Benign prostatic hyperplasia (BPH)

Symptoms: Having a frequent/urgent need to urinate, problems with urine flow, pain during urination, urine with unusual colour/smell.

Causes: The cause of Benign prostatic hyperplasia is not clear. Hormonal changes with ageing are thought to be the cause.

Risk Factors: Age, family history, lack of physical exercise, erectile dysfunction, and medical conditions like heart or circulatory disease, obesity, and type 2 diabetes.

Prevalence: BPH affects about 50% of men between the ages of 51-60 and up to 90% of men older than 80.

Severity: Mild to severe

Which doctor to consult: Urologist, General Physician

OVERVIEW:

Benign prostatic hyperplasia (BPH), also known as benign prostatic obstruction or benign prostatic hypertrophy, is a condition which causes enlargement of the prostate gland. Due to this, the prostate presses against the urethra, and the bladder wall becomes thicker. This causes the weakening of the bladder. The bladder may weaken, losing its ability to empty completely. This causes problems like urinary retention (inability to empty the bladder properly). BPH is the most common condition in men above 50 years. Benign prostatic hyperplasia is non-cancerous, and it does not increase the risk of prostate cancer.

SYMPTOMS:

The symptoms of Benign prostatic hyperplasia may include:

• Urinary urgency (the inability to delay urination)

• Urinary frequency (urination eight or more times a day)

• Trouble starting to urinate

• A weak or interrupted urine stream

• Dribbling at the end of urination

• Nocturia (frequent urination during periods of sleep)

• Urinary retention

• Urinary incontinence (loss of bladder control)

• Urine that has an unusual colour or smell

• Pain after ejaculation or during urination

Seek medical attention if you:

• Are unable to urinate at all

• Have chills and fever with urination that is painful, urgent, and frequent

• Have blood in the urine

• Have pain in the urinary tract or lower abdomen

CAUSES:

The cause of benign prostatic hyperplasia is not well comprehended. It is believed to mainly occur due to hormonal problems resulting from ageing. Men produce testosterone, which is a male hormone, and small amounts of estrogen, which is a female hormone. As men get older, the levels of active testosterone in their blood reduce, leading to a higher proportion of estrogen. This increase in estrogen proportion within the prostate may result in benign prostatic hyperplasia by increasing the activity of substances that encourage prostate cell growth.

An alternative theory suggests that dihydrotestosterone (DHT), a male hormone, plays a role in prostate development and growth. A decline in testosterone levels in the blood leads to the accumulation of high levels of DHT in the prostate. This build-up of DHT may prompt prostate cells to continue to grow, leading to benign prostatic hyperplasia. Researchers have observed that men who do not generate DHT do not develop BPH. 

RISK FACTORS:

The risk factors of Benign prostatic hyperplasia are:

• Age (40 or older)-The chance of getting BPH increases as you get older.

• Family history of Benign prostatic hyperplasia.

• Certain health conditions, such as obesity, type 2 diabetes, and heart/circulation problems.

• Erectile dysfunction.

• Low physical activity.

POSSIBLE COMPLICATIONS:

The complications of benign prostatic hyperplasia may include:

• Acute urinary retention: This condition is common in older adults and may cause you to not urinate at all. It might be triggered by alcohol, medications, cold temperatures, or not moving for a longer period.

• Chronic urinary retention: People with this condition can urinate but cannot completely empty the urine from their bladders.

• Hematuria: The presence of blood in urine is observed due to leakage of blood related to the enlargement of the prostate gland. Urinary tract infections may also cause hematuria.

• Urinary tract infections (UTIs): Urinary tract infections associated with benign prostatic hyperplasia occur as patients are unable to empty their bladder properly, and the stagnant urine acts as a growth medium for bacteria.

• Bladder damage: BPH may cause bladder damage in which the bladder may weaken and lose the ability to empty properly, leaving some urine in the bladder.

• Kidney damage: BPH may damage the kidneys and increase the chance of developing kidney stones.

However, most men with benign prostatic hyperplasia may not develop these complications.

PREVENTION:

Currently, there is no known method to prevent benign prostatic hyperplasia according to researchers. Men with risk factors for benign prostatic hyperplasia are advised to consult the doctor about any lower urinary tract symptoms and the requirement for regular prostate exams. Benign prostatic hyperplasia can be minimised by recognizing lower urinary tract symptoms, identifying an enlarged prostate, and getting early treatment.

WHEN TO SEE A DOCTOR:

Men with symptoms of benign prostatic hyperplasia should consult a doctor for appropriate diagnosis and treatment.

DIAGNOSIS:

The diagnosis of benign prostatic hyperplasia is based on:

1. Personal and family medical history: Personal and family medical history is taken into consideration when diagnosing benign prostatic hyperplasia. Symptoms, history of recurrent UTIs, medications, liquid/fluid intake, alcohol consumption and illnesses are taken into consideration for diagnosis.

2. Physical exam: The doctor conducts physical examinations like checking for discharge from the urethra, enlarged or tender lymph nodes in the groin, swollen or tender scrotum, and digital rectal examination/examination of the prostate.

3. Medical tests: The doctor might advise the following medical tests based on family history and physical examination:

• Urinalysis: This involves testing the urine sample. The doctor/nurse will place, a dipstick (chemically treated paper strip) into the urine sample. If the patches on the dipstick change colour, it indicates signs of infection in urine.

• Prostate-specific antigen (PSA) blood test: The blood sample is tested for PSA levels. Higher levels of PSA may indicate BPH.

• Urodynamic tests: This includes a procedure to determine how well the bladder and urethra store and release urine. It includes:

  • Uroflowmetry: This measures how rapidly the bladder releases urine

  • Postvoid residual measurement: Evaluates how much urine remains in the bladder after urination

  • Reduced urine flow or residual urine in the bladder: This usually suggests urine blockage due to benign prostatic hyperplasia

• Cystoscopy: Cystoscopy is a procedure in which a cystoscope (tubelike instrument) is used to look inside the urethra and bladder for blockage or stones in the urinary tract.

• Transrectal ultrasound: In this procedure a transducer (a device) is used to examine the prostate. It determines the size of the prostate and any abnormalities, such as tumours. 

• Biopsy: In this procedure, a small prostate tissue is examined under a microscope. Imaging techniques such as ultrasound, a computerized tomography scan, or magnetic resonance imaging help guide the biopsy needle into the prostate. A pathologist examines the prostate tissue in a lab and determines whether prostate cancer is present.

TREATMENT:

Medications: The doctor may prescribe certain medications to reduce the symptoms, prevent the growth or shrink the prostate gland, based on your condition. Medicines used to treat BPH include:

1.Alpha blockers: Alpha blockers relax the smooth muscles of the prostate and bladder. This helps improve urine flow and reduce bladder blockage.

• Terazosin

• Doxazosin

• Tamsulosin

• Alfuzosin

• Silodosin

2. Phosphodiesterase-5 inhibitors: These medications are mainly used for erectile dysfunction. It reduces lower urinary tract symptoms by relaxing smooth muscles in the lower urinary tract.

• Tadalafil

3. 5-alpha reductase inhibitors: 5-alpha reductase inhibitors block the production of DHT, a hormone which accumulates in the prostate and might cause prostate growth. They can prevent the progression of prostate growth or shrink the prostate in some men.

• Dutasteride

4. Combination medications: Combining two classes of medications can effectively improve symptoms, urinary flow, and quality of life. The combinations include:

• Dutasteride and Tamsulosin

• Alpha-blockers and Antimuscarinics

Minimally Invasive Procedures: Minimally invasive techniques are employed as a viable alternative in cases where medicines prove to be ineffective. These techniques either destroy the enlarged prostate tissue or expand the urethra, which can aid in relieving the blockage and urinary retention caused by benign prostatic hyperplasia. Some examples of minimally invasive techniques include:

1. Transurethral needle ablation: Heat generated by radiofrequency energy is used to destroy prostate tissue. Shields protect the urethra from heat damage.

2. Transurethral microwave thermotherapy: Microwaves are employed to eliminate prostate tissue, while a cooling system safeguards the urinary tract from any heat damage that may occur during the process.

3. High-intensity focused ultrasound: Enlarged prostate tissue can be treated using a unique ultrasound probe, which is placed near the prostate via the rectum. The probe emits ultrasound waves that heat up and destroy the affected tissue.

4. Transurethral electrovaporization: The resectoscope is inserted through the urethra and uses electricity to vaporize prostate tissue. This process goes deeper than just the surface and also helps to prevent bleeding by sealing blood vessels.

5. Water-induced thermotherapy: Water-induced thermotherapy is a medical procedure that uses heated water to eliminate prostate tissue. This technique utilizes a specialized balloon that precisely targets specific regions of the prostate, while also protecting the surrounding tissues in the urethra and bladder.

6. Prostatic stent insertion: A small device called a prostatic stent is inserted through the urethra to the area that is constricted by the enlarged prostate. Once the stent is in place, it expands like a spring and forces the prostate tissue to retract, thereby widening the urethra.

Surgery: The doctor may recommend surgery when medicines and minimally invasive procedures are ineffective, symptoms become bothersome/severe, or when complications arise. Surgeries to remove an enlarged prostate include:

1. Transurethral resection of the prostate (TURP): This surgery is regarded as the standard method for addressing blockage of the urethra due to BPH. The procedure involves inserting a resectoscope through the urethra to reach the prostate and then using a wire loop to cut and eliminate the sections of the enlarged prostate tissue.

2. Laser surgery: A high-energy laser is used to destroy prostate tissue, but it may not be effective for treating significantly enlarged prostates. 

3. Open prostatectomy: The urologist removes all or part of the prostate through an incision.

4. Transurethral incision of the prostate (TUIP): This procedure involves the use of a cystoscope and an instrument that utilizes an electric current or laser beam to widen the urethra by passing through it.

LIVING WITH BPH:

• Reduce intake of fluids/liquids, especially before going out in public or before periods of sleep.

• Avoid or reduce intake of caffeinated beverages and alcohol.

• Pelvic exercises and bladder training may help control urine flow.

• Prevent or treat constipation.