Benign prostatic hyperplasia (BPH)

Benign prostatic hyperplasia (BPH), also called benign prostatic hypertrophy, is an enlargement of the prostate gland. The risk of developing BPH increases with age. Most men have some degree of prostate enlargement by age 80.


Anatomy
The prostate is a gland located at the base of the bladder in a man. It's normally the size of a walnut, but the size may increase with age and in response to infections or tumors.
The prostate surrounds the urethra (the tube that carries urine from the bladder out through the penis) and the neck of the bladder. The prostate and other smaller glands produce fluids that combine with sperm to make semen. The back section of the prostate gland is located next to the rectum.

The nerves that control erectile function, which are located on both sides of the gland, can be damaged by some BPH treatments.


Causes
Many factors may be involved in the development of BPH. Most researchers think that it's primarily the normal hormonal changes of aging in some men that cause prostate enlargement. A family history of BPH may increase the risk. No other clear-cut risk factors have been identified.
It's uncertain how many men are actually affected by BPH. About half of men in their 60s and as many as 90 percent of men in their 70s and 80s have some symptoms.


Signs/symptoms
Again, the prostate surrounds the urethra and the neck of the bladder. As the prostate enlarges, it may narrow or block the passageway for urine. When prostate enlargement interferes with urine flow, the bladder wall thickens and becomes irritated. Even with a small amount of urine, this irritation causes bladder contractions, which may lead to a frequent urge to urinate.
Other symptoms may include:

waking at night to urinate
difficulty starting urination
urgency or straining to urinate
a urinary stream that starts and stops repeatedly
dribbling or a weak stream of urine
feeling like you can't empty your bladder
If you have symptoms, it's important to contact your doctor. Without proper treatment, you may experience permanent damage to the urinary tract or other complications.


Diagnosis
The doctor will ask about your medical history and may give you a prostate symptom questionnaire to help determine the severity of your condition. Other common tests include:
Digital rectal exam (DRE): Because the prostate gland is located just next to the rectum and can be felt through the rectal wall, the doctor will do a DRE to evaluate its size and condition. He or she will insert a gloved, lubricated finger into the rectum to feel the prostate gland. The doctor may also feel the lower abdomen to determine if the bladder is distended, which indicates urine is being retained in the bladder. Sometimes, the prostate is massaged with a fingertip during the DRE. Fluids that drain from the tip of the penis will be analyzed for signs of infection.

Prostate-specific antigen (PSA): The doctor may also do a prostate-specific antigen blood test, which measures a protein made only by the prostate gland. Small amounts of this protein can normally be found in a man's blood. PSA blood levels often rise when the prostate is enlarged or traumatized, or you have an infection or prostate cancer. It can be used with a digital rectal exam of the prostate. The PSA test should precede the DRE, since rectal manipulation can elevate the PSA level in the blood.

Urinalysis and blood tests: Urine will be tested for infection or bleeding. Your urine or blood may also be tested for creatinine, a natural protein. Increased levels may indicate impaired kidney function.

Abdominal/transrectal prostatic ultrasound (TRUS): An abdominal ultrasound (using sound waves to create an image of internal body parts) may be done to evaluate the bladder and any upper urinary tract changes. If further evaluation of the prostate is needed, your doctor may do a transrectal prostatic ultrasound (TRUS). Using sounds waves from a special probe inserted into the rectum, this test creates an image of the prostate gland and surrounding tissues. If your doctor suspects cancer, a biopsy of the prostate tissue with TRUS guidance may be done to confirm the presence of cancer cells.

Urine flow study (uroflowmetry or urodynamic studies): Your doctor may measure how quickly your urine flows from your bladder by having you urinate into a special device. You'll then be given a Qmax rating, which is the fastest speed your urine flows. A low score suggests a blockage, possibly by an enlarged prostate or prostate cancer. It may also indicate a weak bladder.

Post-void residual urine: This test is done to see how much urine is left in your bladder after you urinate. You'll be asked to urinate, then a scanner will be passed over you lower abdomen. The image it produces will show if urine is left in your bladder. Urine retention may mean you have an enlarged prostate.

Intravenous pyelogram (IVP): An intravenous pyelogram is an X-ray of the urinary tract. A dye, which makes the kidneys, ureters and bladder more visible, is injected into a vein before the X-ray. This procedure helps determine whether a blockage or other abnormalities in the urinary system are present. An allergic reaction to the dye is possible.

Cystoscopy: This test is done for some men to help determine the best surgical treatment for BPH. A small instrument called a cystoscope is inserted into the penis through the urethra to help the doctor look directly at the bladder and prostate. If necessary, samples of prostate tissue can be taken for a biopsy. To prevent discomfort, a local or general anesthetic may be used. Complications may include bleeding or infection.

Treatment options
Deciding whether to treat BPH depends on many factors, such as how bothersome your symptoms are and how much your urinary system is affected. Treatment options include watchful waiting, medication, plant-based treatments, surgery and minimally invasive procedures.
Watchful waiting
BPH progresses slowly and remains stable in about half of men. If your symptoms aren't severe, you and your doctor may decide to wait and see if your symptoms worsen before proceeding with treatment. For some men, symptoms spontaneously improve. Your doctor will schedule yearly exams to monitor the size of your prostate and your symptoms.

Benefits: There are no side effects because there's no treatment.

Risks: A small number of men may become unable to urinate or develop bleeding or an infection. Damage to the kidneys or bladder is possible, but uncommon. There's no way to predict who will develop complications from watchful waiting.
Medication
Various medications, including three alpha blockers and two 5 alpha-reductase inhibitors, can be used to relieve BPH symptoms. A recent study indicated that a combination of doxazosin (an alpha blocker) and finasteride (a 5 alpha-reductase inhibitor) may be more effective than either medication alone. If your doctor recommends medication, you may be scheduled for follow-up visits to evaluate how well it's working. If you experience any adverse effects from your medication, it's important to inform your doctor promptly.


Alpha blockers: These medications, including doxazosin (Cardura, for example), terazosin (Hytrin, for example), tamsulosin (Flomax, for example) or alfuzosin (Uroxatral, for example), help relax the prostate muscles and relieve urinary symptoms. Long-term effects are unknown. There's currently no evidence that alpha-blockers decrease complications of BPH, such as urinary retention or kidney failure, or the need for future surgery.

Benefits: Alpha blockers may relieve the urinary symptoms of BPH, and doxazosin and terazosin can also be used to treat high blood pressure. Compared to 5 alpha-reductase inhibitors, the alpha blockers are fast-acting. Some improvement in symptoms may be noticeable within two to three weeks. They don't affect PSA levels.

Risks: Some men may experience headaches, low blood pressure, dizziness, lightheadedness, weakness, fatigue or retrograde ejaculation (when semen goes back into the bladder instead of out through the penis). Side effects are less common with the newer, more selective alpha-blocker tamsulosin. With the first dose of an alpha blocker you're likely to experience dizziness or light-headedness with position changes. This may be especially noticeable if you get up at night to urinate, so it's important to be cautious to prevent falls.

5 alpha-reductase inhibitors: These medications, including finasteride (Proscar, for example) and the recently approved dutasteride (Avodart, for example), are used to reduce the size of the prostate by blocking the effect of the male hormone testosterone on the prostate gland. Most men experience a decrease in symptoms and prostate size. It takes six to 12 months to determine whether these medications help. Studies show that they may be more effective when the prostate is very enlarged. Men who respond to this treatment and continue taking the medication can usually expect to benefit from it for up to six years.

Benefits: These medications may reduce the size of the prostate gland and improve symptoms. Studies have shown that long-term use significantly lowers the likelihood of urinary retention and surgical treatment.

Risks: Possible side effects include disinterest in sex, erectile dysfunction (difficulty having or sustaining an erection) and retrograde ejaculation. These medications lower the blood level of PSA by 40 to 50 percent, even if prostate cancer is present. This must be considered when interpreting PSA levels.
Plant-based therapy (herbal therapy orphytotherapy)
Several over-the-counter plant-based therapies may improve the symptoms of BPH. However, all plant-based therapies need more scientific study before benefits and risks can be certain. It's unclear how most of them work, and their long-term effects and safety haven't been studied.

If you're thinking about a plant-based therapy, be sure to discuss it with your doctor. It's also important to buy herbal products from a reputable dealer. The FDA doesn't review dietary supplements and over-the-counter products as thoroughly as prescription medications. These products may have contaminants and may vary in potency and quality.

Plant extracts that have shown promise in research thus far include saw palmetto, rye grass pollen and beta-sitosterol plant extracts. Others that need more study include African plum/prune (Pygeum africanum) and stinging nettle root (Urtica dioica).


Saw palmetto (Serenoa repens): This extract, which comes from the American dwarf palm tree, has improved the symptoms of mild to moderate BPH in some studies. It's uncertain how it works, but it may relax the muscles around the bladder and affect the hormones that cause the prostate to enlarge. Mild side effects may include nausea, headache and dizziness.

Beta-sitosterol plant extract: This extract, which comes from the South African star grass and other plants, may improve the BPH symptoms. In some studies, it has worked as well as the drug finasteride, but without the side effects. A small number of men have reported upset stomach and impotence while taking this extract.

Rye grass pollen (Secale cereale): This extract, which comes from several Swedish plants, may slightly improve BPH symptoms. It may cause mild nausea.
Surgery
Surgery is the most effective way to relieve urinary symptoms, but it also has the highest risk of complications. Some symptoms, such as a weak urine stream, may remain after surgery due to a weakened bladder.

Men who have urinary retention, frequent urinary tract infections, repeated episodes of a large amount of blood in the urine, bladder stones or kidney damage are considered appropriate candidates for prostate surgery.


Transurethral resection of the prostate (TURP): This is the most common surgical procedure used to treat BPH. It's done under spinal, epidural or general anesthesia, and takes about an hour. An incision isn't necessary. After the anesthesia is given, a pencil-like instrument called a resectoscope is inserted into the urethra. This instrument is equipped with a tiny telescope that allows the doctor to see the tissue that needs to be removed. A thin wire loop at the end of the resectoscope is used to cut away prostate tissue. An electrical current heats up the wire to ease tissue removal and help prevent bleeding. Tissue samples from the prostate are sent to a lab for examination.
After the excess prostate tissue is removed, the resectoscope is carefully removed and a special catheter (flexible tube) is inserted. This catheter helps direct the flow of an irrigating solution into the bladder and allows excess tissue, blood clots and fluid to be flushed out of the bladder. The catheter is usually needed for two to three days.


Benefits: There's no incision. Compared to an open prostatectomy (see below), the hospital stay after TURP is typically shorter. Some studies have found better symptom improvement with TURP than with some minimally invasive procedures, but more research is needed.

Risks: Postoperative complications may occur more often with TURP than with some of the minimally invasive procedures. Complications may include bleeding, infection, bladder or ureter injury, urinary incontinence (difficulty controlling the flow of urine with leaking of urine), impotence, blood clots, inability to urinate, narrowing of the urethra from scar tissue or retrograde ejaculation.

Open prostatectomy: This proven procedure is usually used for a very large prostate or when other procedures affecting the bladder are also needed. It's the most invasive BPH treatment option. After spinal, epidural or general anesthesia is given, an external incision is made in the lower abdomen. Part of the inside of the prostate is then removed. You'll be hospitalized for several days following surgery.

Benefits: This procedure provides the most improvement in symptoms.

Risks: Hospitalization and recovery time may be longer than with TURP. Because it's the most invasive, the risk of complications is greater than for other treatment options. Possible complications include wound infection, blood clots, bleeding, impotence, loss of bladder control or retrograde ejaculation.
Minimally invasive procedures
Minimally invasive procedures are often used for men who have a higher risk of surgical complications, such as the elderly or those in poor health, or for men who want to reduce the risk of abnormal sexual function following surgery. Research to improve these procedures and develop others is ongoing.


Thermal therapy: BPH causes changes in the blood supply of the prostate, making the prostate more susceptible to the effects of heat. With thermal therapy, heat shrinks the prostate by causing tissue damage to selected areas of the gland. Two thermal treatments are transurethral microwave therapy and transurethral needle ablation.

Transuretheral microwave therapy (TUMT): This technique uses microwaves to heat the prostate tissue. It's done through a tube that's inserted through the urethra. You may be given general anesthesia or medication that helps you relax during the procedure, which only takes an hour or two. You may need a catheter for a while after the procedure to drain your urine. It works best for men who don't have a very enlarged prostate.

Benefits: This procedure may work as well as TURP for some men, usually with fewer side effects.

Risks: A few men get no relief from their symptoms with this procedure. Just after the procedure, it's common to be unable to urinate, and you may need to use a catheter to drain your urine for a week or more. Other complications can include bloody urine or semen, as well as decreased volume of ejaculate. The long-term benefits and risks are not yet known.

Transuretheral needle ablation (TUNA): This technique uses radio frequency waves to heat the prostate tissue. It's done through a tube that's inserted through the urethra. You may be given medication to help you relax during the procedure, which may take up to an hour.

Benefits: Compared to TURP, this procedure usually is easier and has a faster recovery time and fewer side effects, such as urinary incontinence and decreased volume of ejaculate.

Risks: The symptoms may return, requiring further treatment. The most common side effects are bloody urine and infection. The long-term benefits and risks are not yet known.

Transurethral incision of the prostate (TUIP): This procedure is most effective in treating a prostate that's less enlarged. Prostate tissue isn't removed. An instrument is introduced through the penis, and small cuts are made in the prostate to relieve pressure on the urethra. Once the pressure is relieved, it becomes easier to urinate. General anesthesia is needed, but you'll go home the same day.

Benefits: This procedure has a lower risk of sexual dysfunction than TURP. It can be done in an outpatient setting, produces less bleeding, and has a faster recovery time.

Risks: There are minimal risks with carefully selected patients who have a less enlarged prostate. Retrograde ejaculation is possible. The long-term benefits and risks are not yet known.

Laser surgery: Laser surgery is an established, safe treatment option for BPH. Through a process called vaporization, light energy from the laser destroys prostate tissue. The dead tissue is re-absorbed by the body or passed in the urine for about four to six weeks. General anesthesia is used.

Benefits: It may be done as an outpatient procedure, or it may require a short hospital stay. Compared to TURP, there's a decreased risk of bleeding and retrograde ejaculation.

Risks: The long-term effectiveness is unknown. Surgeons must be skilled in the use of a laser, and the surgery is more costly than TURP. There may be more swelling at the surgery site than with TURP, making it difficult to urinate after surgery. A catheter may be needed for a week or more until the swelling subsides.

Transurethral vaporization of the prostate (TUVP): This procedure uses electrical current to destroy prostate tissue by vaporization. It's done during a procedure that's similar to TURP.

Benefits: When compared with TURP, studies have shown similar relief of symptoms, fewer complications (such as bleeding and urinary retention) and shorter hospital stays.

Risks: The operation takes longer than TURP. Complications may include retrograde ejaculation, infection and narrowing of the urethra from scar tissue. The long-term benefits and risks are not yet known.

Urethral stents: These are devices used to dilate the urethral wall at the level of the prostate. Using local anesthetic, the stents are placed inside the urethra using an endoscope. Because of a higher risk of infection and blockage, stents are used most often for men with limited life expectancies who can't tolerate more extensive surgery or anesthesia. Stents can also cause bladder stones or injury to the bladder wall. Temporary stents, some of which are biodegradable, are sometimes used with minimally invasive procedures that have a high risk of urinary obstruction. Those that aren't biodegradable are removed several weeks later.

Balloon dilatation: This procedure has been used with mild enlargement that interferes with urine flow. However, the procedure is rarely used because its effect is only short-term.

Complications
Left untreated, BPH may lead to more serious disorders, such as urinary tract infections, bladder stones, incontinence, inability to urinate, bladder damage or kidney failure. If the bladder is permanently damaged, treating BPH later may be more difficult.
To avoid further complications, seek immediate medical attention for any of the following symptoms:

blood or pus in the urine or draining from the penis
back or groin pain
burning or painful urination
inability to urinate
fever, chills or vomiting along with urinary symptoms

Senior-specific information
Again, the risk of developing prostate cancer increases with age.

Prevention
BPH can't be prevented, but research continues in this area. These tips may help ease your symptoms:
If you're waking up at night to urinate, try drinking less fluid before bedtime.

Discuss your medications with your doctor. Some antidepressants, diuretics and narcotics can worsen the symptoms of BPH.

For colds or sinus congestion, avoid taking decongestants (such as pseudoephedrine), antihistamines (such as diphenhydramine) or any medications that contain a decongestant or antihistamine. These medications can worsen the symptoms of an enlarged prostate and may even cause an inability to urinate.

Avoid foods and beverages that may irritate your bladder, such as coffee, tea, cola, chocolate and alcohol.