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Benign prostatic hyperplasia (BPH)
Reviewed by Mr John Macfarlane, consultant urological surgeon
<http://www.netdoctor.co.uk/diseases/facts/prostaticenlargement.htm>

What is benign prostatic hyperplasia? (BPH)
The prostate is a gland the size of a chestnut. It is only present in men, and it is situated under the bladder surrounding the urethra, the passageway that takes the urine to the outside. The gland produces seminal fluid, which is mixed with sperm to make semen.

 With age, the gland may begin to grow - this happens to most men. The growth may eventually cause problems with urination, because the gland pinches off the urethra as it increases its size.

The growth in itself is harmless and so the condition is called benign prostate hyperplasia (BPH). It occurs most often in men over the age of 60. Up to 30 per cent of men in their 70s have BPH that causes them symptoms.

What kinds of problems can an enlarged prostate cause?

 The enlargement of the prostate gland stretches and distorts the urethra and so obstructs the urine flow. Symptoms include:

  • a weak or interrupted urinary stream. Several attempts to empty the bladder may be necessary.
  • difficulty starting the urine flow, even when the bladder feels full.
  • a feeling the bladder is not completely empty.
  • a need to urinate often during the day and during the night. Increased need to urinate in the night is usually a very early symptom.
  • a need to urinate right away. Some men may experience involuntary discharge of urine.
  • dribbling of urine after urination.
  • burning sensation or pain during urination.
Different men get different symptoms - the symptoms may also vary with each individual throughout the course of the disease. It is important to emphasise that the above symptoms do not necessarily prove that the prostate is enlarged. Other diseases may cause similar symptoms. Men with problems urinating should always see their doctor.

 Can other problems arise?

 There are further complications with this disease.
  • For some men, it suddenly becomes impossible to urinate (known as acute retention). Studies have shown that acute retention affects between 1 and 2 per cent of men with BPH each year. This condition is very painful and demands immediate medical treatment to avoid damage to the kidneys, among other things.
  • Other men find it gradually harder to empty the bladder. As the condition develops, more and more urine is left in the bladder after urination (known as chronic retention).
Other complications of the disease include: repeated attacks of cystitis (infection of the bladder) and the development of stones in the bladder.

How does the doctor diagnose the disease?

 A GP can often make the diagnosis on the following grounds.

  • Patients will be asked about their symptoms and may also be asked to fill out a symptom questionnaire to let the doctor know the nature of the symptoms and how troublesome they are.
  • They may also be asked to record their drinking and urination over a period of three days.
  • By carrying out a rectal examination, the doctor can feel through the rectum wall whether or not the prostate is enlarged.
  • Usually, the patient's urine will be examined, and may be sent for culture, when it will also be tested for sensitivity to antibiotics. Kidney function will also be examined by a blood test.
If there is a need for further tests, they will usually be carried out by a specialist. He or she will be able to check for specific urinary functions like the flow rate of the urine and whether the bladder is emptied on urination. X-rays, including ultrasound examinations, and blood tests, may be necessary. Many hospitals and a number of general practices have specialised prostate clinics where a full prostate check is carried out.

 How is benign prostate hyperplasia treated?

 There are a variety of treatment strategies for this condition and the following factors should be considered:
  • treatment is only necessary if the symptoms are bothersome or complications are present.
  • each treatment has advantages and disadvantages. The patient and his doctor will have to decide which is most appropriate.
Wait and see (watchful waiting): if there are only a few minor symptoms it might be best to wait and see how it develops. A doctor should be consulted regularly to avoid complications setting in.

What kinds of medicines are used?

 There are two types of medication for this problem.
  • Alpha-blockers. These medicines help to relax muscle fibres within the prostate, thereby reducing the obstruction to the urine flow. They do not reduce the size of the prostate. Examples include terazosin (Hytrin), alfuzosin (Xatral) and tamsulosin (Flomax MR). Patients occasionally experience side effects such as dizziness, headache, drowsiness and retrograde ejaculation.
  • 5-alpha-reductase inhibitors such as finasteride (Proscar) inhibit the growth of the prostate and decrease the size of the gland.
Research studies have shown that both types of medical treatment are effective at improving urinary symptoms in men with BPH.

 There are also different kinds of over-the-counter herbal medicine on the market. However, these preparations are not generally recommended because their effect has not been completely documented. Those which do have some supporting evidence are saw palmetto and beta-sitosterol plant extracts and rye grass pollen extract.

What kind of surgery is available?

 An operation on the prostate will involve the removal of parts of the enlarged tissue.

The most common operation is an endoscopic surgical procedure where parts of the enlarged tissue are peeled off. This is called transurethral resection of the prostate (TURP).

If the prostate is only slightly enlarged, it may be enough to make a little cut in the prostate, without removing tissue, to reduce the constriction of the urethra. This is called transurethral incision (TUI).

 If the prostate is considerably enlarged, it may be necessary to make an incision in the lower abdomen and to carry out an open operation. But this procedure is rarely carried out.

 Surgery carries more risk than medical treatment and there are possible complications including retrograde ejaculation. In retrograde ejaculation, the sperm enters the bladder during ejaculation instead of being expelled through the penis. Later it is flushed out with urine.

Studies estimate that 74 per cent of men will experience retrograde ejaculation after transurethral resection of the prostate (TURP).

 Surgery has also been linked with side effects of erectile dysfunction (in 14 per cent of men after TURP) and urinary incontinence (5 per cent). But studies are inconclusive as to whether the same rates of these problems would have occurred anyway in men not undergoing surgery.

The benefits of surgery are long lasting, but because only part of the prostate is removed, some men may eventually need another operation.

 Are there other more gentle surgical treatments?

 Newer treatments for benign prostate hyperplasia already exist and are continually being developed. These techniques are minimally invasive. Some need only local anaesthesia and the risk of complications is smaller.

A couple of general points about these new techniques:
  • it is still not fully known whether the results are as effective as endoscopic surgery. Doctors are continually learning which patients are most suitable for each treatment.
  • the techniques concerned are still being developed and tested.
    Microwave thermotherapy

    In this treatment, the prostate tissue is heated to around 45ºC by means of microwaves. This reduces the size of the prostate by causing cells in the centre of the prostate to die. This treatment is carried out through the urethra.
    Electrovaporisation

    In this procedure, part of the prostate tissue is removed by evaporation by means of electrical current. The treatment is performed with an endoscope.
    Laser-resection

    Another endoscopic treatment, in which part of the prostate tissue is removed with laser energy. For this treatment, a passage is created by inserting a tube made of metal or plastic - which remains in place where the prostate gland obstructs the urethra.

    This procedure is used only on rare occasions, for those patients who are unable to be considered for other forms of treatment.
Is treatment with a catheter a possibility?

 Some patients with urine retention who cannot endure an operation, may have to have a permanent catheter. This can be placed through the urethra or through the lower abdomen into the bladder. But with a permanent catheter, the patient is at greater risk of cystitis (infection of the bladder).

An alternative, is for the patient to learn to empty the bladder himself with a catheter. This way the catheter is removed after each use and the danger of infection is reduced.

References:

NHS Centre for Reviews and Dissemination. Benign Prostatic Hyperplasia. Effective Healthcare Bulletin, December 1995.

McConnell JD, Barry MJ, Bruskewitz RC, et al. Benign Prostatic Hyperplasia: diagnosis and treatment. Clinical Practice Guideline, Number 8. US Agency for Health Care Policy and Research, Pub. No. 94-0582: US Department of Health and Human Services, February 1994.

Barry MJ, Roehrborn CG. Benign prostatic hyperplasia. In Clinical Evidence, Issue 5. BMJ June 2001.
Based on a text by Dr Bettina Norby and Dr Ejnar Kuur

Last updated 02.03.2005

Copyright 1998-2008 NetDoctor.co.uk

(BPH_Overview.htm)
Posted July 5, 2008
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