Benign Prostatic Hyperplasia (BPH)

Enlargement of the prostate gland is a common effect of the ageing process in men and is known as benign prostatic hyperplasia (BPH).

The prostate undergoes two key stages of growth during a man's lifetime. The first is during puberty when the prostate gland doubles in size and it then starts to grow again at around the age of 25. The second growth phase occurs in older men and this is known as benign prostatic hyperplasia.

The development of the prostate gland does not typically result in difficulties until late in a man's life when the gland starts to apply pressure to the urethra causing the bladder wall to thicken. Benign prostatic hyperplasia does not usually lead to symptoms in men under the age of 40, but by the age of 60 more than half of men suffer symptoms. Up to 90 percent of men in their eighties and nineties suffer symptoms of BPH.

When the prostate gland presses against the urethra the bladder becomes irritated and the bladder wall thickens, causing the bladder to contract when there is only a small amount of urine inside. This causes the individual to urinate more frequently and eventually results in the bladder losing the capability to clear itself. This can leave urine inside the bladder. Many of the symptoms associated with BPH are associated with the urethra becoming thinner and urine being left inside the bladder.

Many men feel uncomfortable and embarrassed talking to their doctor about the prostate, but it is essential to discuss prostate problems and symptoms with a doctor. The incidence of BPH is increasing every year in tandem with an increase in life expectancy.

Why does BPH occur?

The exact cause of benign prostatic hyperplasia is not fully understood and there is no concrete information relating to risk factors. It is well-documented that the incidence of BPH increases with age with almost all men over the age of 80 suffering symptoms of BPH. It is also known that BPH does not affect men who have had their testes removed before puberty, and this has led researchers to believe that there is an association between the testes, ageing and BPH.

Men produce two hormones known as testosterone and oestrogen throughout their lives. The amount of testosterone produced is far greater than oestrogen. As men get older the amount of testosterone produced in the body decreases, which means that the proportion of oestrogen (female hormone) is higher. Research carried out on animals suggests that BPH may take place as a consequence of higher levels of oestrogen, which increases cell growth.

Another theory is concentrated on DHT (dihydrotestosterone) which is derived from testosterone found in the prostate and is involved in controlling cell growth. Most animals stop producing DHT as they get older, but research suggests that some men carry on to producing DHT well into old age. This could be the cause of continued development of the prostate gland, especially as researchers have found BPH does not occur in men who discontinue producing DHT.

Researchers believe BPH may also result from a 'code of instructions', which is given to cells early on in a man's life. If this theory is true the cells in one fraction of the prostate gland would become active later in life and spread growth instructions to other cells in the gland. This could cause them to expand or become more susceptible to hormones that control growth.

Symptoms

The symptoms are largely caused by pressure on the urethra and deficient emptying of the bladder, which is brought on by the gradual decrease in bladder function. Symptoms of BPH differ according to the individual but commonly include:

Frequent urination
Difficulty urinating; it can take a long time to start urinating or the stream may be interrupted
Increased urgency in needing to urinate
Urinating frequently during the night

The severity of symptoms does not always depend on the extent of prostate enlargement as some men may experience much more severe symptoms even when the level of enlargement is small.

A proportion of men do not experience symptoms or realise they have BPH until they are unable to urinate. This is known as acute urinary retention and may be caused by using over-the-counter medications for colds, coughs and allergies. These medicines include a decongestant called sympathomimetic which can cause the bladder to lose the ability to relax and prevent urine from emptying the bladder. When there is a partial obstruction other triggers which may cause urinary retention include drinking alcohol, being immobile for a long timeframe or very cold temperatures.

If you experience urinary problems it is vital to inform your doctor because in around 80 percent of cases the signs imply BPH, but they can also be indicative of more serious conditions such as prostate cancer and should always be checked out.

In severe cases, BPH can cause permanent damage to the bladder, as well as conditions such as kidney stones, bladder stones and urinary tract infections (UTIs). If the bladder is damaged permanently treatment for BPH may not be effective. The risk of complications is lower when BPH is diagnosed early.

Diagnosis

You may notice the signs of BPH and decide to visit your doctor, or the prostate may be found to be enlarged during a regular examination. The earlier the condition is diagnosed the lower the risk of complications and permanent bladder damage. If a doctor suspects the patient has BPH they may refer them to a specialist urologist. Tests will be carried out to reach a diagnosis and determine the appropriate course of treatment.

Digital rectal examination

This is normally the initial test carried and involves the doctor placing a finger inside the rectum to examine the prostate gland. This enables them to gauge the size and state of the prostate gland.

Prostate specific antigen test (PSA) blood test

A PSA blood test may be ordered to rule out prostate cancer. PSA is a form of protein produced by the prostate cells and levels are usually high in men with prostate cancer. A PSA test has been approved by the US Food and Drug Administration and is designed to be used alongside a digital rectal examination to help detect cancer early in patients over the age of 50. The PSA test can also be useful in monitoring the condition of patients who have been treated for prostate cancer.

Rectal ultrasound

If a doctor suspects a patient has prostate cancer they may order a rectal ultrasound. This test uses sound waves to generate images of the prostate gland.

Urine flow study

The urine flow test measures the speed of urine flow because if the speed is reduced it is indicative of BPH.

Cystoscopy

This examination involves the insertion of a thin tube called a cytoscope into the urethra. The inside of the penis is numbed in advance to prevent pain. A cystoscope allows doctors to see inside the urethra and the bladder, and doctors can then establish the dimension of the gland and the location and extent of any obstructions.

Treatment

BPH should be treated; although, research has questioned the efficacy of treatment at an early stage when the prostate gland is only mildly enlarged. Some doctors may advise a policy of watchful waiting in the early stages as symptoms may ease without any formal treatment. If this policy is adopted and the patient shows signs of the condition worsening, doctors will then decide to take action.

It is normal for BPH to cause recurrent urinary tract infections, so these will usually be treated with antibiotics before BPH is treated.

The following treatments are used to treat benign prostatic hyperplasia:

Medication

Researchers have been working on a means to reduce the mass of the prostate gland without the need for surgery and four types of medication have been approved by the US Food and Drug Administration. These include Finasteride (approved in 1992) and Dutasteride (approved in 2001) which work by inhibiting the production of DHT. These drugs prevent further growth of the prostate gland, but in some men they can also shrink the gland. Alfuzosinand and Tamsulosin were created specifically to treat men with BPH and they work by relaxing the smooth muscle in the prostate and bladder to allow urine to flow freely and reduce the obstruction. Two other drugs known as Terazosin and Doxazosin work in the same way but they were developed to treat high blood pressure (hypertension). All four drugs are a type of drug called alpha-blockers.

Research has shown that combining Finasteride and Doxazosin is more effective in treating BPH than using either drug alone. Trials showed that the combination of drugs was effective in 67 percent of cases, compared to 34 percent for Finasteride alone and 39 percent with Doxazosin alone.

Minimally-invasive therapy

Medication is not successful in treating all patients with BPH so researchers have developed other minimally-invasive treatments, including:

Transurethral microwave procedures: a treatment called the Prostatron is used to destroy surplus prostate tissue. The Prostatron uses transurethral microwave thermotherapy (TUMT) to heat and kill excess tissue by delivering microwaves through a catheter into specific areas of the prostate gland. The temperature is at least 111 degrees but the urinary tract is cooled to prevent damage. A similar treatment called the Targis System uses the same technology to treat BPH, in which a temperature monitoring device is inserted into the rectum to monitor the treatment. Both treatments take around one hour and can be done as day cases without the need for anaesthetic. The treatments do not cure BPH but they do ease symptoms and help to reduce the frequency of urination. Therapy does not address the difficulty of incomplete bladder emptying. Research into the efficacy of this therapy is ongoing.
Transurethral needle ablation (TUNA): this therapy uses low level radiofrequency energy to burn and destroy targeted areas of the prostate gland. The urethra is protected during treatment and there is no evidence to suggest treatment is linked to incontinence or impotence. TUNA therapy helps to improve urine flow and relieves other symptoms without as many side-effects of other treatments.

Surgical treatment

In most cases, doctors recommend surgical removal of the enlarged area of the prostate gland as the best long-term treatment for BPH. If this is the case, only the affected part of the gland (the area pressing against the urethra) is removed while the rest of the gland is left intact. Surgery removes the obstruction and usually relieves incomplete emptying of the bladder. Types of surgery used to treat patients with benign prostatic hyperplasia include:

Transurethral surgery: this form of surgery involves accessing the prostate by inserting a special instrument called a resectoscope through the urethra and does not require any incisions. Anaesthetic is administered prior to the instrument being inserted into the urethra. A method known as TURP (transurethral resection of the prostate) is used to treat around 80-90 percent of patients with BPH.

The resectoscope is around 12 inches long and half an inch wide. It is fitted with a light source to enable doctors to see and a wire loop to cut the affected tissue causing the obstruction. The tissue pieces are cut away and then carried to the bladder by fluid, after which the bladder is flushed to remove the tissue. The wire loop is also used to seal blood vessels.

TURP is recommended in most cases of BPH because recovery is fairly quick and the procedure (usually lasts around 90 minutes) is less traumatic and intensive than other methods.

TUIP (transurethral incision of the prostate): this procedure involves making small incisions in the bladder neck to widen the urethra but, unlike TURP, the procedure does not involve removing any tissue. The long-term effects of TUIP are relatively unknown and TURP is normally preferred.

Open surgery: in cases when transurethral surgery cannot be carried out open surgery may be an option. Open surgery is usually used when the prostate gland is enlarged to a great extent and the patient has experienced complications, such as damage to the bladder.

Doctors consider a number of factors including the patient's age, general health and the location and severity of enlargement when choosing treatment options best for the individual. Anaesthesia is always used for open surgical procedures when an opening is made and the enlarged tissue is removed.

Laser surgery: laser treatment has been approved for treating BPH. It is a technique that uses YAG lasers to destroy obstructive tissue and side-firing laser beams to destroy specific areas of tissue. The laser is delivered in short, sharp bursts (usually between 30 and 60 seconds) after the prostate gland has been accessed using a cytoscope. Laser surgery necessitates anaesthesia but recovery is usually quick and blood loss minimal. As well as destroying enlarged tissue, laser surgery can also cause the prostate gland to shrink in size. Laser surgery is still relatively new so the long-term effects are unknown.

Recovery after surgery

It is normal for patients to stay in hospital after surgery for BPH, but the length of the hospital stay will depend on the method used and the individual as some people recover quicker than others.

After surgery a catheter known as a Foley catheter containing a water-filled balloon is fitted to the penis to drain the bladder of urine. The fluid then flows into a collection bag. The catheter is left in position for several days to ensure the bladder is fully drained. It is possible for the catheter to cause bladder spasms and this may be painful.

Patients may be given anaesthetic while they are in hospital to reduce the risk of infection, but in some cases doctors decide this is not necessary.

After surgery it is normal for blood to be visible in the urine, but this is part of the healing process and should subside by the time the patient leaves hospital. Patients should seek help if they notice excessive or prolonged bleeding following surgery. It is imperative to take in plenty of fluids throughout the recovery period to cleanse the bladder.

Recovery do's and don'ts:

DO:

Rest and take it easy, especially when you first get home
Take time off to recover, even if you do not feel any pain; your body is healing and doing too much too soon can set the recovery process back
Drink plenty of water (at least 8 glasses of water per day) to drain the bladder and facilitate healing
Eat a healthy, balanced diet as this will help to prevent constipation
Follow your doctor's advice and contact them if you have any questions or concerns

DON'T:

Participate in strenuous activities or exercise until your doctor says it is safe
Lift anything heavy; always ask for help if you need to
Drive or operate any heavy machinery until your doctor advises it is safe
Smoke; smoking slows the body's natural healing process

Returning to normal

Most people feel well when they leave hospital but it can take a few months to make a full recovery. During this time the following problems may occur:

Difficulty urinating: it can take a while for urination to return to normal. Many men find the stream is more powerful after surgery, though it can take weeks for urination to be completely normal. When the catheter is first removed urinating may be uncomfortable as urine will move over the wound. Some men also find that they have greater urgency to urinate, but these problems should wear off with time.
Incontinence (difficulty controlling the bladder): long-term incontinence is rare but it is common to experience short-term difficulty controlling the bladder after surgery. In most cases, the longer the individual had problems before surgery the more time it takes for bladder control to normalise.
Bleeding: bleeding may occur if the scab protecting the wound inside the gland comes loose. This can be a worrying sight but it will not cause any problems and bleeding usually stops shortly after. You should see your GP if you experience thick, red bloody urine, pain when urinating or you notice clots in your urine.
Sexual function: many males worry about how the procedure will affect sexual function. There is debate among doctors about the proportion of men affected by surgery, but any problems experienced after surgery will subside and men can take pleasure in sexual intercourse after the recovery period. In some cases, full recovery can take up to a year but this varies from person to person.
Erections: most experts agree that patients who were able to sustain an erection before surgery will have no problem following treatment. However, it is not usually possible to restore function in men who lost function prior to surgery. In very rare cases, erectile dysfunction may occur after surgery.
Ejaculation: most men can sustain erections following surgery for BPH, but the procedures may make them sterile by causing 'dry climax' or 'retrograde ejaculations'. This is due to the muscles which usually block the bladder being cut during surgery, which causes the semen to enter the bladder rather than penis where it would be ejaculated. Semen entering the bladder is flushed away with urine and expelled from the body. In some cases, it may be possible to treat the condition with a form of medication known as pseudoephedrine. This drug works by improving muscle tone around the bladder neck to prevent semen from going into the bladder.
Orgasm: most men who have had surgery for BPH do not experience a change in the feeling of orgasm, and although it can take time to grow accustomed to dry climax most men continue to find sex enjoyable. Some men find that their worries about sexual function impact their performance and ability to take pleasure in sex. It is important that patients feel they are able to discuss concerns with their doctor and ask questions about the effects of surgery.

Is further treatment required?

Surgery is usually effective although as some of the gland is left behind, there is always a risk of further prostate problems. For this reason regular rectal examinations are recommended. Surgery usually provides relief for symptoms for at least 15 years and only around 10 percent of men require further surgery. In most cases, these patients had surgery for prostate problems at an earlier age than average.

Further treatment is sometimes required as a consequence of scar tissue causing obstruction. This is rare but the tissue can block the bladder opening or cause the urethra to narrow. If this is the case a procedure alike transurethral incision may be recommended. In some cases, the problem can be addressed at the doctor's surgery, as they will be able to stretch the urethra.

Prostatic stents

Stents are small medical devices used to expand vessels and pathways inside the body. In this case, stents are used to widen the urethra by pushing back the prostate tissue. Stents may be recommended for men who have had surgery and still experience urinary obstruction.

Prostate cancer and BPH

Many of the symptoms of prostate cancer and BPH are similar but there is no evidence to suggest having BPH increases your risk of developing prostate cancer. It is advisable to have regular rectal examinations and health experts advise men over the age of 40 to have an examination every year. This will ensure symptoms of either condition are detected early and allow patients to receive treatment during the early stages. This is particularly important with cancer as survival rates are much higher when the condition is diagnosed early.

If a section of the prostate gland is removed after a man has been diagnosed with BPH it is routine procedure to test the cells for cancer. In around 10 percent of cases cancerous tissue is detected. However, this usually represents a very small number of non-aggressive cells which do not require treatment.