Benign prostatic hypertrophy
A benign prostatic hypertrophy (BPH) is the non cancerous enlargement of the prostate. The prostate gland surrounds the urethra in males and produces a fluid that is used in the body’s creation of semen. As the size of the prostate increases, it can add pressure on the urethra. This may cause problems for urinary flow including hesitancy, leakage and frequency. It can also cause urinary retention- the inability to urinate.
Complications from BPH may include urinary tract infections, weakening of the bladder muscle, hematuria (blood in the urine), renal failure, impaired sexual function and bladder stones.
BPH can raise PSA (prostate-specific antigen) levels two to three times higher than the normal level. An increased PSA level does not indicate cancer, but the higher the PSA level, the higher the chance of having cancer.
Some of the signs of BPH and prostate cancer are the same; however, having BPH does not seem to increase the chances of developing prostate cancer. A man who has BPH may also have undetected prostate cancer at the same time or may develop prostate cancer in the future. Therefore, the National Cancer Institute and the American Cancer Society recommend that all men over 50 consult their doctors about having a digital rectal and PSA examination once a year to screen for prostate cancer.
The type and severity of symptoms experienced will vary and may change for an individual. For many men, BPH never progresses beyond a minor to moderate annoyance. For others, it may greatly impair their quality of life.
Having a large prostate doesn’t necessarily signal a health concern. That’s why at Northwell Health, physicians work with patients in a personal, one-to-one setting to develop a tailored approach to diagnosis and treat benign prostatic hypertrophy (BPH).
- A discussion with the patient that goes beyond medical history
- Our clinical experts take the time to understand you and your well-being
- Tests and conversations to see how this affects a patient’s comfort and quality of life
The diagnosis of symptomatic BPH is made on the basis of history and physical examination. Histologic BPH is an enlarged prostate seen by the pathologist under a microscope. Note that not all enlarged prostates cause symptoms.
BPH is very common. The occurrence of histologic BPH (diagnosed under the microscope) in autopsy studies is:
- 20% in men aged 41-50
- 50% in men aged 51-60
- >90% in men older than 80.
Although symptomatic BPH is less common, approximately 25% of 55-year-old men are bothered by BPH, and 50% of 75-year-old men have symptoms. The only proven risk factors for BPH are age and male gender. However, sons and brothers of BPH patients are at increased risk for developing BPH. The causes of BPH are not well understood. It is thought to result from hormonal changes and changes in the prostate that occur as part of the normal aging process. Therefore, there is really no effective prevention of this disease.
The following are the most common symptoms of benign prostatic hyperplasia. However, each individual may experience symptoms differently. Symptoms may include:
- Leaking or dribbling of urine
- More frequent urination, especially at night
- Urgency to urinate
- Urine retention (inability to urinate)
- A hesitant, interrupted, weak stream of urine
These problems may lead to one or more of the following:
- Kidney damage
- Bladder damage
- Urinary tract infections
- Bladder stones
- Inability to pass urine at all
The symptoms of benign prostatic hyperplasia may resemble other conditions or medical problems. Always consult your doctor for a evaluation about your concerns.
Urinary symptoms can be divided into two groups - obstructive symptoms and irritative symptoms.
Obstructive voiding (urinating) symptoms:
These symptoms are caused by the pressure upon the urethra by the prostate:
- Hesitancy (delay in beginning urination)
- Decreased force or caliber of stream
- Incomplete emptying of bladder (perceived or real)
- Double voiding (the need to urinate soon after one has already urinated)
- Straining to urinate
- Post-void dribbling (dripping urine right after urination)
Occasionally, obstructive symptoms may be so severe as to altogether prevent urination, due to complete blockage of the urethra. This entity is called acute urinary retention, and is a medical emergency that requires immediate catheterization to drain the bladder.
Irritative voiding symptoms:
These are caused by the upward pressure upon the bladder by the prostate or thickening of the bladder muscle as it works harder to squeeze urine out against the resistance of the prostate. The bladder's response to BPH can result in:
- Urgency (the sudden and immediate need to urinate)
- Frequency (the recurrent sensation to urinate with little time between urinations)
- Nocturia (numerous and frequent night-time awakenings due to the need to urinate)
Untreated and prolonged BPH can result in damage to the bladder, ureters and kidneys. This may manifest as the inability to sense bladder fullness, inability of the bladder to contract in order to empty itself of urine, bladder diverticula (herniation of bladder lining through the bladder muscle), bladder stones, recurrent or severe infection, or renal failure.
BPH can also cause hematuria (bloody urine). This is due to tearing of enlarged blood vessels on the prostate.
Diagnosing BPH in its earlier stages can lower the risk of developing complications. Delay can cause permanent bladder damage for which BPH treatment may be ineffective. In addition to a complete medical history and physical examination, diagnostic procedures for BPH may include the following:
- Digital rectal exam. A procedure in which the doctor inserts a gloved finger into the rectum to examine the rectum and the prostate gland for signs of cancer.
- Cystoscopy (also called cystourethroscopy). An examination in which a scope--a flexible tube and viewing device--is inserted through the urethra to examine the bladder and urinary tract for structural abnormalities or obstructions, such as tumors or stones.
- Urine flow study. A test in which the patient urinates into a special device that measures how quickly the urine is flowing. A reduced flow may suggest BPH.
- Renal ultrasound. Using ultrasound to evaluate the kidney for abnormalities, such a blockage (hydronephrosis) and kidney stones.
Treatment varies based on severity of a patient’s condition. Schedule an appointment with a Northwell physician to identify the best treatment available.
If treatment is indicated, the specific therapy is based on the severity of a man's symptoms, his overall state of health, the size of his prostate, the geometry (shape) of the prostate and patient preference.
Medicines are usually the first line of treatment. Therapy with alpha-adrenergic blockers (Flomax, Uroxatral, Rapaflo, Cardura or Hytrin), or 5-alpha-reducatase inhibitors (Proscar or Avodart) may be sufficient.
Alph-adrenergic blockers relax the smooth muscle in the prostate to allow urine to pass more freely. These medicines usually give relief of symptoms in a few days. If medicine is stopped, symptoms will recur. 5-alpha-reductace inhibitors work by actually shrinking the prostate but can take 6 months to give optimal effect. In some cases both alpha blockers and 5-alpha reductase inhibitors are given together.
In other situations, a trans-urethral (through the penis) procedure may be necessary. Such therapies include:
- Trans-urethral microwave thermotherapy, which is performed in the office setting on an out-patient basis under local anesthesia
- Trans-urethral needle ablation (TUNA) which can be performed on an outpatient basis.
- Trans-urethral Green-Light laser therapy, which is performed in the operating room, usually on an out-patient basis. This can be performed with patients on blood thinner.
- Trans-urethral resection of the prostate, which is performed in the operating room, and usually requires an overnight hospital stay.
Under certain circumstances, BPH may require an open surgery for removal (suprapubic prostatectomy) that entails removal of the enlarged portion of the prostate through an incision. This can be done laparoscopically or through an incision in the middle of the lower part of the abdomen. Note that in this operation the entire prostate is not removed, as is the case in cancer surgery. The prostate is pealed out and the capsule is left much like one removes the pulp from an orange.
Specific treatment for BPH will be determined by your doctor based on:
- Your age, overall health, and medical history
- Extent of the disease
- Your tolerance for specific medications, procedures, or therapies
- Expectations for the course of the disease
- Your opinion or preference
Eventually, BPH symptoms usually require some kind of treatment. When the gland is just mildly enlarged, treatment may not be needed. In fact, research has shown that, in some mild cases, some of the symptoms of BPH clear up without treatment. This determination can only be made by your doctor after careful evaluation of your individual condition. Regular checkups are important, however, to watch for developing problems.
Treatment for BPH may include:
Lifestyle management for BPH may include:
- Dietary factors. Consuming foods and drinks containing soy, drinking green tea, and taking saw palmetto supplements may benefit the prostate, although this is not yet proven. Also, avoiding or decreasing the intake of alcohol, coffee, and other fluids, particularly after dinner, is often helpful. A higher risk for BPH has been found in association with a diet high in zinc, butter, and margarine, while individuals who eat lots of fruits are thought to have a lower risk for BPH.
- Avoiding medications that worsen symptoms. Decongestants and antihistamines can slow urine flow in some men with BPH. Some antidepressants and diuretics can also aggravate symptoms of BPH. Consult your doctor if you are taking any of these medications to discuss changing dosages or switching medications, if possible.
Nonsurgical treatments may include:
- Medications. To shrink or at least stop the growth of the prostate without using surgery, or to make the muscles surrounding the urethra looser so the urine flows more easily.
- Transurethral microwave thermotherapy. A device called a Prostatron uses microwaves to heat and destroy excess prostate tissue to reduce urinary frequency and urgency.
Surgery. Under anesthesia, enlarged tissue that is pressing against the urethra is removed, with the rest of the inside tissue and the outside capsule left intact. Types of surgery often include the following:
- Transurethral surgery. No external incision is needed. The surgeon reaches the prostate by inserting an instrument through the urethra.
- Transurethral resection of the prostate. A resectoscope--an instrument that is about 12 inches long and 1/2 inch in diameter and contains a light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels--is inserted through the penis. The surgeon uses the resectoscope's wire loop to remove the obstructing tissue one piece at a time. The pieces of tissue are carried by the fluid into the bladder and flushed out at the end of the operation.
- Transurethral incision of the prostate. A procedure that widens the urethra by making some small cuts in the bladder neck, where the urethra joins the bladder, and in the prostate gland itself.
- Laser surgery. Using laser instruments to cut away obstructing prostate tissue.
- Open surgery. Surgery that requires an external incision; often performed when the gland is very enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired.