Benign prostatic hyperplasia (BPH) is a widespread condition in men older than 50. This article explains all there is to know of this condition.
Benign prostatic hyperplasia (BPH) or benign prostatic hypertrophy is an increasingly common condition seen mostly in men over the age of 50. It consists of an enlarged prostate that presses against the urethra, thus narrowing it and making it harder for the bladder to empty itself freely. This condition can severely affect the quality of life of those who have it. However, thanks to new advances in medical knowledge, doctors can offer multiple treatment options for patients.
The risk of having benign prostatic hyperplasia increases with age. Almost one-third of men over the age of 50 and over 90% of men over the age of 85. Worldwide, 30 million men suffer from symptoms related to benign prostatic hyperplasia. There is no significant difference in the frequency of benign prostatic hyperplasia in different race groups. Nevertheless, the disease tends to be more severe and rapidly progressive in African Americans.
What is the prostate?
The prostate is an organ located right below the bladder and directly in front of the rectum. The urethra, which is responsible for transporting urine from the bladder to the outside world, goes right through the prostate. Logically, significant prostate enlargement will interfere with urine flow.
The prostate is in charge of the production of fluid for the semen. During the ejaculation process, fluid from the prostate flows into the urethra simultaneously as sperm from the testicles. This mixture of sperm and lubricating fluid is what comes out of the penis during ejaculation.
What is benign prostatic hyperplasia?
The strict scientific definition of benign prostatic is that it is a histologic diagnosis with excessive proliferation of the bladder’s cellular elements. In simpler words, benign prostatic hyperplasia consists of the excessive reproduction of prostate cells, which, in some cases, leads to an enlarged prostate and urinary symptoms.
It is essential to distinguish between different types of benign prostatic hyperplasia. Histologic benign prostatic hyperplasia shows increased cell proliferation at a microscopic level. It does not necessarily translate into an enlarged prostate gland and urinary problems. Almost all men develop histological benign prostatic hyperplasia, but not all of them develop urinary symptoms.
What causes benign prostatic hyperplasia?
Prostatic enlargement occurs thanks to testosterone receptors located inside the nuclei of prostatic. Testosterone joins androgen receptors inside prostate cells stimulating prostate tissue proliferation.
Testosterone production decreases with age, while benign prostatic hyperplasia increases make researchers question if there are other factors involved. Hyperinsulinemia, metabolic syndrome, hypertension, among others, also appear to be involved in prostate enlargement.
However, the evidence supporting testosterone’s role in prostatic hyperplasia is strong; for example, castrated males do not develop benign prostatic hyperplasia.
Who is more likely to develop benign prostatic hyperplasia?
Several risk factors increase the chance of suffering from symptomatic benign prostatic hyperplasia. As this article has previously stated, aging is the most important one but is not the only one.
Some risk factors for developing symptomatic prostatic hyperplasia include:
- Race: Although all races have the same risk of having BPH, blacks and Hispanics have a higher risk of suffering from a severe form of the disease.
- Family history: Relatives of BPH patients are more likely to suffer from symptomatic BPH than the general population.
- Obesity: The wider the waistline, the higher the risk of suffering from benign prostatic hyperplasia.
- Diabetes: Specifically, type 2 diabetes. Apparently, elevated insulin levels have a role in promoting the growth of prostatic tissue.
- Sedentary lifestyle: Lack of physical activity is also an important risk factor for BPH. It probably has to do with its association with obesity and insulin resistance.
Does benign prostatic hyperplasia have anything to do with cancer?
The symptoms of prostate cancer and benign prostatic hyperplasia can be similar. Still, the two conditions are not the same in any way.
The benign in benign prostatic hyperplasia means that, in this case, cellular proliferation is not malignant and, therefore, does not has the capacity of invading other tissues.
It is worth noting that having benign prostatic hyperplasia does not increase the risk of having prostate cancer at some point.
What are the symptoms of benign prostatic hyperplasia?
Excess prostate tissue can cause a urinary obstruction and urine retention. Please think of the urinary tract as a very small garden hose and the prostate as a big rock sitting on top of it, obstructing water flow.
A urinary tract obstruction can also damage the surrounding nerves, which also contributes to urinary symptoms.
Lower urinary symptoms due to benign prostatic hyperplasia include the following:
- Urinary frequency: refers to the need to urinate often, usually pouring small amounts of urine each time. It can occur both during daytime and nighttime. During the nighttime, the urge to urinate can cause the patient to wake up.
- Urinary urgency: Consists of a strong, sudden urge to urinate. During these episodes, the patient has a fear of imminent urination without control.
- Incomplete bladder emptying: The feeling that, despite urinating frequently, there is still some residual urine inside the bladder, causing the need to urinate never to go away completely.
- Straining: The need to push to initiate urination and to maintain the urinary stream.
- Decreased force stream: Having a weak urinary stream
- Dribbling: Losing small amounts of urine without noticing, often leading to pant staining.
Are there other causes of lower urinary tract symptoms besides benign prostatic hyperplasia?
Lower urinary tract symptoms are the most common BPH symptoms. Lower urinary symptoms are not unique to benign prostatic hyperplasia. They can be the result of many different diseases, some of them severe.
Other causes of lower urinary tract symptoms include:
- Bladder cancer
- Prostate cancer
- Neurogenic bladder
- Foreign objects inside the bladder such as bladder stones
- Prostatic abscess
- Urethral injury due to trauma or sexually transmitted disease
- Overactive bladder
Your doctor’s job is to distinguish between each of these diagnostic alternatives based on a thorough medical history, physical exam, and diagnostic tests to reach an adequate diagnosis.
What are the complications of benign prostatic hyperplasia?
Untreated benign prostatic hyperplasia can lead to a great variety of different complications, some of them life-threatening and some of them unbelievably uncomfortable.
Some complications of having excess prostate tissue include:
- Urinary Retention: Urinary retention means the patient has a sudden inability to urinate due to mechanical obstruction of urine flow through the prostate. However, the kidney continues producing urine that fills up the bladder. As you may already know, having a full bladder while being unable to urinate is incredibly painful. Patients with acute urinary retention require the insertion of a foley catheter to drain urine, and some may even require surgery.
- Urinary tract infection: Urinary obstruction due to enlarged prostate tissue increases the risk of urinary tract infections (UTIs). A patient with recurrent UTIs might require surgery to remove excess prostate tissue.
- Bladder stones: These stones can cause infection, bloody urine, and an obstruction in urine flow.
- Chronic kidney disease: Urine flow obstruction causes a backward pressure that goes all the way back to the kidney, causing them to fill up with liquid (hydronephrosis), which can cause permanent damage.
Contrary to popular belief, having benign prostatic hyperplasia does not increase the risk of prostate cancer suffering in any way.
Can benign prostatic hyperplasia cause erectile dysfunction?
Benign prostatic hyperplasia, by itself, does not cause erectile dysfunction. However, some of the treatments available for benign prostatic hyperplasia can cause erectile dysfunction.
Alpha-blockers are drugs that suppress the action of the testosterone receptors inside prostate tissue. These drugs are currently the standard of care for erectile dysfunction and cause erectile dysfunction in more than 3% of patients. Surgery to resect the prostate in cases where medication fails to produce results can also lead to erectile dysfunction in a small percentage of cases.
How is benign prostatic hyperplasia diagnosed?
The initial presentation of benign prostatic hyperplasia is simply lower urinary symptoms, which, as you know by now, are common to many different diseases.
When you visit your doctor complaining of lower urinary symptoms, it will ask a few questions and do several tests to determine if BPH is causing your symptoms.
Besides your medical history and other diseases such as diabetes, the doctor will ask about things like:
- Bedwetting: This symptom points towards another condition called chronic high-pressure retention, which is a serious urologic condition that has little to do with an enlarged prostate gland.
- Marked frequency and urgency combined with bladder pain: This constellation of symptoms point towards a carcinoma in situ.
- Bloody urine: Although some BPH cases can produce bloody urine, its presence should point towards the diagnosis of bladder or kidney stones as well as bladder cancer.
- Back pain and weakness in the lower limbs: Points towards a neurological cause of lower urinary tract symptoms.
An extensive physical examination is also mandatory in the presence of lower urinary tract symptoms. A digital rectal examination is fundamental in the assessment of BPH symptoms. This exam provides information about the size, contour, and nodules (if present) of the prostate.
Can benign prostatic hyperplasia be identified in the primary care setting using only simple tests?
The complete workup for BPH requires some specialized tests that can only be performed by a certified urologist. However, the initial presumptive diagnosis and some initial tests can be made in the primary care setting.
Some important tests in BPH include:
- Urinalysis and Urine Culture: These tests assess the presence of blood, bacteria, leucocytes, glucose, among others, in the urine. It might help rule out infection.
- Creatinine and BUN: These are renal function markers that help your doctor determine if there is any kidney damage due to hydronephrosis.
- Abdominal, renal, and rectal ultrasonography: Ultrasonography studies are very useful in the context of a patient with lower urinary tract symptoms. They help determine the size of the bladder and prostate and the magnitude of hydronephrosis (if present).
- Prostate-specific antigen: Testing for prostate-specific antigens helps rule out prostate cancer in patients with lower urinary tract symptoms.
- Pressure flow urodynamic studies: These studies are not available in the primary care facility and require special equipment and operators. These studies are the most specific and accurate way of determining the degree of bladder outflow obstruction and help to determine if the problem is the result of prostatic obstruction or a bladder issue.
- Endoscopy of the lower urinary tract (cystoscopy): This test consists of inserting a small catheter with a camera through the opening of the urethra all the way up to the bladder. It is only done in cases where the doctor suspects cancer as an alternative diagnosis to benign prostatic hyperplasia.
- Prostatic biopsy: In this test, a small amount of prostatic tissue is removed with surgery and examined under a microscope.
Can benign prostatic hyperplasia be prevented?
Unfortunately, age and family history are the two most important risk factors for suffering from benign prostatic hyperplasia. As you well know, we can not change our genes or stop ageing. However, there are other preventable risk factors involved.
Here is a list of certain things you can do to prevent BPH:
- Eat less meat and fatty foods; choosing plant protein over animal protein has proven to reduce prostatic disease incidence.
- Exercise regularly and avoid sedentarism, remember a sedentary lifestyle is one of the risk factors for BPH.
- If you already have the disease, avoid antihistamines and nasal decongestants as well as alcohol and caffeine. All of these things can contribute to exacerbating symptoms.
- Avoiding stress can also contribute to improving prostate health.
Can benign prostatic hyperplasia be cured?
There is no actual cure for benign prostatic hyperplasia; however, nowadays, there are many treatment options that can stop prostatic growth, control symptoms, and prevent complications such as acute urinary retention, urinary infections, and hydronephrosis.
There are three main types of BPH treatment:
- Watchful waiting: Consists of lifestyle changes a vigilance without administering medications or performing any kind of surgery.
- Drug Therapy: Involves using medication that stops prostate growth and controls symptoms
- Interventional therapy: For patients that suffer from severe disease and do not respond to pharmacologic therapy.
What is watchful waiting?
Watchful waiting is the preferred treatment for patients with mild symptoms that do not improve their quality of life in any significant way, for example, having a weak stream as the only symptom. In these patients, the risks and adverse effects of drug therapy and surgery outweigh the potential benefits.
Watchful waiting is not the same as sitting around and doing nothing. For this to work in the long run, certain lifestyle changes are mandatory—changes such as having a healthier diet, doing exercise, and changing your fluid intaking habits.
Some healthy fluid intaking habits include avoiding drinking great amounts of fluid before long trips, meetings, or attending events where finding a bathroom fast might be difficult.
Avoiding alcohol or caffeinated drinks in the 2 hours before going to bed can be of great help to slow down disease progression. Other healthy bladder habits, including peeing at every chance you get, don’t hold it in, and taking your time urinating to empty your bladder as much as possible.
BPH patients under the watchful waiting modality should consult with a urologist at least one time every year.
What medications are available for BPH?
In patients with moderate to severe symptoms in which BPH is an important disturbance in everyday life, watchful waiting isn’t going to cut it. The next step is drug therapy.
Here is a list of the most important medications for BPH:
- Alpha-blockers: These drugs relax the muscles in the bladder neck as well as the ones in the prostate, therefore facilitating urination. Some examples include tamsulosin, doxazosin, and silodosin.
- 5- alpha-reductase inhibitors: These drugs block the hormones that induce prostate gland growth; some examples include Finasteride and Dutasteride. It takes months for these drugs to start showing up significant results.
- Phosphodiesterase 5 enzyme inhibitors: Drugs like Cialis and Viagra are better known for other reasons; however, they also mediate smooth muscle relaxation in the lower urinary tract facilitating urination. In patients with both BPH and erectile dysfunction, it is the ideal treatment.
Currently, the American Urological Association recommends combination therapy of 5- alpha-reductase inhibitors and alpha-blockers for most cases of benign prostatic hyperplasia.
What is interventional therapy?
Interventional therapy basically means surgery. Yet, there are many different kinds of surgical options open in BPH.
Transurethral resection of the prostate does not require an open incision or open surgery. Right now, it is the standard of care for cases of BPH that require interventional therapy. In this case, the surgeon removes prostate tissue through a transurethral incision.
Other options include:
- Laser therapy
- Open Prostatectomy
Do you have symptoms of this disease?
This is a BPH symptoms checker. It gathers the most important signs, symptoms, and risk factors of this disease. Therefore, the tool will tell anybody who uses it if they have symptoms because of benign prostatic hyperplasia. It is free and would only take a few minutes.