Benign Prostatic Hypertrophy
BPH is an enlarged prostate. The prostate goes through two main growth cycles during a man’s life. The first occurs early in puberty when the prostate doubles in size. The second phase of growth starts around age 25 and goes on for most of the rest of a man’s life. BPH most often occurs during this second growth phase.
What is Benign Prostatic Hypertrophy (BPH)
As the prostate enlarges, it puts pressure on the urethra. The bladder wall becomes thicker and the bladder weakens and loses the ability to empty fully, leaving some urine in the bladder. Being unable to empty the bladder fully causes many of the problems of BPH.
BPH is benign. This means it is not cancer. It does not cause or lead to cancer. However, BPH and cancer can happen at the same time.
BPH is common. About half of all men between ages 51 and 60 have BPH. Up to 90% of men over age 80 have it.
What is the Prostate
The prostate is part of the male reproductive system. It is about the size of a walnut. The prostate is found below the bladder and in front of the rectum. It goes around a tube called the urethra, which carries urine from the bladder out through the penis.
The prostate’s main job is to make fluid for semen. During ejaculation, sperm made in the testicles moves to the urethra. At the same time, fluid from the prostate and the seminal vesicles also moves into the urethra. This mixture – semen – goes through the urethra and out through the penis.
When the prostate is enlarged, it can block the bladder. Needing to urinate often is a common symptom of BPH. This might be every 1 to 2 hours, mainly at night.
Other symptoms include:
- Feeling that the bladder is full, even right after urinating
- Feeling that urinating “can’t wait”
- A weak flow of urine
- Needing to stop and start urinating several times
- Trouble starting to urinate
- Needing to push or strain to urinate
When BPH becomes severe, you might not be able to urinate at all. This is an emergency that must be treated right away.
How Can BPH Affect Your Life?
It can lead to bladder damage and infection. It can cause blood in the urine and cause kidney damage.
The causes of BPH are not well-understood. Some researchers believe that factors related to aging and the testicles may cause BPH. This is because BPH does not develop in men whose testicles were removed before puberty.
Who is at Risk for BPH?
Aging and a family history of BPH increase a man’s risk for BPH. Obesity, lack of staying active, and erectile dysfunction can also increase risk.
Can BPH be Prevented?
There is no sure way to stop BPH, but losing weight and eating a healthy diet that involves fruits and vegetables may help. This may relate to having too much body fat, may increase hormone levels and other factors in the blood, and stimulate the growth of prostate cells. Staying active also helps control weight and hormone levels.
Your doctor can diagnose BPH based on
- Personal or family history
- A physical exam
- Medical tests
The American Urological Association (AUA) has built a BPH Symptom Score Index. It’s a series of questions about how often urinary symptoms happen. The score rates BPH from mild to severe. Take the test and talk with your doctor about your results.
Your doctor will review your Symptom Score and take a medical history. You will also have a physical exam that involves a digital rectal exam (DRE). Your doctor may also want you to have some or all of these tests:
- Cystoscopy to look at the urethra or bladder with a scope
- Post-void residual volume to measure urine left in the bladder after urinating
- PSA blood test to screen for prostate cancer
- Ultrasound of the prostate
- Urinalysis (urine test)
- Uroflowmetry to measure how fast urine flows
- Urodynamic pressure to test pressure in the bladder during urinating
- Urinary blood test to screen for bladder cancer
PSA Blood Test
Prostate-specific antigen (PSA)
is a protein that is made only by the prostate.
The PSA blood test measures the level of PSA in the blood.The PSA test should be done before the doctor does a DRE. You should not ejaculate for 2 days before a PSA test. That’s because ejaculation can raise the PSA level for 24 to 48 hours.
A rapid rise in PSA may be a sign that something is wrong. BPH is one possible cause of a high PSA level. Inflammation of the prostate, or prostatitis, is another common cause of a high PSA level.
Digital Rectal Exam
The doctor puts a lubricated, gloved finger into the rectum to feel the shape and thickness of the prostate. The DRE can help your doctor find prostate problems.
There are many options for treating BPH. Mild cases may need no treatment at all. In some cases, minimally invasive procedures (surgery without anesthesia) are good choices. And sometimes a combination of treatments works best.
Often, BPH will only require active surveillance. If you and your doctor choose this treatment option, your BPH will be closely watched but not actively treated. This means that BPH is monitored with regular visits to your urologist. A yearly exam is common. Your health care provider will look for worse or new issues before suggesting anything else. Diet and exercise are often recommended as a way to prevent or manage your symptoms.
Active surveillance is best for men with mild to moderate symptoms. It is also an option for men who are not bothered by the effects of BPH. If your symptoms get worse, or if new symptoms appear, your doctor may suggest that you begin active treatment.
Alpha blockers relax the muscles of the prostate and bladder. They improve urine flow, reduce blockage of the urethra and reduce BPH symptoms. They do not reduce the size of the prostate. Men with moderate to severe BPH and men who are bothered by their symptoms are good candidates. Alpha blockers are not a good choice for men who are about to have cataract surgery.
These prescription drugs are pills taken by mouth. Alpha-blocking drugs include alfuzosin, doxazosin, silodosin, tamsulosin and terazosin.
Side effects may include dizziness, lightheadedness, fatigue and trouble ejaculating. One benefit of alpha blockers is they start to work right away.
5-Alpha Reducatase Inhibitors
5-alpha reductase inhibitors shrink the prostate, increase urine flow and reduce the risk of BPH complications. They also make it less likely that you will need surgery. These drugs are best for men with large prostate glands.
These prescription drugs are pills taken by mouth and include dutasteride and finasteride. They may take many months to become fully effective.
You must keep taking the pills to prevent symptoms from coming back.
With combined therapy, an alpha blocker and a 5-alpha reductase inhibitor are used together. Men with larger prostates are good candidates for this treatment.
Alpha blockers and 5-alpha reductase inhibiters may work better together than either drug does alone. They improve symptoms and prevent BPH from getting worse.
Phytotherapies are herbal treatments. They are not prescribed by a doctor, but are sometimes a form of “self-treatment.”
Men buy them over the counter as dietary supplements. One popular herb is saw palmetto. Several important studies show they do not work. Also, the quality and purity of supplements vary. Doctors do not currently recommend herbal treatments for BPH.
Minimally invasive or less invasive surgeries require only tiny cuts or no cuts to the body. Good candidates include men who have taken BPH medication that did not work or men with the following symptoms:
- Weak stream of urine
- Straining to pass urine
- Urinary tract obstruction, bladder stones and/or blood in your urine
- Incomplete emptying
- Bleeding from the prostate
They can often be done as an outpatient, without a stay in the hospital. Recovery time is usually quicker. They can offer relief from symptoms, including urine control problems.
Side effects for having certain types of minimally invasive surgery is the increased risk you will need to have another surgery or need to go back on medications. Other temporary side effects may include:
- Blood in the urine
- Burning when you pass urine
- Needing to pass urine more often
- Sudden urges to pass urine
- Urinary Tract Infection
- Less often, erectile dysfunction or retrograde ejaculation (semen flowing backward into the bladder instead of out of the penis)
Choosing the right type of surgery for you may depend on the size of your prostate, your overall health and your personal choice
Types of Less Invasive Surgeries
Prostatic Urethral Lift (Urolift Procedure)
Urolift uses a needle to place tiny implants in the prostate. These implants lift and compress the enlarged prostate so that it no longer blocks the urethra. The procedure can be done with either local or general anesthesia.
The procedure uses no cutting or heat to destroy or remove prostate tissue. It takes less than an hour and you can usually go home the same day. Most men see symptom improvement within about two weeks.
Click here to learn more about Urolift Procedure
Catheterization uses a tube called a catheter in the bladder to drain urine. Catheters can be placed through the urethra or via a small puncture in the bladder above the pubic bone. This option is helpful for men with bladder control problems and a blocked prostate. Still, catheters’ benefits are temporary.
There are two types of catheters. The catheter may be “clean,” which means it is placed and removed every six to eight hours. Or it may be “indwelling,” which means it is left in the bladder for a short or long time.
Good candidates for using catheters include men who are waiting for medication to work or waiting for surgery. They may be a good choice for men who have many medical problems and for men toward the end of their lives, when surgery is not advised.
When other options fail, more invasive surgery is recommended. More invasive surgery is best if you:
- Are unable to pass urine (MAKE ALL OF THESE WITH BULLETS)
- Have kidney damage
- Have frequent urinary tract infections
- Have a lot of bleeding
- Have stones in the bladder
There are several options. The best option will depend on your health, your doctor’s expertise and your personal choice.
Types of More Invasive Surgeries
Transurethral Incision of the Prostate (TUIP)
TUIP may be used if you have a smaller prostate but still have major blockage of the urethra. Instead of cutting and removing tissue, TUIP widens the urethra. The surgeon uses a laser beam or an electrical current to make small cuts in the bladder neck, where the urethra joins the bladder, and in the prostate. This reduces the pressure of the prostate on the urethra and makes urination easier. A catheter is left in your bladder for one to three days after surgery.
TUIP may improve the ability to pass urine. It may ease symptoms. Temporary urine retention, urinary tract infection, dry orgasm, incontinence and erectile dysfunction are possible side effects.
Men who have a smaller prostate or do not want a more complete prostate resection but need surgery are good candidates for TUIP. The procedure is less likely to interfere with ejaculation than the more substantial TURP.
Photoselective Vaporization (PVP)
PVP is a very common surgery for BPH. In PVP, the surgeon guides a thin tube (a cystoscope) through the urethra to the prostate. Then the surgeon uses a laser to destroy obstructing prostate tissue and stop bleeding.
Good candidates for PVP include men with small- to moderate-sized prostates and those with too many medical problems for more-invasive surgery. Men with weak hearts are also good candidates because there is less blood loss. So are men who want to limit anesthesia. Men with a higher risk of bleeding, such as those taking blood-thinning medications, may also be good candidates for PVP.
Transurethral Resection of the Prostate (TURP)
TURP is also a very common surgery for BPH. After anesthesia, the surgeon inserts a thin, tube-like instrument (a resectoscope) through the tip of the penis into the urethra. The surgeon uses the electrified wire to cut away prostate tissue that is blocking the urethra and seal blood vessels. The removed tissue is flushed into the bladder and from there out of the body. You will need to use a catheter temporarily after the procedure.
This treatment has well known long-term outcomes. Other treatments are generally compared with it. Symptoms generally improve markedly.
TURP does not remove the entire prostate. No incisions (cuts) are needed. TURP does require anesthesia. As with any surgery, anesthesia poses a risk.
Side effects of TURP may include retrograde ejaculation, erectile dysfunction, urinary tract infections right after surgery and urinary incontinence. Full recovery takes about four to six weeks.
Men who require surgery because of moderate to severe BPH symptoms may be good candidates for TURP.
What are the Long–Term Side Effects of Treatment?
Most experts agree that if you were able to have an erection shortly before surgery, you will probably be able to do so after surgery. Most men find little or no difference in orgasm. You may have retrograde ejaculation (when semen enters the bladder rather than being sent out through the penis). For most men, side effects lessen with time.