(Cunningham & Kadmon, 2018). PSA is a protein produced by prostate cells; the PSA level may

be increased in men with BPH (Cunningham & Kadmon, 2018). If PSA is significantly high,

further testing should be done to rule out prostate cancer (Cunningham & Kadmon, 2018).

Other studies that can be done include a urodynamic study, uroflowmetry, post-void
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residual urine volume, pressure-flow studies, and filling cystometry (Lepor, 2004). The most

definitive and accurate testing to determine the volume of the prostate include imaging studies

such as ultrasound, CT, or MRI (Cunningham & Kadmon, 2018). The International Prostate

Symptom Score (IPSS) is recommended as the symptom scoring instrument to be used for the

baseline assessment of symptom severity in men presenting with BPH (Lepor, 2004). When the

IPSS is used, symptoms of BPH can be classified as mild, moderate, or severe (Lepor, 2004).

Management of Disease

Men with mild BPH, with or without symptoms, do not need treatment. During this time,

most experts recommend a “wait and watch approach” (Cunningham & Kadmon, 2018). In some

cases, BPH symptoms improve without treatment (Cunningham & Kadmon, 2018). Men with

moderate to severe symptoms will likely require treatment with medication or surgical

intervention (Cunningham & Kadmon, 2018).

Non-Pharmacologic Therapy

All men with BPH should avoid taking antihistamines or decongestant medications as

both can worsen symptoms and cause urinary retention (Cunningham & Kadmon, 2018).

Lifestyle changes are also recommended if a patient is bothered by having to go to the bathroom

frequently (Cunningham & Kadmon, 2018). These lifestyle changes include: Stop drinking fluids

a few hours before bedtime or going out, avoid or drink less fluids that can make you go more

often, such as caffeine and alcohol, and double void (Cunningham & Kadmon, 2018).

Clinical data demonstrate that alpha blockers and alpha-reductase inhibitors relieve and

increase urinary flow rates in men with BPH (Lepor, 2005). Alpha blockers relax the muscle of

the prostate and bladder neck, which allows urine to flow more easily. There are at least five

medications in this category: terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax),

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alfuzosin (Uroxatral), and silodosin (Rapaflo) (Cunningham & Kadmon, 2018). Alpha blockers

begin to work quickly and are usually recommended as a first-line treatment for men with mild

to moderate symptoms (Cunningham & Kadmon, 2018).

Alpha-reductase inhibitors are medicines that can stop the prostate from growing further

or even cause it to shrink, examples include Finasteride (Proscar) and dutasteride (Avodart)

(Cunningham & Kadmon, 2018). This type of medicine works better in men with a larger

prostate. It can reduce the risk of urinary retention and the need for surgery (Cunningham &

Kadmon, 2018). Most men see an improvement within six months of starting treatment

(Cunningham & Kadmon, 2018).

A combination of an alpha blocker and an alpha-reductase inhibitor might be

recommended for certain men (Cunningham & Kadmon, 2018). This may benefit men with

severe symptoms, a large prostate, and who do not improve with the highest dose of an alpha

blocker (Cunningham & Kadmon, 2018). This can be done to try to prevent surgical intervention

(Cunningham & Kadmon, 2018).

Surgical Intervention

If medicines do not relieve symptoms of BPH, a treatment to remove or destroy some of

the prostate tissue around the urethra may be recommended (Cunningham & Kadmon, 2018).

Most procedures are performed through the urethra using a scope (Cunningham & Kadmon,

2018). These procedures include resection of the prostate, ablation of the prostate, plasma

vaporization, laser ablation, incision of the prostate, radiofrequency ablation, microwave

thermotherapy, prostatic lift, removal of the prostate, or placement of a suprapubic catheter

(Cunningham & Kadmon, 2018).

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Patient Education

Most men that need medication to help manage BPH symptoms need lifelong medication

therapy unless they have surgery (Cunningham & Kadmon, 2018). The most important side

effects of alpha blockers are dizziness and low blood pressure after sitting or standing up.

Terazosin and doxazosin are usually taken at bedtime to reduce lightheadedness (Cunningham &

Kadmon, 2018).

Caution of medication therapy should be used with patients with erectile dysfunction

(ED). A patient should not take terazosin and doxazosin if they take a medicine for ED, such as

sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), or avanafil (Stendra) (Cunningham &

Kadmon, 2018). Tamsulosin and alfuzosin usually do not interact with ED medications

(Cunningham & Kadmon, 2018).

Men who take alpha-reductase inhibitors may have decreased sex drive, difficulty with

erection or ejaculation, or symptoms of depression (Cunningham & Kadmon, 2018). Sometimes,

these problems are significant enough to cause men to interrupt BPH treatment (Cunningham &

Kadmon, 2018). These symptoms will resolve when medication is stopped (Cunningham &

Kadmon, 2018).

Health Maintenance Needs

The IPSS screening tool should be the primary determinant of treatment response or

disease progression in the follow-up period (Lepor, 2004). If the patient’s symptoms are not

bothersome, follow up is recommended yearly (Lepor, 2004). If the symptoms are bothersome,

medical therapy typically represents first-line intervention (Lepor, 2004). If medical therapy is

effective, annual follow up is recommended, which may include uroflowmetry and PVR

measurement (Lepor, 2004). If medical therapy is ineffective, uroflowmetry, PVR measurement,

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and a urodynamic pressure-flow study should be performed and surgery options considered

(Lepor, 2004).
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References

Cunningham, G. R., & Kadmon, D. (2018). Patient education: Benign prostatic hyperplasia (bph)

(beyond the basics). O'Leary, M. P., & Givens, J. (Ed.). Retrieved from https://www.upto

date.com/contents/benign-prostatic-hyperplasia-bph-beyond-the-basics

Lee, C. L., & Kuo, H. C. (2017). Pathophysiology of benign prostate enlargement and lower urin

ary tract symptoms: Current concepts. Tzu Chi Medical Journal, 29(2), 79-83. Retrieved

from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5509197/

Lepor, H. (2005). Pathophysiology of benign prostatic hyperplasia in the aging male populatio

n. Reviews in Urology, 7(4), 3-12. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/arti

cles/PMC1477609/

Patel, N. D., & Parsons, J. K. (2014). Epidemiology and etiology of benign prostatic hyperplasia

and bladder outlet obstruction. Indian Journal of Urology, 30(20), 170-176. Retrieved fro

m https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3989819/