Benign Prostatic Hyperplasia

If you’re a man past middle age, there’s a good chance that you have or may develop a condition known as benign prostatic hyperplasia (BPH). This noncancerous condition affects about 40% of men in their 50s, 60% of men in their 60s, and more than 80% of men in their 80s. You may have BPH but no urinary symptoms but many men who have BPH will have related urinary symptoms. In men who do have urinary issues these are called lower urinary tract symptoms (LUTS). These symptoms may interfere with sleep and normal daily activities.

Having an enlarged prostate does not increase the risk for prostate cancer, although it’s possible to have both BPH and prostate cancer. With BPH, cell growth is primarily in the inside of the prostate that surrounds the urethra. This growth is benign (non-cancerous). Prostate cancer tends to grow more frequently in the outer portion of the prostate.

An enlarging prostate may obstruct this outflow of urine as the tube that carries urine (the urethra) runs through the middle of the prostate.

Not all men have problems because of an enlarged prostate. Those men that do have related urinary issues may have a variety of different symptoms many of which can be frustrating and uncomfortable. These symptoms are often characterized into voiding (obstructive) and storage (irritative) symptoms. Voiding symptoms include weak stream, a sensation of incomplete emptying, difficulty starting the urinary stream (hesitancy), urinary stream starting and stopping (intermittency), and post-void dribbling (leakage after urination). Storage symptoms refer to the bladder having difficulty storing urine due to the enlarged prostate and include frequent urination, urgency to urinate, getting up frequently at night to urinate (nocturia), and urge incontinence (leakage associated with an urge). In men who have urinary symptoms, they generally worsen with age.

The enlarged prostate may not cause just urinary symptoms. Men may also suffer from urinary tract infections, bladder stones, blood in the urine (hematuria) or, in severe cases, kidney damage due to the enlarged prostate.

The function of the prostate gland is to secrete the major portion of ejaculatory fluid. It sits at the base of the urinary bladder where the bladder empties. As a man ages, the prostate may enlarge or otherwise undergo changes so that it presses on the urethra causing problems with urination.

BPH is caused by an increase in the number of cells within the prostate. This increase is controlled by several factors including a man’s genes, hormones, body composition and age. Men may have a very large prostate (many cells) or a smaller prostate (less total number of cells). The size of the prostate and the resulting urinary symptoms are not always correlated—some men have a large prostate and minimal to no symptoms while some men have a small prostate but severe urinary symptoms.

Urinary symptoms in men may be caused by problems other than an enlarged prostate. Neurologic problems like a spinal cord injury, Parkinson’s disease, diabetic neuropathy, or a stroke may also cause urinary symptoms. Other causes can include bladder cancer, infections of the bladder or prostate, or benign (non cancerous) changes in the bladder and prostate itself (receptor type, sensitivity, and number). If you think your urinary symptoms are not just related to an enlarged prostate, you should discuss it with your medical provider. Many of these above problems have simple tests that can help make sure your symptoms are just related to an enlarged prostate.

If you have urinary symptoms, you may have BPH. If you have urinary symptoms, you should mention this to your primary care provider or you can schedule an appointment to see a urologist. Many primary care providers feel comfortable treating men with urinary symptoms related to BPH, and it may not be necessary to see a urologist if you have urinary symptoms.

Your medical provider will probably start by taking a medical history. This will include questions about your urination and related medical problems. The physical exam might include a digital rectal exam (DRE), in which the doctor inserts a gloved, lubricated finger into your rectum to feel for the size of the prostate and any abnormalities. Your urine will also be checked for a variety of conditions including an infection in your bladder (urinary tract infection). Your doctor may take a blood sample to check your prostate-specific antigen (PSA), a measurement that rises with prostate disorders and in some cases prostate cancer. Not all medical providers use PSA testing in men, and if you are concerned about prostate cancer then you should ask your medical provider about PSA testing.

In some cases, your medical provider may order a test to check the speed of your urine flow or use an ultrasound to check on the amount of urine left in the bladder after you have urinated. These measurements can help the doctor determine the extent of your urinary tract obstruction.

In assessing your symptoms, your medical provider may use one of two well-known aids: the “AUA Symptom Score”, which was developed by the American Urological Association (AUA) or the International Prostate Symptom Score (IPSS) developed by the World Health Organization (WHO). The IPSS is identical to the AUA Symptom Score except that, in addition to the seven multiple-choice questions about urinary symptoms, it contains an eighth about how bothersome you find the symptoms. Your answers to the questions can help your doctor determine the nature and severity of your LUTS and how they may pertain to BPH.

If your symptoms are minor and you do not have a UTI or signs of injury to your urinary tract, your doctor may suggest a period of symptom monitoring with no immediate treatment. If, however, you have bothersome symptoms that are moderate to severe, your medical provider will discuss treatment options or referral to a urologist.

Not all men with BPH need treatment. Some men do not have any urinary symptoms despite an enlarged prostate. Other men don’t find the symptoms bothersome enough to start treatment. But for those men that have symptoms that are significant enough to desire treatment, there are many medication and procedure options available.

Below are some of the traditional medications used to treat symptoms due to BPH. In some cases, a combination of medications may be used.

• 5-alpha reductase inhibitors: These drugs trigger hormonal changes that shrink an enlarged prostate.
• Alpha blockers: These medicines work to relax the smooth muscle cells in the prostate. With the prostate more relaxed, there is less pressure on the urethra.
• Phosphodiesterase inhibitors: Tadalafil was originally approved for treatment of erectile dysfunction (ED). This drug has been found to be effective for men with both BPH symptoms and ED.

A variety of procedural or surgical options exist for men with BPH. Minimally invasive treatments (MISTs) are office based procedures to treat the enlarged prostate although they may still be done in an operating room. More invasive procedures on the prostate are also discussed below.

Two older MISTs both use heat to shrink the prostate. The procedures are done via a transurethral approach meaning they are done through the opening at tip of the penis, and no incisions are made.

• Transurethral microwave thermotherapy of the prostate (TUMT): This treatment uses a catheter based antenna to emit microwave heat into the prostate. The heated tissue then gets smaller over time shrinking the prostate.
• Transurethral needle ablation of the prostate (TUNA). Like TUMT, TUNA involves heating prostate tissue to decrease the size of the prostate. This technique uses radio frequency energy delivered through needles inserted into the prostate tissue.

New MISTs are frequently introduced. These are also done transurethrally. 

• Prostate urethral lift (Urolift™): Implants are placed that span from the urethra to the outer portion of the prostate. These compress the prostate gland, opening up the urethra.
• Convective water vapor therapy (Rezum™): Radiofrequency energy is used to turn water into steam which is then injected into the prostate gland. The steam causes cells in the prostate to die allowing the prostate to shrink.

Surgical treatments are not office based; they are done in the operating room. 

• Transurethral resection of the prostate (TURP): often considered the “gold standard” as this procedure has been around for decades and has reliable results. An electrified loop is used to cut the inner portion of the prostate into strips which are then removed through the scope.
• Transurethral incision of the prostate (TUIP): This procedure makes one or two incisions (cuts) in the prostate to open the prostate. It is not recommended for men with larger prostates.
• Laser vaporization of the prostate: A laser is used to deliver energy into the prostate gland to vaporize the tissue (turn it to smoke). The shrinks the prostate gland. Many different lasers were used for this in the past but the most common laser used currently has a wavelength that interacts with the blood in blood vessels to cause vaporization.
  •Laser enucleation of the prostate: Different lasers may be used for this procedure. The inner portion of the prostate is removed from the outer portion and then pushed into the bladder. A morcellator is used to make the lobes into smaller pieces that can be removed through the scope. This procedure may be performed in men with any sized prostate.
• Simple prostatectomy: In this procedure, the inner portion of the prostate is removed entirely. This may be done as an open procedure with an incision in the lower abdomen or may be done robotically with multiple small incisions in the abdomen. These procedures are generally used for men with very large prostates.

Condition overview written by Charles Welliver, MD