Benign Prostatic Hyperplasia (BPH)

Background/Causes

The prostate is a walnut-sized gland that forms part of the male reproductive system. The normal role of the prostate gland is to secrete fluid into the semen that nourishes the sperm.  It is located in front of the rectum and just beneath the urinary bladder, surrounding the urethra.

The gland is composed of several zones or lobes that are enclosed by an outer layer of tissue (capsule). These include the peripheral, central, anterior fibromuscular stroma, and transition zones. Benign prostatic hyperplasia (BPH) originates in the transition zone, which surrounds the urethra.

BPH is characterized by the increase in the overall number of cells in the prostate.  This results in the overall enlargement of the prostate that may restrict the flow of urine from the bladder.  BPH is not cancer and does not lead to cancer.

BPH is considered a normal part of the aging process in men and is hormonally dependent on testosterone and dihydrotestosterone (DHT) production. An estimated 50% of men demonstrate microscopic evidence of BPH by age 60 years. This number increases to 90% by age 85 years.

Symptoms

  • Weak urinary stream
  • Urinary hesitancy (trouble starting flow)
  • Needing to push or strain to urinate
  • Intermittent (stop-and-go) flow
  • Nocturia (waking up at night to urinate)
  • Urinary frequency, often voiding small amounts at a time
  • Urinary urgency – the sudden (and sometimes uncontrollable) urge to urinate
  • Feeling unable to empty completely
  • Post-void dribbling – loss of a small amount of urine at the end of voiding

Complications

  • Urinary retention (unable to urinate at all)
  • Kidney failure
  • Urinary tract infections
  • Bladder stones
  • Hematuria (blood in the urine)

Diagnosis

Diagnosis and evaluation of BPH is usually made by a careful history including discussion of:

  • Onset and duration of symptoms
  • General health issues (including sexual history)
  • Fitness for any possible surgical interventions
  • Severity of symptoms and how they are affecting quality of life
  • Medications
  • Previously attempted treatments

Other conditions can mimic BPH and must be ruled out.  Examples include:

  • UTI
  • Prostatitis
  • Prostatodynia
  • Prostatic abscess
  • Overactive bladder(OAB)
  • Bladder cancer
  • Foreign bodies in the bladder (stones or retained stents)
  • Urethral stricture due to trauma or a sexually transmitted disease
  • Prostate cancer
  • Neurogenic bladder
  • Pelvic floor dysfunction

Evaluation

In order to differentiate between BPH and some of these other conditions, your urologist may order some of the following studies:

  • Urinanalysis
  • Urine culture
  • Electroloyes, BUN, creatinine
  • Prostate specific antigen (PSA)
  • Cystoscopy (looking inside the bladder and urethra with a scope). This can be done under local gel anesthesia in the office, and only takes a few minutes.
  • Uroflow and post-void residual (to measure your urinary flow and bladder emptying)
  • Urodynamics (to measure bladder pressures while voiding)

Treatment

As a general rule, BPH is managed symptomatically.  Treatment decisions are based on the degree of bother experienced by the patient.

Options include:

  • Watchful waiting. Patient has minimal to no bother from their symptoms and is not experiencing any complications from BPH (see above)
  • Medications
    • Alpha blockers (tamsulosin/Flomax, alfuzosin/Uroxatral, terazosin/Hytrin, silodosin/Rapaflo)
      • Relaxes the muscles of the prostate and bladder neck to allow passage of urine.
      • Provides symptomatic relief only. Symptoms will recur if the medication is stopped.
      • Possible side effects include orthostatic dizziness, nasal congestion, fatigue, and ejaculatory dysfunction.
    • 5-alpha reductase inhibitors (5-ARIs; finasteride/Proscar, dutasteride/Avodart)
      • Blocks the conversion of testosterone to dihydrotestosterone (DHT)
      • Shrinks the prostate over time
      • Minimum 6-12 months before symptomatic relief is realized
      • More effective in larger prostates (>50 g)
      • Will cause PSA levels to decrease by about 50%, so this must be accounted for in monitoring for prostate cancer
      • 2 large studies observed that 5-ARIs decrease the overall risk of prostate cancer but an increased incidence of high grade cancer.
      • Possible side effects include decreased libido, erectile dysfunction, ejaculatory dysfunction, breast enlargement/breast tenderness. In some circumstances these sides are irreversible (persist after stopping the medication)
    • Combination therapy (alpha blocker + 5-ARI)
      • More effective than taking either medication alone.
      • Decreased risk of acute urinary retention
      • Decreased risk of requiring BPH-related surgery
      • Jalyn is a single capsule that combines dutasteride and tamsulosin
    • Tadalafil/Cialis
      • Erectile dysfunction medication that has also been shown to improve urinary symptoms in BPH when taken as a small daily dose
      • Now FDA approved for BPH
      • Also acts by mediating smooth muscle relaxation
    • Minimally invasive ablative techniques
      • Generally rely on heat to destroy prostate tissue
      • Examples include transurethral microwave therapy (TUMT) and transurethral needle ablation (TUNA)
      • Office based procedure under local anesthesia
      • Sometimes requires post-procedure catheterization due to prostate swelling
    • Minimally invasive mechanical techniques
        • UroLift prostatic urethral lift

 

  • Surgery
    • Transurethral resection of prostate (TURP) is the gold standard for relief of bladder outlet obstruction due to BPH.
    • Most effective in terms of symptom relief.
    • Usually requires a one-night hospital stay
    • General or regional (spinal) anesthesia
    • Overnight catheterization
    • Various laser techniques can decrease the risk of bleeding and may be appropriate for patients on chronic anticoagulation
    • Side effects/Complications
      • Urinary frequency and urgency, usually short-term
      • Bleeding, usually limited in degree and duration
      • Small risk of urinary incontinence
      • Small risk of erectile dysfunction
      • Small risk of bladder neck contracture or urethral stricture (scarring). If severe, this might require another procedure to relieve
      • Patients should expect greatly decreased or nonexistent ejaculate
      • Electrolyte abnormalities (TUR syndrome). This potentially life-threatening complication is now rarely seen with newer energy techniques and irrigation solutions