Benign Prostatic Hyperplasia (BPH)

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• Symptoms of Benign Prostatic Hyperplasia
• Causes of Benign Prostatic Hyperplasia
• Risk factors of BPH
• Diagnosis
• Treatment

Benign Prostatic Hyperplasia (BPH) 

Benign Prostatic Hyperplasia (BPH) or prostate gland enlargement occurs when the prostate becomes abnormally large, typically with advancing age. An enlarged prostate gland can cause symptoms such as difficulty urinating or incomplete bladder emptying, leading to problems related to the bladder, urinary tract infections, or kidney diseases.

Various effective BPH treatments are available, including medications and minimally invasive surgery. The doctor will discuss the most suitable treatment option with you by considering your symptoms, prostate gland size, health conditions, and preferences.

Symptoms of Benign Prostatic Hyperplasia

The BPH symptoms vary with each person; however, symptoms can gradually worsen over time if left untreated. The common signs and symptoms of BPH are as follows:

• Urinary frequency.
• Nocturia.
• Urinary hesitancy.
• Weak urine stream or intermittency.
• Dribbling after urination.
• Urinary retention, straining, urge incontinence.

Other less common signs and symptoms of BPH include:

• Urinary tract infections.
• Burning or painful urination.
• Blood in the urine.

The size of the prostate does not indicate the severity of the symptoms. BPH patients with slightly enlarged prostates can develop severe symptoms whereas those with extremely enlarged prostates may have mild symptoms. Some may have stable symptoms that can improve on their own.

When to see a doctor

Seek medical attention when you experience urination problems with the above symptoms, even though they are not severe. BPH can lead to obstruction of the urinary tract. If you cannot pass the urine, seek immediate medical care.

Causes of Benign Prostatic Hyperplasia

The prostate gland is situated at the bladder neck. The urethra, a urinary passageway, traverses through the gland. If the prostate becomes enlarged, it can obstruct the urinary flow. Typically, the prostate gradually grows throughout life, causing urinary hesitancy or urinary tract obstruction.

It remains unclear what the causes of the prostate enlargement are. However, one of the causes may be male hormonal imbalances.

Diseases that can cause urinary symptoms like those of BPH are:

• Urinary tract infections
• Prostatitis
• Urethral stricture
• Scar tissue in the bladder neck from the previous surgery
• Bladder stones
• Neurogenic bladder
• Prostate cancer or bladder cancer

Risk factors of BPH

There are several risk factors for prostate gland enlargement, including:

• Old age:  BPH patients who are younger than 40 years of age usually experience fewer symptoms than those who are older. Around one-third of the patients develop moderate to severe symptoms before 60. Others have severe symptoms before turning 80 years old. 
• Certain herbal medicines: Some patients may take herbal supplements to increase male hormones, or they are taking testosterone replacement therapy. Both can cause prostate enlargement. 
• Diabetes and heart disease: According to studies, heart disease, diabetes, and beta blockers can increase the risk of Benign Prostatic Hyperplasia (BPH).
• Prostate infection: Prostatitis can cause swelling, leading to prostate enlargement.

Diagnosis

You will be asked a series of detailed questions about your symptoms when seeing your doctor. The doctor will also run some physical tests initially, such as:

• History and physical exam
• Digital Rectal Exam (DRE): With this exam, the doctor inserts a finger into your rectum to palpate for prostate gland enlargement or if there are other anomalies.
• Urinalysis: The test checks your urine sample for infections and other diseases which cause symptoms similar to BPH. 
• Blood tests: Blood tests can indicate if you are having kidney problems.
• Prostate-specific Antigen (PSA): The prostate-specific antigen (PSA), a protein made only by your prostate, will be checked. If your PSA level is low but increasing, it may indicate an enlarged prostate. A PSA level higher than 4 ng/ml can indicate the possibility of infections, recent prostate surgery, or prostate cancer. 

The doctor may advise further tests to confirm if you have BPH and rule out other possible diseases since BPH and prostate cancer have similar symptoms. These additional tests are:

• Urinary Flow Test: This test measures the strength and rate of urine flow and can inform if your condition improves or worsens. 
• Post-Void Residual Urine Test (PVR): This test checks how well you can empty your bladder. A pelvic ultrasound scan or catheter placement into the bladder post-voiding can gauge the volume of urine remaining in the bladder. 
• 24-hour voiding record: Recording the voiding frequency and volume of your urine over a 24-hour interval gives helpful information, especially when nocturnal urine is more than one-third of your daily total.   

If your conditions are more complicated, the doctor may recommend the following tests:

• Uroflowmetry (UFM): Evaluate the dynamic flow rate of the urinary stream during voiding. 
• Transrectal ultrasound: A special rectal ultrasound probe provides a detailed picture of your prostate.
• Prostate biopsy: To rule out suspected prostate cancer.
• Urodynamic and pressure flow study: The doctor will insert a spiral catheter through the urethra into the bladder, followed by the injection of water or air and measurement of bladder pressures to assess bladder muscle function. The doctor often orders this diagnostic test for patients with neurological problems and those who have had prostate treatment but still have symptoms.
• Cystoscopy: A cystoscope will be inserted through your urethra into the bladder under topical anesthetic for a direct view of the urethra and the inside of the bladder.

Treatment

BPH treatments include medications and minimally invasive surgery.  However, your most suitable treatment option depends on several factors, such as:  

• The size of your prostate
• Your age
• Your health condition
• The severity of your symptoms

Medications

• Alpha-blockers: Help relax the bladder neck, and prostate muscles, facilitating urination. They include alfuzosin, doxazosin, tamsulosin, and silodosin. These medications work better for men with a relatively small prostate. However, side effects are dizziness and retrograde ejaculation, which is harmless.
• 5-alpha reductase inhibitors: These medications can shrink the size of the prostate by preventing hormonal change, which causes prostate growth. These medications are finasteride and dutasteride, requiring around six months for a noticeable outcome. The side effect is low sexual desire. 
• Drug combination: The doctor may prescribe alpha-blockers and 5-alpha reductase inhibitors if taking one cannot improve your symptoms. 
• Tadalafil: According to research, it can treat erectile dysfunction and BPH. 

Minimally invasive surgery

Is suitable if:

• You have moderate or severe symptoms.
• Your symptoms do not improve with medications.
• You have obstructed urinary tract, bladder stone, blood in urine, or kidney problems. You lose the ability to urinate or have kidney problems.

However, minimally invasive surgery may not be suitable if: 

• You have untreated urinary tract infections. 
• You have a urethral stricture.
• You have neurological disorders, such as Parkinson’s disease or multiple sclerosis.

BPH treatment can cause complications such as:

• Retrograde ejaculation 
• Urinary incontinence
• Urinary tract infections
• Blood in urine
• Common Male Sexual Problems

Types of minimally invasive surgery

• Transurethral resection of the prostate (TURP): With this method, the doctor will insert a scope into your urethra to remove prostate tissue and rapidly relieve the symptoms. Most patients have a more forceful urine flow immediately after the procedure. However, temporary drainage of the bladder with a catheter is needed.
• Transurethral incision of the prostate (TUIP): After inserting a scope into your urethra, the doctor will make one or two small incisions in the prostate gland to facilitate the urine flow.
• Transurethral microwave thermotherapy (TUMT): A scope and electrode will be threaded through your urethra into the prostate. Microwave energy from the electrode will be released to shrink the inner part of the enlarged prostate gland, improving the urine flow. However, TUMT can only partially relieve the symptoms and requires time to achieve a satisfactory result. It is usually recommended for patients with small prostate as repeat treatment is usually needed.
• Transurethral needle ablation (TUNA): The doctor will direct a needle through a urethral scope into your prostate gland. It will emit radio waves generating heat that destroys prostate tissues blocking the urine flow. At present, TUNA is not a popular procedure.
• Laser therapy: This procedure uses a high-energy laser to break down or remove the tissue of the enlarged prostate. It can immediately relieve the symptoms and have fewer side effects than non-laser surgical procedures. It is suitable for patients taking blood-thinning medications who cannot use other surgical techniques and those who want to shorten hospital stay and urinary catheter time.

Types of laser therapy include:

• • Ablative procedures: The laser will vaporize obstructive tissue to increase urine flow. This procedure reduces bleeding with faster recovery than MIS surgery.
  • Enucleation procedures: Holmium Laser Enucleation of the Prostate (HoLEP) removes all the obstructive prostate tissue, increasing the urine flow and preventing recurrence. The pathologist will examine the removed tissue for prostate cancer and other diseases.

• Prostatic urethral lift (PUL): The surgeon will use specialized tags to compress the sides of the prostate to increase the urine flow. The doctor may recommend this procedure if your symptoms are mild. However, recurrent symptoms may require endoscopic surgery. 
• Open or robot-assisted prostatectomy: This is an open surgery with an incision at the lower abdomen to reach the prostate and remove the prostate tissue. It is for patients with an enlarged prostate damaging the bladder or those with complications.