MfA - BPH - Benign Prostatic Hyperplasia

Medicine for Africa - Medical Information Service

ENIGN ROSTATIC YPERPLASIA

Definition:

Benign prostatic hyperplasia – BPH – is also called benign adenomatous hyperplasia and was formerly called adenoma of the prostate. BPH is a non-malignant (non-cancerous) enlargement of the prostate gland. It is one of the most common diseases to affect men over the age of 40, with almost half of men over age 65 experiencing some problems related to an enlarged prostate.

BPH is caused by hormonal changes in men in their second half of life. This growth is usually triggered by two hormones, specifically dihydrotestosterone (DHT), which is produced in the prostate itself, and/or 17-beta estradiol, which is produced in the adrenal glands, situated above the kidneys.

In addition, familiar predisposition is also a factor; while the hormonal changes occur in every man with age, not everybody develops BPH or the same extent of BPH. Married men appear to be more inclined to develop BPH than single men.

The existence of BPH does not increase the risk of developing prostate cancer, however, both BPH and prostate cancer can exist side by side, and thus, a thorough work-up should exclude the possibility of cancer in all patients with BPH.

Symptoms:

Since the urethra runs through the prostate, all symptoms associated with BPH are related to the urinary system and the ability to urinate:

Difficulty in starting to pass urine – to get the flow go; urinating often becomes a stop-and-go process with the feeling that the bladder isn’t completely empty yet;
Leaking or dribbling;
Frequent urination – sometimes with the feeling of an urgent need;
Weak flow of urine despite a strong urge;
Burning sensation while urinating (may also be associated with infection of the bladder [cystitis]);
Waking up during the night with the (strong) urge to urinate;
Continuing pain in the lower back, pelvis or upper thighs.

More than half of men with symptoms of BPH feel that their symptoms worsen over time, while only about one-third of affected men feel that they remain stable.

Normal Prostate BPH

In the early stages of BPH, men rarely need to alter their lifestyle; many men get ‘used’ to minor symptoms and adjust accordingly. However, as the condition progresses, it may result in social consequences, such as staying close to a toilet and wearing dark trousers to conceal possible urine leakage.

During urination, the roof of the bladder comes to lie on the arch of the prostate gland, interfering with the complete emptying of the bladder. Thus, a small amount of urine remains in the bladder, which can become a fertile base for bacteria and result in a subsequent infection of the bladder (cystitis) or in a urinary tract infection (UTI), damage to the kidneys and/or bladder, bladder stones and incontinence.

The size of the prostate does not always determine the severity of the symptoms, thus, a slightly enlarged prostate may make more symptoms in one man than a larger prostate in another patient.

And finally, BPH does not cause erectile dysfunction (impotence).

Diagnosis:

Following the patient’s description of his symptoms, a physical examination including a digital rectal examination (DRE) of the prostate can often confirm the first suspicion of an enlarged prostate.

Other tests to confirm BPH, its extent and to rule out prostate cancer may include:

Urine test – to test for blood and bacteria/infection of the bladder;
Urine flow study – to determine the emptying capacity of the bladder;
Cystoscopy – a thin tube with a lens is inserted into the urethra, in order to visualize the urethra, the bladder and the prostate;
Rectal ultrasound – to rule out prostate cancer;
Intravenous pyelogram – IVP, to check the kidney function;
Rectal ultrasound - to rule out prostate cancer;
PSA (Prostate-Specific Antigen) test – to rule out prostate cancer.

If there is still suspicion of possible prostate cancer, for example be due to family history or some inconclusive test results, a biopsy of the prostate (see prostate cancer) will clarify the diagnosis.

Treatment:

As long as the symptoms of BPH are minor and to not interfere with the man’s lifestyle, no treatment is necessary. Regular check-ups once a year will be sufficient.

Once the symptoms become more severe, resulting in urinary retention or severe difficulty to urinate, etc. (see above), other forms of treatment include:

Medical treatment:

Alpha-blockers – relax the smooth muscles of the prostate and the bladder neck, and cause a decrease in tension of the urinary sphincter, thereby improving urinary flow;
Testosterone blocking agents – prevent the conversion of the hormone testosterone to its active form dihydrotestosterone (DHT); side effects may include loss of interest in sex, problems with getting an erection and during ejaculation.

Surgery – more than 75% of patients feel better after surgery:

Trans-Urethral Resection of the Prostate (TURP) – is the most common operation for BPH; prostate tissue that may be blocking the passage of urine is ‘burnt’ away with an electrical current to restore urine flow;
Prostatectomy – is the removal of the entire prostate; this procedure is only done, if there is complete blockage of urine flow or if complications are present, such as bleeding or an infection (prostatitis).

Hormone therapy – herbal medicines interfere in the hormonal metabolism and thus oppose glandular growth; herbal substances include nettle worth (urtica) or saw palmetto (serenoa repens) with questionable results.

There are a number of relatively new surgical and non-surgical procedures in various stages of research or available in select hospital centers, such as e.g. laser therapy, trans-urethral incision of the prostate (TUIP), trans-urethral needle ablation (TUNA), trans-urethral microwave thermotherapy (TUMT), or water induced thermotherapy and high intensity focused ultrasound, to new but a few. Time and experience will tell which of these procedures will be worth replacing currently existing treatment choices.

Sexual function after surgery

Following any kind of surgery, recovery to complete sexual function usually lags behind general post surgery recovery and can take as long as one year. Some surgeries may unfortunately lead to damage of some nerves that are necessary for achieving an erection and thus can result in permanent erectile dysfunction. Also, if there has been erectile dysfunction prior to surgery, it will rarely improve thereafter.

Most men will be able to continue having erections; however, prostate procedures often result in sterility (inability to father children) due to a so-called retrograde ejaculation or dry climax. Surgery often damages the muscle that directs the semen from the testes to the penis, and thus, the semen ends up in the urinary bladder and is flushed out later on when urinating.

Surgery for BPH does not protect you against prostate cancer, because only part of the prostate is removed (unless you had a total prostatectomy), and cancer can and usually does occur in other areas than were BPH usually develops.

Prevention:

There is no real way of protecting oneself from the development of BPH.

The best ‘protection’ against BPH as well as prostate cancer consists of regular medical check-ups, including a digital rectal examination in men past the age of 40.

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