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Benign Prostatic Hyperplasia by Rick Alan

Definition

Benign prostatic hyperplasia (BPH) is an enlargement of the prostate. The prostate is usually a walnut-sized gland located at the neck of the bladder. It surrounds the urethra. The gland is part of the male reproductive system. The enlargement is not due to cancer.

Enlarged Prostate

Causes

The exact cause of BPH is unknown. It may be related to changes in hormone levels as men age. Eventually, the prostate becomes so enlarged that it puts pressure on the urethra. This causes the urethra to narrow or close completely.

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition. The main risk factor for BPH is being over 50 years old.

Symptoms

Narrowing of the urethra caused by growth of the prostate causes the symptoms of BPH. Symptoms usually increase in severity over time.

Symptoms include:

Difficulty starting to urinate
Weak urination stream
Dribbling at end of urination
Sensation of incomplete bladder emptying
Urge to urinate frequently, especially at night
Deep discomfort in lower abdomen
Urge incontinence

Diagnosis

BPH diagnosis is based on:

Your age
Symptoms
Digital rectal exam—the doctor inserts a gloved finger into the rectum to examine the area

Other tests may include:

Urine flow study
Cystometrogram (a functional study of the way your bladder fills and empties)
X-ray of the urinary tract
Transrectal ultrasound
Post-void residual volume test—measures whether you can empty your bladder completely
Cystoscopy —this test allows a doctor to look inside the urethra and bladder

Testing for prostate specific antigen (PSA) is often used to screen for prostate cancer. However, BPH may cause a lesser elevation in PSA levels . This can raise false concerns about the presence of cancer.

Treatment

Treatment is not needed for mild cases. Most men with BPH eventually request medical intervention.

Treatments include:

Medication

Medicines include:

Enzyme ( 5-alpha reductase) inhibitors
- Finasteride
- Dutasteride (Avodart)
Alpha-blockers (eg, tamsulosin , alfuzosin , doxazosin , terazosin ))—reduce bladder obstruction and improve urine flow by relaxing the muscles of the prostate and bladder neck
Antimuscarinics ( oxybutynin , solifenacin , tolterodine , darifenacin , trospium , fesoterodine )—relax the bladder muscles

Each group of medicines have different side effects. Enzyme inhibitors may cause decreased sexual desire and problems with erection. Alpha-blockers may cause decreased blood pressure, dizziness, and stuffy nose. Antimuscarinics can cause dry mouth, constipation, dry eyes, trouble emptying the bladder, and confusion. Doctors may prescribe a combination of drugs from each group, which may work better to prevent worsening of disease.

Men with BPH should not take decongestant drugs containing alpha-agonists, such as pseudoephedrine . These drugs can worsen the symptoms of BPH.

Minimally Invasive Interventions

These are used when drugs are ineffective, but the patient is not ready for surgery. Nonsurgical treatments include:

Transurethral microwave thermotherapy (TUMT)—uses microwaves to destroy excess prostate tissue
Transurethral needle ablation (TUNA)—uses low levels of radio frequency energy to burn away portions of the enlarged prostate
Transurethral laser therapy—uses highly focused laser energy to remove prostate tissue

Surgery

Surgical procedures include:

Transurethral surgical resection of the prostate (TURP) —a scope is inserted through the penis to remove the enlarged portion of the prostate
Transurethral incision of the prostate (TUIP)—small cuts are made in the neck of the bladder to widen the urethra
Open surgery—removal of the enlarged portion of the prostate through an incision, usually in the lower abdominal area, much more invasive then TURP or TUIP
Prostatic stents—tiny metal coils that are inserted into urethra to widen it and keep it open
- Usually used for men who do not wish to take medication or have surgery
- Do not appear to be a good long-term option

Alternative Treatments

Three different herbal products are used for BPH:

Saw palmetto
Beta-sitosterol
Pygeum ( Prunus Africana )

Research regarding its effectiveness and safety is limited. The results are often conflicting. This may be due to variability of the products and difficulty in conducting these types of studies.

If you are diagnosed with BPH, follow your doctor's instructions .

Prevention

Prostate enlargement occurs naturally with age. There are no specific prevention steps.

RESOURCES:

National Kidney and Urologic Diseases Clearinghouse http://kidney.niddk.nih.gov/
The Prostate Institute http://www.prostateinstitute.org/

CANADIAN RESOURCES:

Canadian Urological Association http://www.cua.org/
Prostate Centre http://www.prostatecentre.ca/

References:

Berkow R, et al. The Merck Manual of Medical Information . 17th ed. Simon and Schuster, Inc.; 2000.
Fagelman E, Lowe FC. Saw palmetto berry as a treatment for BPH. Rev Urol . 2001 Summer;3(3):134-8.
Fried NM. New laser treatment approaches for benign prostatic hyperplasia. Curr Urol Rep . 2007 Jan;8(1):47-52.
Guideline on the management of benign prostatic hyperplasia. American Urological Association. Available at: http://www.auanet.org/guidelines/bph.cfm . Updated 2006. Accessed June 30, 2008.
Greco KA, McVary KT. The role of combination medical therapy in benign prostatic hyperplasia. Int J Impot Res . 2008 Dec;20 Suppl 3:S33-43.
Marberger M. Drug insight: 5-alpha-reductase inhibitors for the treatment of benign prostatic hyperplasia. Nat Clin Pract Urol . 2006 Sep;3(9):495-503.
Prostate enlargement: Benign prostatic hyperplasia. National Kidney Urologic Diseases Information Clearinghouse website. Available at: http://kidney.niddk.nih.gov/kudiseases/pubs/prostateenlargement/ . Accessed July 26, 2010.
Roehrborn CG, Siami P, Barkin J, et al; CombAT Study Group. The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes in men with symptomatic benign prostatic hyperplasia: 4-year results from the CombAT study. Eur Urol . 2010 Jan;57(1):123-31. Epub 2009 Sep 19.
Ulbricht C, Basch E, Bent S, et al. Evidence-based systematic review of saw palmetto by the Natural Standard Research Collaboration. J Soc Integr Oncol . 2006;4(4):170-86.

Last reviewed August 2010 by Adrienne Carmack, MD

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