Enlargement: Benign Prostatic Hyperplasia
The Prostate Gland
The prostate is a walnut-sized gland that forms part of
reproductive system. The gland is made of two lobes, or
enclosed by an outer layer of tissue. As the diagrams
prostate is located in front of the rectum and just
below the bladder,
where urine is stored. The prostate also surrounds the
canal through which urine passes out of the body.
Scientists do not know all the prostate's functions.
of its main
roles, though, is to squeeze fluid into the urethra as
through during sexual climax. This fluid, which helps
make up semen,
energizes the sperm and makes the vaginal canal less
Benign Prostatic Hyperplasia: A Common Part of Aging
It is common for the prostate gland to become enlarged
as a man
ages. Doctors call this condition benign prostatic
or benign prostatic hypertrophy.
As a man matures, the prostate goes through two main
growth. The first occurs early in puberty, when the
prostate doubles in
size. At around age 25, the gland begins to grow again.
growth phase often results, years later, in BPH.
Though the prostate continues to grow during most of a
the enlargement doesn't usually cause problems until
late in life. BPH
rarely causes symptoms before age 40, but more than half
of men in
their sixties and as many as 90 percent in their
seventies and eighties
have some symptoms of BPH.
As the prostate enlarges, the layer of tissue
surrounding it stops
it from expanding, causing the gland to press against
the urethra like
a clamp on a garden hose. The bladder wall becomes
irritable. The bladder begins to contract even when it
amounts of urine, causing more frequent urination.
bladder weakens and loses the ability to empty itself,
so some of the
urine remains in the bladder. The narrowing of the
urethra and partial
emptying of the bladder cause many of the problems
associated with BPH.
Many people feel uncomfortable talking about the
prostate, since the
gland plays a role in both sex and urination. Still,
enlargement is as common a part of aging as gray hair.
expectancy rises, so does the occurrence of BPH. In the
in 2000, there were 4.5 million visits to physicians for
Why BPH Occurs
The cause of BPH is not well understood. No definite
risk factors exists. For centuries, it has been known
that BPH occurs
mainly in older men and that it doesn't develop in men
were removed before puberty. For this reason, some
that factors related to aging and the testes may spur
Throughout their lives, men produce both testosterone,
male hormone, and small amounts of estrogen, a female
hormone. As men
age, the amount of active testosterone in the blood
a higher proportion of estrogen. Studies done on animals
that BPH may occur because the higher amount of estrogen
gland increases the activity of substances that promote
Another theory focuses on dihydrotestosterone (DHT), a
derived from testosterone in the prostate, which may
help control its
growth. Most animals lose their ability to produce DHT
as they age.
However, some research has indicated that even with a
drop in the
blood's testosterone level, older men continue to
accumulate high levels of DHT in the prostate. This
accumulation of DHT
may encourage the growth of cells. Scientists have also
noted that men
who do not produce DHT do not develop BPH.
Some researchers suggest that BPH may develop as a
"instructions" given to cells early in life. According
to this theory,
BPH occurs because cells in one section of the gland
instructions and "reawaken" later in life. These
then deliver signals to other cells in the gland,
instructing them to
grow or making them more sensitive to hormones that
Many symptoms of BPH stem from obstruction of the
gradual loss of bladder function, which results in
of the bladder. The symptoms of BPH vary, but the most
involve changes or problems with urination, such as
- a hesitant, interrupted, weak stream
- urgency and leaking or dribbling
- more frequent urination, especially at night
The size of the prostate does not always determine how
obstruction or the symptoms will be. Some men with
glands have little obstruction and few symptoms while
glands are less enlarged, have more blockage and greater
Sometimes a man may not know he has any obstruction
suddenly finds himself unable to urinate at all. This
acute urinary retention, may be triggered by taking
cold or allergy medicines. Such medicines contain a
known as a sympathomimetic. A potential side effect of
this drug may
prevent the bladder opening from relaxing and allowing
urine to empty.
When partial obstruction is present, urinary retention
also can be
brought on by alcohol, cold temperatures, or a long
It is important to tell your doctor about urinary
problems such as
those described above. In eight out of 10 cases, these
BPH, but they also can signal other, more serious
require prompt treatment. These conditions, including
can be ruled out only by a doctor's examination.
Severe BPH can cause serious problems over time. Urine
strain on the bladder can lead to urinary tract
infections, bladder or
kidney damage, bladder stones, and incontinence—the
control urination. If the bladder is permanently
damaged, treatment for
BPH may be ineffective. When BPH is found in its earlier
is a lower risk of developing such complications.
You may first notice symptoms of BPH yourself, or your
find that your prostate is enlarged during a routine
checkup. When BPH
is suspected, you may be referred to a urologist, a
specializes in problems of the urinary tract and the
system. Several tests help the doctor identify the
problem and decide
whether surgery is needed. The tests vary from patient
to patient, but
the following are the most common.
Digital Rectal Examination (DRE)
This examination is usually the first test done. The
a gloved finger into the rectum and feels the part of
the prostate next
to the rectum. This examination gives the doctor a
general idea of the
size and condition of the gland.
Prostate-Specific Antigen (PSA) Blood Test
To rule out cancer as a cause of urinary symptoms, your
recommend a PSA blood test. PSA, a protein produced by
is frequently present at elevated levels in the blood of
men who have
prostate cancer. The U.S. Food and Drug Administration
approved a PSA test for use in conjunction with a
examination to help detect prostate cancer in men who
are age 50 or
older and for monitoring men with prostate cancer after
However, much remains unknown about the interpretation
of PSA levels,
the test's ability to discriminate cancer from benign
conditions, and the best course of action following a
A fact sheet titled "The Prostate-Specific Antigen
Questions and Answers " can be found on the National
website at www.cancer.gov/cancertopics/factsheet/Detection/PSA.
Rectal Ultrasound and Prostate Biopsy
If there is a suspicion of prostate cancer, your doctor
recommend a test with rectal ultrasound. In this
procedure, a probe
inserted in the rectum directs sound waves at the
prostate. The echo
patterns of the sound waves form an image of the
prostate gland on a
display screen. To determine whether an abnormal-looking
area is indeed
a tumor, the doctor can use the probe and the ultrasound
guide a biopsy needle to the suspected tumor. The needle
collects a few
pieces of prostate tissue for examination with a
Urine Flow Study
Your doctor may ask you to urinate into a special
measures how quickly the urine is flowing. A reduced
In this examination, the doctor inserts a small tube
opening of the urethra in the penis. This procedure is
done after a
solution numbs the inside of the penis so all sensation
is lost. The
tube, called a cystoscope, contains a lens and a light
system that help
the doctor see the inside of the urethra and the
bladder. This test
allows the doctor to determine the size of the gland and
location and degree of the obstruction.
Men who have BPH with symptoms usually need some kind
at some time. However, a number of researchers have
questioned the need
for early treatment when the gland is just mildly
enlarged. The results
of their studies indicate that early treatment may not
because the symptoms of BPH clear up without treatment
in as many as
one-third of all mild cases. Instead of immediate
suggest regular checkups to watch for early problems. If
begins to pose a danger to the patient's health or
causes a major
inconvenience to him, treatment is usually recommended.
Since BPH can cause urinary tract infections, a doctor
clear up any infection with antibiotics before treating
the BPH itself.
Although the need for treatment is not usually urgent,
generally advise going ahead with treatment once the
bothersome or present a health risk.
The following section describes the types of treatment
that are most commonly used for BPH.
Over the years, researchers have tried to find a way to
shrink or at
least stop the growth of the prostate without using
surgery. The FDA
has approved six drugs to relieve common symptoms
associated with an
Finasteride (Proscar), FDA-approved in 1992, and
(Avodart), FDA-approved in 2001, inhibit production of
the hormone DHT,
which is involved with prostate enlargement. The use of
either of these
drugs can either prevent progression of growth of the
actually shrink the prostate in some men.
The FDA also approved the drugs terazosin (Hytrin) in
doxazosin (Cardura) in 1995, tamsulosin (Flomax) in
1997, and alfuzosin
(Uroxatral) in 2003 for the treatment of BPH. All four
drugs act by
relaxing the smooth muscle of the prostate and bladder
neck to improve
urine flow and to reduce bladder outlet obstruction. The
belong to the class known as alpha blockers. Terazosin
were developed first to treat high blood pressure.
alfuzosin were developed specifically to treat BPH.
The Medical Therapy of Prostatic Symptoms (MTOPS)
by the National Institute of Diabetes and Digestive and
(NIDDK), recently found that using finasteride and
is more effective than using either drug alone to
relieve symptoms and
prevent BPH progression. The two-drug regimen reduced
the risk of BPH
progression by 67 percent, compared with 39 percent for
and 34 percent for finasteride alone.
Minimally Invasive Therapy
Because drug treatment is not effective in all cases,
recent years have developed a number of procedures that
symptoms but are less invasive than conventional
Transurethral microwave procedures.
In 1996, the
FDA approved a device that uses microwaves to heat and
prostate tissue. In the procedure called transurethral
thermotherapy (TUMT), the device sends
through a catheter to heat selected portions of the
prostate to at
least 111 degrees Fahrenheit. A cooling system protects
tract during the procedure.
The procedure takes about 1 hour and can be performed
outpatient basis without general anesthesia. TUMT has
not been reported
to lead to erectile dysfunction or incontinence.
Although microwave therapy does not cure BPH, it
frequency, urgency, straining, and intermittent flow. It
correct the problem of incomplete emptying of the
research will determine any long-term effects of
microwave therapy and
who might benefit most from this therapy.
Transurethral needle ablation.
Also in 1996, the FDA approved the minimally invasive
needle ablation (TUNA) system for the treatment of BPH.
The TUNA system delivers low-level radiofrequency
twin needles to burn away a well-defined region of the
prostate. Shields protect the urethra from heat damage.
The TUNA system
improves urine flow and relieves symptoms with fewer
side effects when
compared with transurethral resection of the prostate
incontinence or impotence has been observed.
This therapy uses
heated water to destroy excess tissue in the prostate. A
containing multiple shafts is positioned in the urethra
so that a
treatment balloon rests in the middle of the prostate. A
controls the temperature of the water, which flows into
the balloon and
heats the surrounding prostate tissue. The system
focuses the heat in a
precise region of the prostate. Surrounding tissues in
the urethra and
bladder are protected. Destroyed tissue either escapes
through the urethra or is reabsorbed by the body.
High-intensity focused ultrasound.
The use of
ultrasound waves to destroy prostate tissue is still
clinical trials in the United States. The FDA has not
high-intensity focused ultrasound.
Most doctors recommend removal of the enlarged part of
as the best long-term solution for patients with BPH.
With surgery for
BPH, only the enlarged tissue that is pressing against
the urethra is
removed; the rest of the inside tissue and the outside
capsule are left
intact. Surgery usually relieves the obstruction and
emptying caused by BPH. The following section describes
the types of
surgery that are used.
Transurethral surgery. In
this type of surgery, no
external incision is needed. After giving anesthesia,
reaches the prostate by inserting an instrument through
A procedure called transurethral resection of the
prostate (TURP) is
used for 90 percent of all prostate surgeries done for
BPH. With TURP,
an instrument called a resectoscope is inserted through
the penis. The
resectoscope, which is about 12 inches long and 1/2 inch
contains a light, valves for controlling irrigating
fluid, and an
electrical loop that cuts tissue and seals blood
During the 90-minute operation, the surgeon uses the
wire loop to remove the obstructing tissue one piece at
a time. The
pieces of tissue are carried by the fluid into the
bladder and then
flushed out at the end of the operation.
Most doctors suggest using TURP whenever possible.
procedures are less traumatic than open forms of surgery
and require a
shorter recovery period. One possible side effect of
retrograde, or backward, ejaculation. In this condition,
backward into the bladder during climax instead of out
Another surgical procedure is called transurethral
incision of the
prostate (TUIP). Instead of removing tissue, as with
procedure widens the urethra by making a few small cuts
in the bladder
neck, where the urethra joins the bladder, and in the
itself. Although some people believe that TUIP gives the
same relief as
TURP with less risk of side effects such as retrograde
advantages and long-term side effects have not been
Open surgery. In the few
cases when a transurethral
procedure cannot be used, open surgery, which requires
incision, may be used. Open surgery is often done when
the gland is
greatly enlarged, when there are complicating factors,
or when the
bladder has been damaged and needs to be repaired. The
location of the
enlargement within the gland and the patient's general
health help the
surgeon decide which of the three open procedures to
With all the open procedures, anesthesia is given and
made. Once the surgeon reaches the prostate capsule, he
or she scoops
out the enlarged tissue from inside the gland.
Laser surgery. In March
1996, the FDA approved a
surgical procedure that employs side-firing laser fibers
and Nd: YAG
lasers to vaporize obstructing prostate tissue. The
doctor passes the
laser fiber through the urethra into the prostate using
and then delivers several bursts of energy lasting 30 to
The laser energy destroys prostate tissue and causes
shrinkage. As with
TURP, laser surgery requires anesthesia and a hospital
advantage of laser surgery over TURP is that laser
little blood loss. Laser surgery also allows for a
time. But laser surgery may not be effective on larger
long-term effectiveness of laser surgery is not known.
Newer procedures that use laser technology can be
performed on an outpatient basis.
Photoselective vaporization of the
prostate (PVP). PVP uses a high-energy laser
prostate tissue and seal the treated area.
Interstitial laser coagulation.
Unlike other laser
procedures, interstitial laser coagulation places the
tip of the
fiberoptic probe directly into the prostate tissue to
Your Recovery After Surgery in the Hospital
The amount of time you will stay in the hospital
on the type of surgery you had and how quickly you
At the end of surgery, a special catheter is inserted
opening of the penis to drain urine from the bladder
into a collection
bag. Called a Foley catheter, this device has a
water-filled balloon on
the end that is put in the bladder, which keeps it in
This catheter is usually left in place for several
the catheter causes recurring painful bladder spasms the
surgery. These spasms may be difficult to control, but
You may also be given antibiotics while you are in the
Many doctors start giving this medicine before or soon
after surgery to
prevent infection. However, some recent studies suggest
antibiotics may not be needed in every case, and your
doctor may prefer
to wait until an infection is present to give them.
After surgery, you will probably notice some blood or
clots in your
urine as the wound starts to heal. If your bladder is
(flushed with water), you may notice that your urine
becomes red once
the irrigation is stopped. Some bleeding is normal, and
it should clear
up by the time you leave the hospital. During your
recovery, it is
important to drink a lot of water (up to 8 cups a day)
to help flush
out the bladder and speed healing.
Do's and Don'ts
Take it easy the first few weeks after you get home.
have any pain, but you still have an incision that is
transurethral surgery, where the incision can't be seen.
people try to do too much at the beginning and then have
a setback, it
is a good idea to talk with your doctor before resuming
routine. During this initial period of recovery at home,
straining or sudden movements that could tear the
incision. Here are
- Continue drinking a lot of water to flush the
- Avoid straining when having a bowel movement.
- Eat a balanced diet to prevent constipation. If
constipation occurs, ask your doctor if you can take a
- Don't do any heavy lifting.
- Don't drive or operate machinery.
Getting Back to Normal After Surgery
Even though you should feel much better by the time you
hospital, it will probably take a couple of months for
you to heal
completely. During the recovery period, the following
are some common
problems that can occur.
You may notice that your urinary stream is stronger
surgery, but it may take awhile before you can urinate
normally again. After the catheter is removed, urine
will pass over the
surgical wound on the prostate, and you may initially
discomfort or feel a sense of urgency when you urinate.
will gradually lessen, and after a couple of months you
should be able
to urinate less frequently and more easily.
As the bladder returns to normal, you may have some
problems controlling urination, but long-term
occurs. Doctors find that the longer problems existed
the longer it takes for the bladder to regain its full
In the first few weeks after transurethral surgery, the
the bladder may loosen, and blood may suddenly appear in
Although this can be alarming, the bleeding usually
stops with a short
period of resting in bed and drinking fluids. However,
if your urine is
so red that it is difficult to see through or if it
contains clots or
if you feel any discomfort, be sure to contact your
Sexual Function After Surgery
Many men worry about whether surgery for BPH will
ability to enjoy sex. Some sources state that sexual
function is rarely
affected, while others claim that it can cause problems
in up to 30
percent of cases. However, most doctors say that even
though it takes
awhile for sexual function to return fully, with time,
most men are
able to enjoy sex again.
Complete recovery of sexual function may take up to 1
behind a person's general recovery. The exact length of
time depends on
how long after symptoms appeared that BPH surgery was
done and on the
type of surgery. Following is a summary of how surgery
is likely to
affect the following aspects of sexual function.
Most doctors agree that if you were able to maintain an
shortly before surgery, you will probably be able to
afterward. Surgery rarely causes a loss of erectile
surgery cannot usually restore function that was lost
Although most men are able to continue having erections
surgery, a prostate procedure frequently makes them
sterile (unable to
father children) by causing a condition called
or dry climax.
During sexual activity, sperm from the testes enters
near the opening of the bladder. Normally, a muscle
blocks off the
entrance to the bladder, and the semen is expelled
through the penis.
However, the coring action of prostate surgery cuts this
muscle as it
widens the neck of the bladder. Following surgery, the
semen takes the
path of least resistance and enters the wider opening to
rather than being expelled through the penis. Later it
flushed out with urine. In some cases, this condition
can be treated
with a drug called pseudoephedrine, found in many cold
imipramine. These drugs improve muscle tone at the
bladder neck and
keep semen from entering the bladder.
Most men find little or no difference in the sensation
of orgasm, or
sexual climax, before and after surgery. Although it may
take some time
to get used to retrograde ejaculation, you should
eventually find sex
as pleasurable after surgery as before.
Many people have found that concerns about sexual
interfere with sex as much as the operation itself.
surgical procedure and talking over any worries with the
surgery often help men regain sexual function earlier.
Many men also
find it helpful to talk with a counselor during the
Is Further Treatment Needed?
In the years after your surgery, it is important to
a rectal examination once a year and to have any
symptoms checked by
Since surgery for BPH leaves behind a good part of the
gland, it is
still possible for prostate problems, including BPH, to
However, surgery usually offers relief from BPH for at
least 15 years.
Only 10 percent of the men who have surgery for BPH
eventually need a
second operation for enlargement. Usually these are men
who had the
first surgery at an early age.
Sometimes, scar tissue resulting from surgery requires
the year after surgery. Rarely, the opening of the
scarred and shrinks, causing obstruction. This problem
may require a
surgical procedure similar to transurethral incision
(see section on Surgical
More often, scar tissue may form in the urethra and
The doctor can solve this problem during an office visit
A stent is a small device that is inserted through the
the narrowed area and allowed to expand, like a spring.
pushes back the prostatic tissue, widening the urethra.
It is designed
to relieve urinary obstruction in men and improve the
urinate. The device is approved for use in men for whom
surgical procedures to correct urinary obstruction have
BPH and Prostate Cancer: No Apparent Relation
Although some of the signs of BPH and prostate cancer
are the same,
having BPH does not seem to increase the chances of
cancer. Nevertheless, a man who has BPH may have
cancer at the same time or may develop prostate cancer
in the future.
For this reason, the National Cancer Institute and the
Society recommend that all men over 40 have a rectal
examination once a
year to screen for prostate cancer.
After BPH surgery, the tissue removed is routinely
hidden cancer cells. In about one out of 10 cases, some
is found, but often it is limited to a few cells of a
type of cancer, and no treatment is needed.
Hope through Research
The National Institute of Diabetes and Digestive and
(NIDDK) was established by Congress in 1950 as one of
Institutes of Health (NIH), whose mission is to improve
through biomedical research. NIH is the research branch
of the U.S.
Department of Health and Human Services.
The NIDDK conducts and supports a variety of research
the kidney and urinary tract. Much of the research
targets disorders of
the lower urinary tract, including BPH, urinary tract
interstitial cystitis, urinary obstruction, prostatitis,
stones. The knowledge gained from these studies is
understanding of why BPH develops and may lead to
improved methods of
diagnosing and treating prostate enlargement. One such
study was the MTOPS
Trial, which ended in 2003. The results are
under the Drug
American Urological Association. Guideline on the
benign prostatic hyperplasia: Chapter 1: Diagnosis and
recommendations. The Journal of Urology.
2003;170(2 Pt 1):530–537.
National Cancer Institute. The prostate-specific
(PSA) test: Questions and answers. www.cancer.gov/cancertopics/factsheet/Detection/PSA.
August 17, 2004.
Anesthesia: A substance
that prevents pain from being felt, given before an
Anus: The opening of the
rectum where solid waste leaves the body.
Bladder: The muscular bag
in the lower abdomen where urine is stored.
Catheter: A tube inserted
through the penis to the bladder in order to drain urine
from the body.
Cystoscope: A tube-like
instrument used to view the interior of the bladder.
semen from the penis during sexual climax.
Gland: An organ that makes
and releases substances to other parts of the body.
Hormone: A substance that
stimulates the function of a gland.
Impotent: Unable to have an
Incontinence: The inability
to control urination.
Obstruction: A clog or
blockage that prevents liquid from flowing easily.
Rectum: The last part of
the large intestine (colon) ending in the anus.
Reproductive system: The
bodily systems that allow men and women to have
Scrotum: The sac of skin
that contains the testes.
Semen: The fluid,
containing sperm, which comes out of the penis during
Sterile: Unable to father
Testes: The male
reproductive glands where sperm are produced.
Ultrasound: A type of test
in which sound waves too high to hear are aimed at a
produce an image of it.
Urinary tract: The path
that urine takes as it leaves the body. It includes the
ureters, bladder, and urethra.
Urination: Discharge of
liquid waste from the body.
Urethra: The canal inside
the penis that urine passes through as it leaves the
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commercial product or company. Trade, proprietary, or
appearing in this document are used only because they
necessary in the context of the information provided. If
a product is
not mentioned, the omission does not mean or imply that
the product is
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