Benign prostatic hypertrophy (BPH) is growth of the prostate with normal aging and causes symptoms, because the prostate blocks the flow of urine through the prostate as the urine exits the bladder. The name BPH indicates enlargement of the prostate, but men may suffer symptoms even with smaller prostates as they age. Other terms that describe the same process include: lower urinary tract symptoms (LUTS), bladder outlet obstruction (BOO) and benign prostatic enlargement (BPE).
Diagnosis and Treatment of Benign Prostatic Hypertrophy
As men age and the prostate continues to enlarge, symptoms typically slowly progress, and men can develop retention of urine, bleeding, urinary infections, stones in the bladder and even kidney problems. Evaluation and management of these symptoms begin with an assessment of the urinary symptoms and quality of life. In the past treatment was often based on relieving serious problems, such as kidney failure, inability to urinate (retention), bleeding, recurrent infections and bladder stones. These are still indications for aggressive treatment but are less frequently encountered. In modern practice the level of bother from the symptoms most often drives treatment decision-making.
Medical therapy relies on three different types of medications used alone or in combination. Alpha blockers are medications that relax the prostate and bladder opening so the urine can flow more freely. These are typically well tolerated and offer quick improvement in symptoms. Five alpha reductase inhibitors shrink the prostate and work slowly over a four to six month period. These work best for patients with large prostates. Anticholinergic medications help treat bladder over activity and the frequency and urgency that many patients experience with prostate enlargement. These are often used when symptoms of frequency and urgency do not improve after other medical or surgical management and when PVR is reasonably low.
Recently, the phosphdiesterase inhibiting drugs have been shown to improve symptom scores in men being treated for both erectile dysfunction and BPH. Exactly how these drugs improve LUTS is not currently known; but for patients with both problems, this is a new option for medical management.
Surgical management relies on opening the urethra where it runs through the prostate. This can be done with a variety of different procedures including:
- TUIP (transurethral incision of the prostate). Relaxing incisions are made in the prostate using a small scope; typically used for small prostates
- TUMT (transurethral microwave therapy). Destroys prostate tissue with heat delivered by a catheter
- Vaporization of the prostate. Using either laser energy or electrical energy to destroy tissue using a small scope under direct vision
- TURP (transurethral resection of the prostate). Removal of prostatic tissue using electrical energy through a small scope
- HoLEP (holmium laser enucleation of the prostate). Using a laser to carve out the prostate in larger portions and then remove them from the bladder with a morcellating device
- Simple prostatectomy. Removing prostate tissue through an incision in the lower abdomen; typically used for very large prostates
The risks, benefits and indications for each of these procedures are slightly different, and your surgeon will discuss which is best for you. Often, surgeon experience with one technique will also help select the procedure with the lowest risk of complication and best outcome.
In general risks for surgery for BPH include bleeding, urinary tract infection, abnormal healing with scar tissue formation in the urethra and bladder opening, erectile dysfunction, retrograde ejaculation (where semen flows backward into the bladder with orgasm) and incontinence (leaking urine without control). Complications are not common and most surgeries work very well to increase the strength of men’s urinary flow and relieve the symptoms of frequency and urgency of urination. Surgery is a very good option for men that do not tolerate medicines because of side effects or men for whom the medicines are not strong enough to relieve the symptoms of the problem.
Benign Prostatic Hyperplasia (BPH)
What is benign prostatic hyperplasia?
Benign prostatic hyperplasia (BPH) is also called benign prostatic hypertrophy. It’s when the prostate gland becomes very large and may cause problems passing urine. BPH is not cancer, and is a common part of aging.
The prostate gland is found only in males. It’s located in front of the rectum and below the bladder. It wraps around the urethra, the tube that carries urine out of the body. The prostate's job is to make some of the fluid that protects and nourishes sperm cells in semen, making the semen more liquid.
BPH can raise PSA (prostate-specific antigen) levels. PSA is made by the prostate and can be measured with a blood test. An increased PSA level does not mean you have cancer, but the higher the PSA level, the higher the chance of having cancer.
Some of the symptoms of BPH and prostate cancer are the same, but BPH is not cancer and does not develop into prostate cancer.
What causes BPH?
The cause of BPH is not known. The prostate goes through 2 main periods of growth. In early puberty, it doubles in size. Then, around age 25, the prostate starts to grow again and continues to grow throughout most of a man's life.
The continuing growth of the prostate may not cause problems until much later in life, when the second period of growth may result in BPH. It is a common problem for men starting in their 60s and becomes more very common for men in their 70s and 80s have some symptoms of BPH.
What are the symptoms of BPH?
As the prostate grows, it presses against the urethra, the tube that carries urine out of the body. This interferes with urination. At the same time, the bladder wall becomes thicker and irritated, and begins to contract, even when it contains only small amounts of urine. This can cause more frequent urination. These changes cause the bladder muscle to weaken. It may not empty fully and leave some urine behind, leading to symptoms.
The following are the most common symptoms of BPH:
- Leaking or dribbling of urine
- Trouble starting urine stream
- More frequent urination, especially at night
- Urgency to urinate
- Holding urine (cannot pass urine)
- An interrupted, weak stream of urine
These problems may lead to one or more of the following if BPH is not treated:
- Loss of urine control
- Kidney damage
- Bladder damage
- Urinary tract infections
- Bladder stones
- Inability to pass urine at all
The symptoms of BPH may look like other conditions or medical problems. Always consult a health care provider for a diagnosis.
How is BPH diagnosed?
Diagnosing benign prostatic hyperplasia (BPH) in its earlier stages can lower the risk of complications. Your doctor will review your medical history and do a physical exam. Other tests may include:
- Urine tests. To check for infection.
- Digital rectal exam. A procedure in which the health care provider puts a gloved finger into the rectum to feel the part of the prostate next to the rectum.
- Ultrasound (also called sonography).An imaging test that uses high-frequency sound waves to create images of the prostate and nearby organs on a computer screen.
- Intravenous pyelogram. A series of X-rays of the kidney, ureters, and bladder done after a contrast dye is injected into a vein. It’s used to look for tumors, abnormalities, kidney stones, or any blockages, and to check blood flow in the kidneys.
- Cystoscopy. A thin flexible tube and viewing device is put into the penis and through the urethra to examine the bladder and urinary tract for structure changes or blockages.
- Urine flow study. A test in which the man urinates into a device that measures how quickly the urine is flowing. Reduced flow may suggest BPH.
How is BPH treated?
With time, BPH symptoms usually require some kind of treatment. When the prostate 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 get better without treatment. The need to start treatment will be decided by your health care provider after careful evaluation of your symptoms. Regular check-ups are important, and they’re needed to watch for developing problems.
Treatment for BPH may include:
To remove only the enlarged tissue that is pressing against the urethra (the tube that carries urine out of the body), with the rest of the inside prostate left intact. Types of surgery often include:
- Transurethral surgery. No outside incision (cut) is needed. The surgeon reaches the prostate by putting an instrument through the urethra.
- Transurethral resection of the prostate (TURP). A resectoscope—a thin, narrow tube is put into the urethra through the penis. The surgeon uses tools through the resectoscope to remove the prostate tissue blocking the urethra one piece at a time. The pieces of tissue are carried by 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 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 the prostate tissue blocking the urethra. The laser fiber is passed through the urethra to the prostate.
- Open surgery. Surgery that requires an incision (cut) in the skin; often done when the gland is very big, when there are complicating factors, or when the bladder has been damaged and needs to be repaired.
These may include:
- Balloon urethroplasty. A thin tube with a balloon is put into the opening of the penis and guided to the narrowed portion of the urethra. The balloon is inflated to stretch and widen the urethra and ease the flow of urine. Then the balloon is deflated and removed.
- Transurethral microwave thermotherapy (TUMT). Microwaves are used to heat and destroy prostate tissue to reduce urinary frequency and urgency. A thin flexible tube is put into the urethra to get the microwaves to the right parts of the prostate.
- Medications. To shrink or at least stop the growth of the prostate without using surgery, or to make the muscles around the urethra looser so urine flows more easily.
- Water-induced thermotherapy. Heated water is sent through a soft flexible tube into the urethra to heat and destroy prostate tissue.
- Prostatic stents. Stents are narrow tubes put through the urethra into the narrowed area where they are allowed to expand, like a spring, to push back the prostate tissue and widen the urethra. Stents may be used when other treatments have not worked.
What are the complications BPHDelay in treatment can cause permanent bladder damage that cannot be treated.
Living with BPH
Management of BPH may include:
- Lifestyle factors. Limit fluids in the evening, empty your bladder before going to bed, and don’t take diuretics (water pills) that are active at night. Not smoking can also help ease BPH symptoms.
- Dietary factors. Avoid or decrease alcohol, coffee, and other fluids. This is especially important after dinner. A higher risk for BPH has been linked to a diet high in zinc, butter, and margarine. Men 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 worsen symptoms. Consult your health care provider if you are taking any of these medications.
- Kegel exercises. Repeated tightening and releasing the pelvic muscles is called Kegel exercises. These can help prevent leaking urine. Practice these exercises while urinating to train the specific muscle. To do Kegels, contract the muscle until the flow of urine decreases or stops and then release the muscle.
Key points about BPH
- BPH is when the prostate gland becomes very large and may cause problems passing urine.
- The cause of BPH is not known. Growth of the prostate may not cause problems until much later in life.
- As the prostate enlarges, it presses on the urethra. This causes symptoms such as changes in urination.
- BPH may not need treatment. If needed, treatment includes medications, and various procedures and surgeries used to remove the part of the prostate that’s pressing on the urethra.
- Management of benign prostatic hyperplasia (BPH) may include lifestyle changes.
Next stepsTips to help you get the most from a visit to your health care provider:
- Before your visit, write down questions you want answered.
- Bring someone with you to help you ask questions and remember what your provider tells you.
- At the visit, write down the names of new medicines, treatments, or tests, and any new instructions your provider gives you.
- If you have a follow-up appointment, write down the date, time, and purpose for that visit.
- Know how you can contact your provider if you have questions.