What is Benign Prostatic Hyperplasia?
Benign prostatic hyperplasia (BPH) is a condition where the prostate, a small gland that produces fluid for semen, grows in an abnormal, non-cancerous way. This growth is a common reason that older men experience lower urinary tract symptoms (LUTS), which are problems with urination. It is most common in older men, with around half to two-thirds of men in their 60s having BPH, rising to 80% to 90% in men older than 70.
When discussing BPH, several key terms are used. Bladder outlet obstruction refers to a blockage in the urinary flow. LUTS encompasses the urinary issues caused by conditions affecting the bladder and prostate, typically due to BPH. ‘Benign prostatic enlargement (BPE)’ describes the prostate’s increased size, often as a result of BPH. If someone with BPE has a bladder outlet obstruction, they are said to have ‘benign prostatic obstruction’.
BPH occurs when cells in the prostate transition zone- this is the area surrounding the urethra (the tube from the bladder that urine passes through)- begin to overproduce. This can compress the urethra, leading to bladder outflow obstruction- essentially, problems with urination. This can cause symptoms like urinary retention (trouble fully emptying the bladder), which could potentially lead to infections. Long-term BPH that isn’t treated can lead to severe conditions such as chronic high-pressure retention, which is life-threatening, and permanent changes to the bladder muscle.
There are a range of treatments for BPH, from simply monitoring the condition to different medications and surgical procedures. Factors contributing to BPH can be split into those that can’t be changed, like age and genetics, and those that can, such as obesity and possibly geographical location. All of these have been shown to affect the likelihood of developing BPH.
What Causes Benign Prostatic Hyperplasia?
BPH, or Benign Prostatic Hyperplasia, happens when your body has trouble maintaining a balance between the creation and death of your prostate cells. When this balance is off, the number of cells around your urethra (the tube that allows urine to flow from the bladder) increases, which can ultimately lead to BPH.
Many different factors could contribute to BPH. However, it’s essential to note that men who were castrated before puberty or have a condition related to their androgens, male hormones, don’t develop BPH.
There’s disagreement over whether non-steroidal anti-inflammatory medications (NSAIDs) can cause BPH. Some studies say yes, and others say no. Allopurinol, a medication often used to treat gout, can help prevent BPH since it reduces the effect of hyperuricemia, a condition where you have too much uric acid in your body.
Androgens, hormones produced by the testicles, play a significant role in BPH. Specifically, dihydrotestosterone (DHT), which is formed when testosterone interacts with an enzyme called 5-alpha-reductase 2, stimulates cell growth in the prostate. However, contrary to what you might think, there doesn’t seem to be a correlation between levels of testosterone or DHT and symptomatic BPH.
Apart from medical conditions and drugs, several other factors make you more likely to develop BPH. These include having diabetes, aspects of your diet and genetic factors, local inflammation, obesity, and metabolic syndrome.
Having diabetes, especially if you’re on antidiabetic medications like insulin, seems to increase your chances of developing BPH and undergoing surgery for it.
Your diet might also influence whether you get BPH. Beta-carotene, carotenoids and vitamin A may help protect you against BPH, while too much alcohol, caffeine, and large amounts of supplemental vitamin C may make BPH and its symptoms worse.
If family members have had BPH, your chances of getting it may be much higher. For example, one study found that brothers and sons of men with BPH were four times more likely to get it themselves.
Inflammation in your lower urinary tract can also lead to BPH. Although the exact causes of this inflammation aren’t clear, it’s thought that NSAIDs might be able to help treat symptomatic BPH. However, the improvements saw from using these drugs is relatively small.
Being obese also seems to raise your chances of developing BPH. The exact reason isn’t known but might have to do with obesity leading to heightened levels of inflammation and an increase in estrogen, a female hormone.
Metabolic syndrome, a health condition that includes high blood pressure, issues with how your body uses sugar, and abnormal cholesterol levels, could make your prostate bigger and worsen BPH. However, more research is needed, as studies haven’t been able to prove a specific cause and effect.
Risk Factors and Frequency for Benign Prostatic Hyperplasia
Understanding population-based studies on BPH (Benign Prostatic Hyperplasia) can be challenging due to the various definitions for BPH. It could refer to several conditions, including histology, prostate enlargement, prostatic glandular hypertrophy, bladder outlet obstruction, or a diagnosis of BPH by a doctor. LUTS (Lower Urinary Tract Symptoms) represents a wide range of urinary symptoms common in disorders affecting the prostate or bladder, and these may or may not be due to BPH.
Your age plays a crucial role in determining the likelihood of developing BPH and the associated LUTS. For instance, half of the men over 50 years show signs of BPH, and it has been observed that the development of LUTS increases in direct proportion to age. Studies have also shown that prostate size increases with age, by about 2% to 2.5% each year.
- In the US, as many as 70% of people between 60 and 69, and over 80% of those aged over 70, have BPH.
- In a study conducted in the Boston area, the percentage of men with LUTS alone jumped from 8% (ages 30 to 39) to 35% (ages 60 to 69).
- Other studies indicate that 56% of men aged between 50 and 79 reported symptoms of BPH.
The reported cases of BPH in the US nearly doubled from 1998 to 2007 due to the nation’s aging population. As the number of people over 80 years of age is expected to rise from 9.3 million in 2003 to 19.5 million by 2030, the number of BPH cases is likely to increase as a result.
Studies conducted internationally suggest that prostate sizes are generally larger in Western populations than in other regions of the world, such as Southeast Asia. However, smaller prostate sizes do not necessarily mean fewer symptoms, as a group of Indian men showed higher mean IPSS (International Prostate Symptom Score) than similar Western populations, despite having smaller prostates.
Signs and Symptoms of Benign Prostatic Hyperplasia
When a patient goes for a check-up and their medical history is taken, several important aspects related to urinary issues are usually considered. These include when the symptoms started, how intense they are, what makes them worse or better, and how annoying they are to the patient.
Lower urinary tract symptoms (LUTS) can be grouped based on whether they are related to storing urine – such as needing to urinate often, waking up at night to urinate, and an urgent need to urinate – or releasing urine – such as weak urine stream, straining to urinate, hesitating before urinating, spending a long time urinating, and feeling as though the bladder isn’t fully empty. These symptoms help doctors to figure out if other conditions like urinary tract infections, overactive bladder, or issues related to the nervous system might be the cause of the problems, and whether they are related to the bladder or prostate. Men with a non-cancerous enlargement of the prostate (BPH) are likely to experience waking up at night to urinate, poor urine stream, hesitating before urinating, or spending a long time urinating.
Doctors also use certain ‘red flags’ to determine if the urinary symptoms could be due to more serious conditions like prostate cancer, spinal disorders like cauda equina, or high-pressure retention that can lead to silent kidney failure.
Furthermore, information on the patient’s medicine, including any drugs or supplements they may have tried for BPH and their use of anticoagulants that might affect surgeries, is also important. The doctor will also need to understand the patient’s general health to decide if they can have future treatments, considering their fitness for anesthesia, independence, exercise tolerance, and ability to carry out daily activities. The patient’s quality of life and how it’s affected by the symptoms should also be evaluated.
Various conditions not related to the urinary system can worsen urinary symptoms. For instance, using diuretics for heart failure and high blood pressure can increase the need to urinate and waking up at night to urinate. Neurological conditions like Parkinson’s, stroke, cauda equina syndrome, multiple sclerosis, and different spinal cord disorders can affect bladder storage and urination. Poorly controlled diabetes can result in increased urination due to the production of large amounts of urine and damage to the bladder nerves, reducing bladder sensation, weakening bladder muscles, and leaving some urine in the bladder after urinating. Diabetes insipidus can also increase urination and the production of large amounts of urine.
- Abdominal examination to check for palpable bladder/loin pain, lumps, hernias, or masses
- Examination of the external genitalia for meatal stenosis, testicular abnormalities, or phimosis
- Neurological examination to identify any neuropathy
- Digital rectal examination (DRE) to assess the prostate’s size, shape, symmetry, nodularity, and consistency
Further evaluations include urinalysis to analyze the urine, digital rectal examination for prostate checks, an assessment of the LUTS severity, verification of whether your bladder is emptying properly, a chart or diary of your urination habits, peak flow test, lab tests for kidney function and diabetes if not done earlier, and a prostate-specific antigen (PSA) test if needed.
Doctors also use symptom scores to gauge the severity of LUTS and their type. This helps quantify symptom severity, monitor symptom relief with therapy, and categorize patients for treatment. New male patients aged 50 and over are often given a simplified questionnaire . With a quick look at the symptom score, urinary problems that need to be discussed can be immediately identified. Treatment is usually needed when the symptom scores hit 10 and over. The scoring can also be used after treatment to track the improvement of symptoms.
The LUTS symptom scoring categorizes patients into three groups based on their symptoms. These groups range from mild (scores 0-9), moderate (scores 10-19), and severe (scores 20-35) symptoms. A symptom score of 10 or above suggests that BPH treatment should begin, be increased, or altered to provide additional relief. Those with more severe symptoms are less likely to find significant relief from conservative or medical measures alone.
Testing for Benign Prostatic Hyperplasia
If you’re being evaluated for benign prostatic hyperplasia (BPH), a condition that causes an enlarged prostate, there are several standard tests that your doctor may perform.
Urinalysis is a basic test that checks your urine for signs of infection or other problems, such as blood or glucose. Blood tests can help your doctor understand how well your kidneys are functioning and identify conditions like diabetes.
You might also be asked to keep a 24-hour toilet diary, where you record when and how much you pee during a whole day. This can help your doctor understand the nature of your symptoms, especially if you have to pee often at night.
Your doctor may also perform a prostate-specific antigen (PSA) test. This test measures a specific protein in your blood that might be higher if your prostate is enlarged. It’s not commonly run for BPH alone, but can help rule out prostate cancer.
Postvoid residual volume is a measure of how much urine remains in your bladder after you pee. This can be done with a bladder scan or a catheter. A normal measure is less than 150 mL, and anything over 200 mL could be a sign of a problem.
Your doctor might also ask you to do a urine flow study where you pee into a device that measures how fast urine comes out. This can provide extra information about whether there’s an obstruction in your urinary tract.
Pressure/flow studies, urodynamic studies, renal ultrasounds, and cystoscopy are more in-depth tests that might be needed depending on your symptoms and history. They can shed more light on how your bladder is functioning and whether there are any blockages or damage to your urinary tract.
Before you have any surgery for an enlarged prostate, your doctor will need to measure your prostate size. This can be done with cystoscopy, ultrasound, CT scan, or MRI.
Treatment Options for Benign Prostatic Hyperplasia
Men with an enlarged prostate, also known as benign prostatic hyperplasia (BPH), can experience acute or chronic urinary retention. Acute retention is a sudden inability to urinate, often accompanied by lower abdominal pain and weak urine flow. Chronic retention is a long-term issue that slowly worsens over time.
Standard treatment for acute urinary retention involves draining the bladder with a thin tube known as a Foley catheter. This immediate solution relieves the blockage, minimizes discomfort, and allows the bladder muscles to recover. The amount of urine drained can help doctors predict how well the bladder muscle will recover.
Alongside this, doctors typically give medication to aid recovery. Studies suggest that using a type of medication called an alpha-blocker can help improve the success rate of future attempts to urinate naturally. It’s important to wait at least 72 hours before attempting to urinate without the catheter, to give the medication time to take effect and the muscles time to recover.
If these treatments aren’t effective, surgical intervention may be needed. It’s also worth noting that men who have had one episode of acute urinary retention have a 15% chance of experiencing it again, with a large proportion of these men requiring surgery in the future.
In cases of chronic urinary retention, patients may also be treated with a Foley catheter and medication. If the condition becomes unmanageable with these treatments, surgery may be required.
The type of treatment chosen for benign prostatic hyperplasia depends on the patient’s symptoms and their impact on daily life. Options range from lifestyle changes and medication to surgical intervention. In cases where symptoms are mild, doctors might suggest a watchful waiting approach, advising lifestyle changes to alleviate symptoms.
The medication used to treat BPH work to relax the muscles in the prostate and bladder neck, improving urine flow and reducing symptoms. These medications involve alpha-blockers, and in certain cases, medications originally used for erectile dysfunction, such as tadalafil.
In some instances, surgery may be recommended, especially when other treatments are not effective. Various procedures can be done, including a transurethral resection of the
What else can Benign Prostatic Hyperplasia be?
When a patient presents with symptoms of Lower Urinary Tract Symptoms (LUTS), doctors have to consider different possible causes that might look alike in terms of symptoms. These possible causes could be any of the following:
- Bladders that have lost their strength or are overused
- Narrowing of the bladder neck
- Cancer of the bladder or prostate
- Overactive bladder
- Cauda equina syndrome or a bladder affected by nerve diseases which could lead to acute retention
- Chronic high pressure retention that may present subtly or with acute kidney failure
- Hydronephrosis (swelling of a kidney)
- Neurogenic bladder (a bladder affected by nerve diseases, could result from Parkinson’s disease, multiple sclerosis, or diabetes)
- Cancer of the penis
- Phimosis (tight foreskin)
- Prostate cancer
- Prostatitis (inflammation of the prostate gland)
- Kidney failure
- Sexually transmitted diseases
- Spinal disorders
- Narrowing of the urethra
- Inability to pass urine (urinary retention)
- Urinary Tract Infections (UTIs)
- Stones in the urinary tract or bladder
It’s very crucial to make a correct diagnosis, and these different possibilities need to be carefully examined and tested for an accurate diagnosis and treatment plan.
What to expect with Benign Prostatic Hyperplasia
Lower urinary tract symptoms (LUTS), which result in issues with passing urine, often worsen and indicate BPH (benign prostatic hyperplasia), a condition where the prostate gland gets bigger. Patients may also experience complications such as difficulty to completely empty the bladder, urinary infections, or blood in the urine.
Observational studies showed that without treatment, BPH tended to worsen over 48 months. In these studies, 31% of patients needed further treatment and 5% developed acute (sudden or severe) urinary retention in the same period.
The risk of suddenly not being able to pass urine, known as acute urinary retention, increases with age. A study in Olmsted County, Minnesota, found that the incidence of this condition in men increased over 10 times, from 3 per 1000 (in the 40 to 49 years age group) to 34.7 per 1000 (in the 70 to 79 years age group). If left untreated, BPH has a high risk of progression, especially in men with significantly enlarged prostates (greater than 30 grams).
In another study, up to 42% of men who initially had trouble passing urine ended up needing surgery. However, medications called 5 alpha-reductase inhibitors were found to reduce the incidence of urinary retention and delay the need for surgery. In contrast, another type of medication called alpha-blockers did not have this effect.
Possible Complications When Diagnosed with Benign Prostatic Hyperplasia
Common problems can arise after medical procedures for urinary issues, such as:
- Acute urinary retention
- Bladder stones
- Chronic urinary retention
- Weakened bladder
- Slack bladder muscles
- Unrelated increased Prostate-Specific Antigen levels
- Blood in urine
- Swelling of the kidney due to excess urine
- Incomplete bladder emptying
- Kidney failure
- Lower abdominal discomfort
- Urinary tract infections from incomplete bladder emptying
- Weak or on-and-off urine flow
More complications may occur as a result of inserting a catheter to manage Lower Urinary Tract Symptoms in Benign Prostatic Hyperplasia:
- Trial without catheter fails
- Complications related to long-term catheter use (such as blocked catheters, issues retaining urine, and blood in urine)
- Urinary tract infections due to long-term catheter use
Urinary tract infections are a common problem. They often occur if the bladder doesn’t empty properly, causing urine to stay in the bladder for too long. This can lead to infections and bladder stones. Frequent infections might indicate the need for further treatment to prevent other health issues.
Blood in urine is also frequent in people with Benign Prostatic Hyperplasia, a common reason for being referred to a urologist for further investigations. Because larger prostates have more blood vessels, small superficial vessels may sometimes burst, leading to bleeding. The drug Finasteride can be used to decrease the number of vessels in the prostate and can also help manage blood in the urine related to this condition.
Preventing Benign Prostatic Hyperplasia
Patients should understand that making certain lifestyle changes, like losing weight and managing diabetes more effectively, can help lower the chances of needing surgery for an enlarged prostate (BPH). In addition, there are practical steps, such as reducing the amount of caffeine you drink and being mindful about when you drink fluids, that might help to lessen some of the troublesome urinary symptoms. For instance, taking a medication like furosemide earlier in the day, about 6 to 8 hours before bedtime, can help to reduce frequent nighttime urination (nocturia).
For those patients who are living with long-term catheters or who use intermittent self-catheterization, it’s crucial to learn about proper hygiene and how to take care of the catheter. This can prevent urinary tract infections (UTIs). Nurses who specialize in this area can assist with this process. There should also be ways to manage the catheter when the patient is at home or out in the community.
It’s extremely important for patients with an enlarged prostate (BPH) to understand that their condition can get worse over time. Before deciding on a treatment option, patients should be aware of all alternatives, including waiting and observing the condition, medical therapy, or different types of surgeries. This information will empower patients to make an informed decision.
