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Benign prostatic hyperplasia

Benign prostatic hyperplasia

Also known as Benign prostatic enlargement

Overview

Benign prostatic hyperplasia (BPH) is a medical condition that commonly occurs in older men. It is a benign (non-cancerous) condition in which the prostate (a walnut-sized gland) enlarges in size. The prostate gland surrounds the urethra, a tube that carries urine and semen outside of the body. When the prostate gland enlarges, it can make the passage of urine and semen through the urethra a difficult process.  This causes symptoms such as blocking urine outflow, frequent urge to urinate, difficulty in starting urination, dribbling at the end of urine flow, urinary tract infection etc. 

In India, benign prostatic hyperplasia is a common elderly problem with an incidence rate of 92.97% and 93.3%. AUA guidelines suggested that BPH incidence worldwide will increase, and by the age of 60 years, more than 50% of men would have some evidence of the disease. 

There are several treatment options available for benign prostate hyperplasia. If you have been diagnosed with the condition, you might be prescribed medications such as finasteride and dutasteride. These medications have proven to be effective in treating BPH. Depending on your condition, your doctor may also advise different types of surgeries that can be used to remove the prostate tissue that is blocking the urinary flow. 

Key Facts

Usually seen in
  • Adults above 40 years of age
Gender affected
  • Men
Body part(s) involved
  • Prostate gland 
  • Bladder 
  • Kidney
Mimicking Conditions
  • Prostate cancer
  • Bladder stones
  • Bladder trauma
  • Overactive bladder
  • Prostatitis
Necessary health tests/imaging
Treatment
Specialists to consult
  • Urologist
  • General surgeon
  • General physician

Symptoms Of Benign Prostatic Hyperplasia


Benign prostatic hyperplasia can cause several symptoms that affect your urine flow. It is possible to experience more than one symptom at the same time. Some of the common symptoms are:

  • Decreased flow of urine

  • Weak urine flow 

  • Sensation of incomplete bladder emptying

  • Need to start and stop urine several times

  • Trouble in starting urination or straining to pass urine 

  • Dribbling at the end of urine flow

  • Urge to urinate frequently 

  • Increase in the urgency to urinate 

  • Increased need to get up at night to urinate 

  • Pain while urinating or ejaculation 

  • Urine that looks or feels different 

If your condition worsens with time, then you might experience:

  • Development of bladder stone

  • Bladder infection

  • Damage to kidneys because of backpressure caused due to retention of large amounts of urine in the bladder 

  • Blood in urine 

  • Pus in urine

  • Experiencing pain in the lower part of abdomen or genitals during urination

  • Inability to urinate 

  • Chills or fever while urinating

In severe cases, BPH can lead to bladder damage and infection. In such cases, you can spot blood in the urine. It can also cause kidney damage, if left untreated for a long time and can lead on to development of chronic kidney disease and renal failure.

Here are a few common causes of frequent urination and why you should not ignore this symptom.

 

Causes Of Benign Prostatic Hyperplasia


The prostate gland is located beneath your bladder. The urethra is a tube that passes urine from your bladder to the outside of your penis. The urethral tube passes through the centre of the prostate. When the prostate enlarges, urine flow can begin to get blocked. The actual cause of BPH is not exactly well understood. 

It is postulated that testosterone, a hormone produced by testicles, is a major contributing factor towards BPH. Men produce testosterone, the primary male sex hormone, throughout their lives, along with a minute amount of estrogen. With declining age, the testosterone produced by the body also reduces. This, in turn, increases the proportion of estrogen in the system. Studies have suggested that benign prostatic hyperplasia may result due to this disproportion between estrogen and testosterone. The high level of estrogen within the prostate boosts the activity of substances that increase the growth of prostate cells. 

Experts also believe that dihydrotestosterone (DHT), a hormonal byproduct of testosterone, plays a vital role in the growth of the prostate gland. Research has revealed that older adults continue producing DHT that gets accumulated within the prostate despite a drop in testosterone levels. This increase in DHT may boost the growth of prostate cells. Studies have also shown that a decline in the level of DHT improves BPH. 

Risk Factors For Benign Prostatic Hyperplasia


You are more likely to develop benign prostatic hyperplasia, if you:

  • Are 40 years of age or above

  • Have a family history of BPH

  • Have medical conditions such as cardiovascular problems, obesity and type 2 diabetes 

  • Lack physical exercise and live a sedentary lifestyle 

  • Have erectile dysfunction

Did you know?
Men also go through hormonal changes during old age which can put them at risk of male menopause. Also known as andropause, it as a condition which causes a decrease in sexual satisfaction or a decline in the generalized feeling of well-being due to testosterone deficiency. Click here to know more about it.
Did you know?

Diagnosis Of Benign Prostatic Hyperplasia


Your doctor will consider your symptoms and carry out some tests to rule out the diseases that mimic the symptoms of benign prostate hyperplasia. 


1. Digital rectal exam

Your prostate can be felt through the anus. Your doctor will smear some topical anaesthesia (numbing gel) onto your anal passage. Then the doctor will insert a gloved hand into the rectum to feel the prostate's shape, thickness, and size. This will give them an idea if your prostate has an average size or is more prominent than usual. 


2. Cystoscopy

This procedure allows a healthcare provider to examine the lining of your bladder and urethral tube. A hollow tube called a cystoscope that has a lens will be inserted inside your urethra. Slowly the doctor will advance the cystoscope inside your bladder. This procedure usually doesn't hurt but can cause some discomfort. You may feel that you need to pee during the process, but it only lasts for a few minutes. 


3. Ultrasound

Ultrasound has become the standard first-line investigation after the urologist's finger. Ultrasound of the kidneys and urinary bladder (USG KUB) is done routinely to evaluate size and volume of prostate gland.


4. Intravenous pyelogram (IVP) 

An intravenous pyelogram (IVP) is a type of x-ray that provides images of the urinary tract. During an IVP, a health care provider will inject one of your veins with a substance called contrast dye. The dye travels through your bloodstream and into your urinary tract. It helps in detection of an enlarged prostate. Due to availability of better alternatives, IVP is not commonly used these days.


5. Urine tests

Your doctor may ask for a urine test. This will help them rule out any infection or other urinary conditions that cause similar symptoms. 


6. Prostate-specific antigen (PSA) test

Prostate-specific antigen is a compound released by your prostate. When you have an enlarged prostate, your levels of PSA will also increase. It helps detect prostate cancer, but it's not perfect and doesn't detect all prostate cancers. Your PSA levels can be elevated due to recent procedures, surgeries or infections. 


7. Urinary flow test 

This test measures your urine flow. You will be asked to urinate into a receptacle that is attached to a machine. This machine will measure the strength and amount of your urine flow and determine, if your condition is improving or worsening over time. 


8. Postvoid residual volume test

This test evaluates if you can fully empty your bladder while urinating. The test can be done through ultrasound or by inserting a catheter into your bladder after you finish urinating. This will allow a healthcare provider to measure how much urine is left in your bladder. 


9. 24-hour voiding diary

Your doctor may ask you to maintain a record of the frequency and amount of urine you pass. This is especially helpful if more than one-third of your daily urine output occurs during the night. 


10. Prostate biopsy 

Transrectal ultrasound is an ultrasound probe inserted into the rectum to measure and evaluate your prostate health. The probe sends and receives sound waves through the wall of the rectum into the prostate gland which is situated right in front of the rectum. Your doctor can suggest a prostate biopsy using a transrectal biopsy. A needle will be guided inside the rectum to take tissue samples of the prostate. Examining the tissue will help the doctor evaluate if you have prostate cancer or not. 


11. Urodynamic and pressure flow studies

This test allows doctors to measure and determine how well your bladder muscles are functioning. Your doctor will insert a catheter inside your urethra and into your bladder. Water or air is slowly injected into the bladder, which allows for the evaluation of muscle functioning. 

Celebs affected

Ronald Wilson Reagan
The 40th USA president underwent prostatic surgery in 1967 and 1986 to relieve discomfort associated with BPH.
Ian McKellen
Famous British actor Ian McKellen was diagnosed with prostate cancer in 2005.

Prevention Of Benign Prostatic Hyperplasia


Unfortunately, researchers have not found a way to prevent benign prostatic hyperplasia till date. Men who have risk factors for BPH such as being over 40 years of age or having a family history of BPH, should contact their doctor.

You can talk to their doctor if you identify any symptoms of BPH. Moreover, you can also go for regular prostate exams as it can help you to identify early signs of prostate cancer. Getting early treatment can minimise prostatic hyperplasia effects and reduce the chances of enlarged prostate. 

Specialist To Visit


You should visit a doctor, if you are experiencing symptoms such as difficulty in urinating, blood in urine, pain while passing urine, straining while urinating, dribbling at the end of urine, weak urine flow or increased frequency of urination during the night. These symptoms might indicate the possibility of benign prostate hyperplasia. You can consult the following doctors for diagnosis:

  • Urologist 

  • General surgeon 

  • General physician

Here’s more on who is the right expert to consult for male sexual and reproductive health problems.

Treatment Of Benign Prostatic Hyperplasia


BPH can be managed through several kinds of treatment modalities. The best approach is decided based on the patient's age, overall wellbeing, underlying cause and severity of the disorder. If your symptoms are tolerable, your doctor might advise you to postpone treatment and monitor the condition for some time. The treatments include:


1. Alpha-blockers 

These medications work by relaxing the prostate muscles, making it easier to pass urine. Alpha-blockers work effectively in men with relatively small prostates. These medications might cause low blood pressure (orthostatic hypotension), dizziness and retrograde ejaculation (a condition in which the semen goes back into the bladder instead of going out of the tip of the penis). These drugs start exerting their effects early, within days to weeks. Some of the commonly recommended medicines are:

2. 5-alpha reductase inhibitors

These drugs act by shrinking the size of your prostate by preventing the formation of dihydrotestosterone (DHT). Medications such as finasteride and dutasteride inhibit the 5-alpha reductase enzyme that converts testosterone into DHT. A decline in the DHT level causes the prostate size to decrease. The effect usually starts after a month and may take upto 6 months for maximum effect. Some common side effects are low libido, decreased ejaculate volume and impotence. Some of the common medications are:

3. Tadalafil

Tadalafil is a medication that is primarily used to treat erectile dysfunction. Studies have shown that it's also effective in treating prostate enlargement. 


4. Transurethral resection of the prostate (TURP)

TURP is a surgical procedure that helps in quickly relieving the symptoms of BPH. Men usually have a strong urine flow soon after the surgery. This procedure requires a lighted scope to be inserted into your urethra. The surgeon will remove most of the prostate except the outer part.  After TURP, you will need a catheter to drain your bladder for some time.

Some of the risks that are associated with TURP are retrograde ejaculation & urinary incontinence. The common complications of TURP are:

  • Bleeding

  • Urethral stricture

  • Bladder neck contracture

5. Transurethral incision of the prostate (TUIP)

A surgeon will insert a lighted scope into your urethra and create one or two minor cuts in the prostate gland. This will make it easier for urine to pass through the urethra. This surgery is usually recommended for men who have a small or moderate-sized prostate gland and for men with health problems that may make other surgeries too risky.

TUIP has relatively lower incidence of complications and hence might be a better option for patients with smaller gland size. Consult your doctor regarding the choice of surgical procedure as it may vary from case to case basis.


6. Transurethral microwave thermotherapy

A particular electrode will be inserted through your urethra to reach the prostate. The electrode will release microwave energies that will destroy the inner part of the enlarged prostate gland. This will result in prostate shrinking, allowing easy outflow of the urine. This surgery may only partially relieve your symptoms and may take some time before its full effect is seen. It is usually recommended for men who have a small prostate, and this procedure might require re-treatment, if needed. 


7. Transurethral needle ablation 

Your doctor will pass a scope into your urethra and with a needle into the prostate gland. The needles will release radio waves that will heat and destroy the excess prostate tissue that's been blocking urine flow. 


8. Ablative laser therapy

This procedure uses a high energy laser to vaporize the prostate tissue that's been obstructing urine flow. These procedures can cause irritative symptoms for some time after the surgery. 


9. Enucleation procedure 

These procedures generally remove all of the prostate tissue blocking urinary flow and preventing regrowth of the tissue. The tissue that has been removed can later be examined for signs of prostate cancer and other disorders. 


10. Prostatic urethral lift

Doctors use special tags to compress the sides of the enlarged prostate. This allows the urinary flow to increase and is recommended to men who have lower urinary tract symptoms. This procedure also produces less effect on ejaculation and sexual function than procedures such as TURP. 

Consult India's best doctors here from the comfort of your home.

Home-care For Benign Prostatic Hyperplasia


1. Take medicine as recommended

If you have been prescribed BPH medications, make sure to take those medications as and when directed. Different BPH medications take an additional amount of time to show their effects. Some medicines can take six months to work, so it's essential to continue your medication as directed by your doctor. 

To remember to take the drugs on time, you can put the pill in labelled medicine boxes and set the alarm for the time you are supposed to take your medications. 


2. Follow-up without fail

Usually, doctors recommend their patients actively monitor the progress of BPH. This means that you and your doctor will watch for any symptoms that may worsen but not actively treat the BPH. You will need to make regular visits to your urologist.

If your symptoms don't improve in some time, your doctor may change your dosage and recommend some other tests to check your prognosis. If you have undergone surgery to manage your enlarged prostate gland, make sure to get all the follow-up instructions from your doctor. The specific follow up care would depend on the type of surgery you opted for.

Yearly visits are recommended beacuse your doctor look for any new or old symptoms that have worsened since the last visit, before recommending a treatment plan. Active surveillance is the best course of treatment for men with mild symptoms of BPH or for patients who are not bothered by their symptoms. 


3. Exercise to strengthen pelvic muscles 

You will be recommended some basic Kegel exercises that strengthen the pelvic floor. These exercises include holding your pelvic floor muscles for five seconds and releasing them. You should practise 10 to 20 repetitions of kegel exercises for three to four times a day. Kegel exercises are beneficial for men with prostate problems. 

It strengthens the pelvic floor and trains the pelvic floor muscles to help in controlling urine. Apart from kegel exercises, you can also commit to daily walking, jogging, swimming, or playing sports. Obesity is a risk factor for developing BPH; hence, maintaining a healthy weight is essential to treat BPH. 

Your doctor may advise against heavy lifting and excessive training for a week after your laser ablation or transurethral needle ablation. Other surgeries may require restricted activities for nearly six weeks after the procedure. 


4. Manage your stress

You can meditate or practise yoga that encourages mindfulness. Stress and nervousness usually increase the urge to urinate, which can worsen your symptoms of BPH. Practising meditation in the morning and before sleeping can help you manage your stress levels, reducing your urge to urinate during the night. 

Here are all your queries on stress and its role in the body answered.

Complications Of Benign Prostate Hyperplasia


Untreated benign prostatic hyperplasia can cause several complications that affect your urinary bladder and kidney. These include:


Urinary tract infections 

Untreated benign prostate hyperplasia can lead to the accumulation of stagnant urine since patients cannot completely empty their bladder. The stagnant urine acts as a growth medium for bacteria that cause urinary tract infections. Some infections can be asymptomatic, whereas others can cause mild dysuria (painful or difficult urination), increased frequency and urgency to urinate, severe systemic infection, and frank hematuria (presence of blood cells in urine). 


Blood in urine 

The presence of blood in urine is called hematuria. It is usually a result of friable hypervascularity, a condition in which superficial vessels of the enlarged prostate easily get damaged by any physical activity. It can also result in the formation of a clot and retention of the clot. 

Generally, the condition presents as initial hematuria while the rest of the urine stream is clear. Finasteride has proven to be effective in treating BPH related hematuria since it lowers the density of microvessels. 


Urinary stones 

Stones or calculi in the bladder make for 5% of all urinary tract calculi. The formation of stones is a known risk factor in cases with chronic urinary infections due to a microorganism that splits urea.

Recurrent UTI and a residual volume of urine in the bladder usually precede the formation of bladder stones. Patients who have large residual volume in the bladder are more at risk of developing multiple bladder stones. The symptoms of urinary stones include abdominal pain, visible blood in urine, recurrent UTI and signs of sepsis (severe infection) in extreme cases. 


Kidney damage 

Untreated BPH can lead to chronic urinary retention that can further lead to the development of chronic kidney disease in patients. This leads to a decline in the rate at which the kidney filters toxins and other substances. A patient suffering from recurrent urinary tract infections who already have chronic urinary retention due to BPH are more at risk of developing renal failure in BPH patients. 

Did you know?
Prostate cancer is a disease that primarily affects the elderly. It is relatively common in people above 65 years of age, although people in their 50s may also suffer from the condition. It has become a major health concern around the world during the last few decades. It is reported to be the second most common cause of cancer in men worldwide and the fifth most common cancer overall. Here’s more causes and risk factors of prostate cancer.
Did you know?

Alternative Therapies For Benign Prostate Hyperplasia


Always consult your doctor before using any herbal remedy, and do not stop taking your regular medications without consulting your healthcare provider. 

  • Saw palmetto and stinging nettle have shown some benefits when used together to manage BPH symptoms in men. 

  • African plum tree and lycopene are other herbal remedies that have shown some benefits in improving the signs associated with BPH. 

  • You can include pumpkin seeds into your diet. A study revealed that men with BPH who took pumpkin seed extracts once a day for 12 days experienced a better quality of life, and they also had a decrease in the urgency to urinate. 

  • Flaxseed has also shown some promising results. A report suggested that people who took flaxseed hull extract for eight weeks saw improved obstructive and irritable symptoms seen with BPH. 

Here are 7 superfoods good for maintaining prostate health.

Living With Benign Prostate Hyperplasia


Being diagnosed with benign prostate hyperplasia can cause stress and anxiety in men. This medical condition directly affects the quality of life, and patients struggle with the urge to urinate in difficult situations. Some men also face incontinence (inability to control the evacuation of urine), leading to embarrassment. However, timely diagnosis and treatment can help you in managing the signs and symptoms linked with BPH. 


1. Avoid certain medications 

Talk to your doctor, if you take medications such as diuretics or water pills which are used to treat high blood pressure, liver disease, and heart failure. Diuretics remove excess fluid from your body and increase urination which can worsen your BPH symptoms. Tricyclic antidepressants are an older generation of antidepressant drugs that reduce bladder muscle contractions, increasing your risk of urinary retention. 


2. Avoid taking antihistamines and decongestants

Antihistamines are anti-allergic drugs that prevent the bladder muscles from contracting. This can slow or inhibit the urine flow and worsen BPH. Medications used to treat colds such as decongestants aggravate BPH since they tighten the prostate and bladder muscles. This makes it difficult for urine to leave the bladder. 


3. Monitor your fluids

It is essential to be aware of how much fluid you are taking in. The more fluid you drink, the more you will feel the urge to urinate. You can stop or limit drinking water a few hours before you go to bed. This will reduce your chances of awakening during the night to urinate. Drinks such as alcohol, soda, coffee or other caffeinated beverages also cause your body to release more urine. 


4. Eat a healthy diet

Avoid eating red meat and dairy. Reports suggest that going free from red meat can significantly improve your prostate health. Eating meat daily can triple your risk of prostate enlargement. Eating dairy products too has been linked with an increased risk of developing benign prostatic hyperplasia. Instead of that, include tomatoes, berries, salmon, and broccoli in your diet. These foods have been shown to improve your signs and symptoms linked with BPH. 

Frequently Asked Questions

References

  1. Speakman MJ, Cheng X. Management of the complications of BPH/BOO. Indian J Urol. 2014;30(2):208-213. doi:10.4103/0970-1591.127856.External Link
  2. Benign Prostatic Hyperplasia. Prostate Enlargement. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Last reviewed in Sept, 2014.External Link
  3. Prostate Tests. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Last reviewed in Sept, 2014. External Link
  4. What is Benign Prostatic Hyperplasia (BPH)? American Urological Association. External Link
  5. McVary KT, Roehrborn CG. Three-year outcomes of the prospective, randomized controlled Rezūm system study: Convective radiofrequency thermal therapy for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. External Link
  6. Wein AJ, et al., eds. Benign prostatic hyperplasia: Etiology, pathophysiology, epidemiology, and natural history. In: Campbell-Walsh Urology. 11th ed. Philadelphia, Pa.: Elsevier; 2016. External Link
  7. Prostate enlargement (Benign prostatic hyperplasia). National Institute of Diabetes and Digestive and Kidney Diseases. External Link
  8. Management of benign prostatic hyperplasia (BPH). American Urological Association. . Accessed Sept. 25, 2017.External Link
  9. Cunningham GR, et al. Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia. External Link
  10. Ferri FF. Benign prostatic hyperplasia. In: Ferri's Clinical Advisor 2018. Philadelphia, Pa.: Elsevier; 2018. External Link
  11. Wein AJ, et al., eds. Evaluation and nonsurgical management of benign prostatic hyperplasia. In: Campbell-Walsh Urology. 11th ed. Philadelphia, Pa.: Elsevier; 2016. External Link
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