Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is a noncancerous (benign) enlargement of the prostate gland.

See the figure What Happens When the Prostate Gland Enlarges?

The prostate gland is located just under the bladder and surrounds the tube that carries urine from the bladder out of the body (urethra). The prostate gland produces fluid that nourishes sperm. As men age, the prostate gland, which is usually the size of a walnut, enlarges, usually because of BPH. The longer a man lives, the more likely BPH is to develop. The precise cause of BPH is unknown. But changes stimulated by hormones, especially testosterone, are probably involved.

BPH is very unlikely to shorten life. However, as BPH progresses, the urethra can become squeezed (compressed) and partially blocked. The enlarged prostate may prevent the bladder from emptying completely and interfere with the flow of urine. Thus, BPH may cause bothersome symptoms and ultimately damage the bladder and kidneys. Nonetheless, how large the prostate gland is does not always predict how severe the symptoms are. BPH can be effectively treated with drugs and surgery.

Symptoms

When BPH first develops, starting to urinate may be difficult. After urination, the bladder may not empty completely. So shortly thereafter, men may feel the need to urinate again. They may have to urinate more frequently, often at night (a symptom called nocturia). Frequent trips to the bathroom interrupt sleep, sometimes causing irritability and difficulty concentrating during the day. Also, the need to urinate becomes more urgent. The volume and force of the urine flow may decrease noticeably, and urine may dribble after urination is finished.

If the bladder does not empty completely, urine can stagnate there. Then, bladder stones and urinary tract infections are more likely to develop. The urine that remains in the bladder can stretch the bladder too much. Eventually, such stretching leads to uncontrollable leakage of small amounts of urine (overflow incontinence). The bladder can become overactive, leading to an uncontrollable urge to urinate followed by loss of urine (urge incontinence). If urine flow is blocked for a long time, urine backs up in the ureters and the kidneys, which may be damaged.

Symptoms due to BPH can become worse if certain drugs are used. If men with BPH take certain nonprescription drugs, they may be temporarily unable to urinate at all (a condition called urinary retention). These drugs include nonprescription antihistamines (which are in almost all nonprescription sleeping aids, cold remedies, and allergy drugs) and nasal decongestants.

Diagnosis

During a rectal examination, a doctor feels (palpates) the prostate gland to determine whether it is enlarged. The doctor inserts a gloved, lubricated finger into the rectum. The prostate gland can be felt just in front of the rectum. A prostate gland affected by BPH feels enlarged and smooth. But palpation does not cause pain.

For men 50 or over, the doctor may recommend a blood test to measure the level of prostate-specific antigen (PSA). The purpose is to check for prostate cancer. An increase in the PSA level may result from prostate cancer, BPH, or inflammation of the prostate (prostatitis). Nonetheless, PSA measurements may help distinguish between these disorders. The higher the PSA level and the faster it is increasing, the more likely that cancer is the cause. PSA measurements are usually not recommended for men whose life expectancy is less than 10 years because of their age or disorders they have.

If the doctor suspects that the bladder is not emptying completely, a small flexible tube (catheter) may be passed through the urethra and into the bladder. This procedure (called urinary catheterization) is done after a person urinates as completely as possible. The catheter is used to drain the urine left in the bladder and is then removed. The amount is measured and compared with the range that is considered normal.

A doctor may also take a blood sample, which can be used to assess kidney function. Levels of creatinine and blood urea nitrogen (BUN), both waste products, are measured. Levels are high when the kidneys cannot remove waste products from the blood as they normally do. Thus, high levels indicate kidney damage.

Treatment

For men with BPH, taking extra time to empty the bladder completely when urinating can help prevent infections, bladder stones, and kidney damage. After men urinate once, urinating a second time almost immediately (double voiding) can help empty the bladder. Gently pressing the lower abdomen with the hand may also help. Men who urinate frequently at night should not consume foods or fluids that contain caffeine or excessive amounts of fluids during the hours before sleep.

Treatment is not necessary unless BPH causes bothersome symptoms or blood test results suggest kidney damage.

Alpha-blockers (such as alfuzosin, terazosin, doxazosin, or tamsulosin) relax the urinary sphincter (the band of muscle around the opening between the bladder and the urethra) and the urethra. Thus, urine may flow through more easily. 5-Alpha reductase blockers (such as finasteride and dutasteride) block male hormones from stimulating the prostate gland to grow. The enlarged prostate gland gradually becomes smaller, helping delay the need for surgery or other treatments. However, finasteride or dutasteride may need to be taken for 3 months or more before symptoms are relieved. Saw palmetto, a medicinal herb, appears to relieve symptoms in some men.

If drugs are ineffective, surgery can be performed. Surgery provides the greatest relief of symptoms but can cause problems.

The most common procedure is transurethral resection of the prostate gland (TURP). After an anesthetic is given, a doctor passes a viewing tube (endoscope) through the urethra. Attached to the endoscope is a surgical instrument used to remove part of the prostate gland. TURP can cause infection and bleeding. Some men have urinary incontinence afterward, but it is usually temporary. A few men develop permanent erectile dysfunction (impotence). Occasionally, urine flow becomes blocked again, and TURP must be repeated.

Other surgical procedures provide less symptom relief than TURP, but most are less likely to cause problems. In most of these procedures, an instrument is inserted into the urethra. On the end of the instrument is an attachment used to destroy prostate tissue. Depending on the procedure, the attachment may generate microwave heat, ultrasound waves, electricity, or laser beams. Or the attachment may be a needle.

If a problem such as urinary retention or infection is already present when BPH is diagnosed, the problem may need to be treated before BPH can be treated. Urinary retention, can be treated by draining the bladder with a catheter inserted through the urethra. Infections can be treated with antibiotics.