Benign Prostatic Hyperplasia (BPH)

(Non-cancerous enlargement of the prostate)

The Prostate Gland

The prostate is a walnut-sized gland that forms part of the male reproductive system. The prostate is located in front of the rectum and just below the bladder. The urethra, the canal through which urine passes out of the body, passes through the prostate. Scientists do not know all the prostate's functions. One of its main roles is to contribute fluid into the semen, and the ejaculatory ducts, small tubes that the semen passes through during ejaculation, enter into the prostatic urethra.

BPH: A Common Part of Aging

It is common for the prostate gland to become enlarged as a man ages. Doctors call the condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy. Starting around age 25 the inner part of the prostate begins to grow in all men, and most of the prostate growth occurs between ages 50 and 70. In some men the prostate grows only a small amount and in others the prostate grows to 2-3 times (or more) the size of a young man's prostate. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and as many as 90 percent in their seventies and eighties have some symptoms of BPH.

As the prostate enlarges, the inner part of the gland presses against the urethra like a clamp on a garden hose. The bladder must squeeze harder to push the urine through the prosate, and the bladder wall becomes thicker and and stronger. The thickened bladder becomes irritable and begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder may not be able to empty completely and some urine remains in the bladder. Finally, the bladder may become overstretched and weakened, and the patient may be unable to urinate at all, a condition called urinary retention.

Symptoms

The symptoms of BPH vary, but the most common ones involve changes or problems with urination, such as:

• a hesitant, interrupted, or weak urinary stream
• urgency to urinate right away
• leaking of urine, called incontinence
• more frequent urination, especially at night
• the sensation of incomplete bladder emptying

The size of the prostate does not always determine how severe the obstruction or the symptoms will be. Some men with greatly enlarged glands have little obstruction and few symptoms while others, whose glands are less enlarged, have more blockage and greater problems. Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to urinate at all. This condition, called acute urinary retention, may be triggered by taking over-the-counter cold or allergy medicines. Urologists use a standard questionaire called the AUA symptom score to grade the severity of a man's symptoms.

It is important to tell your doctor about urinary problems such as those described above. In 8 out of 10 cases, these symptoms suggest BPH, but they also can signal other conditions that require prompt treatment such as urethral scarring, prostate cancer, bladder stones, urinary or prostate infection, or others.

Severe BPH can cause serious problems over time. Urine retention and strain on the bladder can lead to urinary tract infections, bladder or kidney damage, bladder stones, and incontinence. If the bladder is permanently damaged, treatment for BPH may be ineffective. When BPH is found in its earlier stages, there is a lower risk of developing such complications.

Diagnosis

You may first notice symptoms of BPH yourself, or your doctor may find that your prostate is enlarged during a routine checkup. When BPH is suspected, you may be referred to a urologist, a doctor who specializes in problems of the urinary tract and the male reproductive system. The following tests are part of the evaluation of urinary symptoms in men.

Digital Rectal Exam (DRE)

This exam is usually the first test done. The doctor inserts a gloved finger into the rectum and feels the part of the prostate next to the rectum. This exam gives the doctor a general idea of the size and condition of the gland.

Prostate Specific Antigen (PSA) Blood Test

In order to rule out prostate cancer as a cause of urinary symptoms, your doctor may recommend a PSA blood test. PSA, a protein produced only by prostate cells, is frequently present at elevated levels in the blood of men who have prostate cancer. If the PSA test is elevated there is a 30% chance or more of prosate cancer and further tests, such as prostate biopsy, may be necessary.

Prostate Ultrasound

Prostate ultrasound is a test done in the urologist's office to measure the size and shape of the prostate. If there is a suspicion of prostate cancer, your doctor may also recommend a test called prostate needle biopsy.

UroFlow Study

A uroflow test measures the force and pattern of the urinary stream. The patient comes to the office with a full bladder and voids into a special device that measures how quickly the urine is flowing. A reduced flow often suggests BPH.

Cystoscopy

In this exam, the doctor inserts a small, flexible tube called a cystoscope through the urethra into the bladder. This test allows the doctor to determine the size of the gland and identify the location and degree of the obstruction, and rule out other causes of the symptoms.

BPH Treatment

Many men with mild urinary symptoms may not need treatment. Patients with symptoms that are bothering them, or men with urinary infections, incontinence, or incomplete bladder emptying usually need some kind of treatment. Fortunately there are a number of good treatments for BPH.

Herbal Treatment

A number of herbal extracts have been used to treat urinary symptoms in men. The most widely known is Saw Palmetto, but others include beta-sitosterol, stinging nettle extract, pygeum, quercitin, and many others. It is difficult to determine just how effective these treatments are because most of the studies that have been performed are of low quality and short-term. Some studies show that these herbal treatments are as effective as medications, and others show little effectiveness. A study from UCSF in 2005 randomized 225 men to Saw Palmetto or placebo and followed them for one-year. No benefit at all was seen when they looked at urinary symptoms, urine flow rate, completeness of bladder emptying, prostate size, or general health measures. There seems to be very little risk related to these herbal extracts, and a trial for 3 months is a good idea for many men. If no improvement is seen in 3 months then men should consider other treatments.

Drug Treatment

There are two main types of drugs used to treat BPH.The first type, called alpha-blockers, relax the muscle in the prostate so the urethra can open and let the urine flow through easier. There are a number of drugs in this class, including Flomax (tamsulosin), Uroxatral (alfluzosin), Hytrin (teazosin), and Cardura (doxazosin). These drugs usually give some improvement within 1-2 weeks. The second class of drugs, call 5-alpha reductase inhibitors, cause the prostate to shrink in size by about 1/3 over 3-6 months. The two drugs in this class are Proscar (finasteride) and Avodart (dutasteride). A recent large study found that using finasteride and doxazosin together is more effective than either drug alone to relieve symptoms and prevent BPH progression. The drugs are safe with only mild side effects. A disadvantage of drug therapy is that patients usually need to stay on the drugs forever, because the symptoms return in a short time after the drugs are stopped.

Minimally-Invasive Treatment

Transurethral Needle Ablation (now called Prostiva RF)

In the 1990s a number of minimally-invasive treatments for BPH were developed. In these treatments a device is passed through the urethra into the prostate and used to heat the inner part of the prostate, which causes the prosate to shrink and the urinary symptoms to improve over 6-12 weeks. Approximately 80% of men will get substantial improvement from these outpatient treatments, and most can stop drug therapy for BPH. The degree of improvement in urinary symptoms is usually better than with drugs alone, and roughly the same as prostate surgery. The minimally-invasive treatments give at least 8 years of improvement in the vast majority of men, and can be repeated if necessary. There are several methods of heating the inside of the prostate, including microwave, radiofrequency, or laser energy. We believe that Transurethral Needle Ablation of the prostate, now called Prostiva RF , gives excellent long-term results and is suitable for the broadest variety of prostate shapes and sizes. Prostiva RFis performed in the office with oral sedation and local anesthesia of the prostate. Because no surgery is performed and nothing is cut out of the prostate, these procedures are very safe with minimal risk of bleeding, incontinence, change in ejaculation, or impotence.

Surgical Treatment

The oldest treatment for BPH is surgery called transurethral resection of the prostate, or TURP. In TURP a telescope is passed throught the urethra into the prostate under spinal anesthesia. The inner, enlarged part of the prostate is shaved out in slivers which are removed through the telescope. A new method of performing TURP has recently become available, called Greenlight PVP laser prostatectomy. This procedure uses a high-powered laser to vaporize the obstructing prostate tissue. It prevents bleeding, and most patients do not need to stay in the hospital. Many patients are able to go home without a catheter. We believe the PVP laser surgery is the new gold-standard surgery for BPH because it has all of the benefits of traditional TURP with less risk. Because the obstructing part of the prostate is removed, most patients notice dramatic improvement in their urination immediately after the surgery, and the improvement is usually permanent. Because laser surgery is a surgical removal of part of the prostate the risks are greater than TUNA, and include bleeding, need for transfusion (5%), impotence (5%), incontinence (1-2%), urethral scarring (5-10%), and loss of ejaculation (90%).