Benign Prostate Hyperplasia – Causes, Symptoms, Treatments

What is Benign Prostate Hyperplasia?

Benign prostatic hyperplasia (BPH), also referred to as prostate enlargement, is a condition in older men where the prostate gland enlarges. The prostate gland is a small, walnut-shaped gland that sits below the bladder and surrounds the urethra, the tube that carries urine from the bladder out of the body. As the prostate enlarges, it can squeeze the urethra, blocking the flow of urine. This can cause a number of symptoms.

BPH is a very common condition. It’s estimated that about half of all men over the age of 50 will experience some symptoms of BPH. However, the symptoms are often mild and don’t require treatment. The exact cause of BPH is unknown, but it’s thought to be related to changes in hormone levels as men age.

Symptoms of Benign Prostate Hyperplasia

Benign Prostatic Hyperplasia (BPH) can manifest with various symptoms, primarily related to urinary function. The severity of BPH symptoms can vary widely among individuals, from mild inconvenience to significantly impacting quality of life. Common symptoms include:

• Frequent Urination: Men with BPH often experience the need to urinate more frequently, especially during the night (nocturia).
• Urgency: There may be a sudden, urgent need to urinate, sometimes making it difficult to hold urine until reaching a restroom.
• Weak Urinary Stream: Urination may involve a weak or hesitant urinary stream, which can make the process of emptying the bladder feel incomplete.
• Difficulty Starting Urination: Men with BPH may have trouble initiating urination, often requiring straining or pushing to begin the flow.
• Intermittent Urination: Urination may start and stop intermittently rather than flowing continuously.
• Dribbling at the End of Urination: After completing urination, some men may experience dribbling or leaking of urine due to incomplete emptying of the bladder.
• Feeling of Incomplete Bladder Emptying: Despite urinating, there may be a persistent sensation of not fully emptying the bladder, leading to a need for frequent trips to the restroom.
• Urinary Retention: In severe cases, BPH can lead to urinary retention, where the bladder cannot empty completely, causing discomfort, pain, or the inability to urinate at all.
• Urinary Tract Infections (UTIs): Men with BPH are at an increased risk of developing UTIs due to incomplete bladder emptying and urinary stasis.
• Hematuria: Blood in the urine (hematuria) can occur in some cases of BPH, although it’s more commonly associated with other urinary tract issues.

Long term Complications of Benign Prostate Hyperplasia

Benign Prostatic Hyperplasia (BPH) can lead to various long-term complications if left untreated or inadequately managed. Acute Urinary Retention (AUR): This is a sudden inability to urinate, which can be extremely uncomfortable and requires immediate medical attention. AUR often necessitates catheterization to relieve urinary obstruction.

Chronic Urinary Retention: If BPH progresses untreated, it can lead to chronic urinary retention, where the bladder cannot fully empty. This condition may require long-term catheterization or surgical intervention to relieve the obstruction.

Urinary Tract Infections (UTIs): Incomplete bladder emptying associated with BPH increases the risk of recurrent UTIs. Chronic UTIs can lead to kidney damage if left untreated.

Bladder Stones: Stagnant urine in the bladder can lead to the formation of bladder stones (calculi). These stones can cause pain, discomfort, and may require surgical removal.

Bladder Damage: Over time, the bladder muscles may weaken due to the strain of trying to overcome urinary obstruction, leading to bladder dysfunction and decreased bladder capacity.

Kidney Damage: Severe or prolonged urinary obstruction can cause pressure backflow (hydronephrosis) from the bladder into the kidneys, potentially leading to kidney damage or kidney failure if left untreated.

Bladder Diverticula: Chronic urinary obstruction can cause the bladder wall to weaken and form outpouchings called diverticula. These diverticula can retain urine and increase the risk of infection and stone formation.

Urinary Incontinence: BPH can contribute to urinary incontinence, particularly overflow incontinence, where the bladder overflows due to chronic urinary retention.

Risk Factors for Benign Prostate Hyperplasia

The exact cause of Benign Prostatic Hyperplasia (BPH) is still not entirely understood by medical professionals. However, there are strong links to several factors. There are two main categories of risk factors for Benign Prostate Hypertrophy (BPH): non-modifiable and modifiable.

Non-modifiable factors:

• Age: This is the biggest risk factor. BPH is uncommon in men under 40 but becomes increasingly likely as men age.
• Genetics: Having a family history of BPH increases your risk.
• Geography: Studies suggest there may be geographic variations in BPH prevalence.

Modifiable factors:

• Sex hormones: Changes in testosterone, dihydrotestosterone (DHT), and estrogen levels as men age are believed to play a role in BPH development.
• Metabolic syndrome and cardiovascular disease: These conditions are linked to an increased risk of BPH.
• Obesity: Carrying excess weight is a risk factor for BPH.
• Diabetes: Disruptions in blood sugar regulation may increase BPH risk.
• Physical activity: Lack of exercise may be a risk factor.
• Diet: A diet high in red meat and dairy may increase BPH risk, while other dietary patterns might be protective.
• Inflammation: Chronic inflammation in the body may contribute to BPH development.

The most common risk factor for BPH is age. The prostate gland naturally enlarges with age. BPH is rare in men younger than 40, but it becomes more common as men age. By age 60, about half of all men will have some enlargement of their prostate. By age 80, that number rises to about 90%.

Shifts in hormone levels as men age are believed to play a key role. As testosterone levels decrease, the ratio of testosterone to estrogen changes. This hormonal imbalance may stimulate prostate cells to grow.

Men who have had their testicles removed before puberty don’t develop BPH, further suggesting a link to hormones produced in the testicles. Additionally, men with a family history of BPH are at higher risk of developing the condition themselves. Genetics likely play a role in predisposing individuals to BPH.

Certain medical conditions, such as obesity, heart disease, and type 2 diabetes, may increase your risk of BPH. It is not entirely clear why these conditions increase the risk of BPH, but it may be related to the effects these conditions have on hormone levels or inflammation in the body.

Some lifestyle factors, such as a lack of physical activity and a diet high in unhealthy fats, may also increase your risk of BPH. 

How is Benign Prostate Hyperplasia Diagnosed?

Diagnosing Benign Prostate Hyperplasia (BPH) typically involves a combination of steps. Your doctor will discuss your medical history, including any medications you take, and ask detailed questions about your urinary symptoms. They might use a standardized questionnaire to gauge the severity of your BPH symptoms.

A physical examination is also often required. This often includes a digital rectal exam (DRE) where the doctor inserts a gloved finger into your rectum to feel the size, shape, and consistency of your prostate gland. This can help detect enlargement or abnormalities suggestive of cancer.

Additional testing in the form of a urinalysis and a urine flow test are also conducted. For the urinalysis, a urine sample is tested for signs of infection, blood, or other abnormalities that could explain your symptoms. The urine flow test measures the rate and force of your urine flow, which can indicate potential blockage caused by BPH.

A test that measures the level of prostate-specific antigen (PSA) in your blood. While an elevated PSA can be a sign of prostate cancer, it can also be caused by BPH or inflammation. A high PSA alone isn’t diagnostic of BPH, but it may prompt further investigation.

In some cases, your doctor might recommend further tests such as:

• Cystoscopy: A thin, lighted tube is inserted into your urethra to examine the inside of your bladder and urethra.
• Urodynamic testing: This series of tests evaluates how your bladder and urethra store and release urine.
• Prostate biopsy: A small sample of prostate tissue is removed using a needle and examined for cancer cells. This is usually only necessary if there’s a concern about prostate cancer.

Treatment Options for Benign Prostate Hyperplasia

Treatment options for Benign Prostate Hyperplasia (BPH) vary depending on the severity of symptoms, the individual’s overall health, and personal preferences. 

Lifestyle Modifications:

Consuming a balanced diet rich in fruits, vegetables, whole grains, and lean proteins may help alleviate BPH symptoms. Limiting caffeine and alcohol intake, as well as avoiding spicy foods and beverages, can also be beneficial.

Limiting fluid intake, especially before bedtime, can reduce the frequency of nighttime urination (nocturia) associated with BPH. Additionally, engaging in regular physical activity can help improve urinary flow and overall prostate health.

Medication:

Alpha-Blockers relax the muscles of the bladder neck and prostate, improving urine flow and relieving symptoms such as urinary urgency and hesitancy. 5-Alpha Reductase Inhibitors reduce the production of dihydrotestosterone (DHT), which can shrink the prostate gland and alleviate symptoms over time.

In some cases, alpha-blockers and 5-alpha reductase inhibitors are prescribed together for more significant symptom relief.

Phosphodiesterase-5 Inhibitors like tadalafil (Cialis) can help relax the muscles in the prostate and bladder, improving urinary symptoms.

Minimally Invasive Procedures:

These procedures are typically performed on an outpatient basis under local anesthesia or light sedation. They involve inserting instruments through the urethra to access the prostate gland and address the blockage.

• Transurethral Microwave Thermotherapy (TUMT): This procedure uses microwave energy to heat and destroy excess prostate tissue, relieving urinary symptoms.
• Transurethral Needle Ablation (TUNA): TUNA uses radiofrequency energy to heat and destroy prostate tissue, reducing urinary symptoms.
• Water Vapor Thermal Therapy (Rezum): A device inserted into the urethra uses water vapor to create steam channels within the prostate tissue. This controlled tissue death opens the blockage and improves urination.
• Prostatic Urethral Lift (UroLift): Tiny implants are inserted like staples to hold open the prostate opening, relieving pressure on the urethra and improving urine flow. PUL is a relatively new procedure with promising results for mild to moderate BPH.

Advantages of Minimally Invasive Procedures:

Typically outpatient procedures with shorter recovery times compared to surgery. As these procedures are less invasive, there is potentially less bleeding and discomfort. These procedures may also be suitable for men with higher surgical risk or those who prefer to avoid traditional surgery.

Disadvantages of Minimally Invasive Procedures:

• May not be as effective as surgery for all men, particularly those with larger prostates.
• Some procedures may require repeat treatments over time.
• Certain MIPs might carry risks of sexual side effects like erectile dysfunction or retrograde ejaculation (semen ejaculating into the bladder).

Surgical Procedures

• Transurethral Resection of the Prostate (TURP): This is the most common and effective surgical procedure for BPH. A resectoscope, a cutting instrument with a built-in camera, is inserted through the urethra to remove prostate tissue blocking the urethra to improve urine flow.
• Open Prostatectomy: In severe cases of BPH, particularly when the prostate is significantly enlarged, open prostatectomy may be necessary to remove the obstructive tissue.
• Laser Therapy: Laser procedures such as Holmium Laser Enucleation of the Prostate (HoLEP) or GreenLight Laser Photoselective Vaporization of the Prostate (PVP) can be used to remove excess prostate tissue while minimizing blood loss and recovery time.

Advantages of Surgery:

• Offers the most durable solution for BPH, with long-lasting symptom relief.
• Generally very effective for men with moderate to severe BPH.

Disadvantages of Surgery:

• More invasive procedures requiring hospitalization and general anesthesia.
• Higher risk of complications compared to minimally invasive procedures, including bleeding, infection, and urinary incontinence.
• Potential for sexual side effects like erectile dysfunction or retrograde ejaculation.

What Medications are Most Often Prescribed for the Treatment of Benign Prostate Hyperplasia?

There are two main categories of medications commonly prescribed for Benign Prostate Hyperplasia (BPH):

1. Alpha-Blockers: These medications relax the muscles in the prostate and bladder neck, allowing urine to flow more easily. Some common alpha-blocker brand names include:
   • Tamsulosin (Flomax)
   • Silodosin (Rapaflo)
   • Alfuzosin (Uroxatral)
   • Doxazosin (Cardura)
   • Terazosin (Hytrin)
2. 5-alpha Reductase Inhibitors: These medications work by blocking the conversion of testosterone to dihydrotestosterone (DHT), which shrinks the prostate gland over time. Examples of 5-alpha reductase inhibitors include:
   • Finasteride (Proscar)
   • Dutasteride (Avodart)