Benign Prostatic Hypertrophy (BPH)

 

What is the prostate?

  • The prostate is a small chestnut sized gland within the male pelvis.  It sits beneath the bladder and rests on the pelvic floor muscles. It is part of the male reproductive tract and normally contributes fluid to the ejaculate

What is BPH?

  • BPH is a benign (non cancerous) enlargement (hypertrophy) of the prostate.
  • The part of the prostate that tends to be affected by BPH is called the transition zone. The transition zone wraps around the urine tube that empties the bladder (urethra).
  • As the prostate enlarges around the urethra, it causes obstruction by progressively compressing and occluding the urethra

How common is BPH?

  • BPH is the commonest cause of male urinary symptoms
  • All men’s prostates will grow to some degree with ageing, however, some prostates grow faster and more so than others
  • BPH causing urinary symptoms will effect >50% men over 60 years age
  • The severity of symptoms however will differ significantly, from mild to severe

What are the symptoms of BPH?

  • The typical symptoms of BPH are collectively called LUTS – lower urinary tract symptoms
  • LUTS include 2 broad categories of symptoms:
    • Voiding (obstructive) symptoms:
      • Slow flow
      • Dribbling
      • Intermittent flow/stop start
      • Difficulty initiating urine stream – hesitancy
  • Storage (irritative) symptoms:
    • Frequency – frequent passage of urine (usually >7/day)
    • Urgency – sudden and compelling desire to urinate
    • Nocturia – need to wake from sleep and pass urine
  • Other symptoms that may be as a result of BPH include:
    • Blood in urine – haematuria
    • Urinary tract infections – UTI’s
    • Incontinence
    • Urinary retention – inability to urinate

How is BPH diagnosed?

  • BPH will be diagnosed after taking a history of your symptoms, preforming an examination of the abdomen and prostate (digital rectal examination) and preforming some or all of the following tests.
  • Tests that may be used to help diagnose BPH include:
    • Urine culture – to exclude infection
    • Blood tests – including kidney function
    • PSA – tumour marker for prostate cancer. May also be elevated in men with enlarged benign prostates. (For details on PSA – see prostate cancer section)
    • Kidney bladder and prostate ultrasound – provides useful information including:
      • Estimated prostate size/volume
      • Post void residual volume – remaining urine volume in bladder after voiding
      • Rule out bladder stones and other bladder abnormalities
  • Bladder diary – you may be asked to complete a diary of your voiding habits over 1-2 days including the volume of fluids consumed
  • Cystoscopy – not indicated in all men with suspected BPH, but may be used if
    • Uncertainty about cause of symptoms
    • Blood in urine (haematuria)
    • Previous prostate/urethral surgery
    • Recurrent urine tract infections
    • Younger men
    • Men with small prostates
  • Urodynamics – may be used in selected men with LUTS to help dictate treatment. (for details see – Urological Procedures explained)
    • Involves monitoring the pressure within the bladder whilst simulating filling of the bladder
    • Measures pressure within the bladder on voiding
    • Can help determine the cause of LUTS in men with:
      • mixed symptoms
      • symptoms that are not improving with treatment
      • young men with symptoms (i.e. when BPH is considered less likely)

What are the treatment options for BPH:

  • As BPH is a non cancerous condition, treatment is not required in all men.
  • Treatment is largely dictated by the severity of symptoms and degree of bother to the patient
  • Treatment options include:
    • Conservative management:
      • Often used for men with mild symptoms not causing significant bother
      • Involves modifying fluid intake
      • Decreasing bladder irritants – caffeine, alcohol
      • Weight loss
      • Modifying other medications
  • Medications:
    • Usually first line option for men with mild to moderate symptoms with some bother
    • 2 main classes of medications exists:
      • Alpha blockers – Tamsulosin (Flomaxtra), Prazosin (Pressin), Alfuzosin (Xatral)
        • these work rapidly to “relax” the muscle within and around the prostate to improve urinary flow
        • 5 alpha reductase inhibitors – Finasteride (Proscar), Dutasteride (Avodart)
          • these agents lower the testosterone level within the prostate, progressively causing a reduction in size of the prostate
          • these agents take at least 3 months to begin improving symptoms
    • Combination therapy – involves the use of newer medications containing both alpha blockers and 5 alpha reductase inhibitors
      • Duodart – Tamsulosin & Dutasteride
      • They therefore have the benefit of rapid onset of symptom relief as well as the benefit of progressive reduction in prostate size with time
      • Contemporary studies have shown these combination medications to be the most effective medication at improving urinary symptoms caused by BPH
  • Surgical options:
    • Surgery remains the most effective way of improving symptoms caused by BPH
    • Compared to medications, they are significantly better at improving: speed of urine flow, severity of symptoms and degree of bother as well as chance of future urinary retention
    • Surgical options for BPH include: (for details see Urological procedures explained)
      • TURP – Transurethral resection of the prostate
        • Often referred to as a prostate “re-bore”, a TURP involves the use of a telescope (cystoscope) via the urethra. A small hot wired loop is used to shave away chips of the enlarged prostate to open up a larger channel
        • Green light laser prostatectomy – is a newer technique using a high power laser to vaporise the enlarged prostate tissue.  Much like a TURP, this creates a wider channel to pass urine through.
        • Open prostatectomy – is rarely required these days, however may be needed for very large prostates. This involves an open operation with the enlarged prostate tissue (adenoma) removed via a lower abdominal incision.  This differs to the operation required for prostate cancer, as the whole prostate is not removed, rather just the enlarged transitional zone (see above)

Are there any risks in not treating an enlarged prostate?

  • Not all men with BPH left untreated will progress or worsen.
  • Those men at an increased risk of progression are those with:
    • Larger prostates (>50cc)
    • Higher PSA’s
    • Older men
    • More severe baseline urinary symptoms
    • Lower starting urine flow rates
  • Potential complications that may arise in some men with BPH left untreated or monitored include:
    • Urinary tract infections
    • Blood in urine – haematuria
    • Kidney impairment/failure
    • Inability to void – urine retention
    • Development of bladder stones
    • Development of bladder out-pouches – diverticulum
  • In general, men with any of the above complications require surgical treatment of their enlarged prostates