What is Benign Prostatic Hyperplasia (BPH)?
Benign prostatic hyperplasia—also called “BPH”—is a condition in men in which the prostate gland is enlarged but is and not cancerous.
Benign prostatic hyperplasia is also called benign prostatic hypertrophy or benign prostatic obstruction.
The prostate goes through two main growth periods as a man ages. The first occurs early in puberty, when the prostate doubles in size. The second phase of growth begins around age 25 and continues during throughout most of a man’s life. Benign prostatic hyperplasia often occurs with the second growth phase.
As the prostate enlarges, the gland presses against and pinches the urethra. The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the ability to empty completely, leaving some urine in the bladder. The narrowing of the urethra and urinary retention—the inability to empty the bladder completely—cause many of the problems associated with benign prostatic hyperplasiaBPH.
What causes benign prostatic hyperplasia?
The cause of benign prostatic hyperplasia is not well understood; however, it occurs mainly in older men.
Throughout their lives, men produce testosterone, a male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in their blood decreases, which leaves a higher proportion of estrogen. Scientific studies have suggested that benign prostatic hyperplasia may occur because the higher proportion of estrogen within the prostate increases the activity of substances that promote prostate cell growth.
Another theory focuses on dihydrotestosterone (DHT), a male hormone that plays a role in prostate development and growth. Some research has indicated that even with a drop in blood testosterone levels, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage prostate cells to continue to grow. Scientists have noted that men who do not produce DHT do not develop benign prostatic hyperplasia (BPH).
How common is benign prostatic hyperplasia?
BPH is the most common prostate problem for men older than age 50. In 2010, as many as 14 million men in the United States had lower urinary tract symptoms suggestive of benign prostatic hyperplasia.1 Although benign prostatic hyperplasia rarely causes symptoms before age 40, the occurrence and symptoms increase with age. Benign prostatic hyperplasia affects about 50 percent of men between the ages of 51 and 60 and up to 90 percent of men older than 80.2 Deters LA. Benign prostatic hypertrophy. Emedicine website. http://emedicine.medscape.com . Updated March 28, 2014. Accessed July 29, 2014.
 BPH: surgical management. Urology Care Foundation website. www.urologyhealth.org . Updated July 2013. Accessed July 29, 2014.
What are the symptoms of benign prostatic hyperplasia?
Lower urinary tract symptoms suggestive of benign prostatic hyperplasia may include:
• urinary frequency—urination eight or more times a day
• urinary urgency—the inability to delay urination
• trouble starting a urine stream
• a weak or an interrupted urine stream
• dribbling at the end of urination
• nocturia—frequent urination during periods of sleep
• urinary retention
• urinary incontinence — the accidental loss of urine
• pain after ejaculation or during urination
• urine that has an unusual color or smell
Symptoms of benign prostatic hyperplasia most often come from
• a blocked urethra
• a bladder that is overworked from trying to pass urine through the blockage
The size of the prostate does not always determine the severity of the blockage or symptoms. Some men with greatly enlarged prostates have little blockage and few symptoms, while other men who have minimally enlarged prostates have greater blockage and more symptoms. Less than half of all men with benign prostatic hyperplasia have lower urinary tract symptoms.
How is BPH diagnosed?
In addition to a complete medical history, there is a special questionnaire called the International Prostate Symptom Score (I-PSS) that screens for BPH and other possible prostate conditions, including infection, inflammation and prostate cancer. To rule out other prostate diseases, the doctor might conduct any or all of the following tests:
• Blood test, including PSA, free PSA or PSA density
• Urodynamic studies – Urodynamic tests include a variety of procedures that look at how well the bladder and urethra
store and release urine. A health care provider performs urodynamic tests during an office visit or in an
outpatient center or a hospital.
• uroflowmetry, which measures how rapidly the bladder releases urine
• postvoid residual measurement, which evaluates how much urine remains in the bladder after urination
• reduced urine flow or residual urine in the bladder, which often suggests urine blockage due to benign prostatic
• Cystoscopy – It is a procedure that uses a tube-like instrument, called a cystoscope, to look inside the urethra
and bladder. A urologist performs cystoscopy during an office visit or in an outpatient center or a hospital.
Imaging using a contrast dye to reveal aspects of the urinary system
• Transrectal ultrasound. Urologists most often use transrectal ultrasound to examine the prostate. The ultrasound
image shows the size of the prostate and any abnormalities.
• 3T multiparametric MRI of the prostate (this type of MRI when interpreted by an experienced radiologist can clearly
How is BPH treated?
For many patients, changes in behavior (e.g. reduced fluids before bedtime, dietary changes to exclude bladder irritants) will reduce symptoms. There are also medications that can make urination easier to begin, or to shrink the prostate gland. These can relieve symptoms for many men. However, when symptoms become too problematic, other interventions may become necessary.
Transurethral Resection of the Prostate (TURP)
A surgical procedure done under anesthesia in which the surgeon uses a narrow instrument inserted into the urethra through the penis in order to scrape away excess prostate tissue with tiny instruments. Usually involves 1-3 days in the hospital. A tube (catheter) is inserted into the bladder and is left in place for 24 to 48 hours. The hospitalization lasts from one to three days and requires two weeks of severe activity restrictions and another two weeks of modest restrictions. Complete recovery may take as long as 12 weeks in some individuals. Side effects: difficulty controlling urine stream, erectile dysfunction, retrograde ejaculation (semen flows backward into the bladder), urinary blockage, and infertility.
Transurethral Microwave Thermotherapy (TUMT)
A minimally invasive outpatient procedure that uses an antenna inserted into the urethra through the penis to generate sufficient heat to destroy overgrown tissues without damage to healthy tissues. Patients with very large prostates or enlargement of the middle lobe of the prostate are not good candidates for TUMT. Because the prostate is likely to swell initially, most patients are discharged with a catheter in the bladder for a few days to allow drainage until the prostatic swelling subsides. May take time to produce results as dead cells are broken down and reabsorbed by the body.
Transurethral Needle Ablation (TUNA)
Uses a needle inserted through the urethra to deliver radiofrequency energy to destroy tissue. It is usually done as an outpatient procedure under local, general or spinal anesthesia. Most men require a catheter for a period of time after the TUNA procedure until the swelling subsides. Possible side effects: blood in urine, painful urination, difficulty urinating, risk of infection.
Transurethral vaporization of the prostate
The vaporizer uses a high-energy electric source similar to the electrical source used for transurethral resection or incision of the prostate mentioned above. The difference is the amount of electrical current used (all are safe) and the type of contact made with the instrument. For transurethral resection the electric current is passed through a small wire. This allows cutting of the prostate tissue to remove it, but if the current is turned to a higher setting and a blunt roller ball is used, the tissue actually melts or vaporizes.
Focal laser ablation
Different minimally invasive approaches are used to place a laser fiber in the prostate in an outpatient setting. The goal is to coagulate and reduce the enlarged TZ (transition zone) tissue causing urinary blockage. By ablating targeted areas of the transitional zone, it causes tissue shrinkage by generating harmless scar tissue that will be reabsorbed by the body. Depending on the location and extent of the ablation, some patients may wear a catheter for several days to protect the urethra as post-treatment inflammation diminishes.