Benign Prostatic Enlargement/Hyperplasia (BPE/BPH)
What is benign prostatic hyperplasia (BPH)?
Benign prostatic hyperplasia (BPH) is a condition in which the prostate, a walnut-sized body part made of glandular and muscular tissue, grows in size. The prostate surrounds part of the urethra, which is the tube that carries urine and sperm out of the body. The benign (noncancerous) condition is also called benign prostatic enlargement (BPE).
The prostate is located directly beneath the bladder and in front of the rectum. The urethra passes through the prostate, so if the prostate becomes enlarged, it can keep urine or semen from passing through the urethra.
The main function of the prostate is to produce fluid for the semen, the milky fluid in which sperm swims. Sperm is produced in the testicles, which also make the main male hormone testosterone. During puberty, testosterone stimulates the growth and function of the prostate, and helps with the production of fluid for semen.
How common is benign prostatic hyperplasia (BPH)?
BPH is the most common prostate problem in men. Almost all men will develop some enlargement of the prostate as they grow older. By age 60, 50% of men will have some signs of BPH; by age 85, 90% of men will have signs of the condition. About half of these men will develop symptoms that need to be treated.
Does having benign prostatic hyperplasia (BPH) increase the risk of prostate cancer?
Based on research to date, having BPH does not seem to increase the risk of developing prostate cancer. However, BPH and prostate cancer have similar symptoms, and a man who has BPH may have undetected cancer at the same time.
To help detect prostate cancer in its early stages, the American Urological Association and the American Cancer Society recommend a prostate screening every year for men ages 55 to 69. They also recommend that men who are at high risk – such as African-American men and men who have a family history of prostate cancer – begin screening at age 40. Screening tests for prostate cancer include a blood test for a substance called prostate-specific antigen (PSA) and the digital rectal exam (DRE).
Symptoms and Causes
What are the symptoms of benign prostatic hyperplasia (BPH)?
Since the prostate gland surrounds the urethra (the tube that carries urine outside the body), it is easy to understand that enlargement of the prostate can lead to blockage of the tube. Therefore, you may develop early symptoms of BPH:
- Slowness or dribbling of your urinary stream.
- Hesitancy or difficulty starting to urinate.
- Frequent urination.
- Feeling of urgency (sudden need to urinate).
- Need to get up at night to urinate.
- Pain after ejaculation or while urinating.
- Urine that looks or smells "funny" (for instance, it's a different color).
The enlargement of the prostate can lead to blockage of the urethra.
If left untreated BPH can block the urethra further causing symptoms to worsen, you may develop:
- Bladder stones.
- Bladder infection.
- Blood in your urine.
- Damage to your kidneys from back pressure caused by retaining large amounts of extra urine in the bladder.
If you have any of these symptoms, see your doctor right away:
- Pain in the area of the lower abdomen or genitals while urinating.
- Can’t urinate at all.
- Pain, fever and/or chills while urinating.
- Blood in the urine.
Diagnosis and Tests
How is benign prostatic hyperplasia (BPH) diagnosed?
Your doctor will look at your medical history and give you a complete physical examination.
Your doctor will perform a digital rectal examination by inserting a gloved, lubricated finger into your rectum to feel the prostate, estimate its size and detect any hard areas that could be cancer.
Several studies may be performed to help diagnose your condition:
- A survey to evaluate how severe your symptoms are.
- A flow study may be conducted to measure how slow the urinary stream is compared with normal urine flow.
- A study to detect how much urine is left in the bladder after you finish urinating.
- A cystoscopy to look into the bladder.
Management and Treatment
How is benign prostatic hyperplasia (BPH) treated?
Patients who have mild symptoms may not require treatment other than continued observation to make sure their condition doesn't get worse. This approach is sometimes called "watchful waiting" or surveillance. There are a number of treatment options available if your symptoms are severe.
Finasteride (Proscar®) and dutasteride (Avodart®) work by decreasing the production of the hormone dihydrotestosterone (DHT), which affects the growth of the prostate gland. These appear to be most beneficial for men with larger prostates.
Drugs that relax the muscle in the prostate (to reduce the tension on the urethra) are more commonly used. These include terazosin (Hytrin®), doxazosin (Cardura ®), tamsulosin (Flomax®), alfuzosin (Uroxatral®), and silodosin (Rapaflo®). The most common side effects are lightheadedness, weakness and retrograde ejaculation.
Medications are sometimes combined to help treat symptoms and improve the flow of urine. One such medication is dutasteride and tamsulosin (Jalyn®).
Several different types of surgery can be used to remove the prostate tissue that blocks the flow of urine, including:
- Transurethral resection of the prostate (TURP): The urologist removes the tissue blocking the urethra with a special instrument. Side effects include bleeding, infection, impotence (inability to maintain an erection suitable for sex), incontinence (inability to control the flow of urine) and retrograde ejaculation.
- Transurethral incision of the prostate (TUIP): The urologist makes two small cuts in the bladder neck (where the urethra and bladder join) and in the prostate to widen the urethra to improve urine flow.
- Transurethral electrovaporization: This technique uses electrical energy applied through an electrode to rapidly heat prostate tissue, turning the tissue cells into steam. This allows the doctor to vaporize an area of the enlarged tissue and relieve urinary blockage.
- The GreenLight™ laser: This procedure removes prostate tissue with a laser. It is associated with less bleeding during and after the procedure.
Minimally invasive treatments
New treatments for BPH have been developed that are less invasive and less damaging to healthy tissue than surgery. In general, minimally invasive procedures are done on an outpatient basis, result in fewer side effects, are less costly and allow for quicker recovery. The most common side effects reported with these treatments include urinary frequency and irritation while the prostate is healing. Because these techniques are new, little is known about their long-term effectiveness and complications.
Minimally invasive treatments include:
- Prostatic urethral lift: A prostatic urethral lift is a procedure that separates the enlarged prostate lobes to make the urethra wider, so that it is easier to urinate. The urologist inserts an instrument into the urethra and moves it forward. When the device reaches the lateral (side) wall of the prostate, it ejects small, thin implants into both sides of the prostate, pulling the urethra and prostate to open the channel. Depending on the size of the prostate, the urologist will place from 2 to 6 implants.
- Water vapor therapy: The urologist inserts an instrument into the urethra and moves it to the prostate. A needle is injected from the instrument into the prostate and emits steam vapor. The vapor turns into water in the prostate, and the thermal energy created by the water kills the cells of the prostate. The patient reabsorbs the dead cells and the prostate shrinks.
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