Enlarged Prostate

1 What is Benign Prostatic Hyperplasia (BPH)?

Benign prostatic hyperplasia (BPH), also called benign prostatic hypertrophy or benign prostatic obstruction is a common condition in which the prostate gland enlarges, and it occurs in older men.

It causes urinary symptoms that are very bothersome. Normally, the prostate gland undergoes two main growth phases during a man's life.

The first one occurs during early puberty when the prostate gland doubles in its size. The second phase of growth starts around the age of 25 and continues throughout life.

BPH often occurs during the second growth period. As the prostate increases in its size, it impinges or compresses upon the urethra.

The wall of the bladder thickens, and gradually the bladder weakens resulting in an inability to empty the urine completely.

If left untreated, this condition causes bladder, urinary tract, and kidney problems. There are various treatments available for BPH.

These include medications, minimally invasive therapies, and surgery.

The best treatment option is chosen based on your symptoms, the size of your prostate gland, other coexisting health conditions, and your preferences.

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2 Symptoms

The severity of symptoms in men with Benign prostatic hyperplasia (BPH) varies, and symptoms tend to gradually worsen over a period of time.

Common signs and symptoms of BPH include:

  • Increased urinary frequency: Urinating more than 8 times in a day.
  • Urgency to urinate: Inability to control or delay urination
  • Increased frequency of urination at night (nocturia), which may wake you up during sleep
  • Difficulty in beginning to urinate
  • A weak stream of urine or an interrupted stream that stops suddenly and then starts
  • Dribbling at the end of urine stream
  • Difficulty or need to strain while urinating
  • Inability to completely void the urine

Less common signs and symptoms include:

The size of your prostate is not an indicator of the severity of blocked urethra or its associated symptoms.

Sometimes, men with a slight enlargement of the prostate gland may have significant symptoms while other men with greatly enlarged prostates may have only a few urinary symptoms due to minimal blockage.

In some men, symptoms eventually stabilize and might even improve over time.

Other conditions that can cause symptoms similar to those of BPH include:

  • Urinary tract infection
  • Prostatitis or inflammation of the prostate gland
  • Urethral stricture or narrowing of the urethra
  • Scarring in the bladder neck as a result of previous surgery
  • Bladder or renal stones
  • Problems with nerves that control the bladder
  • Cancer of the prostate or bladder

If you are having urinary problems, consult your doctor, even if these symptoms do not bother you much. It is necessary to recognize or rule out any underlying causes.

If left untreated, urinary problems might cause obstruction in the urinary tract. Seek immediate medical care if you are unable to urinate.

3 Causes

The exact cause of Benign Prostatic Hyperplasia (BPH) is not clearly understood, however, factors related to aging are thought to be involved as it occurs mainly in older men.

Men produce testosterone, a male hormone, and a small quantity of estrogen, a female hormone, throughout their life.

With advancing age, the level of active testosterone in their blood drops, which in turn leaves a higher amount of estrogen within the prostate.

Studies have shown that this higher level of estrogen enhances the activity of substances that promote cell growth in the prostate.

Another theory indicates that even with a decrease in blood testosterone levels, older men continue the production and accumulation of high levels of dihydrotestosterone (DHT) in the prostate.

This accumulated DHT encourages the continued growth of prostate cells. In most men, this persistent growth makes the prostate gland large enough to cause significant blockage in the urinary flow and other symptoms.

4 Making a Diagnosis

Making a diagnosis of Benign prostatic hyperplasia (BPH) is done by several tests.

Your primary care doctor may refer you directly to a doctor who specializes in urinary tract problems (urologist).

What you can do:

  • Make a list of your symptoms, including those that may seem unrelated to the reason for your appointment.
  • Keep a track of how often and when you urinate, the amount of fluids you drink, and whether you feel that you are completely emptying your bladder or not.
  • Make a list of your key medical information, including the other conditions you may have.
  • Make a list of all your regular medications including the vitamins or supplements.

Write down the questions you may want to ask your doctor.

Some basic questions to ask your doctor include:

  • What is the likely reason for my symptoms?
  • What kind of diagnostic tests do I need?
  • What treatment options do you suggest?
  • How can I manage other health conditions along with an enlarged prostate?
  • Are there any restrictions on sexual activity?

Your doctor is likely to ask you a number of questions such as:

  • When were your urinary symptoms first noticed?
  • Have your symptoms been continuous or occasional?
  • Have these symptoms become worse over time, or did they appear suddenly?
  • How often do you urinate during the day, and how many times do you get up at night to urinate?
  • Have you ever experienced leakage of urine?
  • Do you have a frequent urge to pass urine?
  • Do you find difficulty while starting to urinate?
  • Do you have an interrupted stream of urine or do you have to strain in order to pass urine?
  • Do you feel as if you have not completely emptied your bladder?
  • Do you feel any burning while you urinate or pain in your bladder area or blood in your urine?
  • Have you had an infection of the urinary tract?
  • Do you have a family history of enlarged prostate, prostate cancer or kidney stones?
  • Have you ever had any trouble getting and maintaining an erection (erectile dysfunction), or other sexual problems?
  • Have you ever had surgery or any procedure that involved insertion of an instrument through the tip of your penis into your urethra?
  • Are you on treatment with blood-thinning medications such as aspirin, warfarin (Coumadin) or clopidogrel (Plavix)?
  • How much of caffeine do you consume?
  • What is your fluid intake per day?

Your doctor will take your medical history by asking you detailed questions about your symptoms and perform a physical examination.

This initial exam includes:

Digital rectal examination: Your doctor will gently pass a gloved finger into the rectum to feel the part of your prostate that is adjacent to the rectum.

This helps your doctor to check whether your prostate is enlarged, tender or has any other abnormalities that require further testing.

Urine test: Analyzing a sample of your urine can help rule out a urinary tract infection or other conditions that can cause similar urinary symptoms.

Blood test: The blood sample may be tested to rule out kidney problems.

Prostate-specific antigen (PSA) blood test: The cells of prostate produce a protein substance called PSA. High levels of PSA indicates an enlarged prostate.

However, elevated PSA levels may also be due to age, recent surgical procedures, infection, inflammation, surgery or prostate cancer.

Neurological examination: This includes a brief evaluation of functions of your nervous system, and it helps to find out the causes of urinary problems other than enlarged prostate.

After the results of these tests are obtained, your doctor will order additional tests to confirm the diagnosis of an enlarged prostate and to rule out other conditions.

These additional tests include:

Urinary flow test: In this test, you are told to urinate into a receptacle attached to a machine that can measure the strength and amount of the flow of your urine.

The combined results of this test help to determine whether your condition is getting better or worse.

Postvoid residual volume test: This test determines whether you can empty your bladder completely.

This test can be performed either by using ultrasound or by inserting a catheter into your bladder after you urinate and measuring the amount of urine left in your bladder.

24-hour voiding diary: This records how often you urinate as well as the amount of urine. It is particularly helpful when more than one-third of your daily urinary output occurs at night.

If your condition seems to be more complex, your doctor may recommend:

Transrectal ultrasound: An ultrasound probe or transducer is inserted into your rectum to examine your prostate.

The images created by ultrasound waves can reveal the size of the prostate and other abnormalities such as tumors.

Prostate biopsy: Under the guidance of transrectal ultrasound, needles are inserted to take tissue samples (biopsies) of the prostate.

Microscopic examination of the tissue sample can help your doctor to rule out prostate cancer.

Urodynamic and pressure flow studies: In these studies, a catheter is passed through your urethra into your bladder.

Water or rarely air may be slowly injected into your bladder. Your doctor will then measure the bladder pressure and determine whether your bladder muscles are functioning properly or not.

Cystoscopy: This test involves insertion of a lighted, flexible cystoscope into your urethra. This allows your doctor to visualize the inner portion of your urethra and bladder.

A local anesthesia will be administered before this test.

An intravenous pyelogram or CT urogram: A tracer is injected into your vein followed by which X-rays or CT scans are taken of your kidneys, bladder and the tubes that connect your kidneys to your bladder (ureters).

These tests can detect urinary tract stones, tumors or blockages in the ureters.

5 Treatment

A wide range of treatment options is available for Benign prostatic hyperplasia (BPH). These include medications, minimally invasive therapies, and surgery.

The treatment best suitable for you depends on factors such as:

  • The size of your prostate
  • Your age
  • Your overall health
  • The amount of discomfort you have

If you have symptoms that do not bother you much, postponing the treatment or simple monitoring of your symptoms may be considered. 

In some men, symptoms may get relieved without any treatment.
Medication: Medication is the most common treatment for mild to moderate symptoms of prostate enlargement. 

Medications that retard the growth or shrink the prostate or control the symptoms associated with BPH are prescribed. The options include:

Alpha blockers: These medications relax the smooth muscle fibers in the prostate and bladder neck, thus improve a flow of urine by reducing blockage.

Alpha blockers — which include alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax), and silodosin (Rapaflo) — usually acts rapidly in men with relatively small prostates.

Side effects might include dizziness and a harmless condition in which semen goes back upwards into the bladder instead of out to the tip of the penis (retrograde ejaculation).

5-alpha reductase inhibitors: These medications can shrink your prostate by preventing hormonal changes that cause the progressive growth of the prostate.

These medications — which include finasteride (Proscar) and dutasteride (Avodart) may take up to six months to be effective. Side effects include retrograde ejaculation.

Combination drug therapy: Your doctor might prescribe an alpha-blocker and a 5-alpha reductase inhibitor at the same time if either medication alone does not seem to be effective.

Tadalafil (Cialis). Studies suggest this medication, which is often used to treat erectile dysfunction, can also treat prostate enlargement.

However, this medication is not routinely used in BPH and is generally prescribed only in men who also have erectile dysfunction.

Minimally invasive or surgical therapy: Minimally invasive or surgical therapy is recommended in the following conditions:

As with any surgery, all prostate procedures can cause side effects. Complications might include:

  • Semen flowing backward into the bladder instead of out through the penis during ejaculation
  • Temporary difficulty during urination
  • Urinary tract infection
  • Bleeding
  • Erectile dysfunction
  • Very rarely, loss of bladder control (urinary incontinence)

There are several types of minimally invasive procedures:

Transurethral resection of the prostate (TURP): A resectoscope is inserted into your urethra to reach the prostate, and then the surgeon cuts a portion of the enlarged prostate using a wire loop.

Special kind of fluid takes the tissue pieces into the bladder from where they are flushed out at the end.

TURP relieves symptoms quickly, and most men have a proper urine flow soon after the procedure.

After TURP, a catheter may be placed temporarily to drain your bladder, and you can perform light activities until healing is complete.

Transurethral incision of the prostate (TUIP): This procedure is performed to widen the urethra.

The surgeon inserts a cystoscope and an instrument with a laser beam or electric current through the urethra to reach your prostate.

Then, one or two small cuts are made in the prostate and in the bladder neck to widen the urethra and facilitate an easier flow of urine.

A Foley's catheter is inserted and kept in place to avoid urinary retention that results due to irritated tissues.

This surgery is a good option if you have a small or moderately enlarged prostate gland, and if you have health conditions that make other surgeries too risky.

Transurethral microwave thermotherapy (TUMT): Your doctor inserts a catheter through your urethra into your prostate, and a device called antenna transmits microwaves through the catheter to destroy the inner portions of the enlarged prostate gland, thereby shrinking it, and easing urine flow.

This surgery is commonly used only on small prostates in special conditions as re-treatment might be required.
Transurethral needle ablation (TUNA): In this outpatient procedure, a cystoscope is passed into your urethra, which allows your doctor to place small needles into your prostate gland.

These needles send radio waves that heat and destroy the excess prostate tissue that blocks the urine flow. This procedure is a good option if you tend to bleed easily or have certain other health problems.
Laser therapy: A high-energy laser is used to destroy or remove the overgrown prostate tissue. Laser therapy generally relieves symptoms quickly and has a lower risk of side effects.

Laser therapy is indicated in men who cannot undergo other prostate procedures as they take blood-thinning medications. The options for laser therapy include:

Ablative procedures: These procedures vaporize the obstructive prostate tissue in order to increase your urine flow.

Examples include photoselective vaporization of the prostate (PVP) and holmium laser ablation of the prostate (HoLAP).

Ablative procedures can cause irritating urinary symptoms after surgery, so in rare situations, another resection procedure might be needed.

Enucleative procedures: Enucleative procedures, such as holmium laser enucleation of the prostate (HoLEP) remove all the prostate tissues that block urine flow and also prevent the regrowth of these tissues.

The tissue that is removed is examined for prostate cancer and other conditions.
Open prostatectomy: The surgeon makes an incision in your lower abdomen to reach the prostate. Either all or a part of the prostate is removed through this incision.

Open prostatectomy is generally performed when the prostate is enlarged greatly or complications such as bladder damage have occurred which needs to be repaired.

Open surgery usually requires general anesthesia, longer hospital stay and rehabilitation period, and is associated with a higher risk of needing a blood transfusion.

The three open prostatectomy procedures include retropubic prostatectomy, suprapubic prostatectomy, and perineal prostatectomy. The recovery period varies from 3 to 6 weeks.

Follow-up care: Your follow-up care depends on the type of technique used to treat your enlarged prostate.

Your doctor will advise you to avoid heavy lifting and excessive exercises for seven days if you have had laser ablation, transurethral needle ablation or transurethral microwave therapy.

If an open or robot-assisted prostatectomy was performed, you might need to restrict your activities for six weeks. Your doctor will suggest you to drink plenty of fluids after every procedure.

6 Alternative and Homeopathic Remedies

A few alternative and homeopathic remedies are used for Benign prostatic hyperplasia (BPH).

Studies conducted on herbal therapies as a treatment for enlarged prostate gland have given mixed results.

One of these studies established that saw palmetto extract was as effective as finasteride in relieving the symptoms of BPH, although prostate volumes were not reduced.

However, a subsequent placebo-controlled trial found no evidence that saw palmetto is better than a placebo.

Other herbal treatments using beta-sitosterol extracts, pygeum, and rye grass have been suggested to be helpful in relieving symptoms of enlarged prostate, although their safety and efficacy has not been proved yet.

The Food and Drug Administration has not approved any herbal medications for treatment of an enlarged prostate.

 If you take any herbal treatment, inform your doctor as certain herbal products might increase the risk of bleeding or interfere with other medications you are taking.

7 Lifestyle and Coping

There are different ways to adapt your lifestyle in coping with Benign prostatic hyperplasia (BPH).

You may follow these self-care measures to manage symptoms of enlarged prostate gland.

Limit intake of fluids or beverages in the evening. Avoid drinking anything for at least 1-2 hours before going to bed to avoid getting up in the middle-of-the-night to go to the toilet.

Limit caffeine-containing and alcoholic beverages. These can increase your urine production, irritate your bladder, and further worsen your symptoms.

Avoid taking medications such as decongestants or antihistamines. These drugs tighten the band of muscles surrounding the urethra that controls the flow of urine, making it difficult to urinate.

Urinate when you first feel the urge to. Do not hold back for too long as it might overstretch the bladder muscle and cause damage.

Schedule your bathroom visits. Urinate at regular intervals of every 4-6 hours during the day so as to "retrain" the bladder. This can be useful if you have severe frequency and urgency.

Maintain a healthy body weight. Obesity is associated with enlarged prostate.

Be physically active: Inactivity or low activity levels contribute to retention of urine. Exercise can help reduce urinary problems caused by an enlarged prostate.

Urinate - and then urinate again after a few moments. This practice is called double voiding.

Keep yourself warm. Colder temperature facilitates urine retention and increases the urgency to urinate.

8 Risks and Complications

Men with the following risk factors are more likely to develop benign prostatic hyperplasia (BPH).

Age above 40 years: Prostate gland enlargement rarely occurs in men younger than the age of 40.

At least one-third of men may experience moderate to severe symptoms by the age of 60, and about half do so by age 80. 

Family history: You are more likely to develop BPH if you have a blood relative, for example, your father or brother with prostate problems.

Ethnic background: Prostate enlargement is found to be comparatively less common in Asian men. Black men might experience symptoms at a younger age than white men.

Medical conditions such as diabetes and heart disease: Studies have shown that type 2 diabetes, obesity, heart disease, and use of beta blockers can increase the risk of BPH.

Sedentary lifestyle and lack of exercise: Lack of exercise can increase your risk of developing BPH.

The complications of BPH may include:

Acute urinary retention or sudden inability to pass urine. In such conditions, you might need an insertion of a catheter into your bladder to drain the urine.

Sometimes, surgery may be required to relieve urinary retention.

Urinary tract infections (UTIs): Chronic urinary retention or inability to completely empty your bladder can increase the risk of developing an infection in your urinary tract.

If UTIs occur very frequently, surgery may be done to remove part of the prostate gland. 

Bladder stones: These are caused as a result of an inability to empty the bladder fully. Bladder stones can lead to infection, irritated bladder, blood in the urine, and obstruction in the flow of urine.

Bladder damage: A bladder that hasn't emptied completely can stretch and weaken over time. As a result, the muscular wall of the bladder no longer contracts properly, making it harder to fully empty your bladder.

Kidney damage: Pressure that develops within the bladder due to urinary retention can cause direct damage the kidneys or allows bladder infections to reach the kidneys.

Most men with BPH may not develop all of these complications. However, if acute urinary retention and kidney damage occur, it can pose a serious health threat.

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