Benign Prostatic Hyperplasia

As men get older, most of them will develop an enlarged prostate, a condition known as Benign Prostatic Hyperplasia or BPH. “Benign” means that it is not cancerous, and “hyperplasia” means excess growth. BPH is so common that a 50-year-old man has more than a 50% chance of developing symptoms; this increases to over 90% in men older than 80 years. BPH is not normally a life-threatening condition but symptoms can significantly impact your quality of life. If severe and left untreated for a prolonged period of time, it could cause very serious problems with the function of the bladder, and, less commonly, the kidneys.

For those with BPH, the enlarged prostate squeezes the urethra (the tube where urine exits the bladder) tighter than normal, like a clamp around a hose, and begins to block the flow of urine from the bladder. When this occurs, the bladder becomes thicker and stronger and must work harder to push the urine past the obstruction. The urethra may eventually become so narrow that the bladder is unable to empty completely, allowing urine to remain in the bladder. At this stage the bladder will fill up again that much sooner, causing more frequent urination. When this problem worsens, it is sometimes known as “prostatism” or lower urinary tract symptoms (LUTS). Someone suffering from this problem will notice:

• A weak, hesitant urine stream
• A need to strain when urinating
• A sense that the bladder is not empty
• Dribbling or leaking after urination
• An inability to completely empty the bladder
• Frequent urination, including several times during the night

Occasionally, an enlarged prostate may bleed a little bit into the urine. This is known as “hematuria” and is usually painless. It happens because small, fragile blood vessels on the surface of the prostate stretch and rupture, usually due to the pressure caused when urinating or having a bowel movement. Sometimes a blood vessel may break as the result of heavy lifting or crouching. In most cases, the amount of blood is so small that it can only be seen under a microscope. It is rare for anyone to lose a significant amount of blood from a small vessel on the prostate gland.

Enlarged prostates are not the only condition that may cause blood to be present in the urine. Other more serious conditions such as bladder or kidney cancer commonly cause bleeding. Any man who sees blood in his urine should see his doctor immediately and ask to be referred to a urologist to rule out more serious possibilities before assuming that “it’s nothing” or “it’s just my prostate.”

To date, the exact causes of BPH are not known. However, research has identified several factors that increase the risk of BPH. You could be at higher risk of BPH if:

• You are over the age of 45
• You are still producing testosterone
• It runs in your family
• You are obese

For the majority of patients, urinary symptoms are the first sign of BPH. When urinary symptoms are present, a digital rectal exam (DRE) must take place. This is where the doctor places a finger inside the rectum to check for changes to the size and surface of the prostate. Most men find the digital rectal exam to be uncomfortable, but an untreated prostate will become even less comfortable. Your doctor will then conduct a blood test to determine if the prostate is inflamed.

The doctor may also check the amount of urine left in the bladder after urinating by using an ultrasound bladder scanner or a catheter. In some cases a flow measurement or even urodynamics may be required to properly diagnose BPH.

If there is concern about kidney function or abnormalities in the urine, an ultrasound of the kidneys and/or a cystoscopic examination of the bladder may be required to rule out more serious problems.

There are a number of treatment options depending on the degree of discomfort and bother associated with BPH, lifestyle factors, and complications from the enlarged prostate or the blockage of urine. Treatment options include the following:

No Treatment or Watchful Waiting

For those with mild cases of BPH, where symptoms are tolerable, treatment may not be necessary. In these cases, the patient must still be monitored to ensure their problem does not worsen. Monitoring involves keeping an eye on the BPH symptoms, the size of the prostate, and regular blood tests. Limiting fluids in the evening, avoiding caffeinated drinks, alcohol, and spicy foods may minimize symptoms.

Drug Treatment

Men with mild to moderate symptoms may try over-the-counter herbal/plant therapy (e.g. Serenoa Repens, Saw Palmetto, and Pygeum Africanum). It should be noted that manufacturers have found it difficult to ensure potency and product-to-product consistency, given the nature of herbal/plant therapies.

There are two types of prescription medications available to treat Benign Prostatic Hyperplasia symptoms: alpha-blockers and 5-alpha reductase inhibitors.

Alpha-blockers relax the muscles in the prostate gland and the bladder opening, which is like “taking the clamp off of a hose.” If this treatment option works, symptoms associated with BPH usually improve within one to two weeks. The drugs currently available include doxazosin, terazosin, tamsulosin, silodosin, and alfuzosin.

Side effects associated with alpha blocker treatment may include the following:

• Dizziness, tiredness, or decreased blood pressure
• Retrograde ejaculation, where semen passes back into the bladder during orgasm instead of being ejected externally
• Nasal stuffiness

All these side effects are usually reversible when the medication is stopped. Care must be taken in men being treated for high blood pressure as some alpha blockers might interact with erection drugs. Also, if you are going to have cataract surgery, be sure to inform your eye surgeon that you are on these medications as it could impact on the surgery (“floppy iris syndrome”).

5-alpha reductase inhibitors are a “mild form” of hormone treatment that reduces the size of the prostate gland by blocking a male hormone from stimulating prostate growth. It may take three to six months for symptoms associated with BPH to improve while taking this type of medication. This drug is most useful in men with larger prostates.

Approximately three percent of patients experience reduced sex drive, poor erections, or decreased volume of semen as a side effect of this treatment. Small numbers of men may notice breast tenderness and enlargement.

Combination therapy involves the use of both an alpha blocker and a 5-alpha reductase inhibitor. Two studies have confirmed that in men with larger prostates this approach appeared to be effective in relieving and preventing symptoms and reduced the long-term need for BPH-related surgery.

Surgical Treatment

Surgery is typically used in men with moderate to severe symptoms, when drug treatment fails, or those with complications such as frequent infections, bleeding, or episodes of retention. There are several minor therapies that may be effective to a degree and have few complications and a short healing time. These are mostly heat based treatments, which include microwave thermotherapy, radiofrequency needle waves, laser coagulation, water-induced thermal therapy, and high intensity ultrasound. More invasive surgery for BPH involves cut(s) through, or removal of part of the prostate gland, either through the urethra (Transurethral Resection) or, less commonly, through an open operation via the abdomen (Retropubic Prostatectomy).

Transurethral Resection of the Prostate (TURP) is considered by many urologists to be the gold standard procedure for Benign Prostatic Hyperplasia. TURP involves removal of the inner portion of the prostate in small pieces, perhaps like removing the core of an apple. It is done by using a small camera that is guided through the urethra in the penis, therefore avoiding any external cuts into the abdomen. The tissue may be removed using electrocautery or vaporized with an electrode or with laser energy.

Retropubic Prostatectomy involves the removal of most of the inner prostate via a cut in the abdomen. It is required for very large prostate glands. Modern laser techniques are being used successfully for large prostates, which avoids the need for an abdominal scar. Several centres are also using the daVinci robot to remove BPH.

The side effects of surgery may include frequent urination, blood in the urine, difficulty achieving an erection, urinary leakage, or narrowing (scarring) in the urethral channel. Approximately 75% of men will experience retrograde ejaculation following a TURP. Some men require a repeat of this procedure several years later as the benign growth can reform.

BPH is not cancer. Because it is non-cancerous, it will not spread to other parts of the body. Having BPH does not increase the risk of getting prostate cancer. However, men with benign prostate disease can still develop prostate cancer, but not because of BPD. Doctors may perform regular prostate checks to monitor any changes to the prostate.