Benign Prostatic Hyperplasia (BPH)/Enlarged Prostate
Important Facts
- Benign prostatic hyperplasia, BPH, also is called an enlarged prostate gland
- Tissue growth in the prostate gland is controlled by hormones
- An enlarged prostate can cause urinary symptoms
- BPH is a common condition in men over the age of 50
Risk Factor
BPH is a condition of aging. Nearly all men over the age of 50 have an enlarged prostate.
Causes
The cause of benign prostatic hyperplasia is unknown. It is possible that the condition is associated with hormonal changes that occur as men age. The testes produce the hormone testosterone, which is converted to dihydrotestosterone (DHT) and estradiol (estrogen) in certain tissues. High levels of dihydrotestosterone, a testosterone derivative involved in prostate growth, may accumulate and cause hyperplasia. How and why levels of DHT increase remains a subject of research.
Medical Treatment
There are several treatment options for men with benign prostate hyperplasia, depending on the severity of symptoms. If symptoms do not threaten the man’s health, he may choose not to be treated. If symptoms are severe enough to cause discomfort, interfere with daily activities, or threaten health, treatment is usually recommended.
Watchful waiting
Men with mild symptoms may choose to return for annual examinations. The physician will perform an examination that includes a DRE, PSA tests, and a urinary flow rate. The patient will be asked to describe symptoms in order to determine if the condition is worsening.
Medication
5-Alpha reductase inhibitors such as finasteride (Proscar®) and dutasteride (Avodart®) prevent the conversion of testosterone to the hormone dihydrotestosterone (DHT). In many cases, a treatment period of 6-month is necessary to see if the therapy is going to work. These drugs are taken orally, once a day. Finasteride is available in tablet form and dutasteride is available as soft gelatin capsules. Patients should see their physician regularly to monitor side effects and adjust the dosage, if necessary.
Side effects include reduced libido, impotence, breast tenderness and enlargement, and reduced sperm count. Long-term risks and benefits have not been studied.
Women who may be pregnant must avoid handling dutasteride capsules and broken or crushed finasteride tablets because exposure to the drugs may cause serious side effects to the fetus. Intact tablets are coated to prevent absorption through the skin during normal handling. Patients should wait at least 6 months after dutasteride treatment to donate blood to prevent pregnant women from being exposed to the drug through blood transfusion.
Alpha blockers relax smooth muscle tissue in the bladder neck and prostate, which increases urinary flow. They typically are taken orally, once or twice a day.
Commonly prescribed alpha blockers include the following:
- alfuzosin (UroXatral®), extended-release tablet taken once daily
- doxazosin (Cardura®), tablet taken once daily
- prazosin (Minipress®), capsule taken 2 or 3 times daily
- tamsulosin hydrochloride (Flowmax®), capsule taken once daily
- terazosin (Hytrin®), capsule taken once daily
Patients taking an alpha blocker require follow-up during the first 3 or 4 weeks to evaluate the effect on symptoms and adjust the dosage, if necessary. Side effects include headache, dizziness, low blood pressure, fatigue, weakness, and difficulty breathing. Long-term risks and benefits have not been studied.
Prostatic stents
Although a prostatic stent is not a medical treatment, neither does it fall under the classification of a surgical procedure. Prostatic stents are used most often for patients with significant medical problems that prohibit medication or surgery. It is a tiny, springlike device inserted into the urethra. When expanded, it pushes back the surrounding tissue and widens the urethra. Prostatic stents have several advantages:
- They can be placed in less than 15 minutes under regional anesthesia.
- Bleeding during and after surgery is minimal.
- The patient can be discharged the same day or the next morning.
There are also several disadvantages:
- Prepositioning can be difficult.
- They may cause irritation and frequent urination.
- They may cause pain or incontinence.
- Removing them (necessary in one-third of cases) can be difficult.
Minimally Invasive Treatment
Minimally invasive BPH treatments use state-of-the-art tools and techniques to reduce or eliminate symptoms. Men are treated on an outpatient basis in a urologist’s office or the hospital.
Other advantages of minimally invasive treatments are
- less pain,
- faster recovery,
- lower costs, and
- local anesthesia and mild sedative.
Usually, heat is used to destroy excess prostate tissue. Techniques differ in heat source, heat delivery method, side effects, and number of treatments. Delivery methods include:
Laser (e.g., non-contact, contact, interstitial)
o Indigo®
o PVP
o HoLAP
Microwave
o CoreTherm®
o Cooled ThermoTherapy™/TUMT™
o TherMatrx®
o Prolieve™
Signs and Symptoms
Common symptoms of benign prostatic hyperplasia include the following:
- Blood in the urine (i.e., hematuria), caused by straining to void
- Dribbling after voiding
- Feeling that the bladder has not emptied completely after urination
- Frequent urination, particularly at night (i.e., nocturia)
- Hesitant, interrupted, or weak urine stream caused by decreased force
- Leakage of urine (i.e., overflow incontinence)
- Pushing or straining to begin urination
- Recurrent, sudden, urgent need to urinate
In severe cases of BPH, another symptom, acute urinary retention (the inability to urinate), can result from holding urine for a long time, alcohol consumption, long period of inactivity, cold temperatures, allergy or cold medications containing decongestants or antihistamines, and some prescription drugs (e.g., ipratropium bromide, albuterol, epinephrine). Any of these factors can prevent the urinary sphincter from relaxing and allowing urine to flow out of the bladder. Acute urinary retention causes severe pain and discomfort. Catheterization may be necessary to drain urine from the bladder and obtain relief.
Diagnosis
A physical examination, patient history, and evaluation of symptoms provide the basis for a diagnosis of benign prostatic hyperplasia. The physical examination includes a digital rectal examination (DRE), and symptom evaluation is obtained from the results of the AUA Symptom Index.
Digital rectal examination (DRE)
DRE typically takes less than a minute to perform. The doctor inserts a lubricated, gloved finger into the patient’s rectum to feel the surface of the prostate gland through the rectal wall to assess its size, shape, and consistency. Healthy prostate tissue is soft, like the fleshy tissue of the hand where the thumb joins the palm. Malignant tissue is firm, hard, and often asymmetrical or stony, like the bridge of the nose. If the examination reveals the presence of unhealthy tissue, additional tests are performed to determine the nature of the abnormality.
AUA Symptom Index
The AUA (American Urological Association) Prostate Symptom Index is a questionnaire designed to determine the seriousness of a man’s urinary problems and to help diagnose BPH. The patient answers seven questions related to common symptoms of benign prostatic hyperplasia. How frequently the patient experiences each symptom is rated on a scale of 1 to 5. These numbers added together provide a score that is used to evaluate the condition. An AUA score of 0 to 7 means the condition is mild; 8 to 19, moderate; and 20 to 35, severe.
PSA and PAP Tests
Blood tests taken to check the levels of prostate specific antigen (PSA) and prostatic acid phosphatase (PAP) in a patient who may have benign prostatic hyperplasia helps the physician eliminate a diagnosis of prostate cancer.
Prostate-specific antigen (PSA) is a specific antigen produced by the cells of the prostate capsule (membrane covering the prostate) and periurethral glands. Patients with benign prostatic hyperplasia (BPH) or prostatitis produce larger amounts of PSA. The PSA level also is determined in part by the size and weight of the prostate.
The test measures the amount of PSA in the blood in nanograms per milliliter (ng/mL). A PSA of 4 ng/mL or lower is normal; 4–10 ng/mL is slightly elevated; 10–20 is moderately elevated; and 20–35 is highly elevated. Most men with slightly elevated PSA levels do not have prostate cancer, and many men with prostate cancer have normal PSA levels. A highly elevated level may indicate the presence of cancer.
The PSA test can produce false results. A false positive result occurs when the PSA level is elevated and there is no cancer. A false negative result occurs when the PSA level is normal and there is cancer. Because of this, a biopsy is usually performed to confirm or rule out cancer when the PSA level is high.
Free and total PSA (also known as PSA II) PSA in the blood may be bound molecularly to one of several proteins or may exist in a free, or unbound, state. Total PSA is the sum of the levels of both forms; free PSA measures the level of unbound PSA only. Studies suggest that malignant prostate cells produce more bound PSA; therefore, a low level of free PSA in relation to total PSA might indicate a cancerous prostate, and a high level of free PSA compared to total PSA might indicate a normal prostate, BPH, or prostatitis.
Age-specific PSA Evidence suggests that the PSA level increases with age. A PSA of up to 2.5 ng/mL for men age 40–49 is considered normal, as is 3.5 ng/mL for men age 50–59, 4.5 ng/mL for men age 60–69, and 6.5 ng/mL for men 70 and older. The use of age-specific PSA levels is not endorsed by all medical professionals.
Use the PSA Age/Race Quiz or the PSA Velocity Quiz to determine your risk of prostate cancer.
Urodynamic Testing
Urodynamic tests, usually performed in a physician’s office, are used to measure the volume and pressure of urine in the bladder and to evaluate the flow of urine. They are particularly useful for the diagnosis of Intrinsic sphincter deficiency and uncertain cases of mixed, overflow, urgency, or total incontinence. Additional tests may be conducted if symptoms indicate that blockage is caused by a condition other than BPH.
Uroflowmetry is a simple test performed to record urine flow, to determine how quickly and completely the bladder can be emptied, and to evaluate obstruction. With a full bladder, the patient urinates into a device that measures the amount of urine, the time it takes for urination, and the rate of urine flow. Patients with stress or urge incontinence usually have a normal or increased urinary flow rate, unless there is an obstruction in the urinary tract. A reduced flow rate may indicate BPH.
A pressure flow study measures pressure in the bladder during urination and is designed to detect a blockage of flow. It is the most accurate way to evaluate urinary blockage. This test requires the insertion of a catheter through the urethra in the penis and into the bladder. The procedure is uncomfortable and rarely may cause urinary tract infection UTI).
Post-void residual (PVR) test measures the amount of urine that remains in the bladder after urination. The patient is asked to urinate immediately prior to the test and the residual urine is determined by ultrasound or catheterization. PRV less than 50 mL generally indicates adequate bladder emptying and measurements of 100 to 200 mL or higher often indicate blockage. Nervousness and other types of stress may affect the result; therefore, the test is often repeated.