Understanding Benign Prostatic Hyperplasia

​Benign prostatic hyperplasia (BPH) is a common condition that exists in men as they age where lower urinary tract symptoms (LUTS) develop due to enlargement of the prostate gland. Roughly 50 percent of men above of the age of 60 and 90 percent of men above the age of 85 will develop BPH. One is more likely to develop BPH if there is a strong family history of the condition but there also seems to be some modifiable risk factors associated with its development including the presence of diabetes and obesity.

The prostate gland is found below the bladder. It produces seminal fluid, and it grows as one ages. The urethra, which helps pass urine and semen out of the body, passes through the prostate’s center. As the prostate enlarges, it can block the urethra and if left untreated, this can lead to complications including the development of acute urinary retention, blood in the urine, bladder stones, recurrent urinary tract infections and kidney failure. In some cases, the bladder may become so damaged over time, that it may completely lose its ability to empty on its own, necessitating catheterization.

The primary cause of BPH is multifactorial with the exact cause largely unknown. However, it seems be related to be hormonal changes, particularly declining testosterone with rising levels of dihydrotestosterone (the more potent form of testosterone) and androgen receptor. Other factors may also play a role in the development of BPH including circulating estrogens and growth factors as well as sympathetic nervous system and inflammatory pathways.

Men with BPH experience symptoms that are generally classified as storage or voiding. Storage symptoms include sudden and strong urges to urinate, frequent urination, waking up multiple times at night to urinate, and in severe cases, urgency urinary incontinence, where urine leaks out involuntarily. Voiding symptoms include difficulty starting urination (hesitancy), a weak urinary stream, a need to push to initiate or maintain urination, and a urine flow that starts and stops intermittently.

Technically speaking, BPH is a histological diagnosis (seen by examining tissue under a microscope) which may lead to benign prostatic enlargement. However, not all men with microscopic BPH will develop enlargement of the prostate. As the prostate grows, it may cause obstruction but not all men with enlargement will develop obstruction. To make things more confusing, many men without any BPH at all may develop prostate obstruction and this may occur in the setting of a dysfunctional bladder neck, a bladder neck contracture or urethral stricture disease. Further, men may present with LUTS in the absence of obstruction such as in the setting of an overactive bladder or a neurogenic bladder. Thus, it is important to seek the advice of a Urologist if you develop bothersome LUTS, particularly if you do not respond to first-line medical management.

At the initial evolution, your doctor will take a full medical history from you in order to determine what other factors may be contributing to your symptoms and what other diagnostic tests should be ordered. A common way for your doctor to quantify how bothered you are by your symptoms is by having you fill out a validated questionnaire, the most common one being the International Prostate Symptom Score. This will allow your doctor to obtain a baseline of your symptoms and repeating the same questionnaire over time can give valuable information about symptom progression or response to medical therapy.

Urinary flow tests, post-void residual urine measurement, urine analysis, prostate-specific antigen (PSA) blood tests, and digital rectal exams are other common tests used in the workup of patients with BPH. PSA is an antigen made by the prostate, and generally speaking, it rises when the prostate is enlarged, swollen or in the presence of prostate cancer. Your physician may also perform other, specialized studies such as cystoscopy and/or urodynamic studies to fully evaluate your lower urinary tract anatomy and function.

Once the diagnosis of BPH has been made, patients may be counseled on behavioral and lifestyle modifications, treatment with medications and/or procedural options. Medical therapy for BPH includes alpha-blockers such as tamsulosin, 5-alpha reductase inhibitors such as finasteride and phosphodiesterase inhibitors such as tadalafil. In some cases, particularly if storage symptoms predominate, you may also be offered anticholinergic medication such as oxybutynin or a beta-3 agonist such as mirabegron.

If medication does not relieve your symptoms or if they are not tolerated due to their bothersome side effects, various procedural options may be recommended in an attempt to open up your bladder outlet The most common such procedure performed worldwide is transurethral resection of the prostate (TURP). Here, a small camera is inserted into your urethra and the obstructive tissue is removed using a special electrocautery device. This is usually performed at a hospital or an outpatient surgery center, either under general or regional anesthesia. Many other options exist to treat BPH including transurethral incision of the prostate, transurethral vaporization of the prostate, photo selective vaporization of the prostate, prostatic urethral lift, water vapor thermal therapy, laser enucleation and prostatic artery embolization. For patients with very large prostates, open, laparoscopic or robotic assisted prostatectomy may be considered.

David Horovitz MD

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