Benign prostatic hypertrophy (hyperplasia)

Definition

The prostate is a male reproductive gland that produces the fluid that carries sperm during ejaculation. It surrounds the urethra, the tube through which urine passes out of the body.

An enlarged prostate means the gland has grown bigger. Prostate enlargement happens to almost all men as they get older. As the gland grows, it can press on the urethra and cause urination and bladder problems.

An enlarged prostate is often called benign prostatic hyperplasia (BPH) or benign prostatic hypertrophy. It is not cancer, and it does not raise your risk for prostate cancer.

Alternative Names

BPH; Benign prostatic hypertrophy (hyperplasia); Prostate - enlarged

Causes

The actual cause of prostate enlargement is unknown. It is believed that factors linked to aging and the testicles themselves may play a role in the growth of the gland. Men who have had their testicles removed at a young age (for example, as a result of testicular cancer) do not develop BPH.

Similarly, if the testicles are removed after a man develops BPH, the prostate begins to shrink in size.

Some facts about prostate enlargement:

• The likelihood of developing an enlarged prostate increases with age.
• BPH is so common that it has been said, "All men will have an enlarged prostate if they live long enough."
• A small amount of prostate enlargement is present in many men over age 40 and more than 90% of men over age 80.
• No risk factors have been identified other than having normally functioning testicles.

Symptoms

Less than half of all men with BPH have symptoms of the disease, which include:

• Slowed or delayed start of the urinary stream
• Weak urine stream
• Dribbling after urinating
• Straining to urinate
• Strong and sudden urge to urinate
• Incomplete emptying of your bladder
• Needing to urinate two or more times per night
• Urinary retention (complete inability to urinate)
• Incontinence
• Pain with urination or bloody urine (these may indicate infection)

Exams and Tests

After taking a complete medical history, your doctor will perform a digital rectal exam   to feel the prostate gland. The following tests may also be performed:

• Urine flow rate
• Post-void residual urine test to see how much urine is left in your bladder after urination
• Pressure flow studies to measure the pressure in the bladder as you urinate
• An IVP (an x-ray study) to confirm BPH or look for blockage
• Urinalysis to check for blood or infection
• Urine culture to check for infection
• Voiding cystourethrogram  
• A prostate-specific antigen (PSA) blood test to screen for prostate cancer
• Cystoscopy

In addition, you may be asked to complete a form to evaluate the severity of your symptoms and their impact on your daily life. Your score may be compared to past records to determine if the condition is getting worse.

Treatment

The choice of a treatment is based on the severity of your symptoms, the extent to which they affect your daily life, and the presence of any other medical conditions. Treatment options include "watchful waiting," lifestyle changes, medication, or surgery.

If you are over 60, you are more likely to have symptoms. But many men with an enlarged prostate have only minor symptoms. Self-care steps are often enough to make you feel better.

If you have BPH, you should have a yearly exam to monitor the progression of your symptoms and determine if any changes in treatment are necessary.

SELF-CARE

For mild symptoms:

• Urinate when you first get the urge. Also, go to the bathroom when you have the chance, even if you don't feel a need to urinate.
• Avoid alcohol and caffeine, especially after dinner.
• Don't drink a lot of fluid all at once. Spread out fluids throughout the day. Avoid drinking fluids within 2 hours of bedtime.
• Try NOT to take over-the-counter cold and sinus medications that contain decongestants or antihistamines. These medications can increase BPH symptoms.
• Keep warm and exercise regularly. Cold weather and lack of physical activity may worsen symptoms.
• Learn and perform Kegel exercises (pelvic strengthening exercises).
• Reduce stress. Nervousness and tension can lead to more frequent urination.

MEDICATIONS

• Finasteride lowers levels of hormones produced by the prostate, reduces the size of the prostate gland, increases urine flow rate, and decreases symptoms of BPH. It may take 3 to 6 months before you notice a significant improvement in your symptoms. Potential side effects related to use of finasteride include decreased sex drive and impotence.
• Alpha 1-Blockers (doxazosin, prazosin, tamsulosin, and terazosin) are a class of medications also used to treat high blood pressure. These medications relax the muscles of the bladder neck, allowing easier urination. Two thirds of the people treated with alpha 1-blocker medications report an improvement in symptoms.
• Antibiotics may be prescribed to treat chronic prostatitis (inflammation of the prostate), which may accompany BPH. Some men note relief of their BPH symptoms after a course of antibiotics.

SAW PALMETTO

Saw palmetto has been used by millions of men to ease BPH symptoms and is often recommended as an alternative to medication. Experts suggest a fat-soluble saw palmetto extract with 85-95% fatty acids and sterols. However, a well-conducted study published in the February 9, 2006 edition of the New England Journal of Medicine found that the popular herb was no better than a dummy pill in relieving the signs and symptoms of BPH. Further studies are needed. If you use saw palmetto and think it works, ask your doctor if you should still take it.

SURGERY

Prostate surgery may be recommended if you have:

• Incontinence
• Recurrent blood in the urine
• Urinary retention
• Recurrent urinary tract infections

The choice of a specific surgical procedure is usually based on the severity of your symptoms and the size and shape of your prostate gland.

• Transurethral resection of the prostate (TURP): This is the most common surgical treatment for BPH. The TURP is performed by inserting a scope through the penis and removing the prostate piece by piece.
• Transurethral incision of the prostate (TUIP): This procedure is similar to TURP, but is usually performed in men who have a relatively small prostate. This procedure is usually performed as an outpatient without need for a hospital stay. Like the TURP, a scope is inserted through the penis until the prostate is reached. Then, rather than removal of the prostate, a small incision is made in the prostatic tissue to enlarge the opening of the urethra and bladder outlet.
• Open Prostatectomy: An open prostatectomy is usually performed using general or spinal anesthesia. An incision is made through the abdomen or perineal area (i.e., through the pelvic floor, including the region from the scrotum to the anus). Then, the prostate is removed. This is a lengthy procedure, and it usually requires a hospital stay of 5 to 10 days.

The majority of men who have prostate surgery have improvement in urine flow rates and symptoms. Possible complications include impotence, urinary incontinence, retrograde ejaculation (semen flowing back into the bladder rather than out the penis), infertility, and urethral stricture

Various other procedures are available, such as those that destroy prostate tissue with heat generated by microwaves or lasers. Photoselective vaporization of the prostate (PVP), one of the newer laser technologies, is typically done as an outpatient procedure. The patient goes home on the same day. However, there is no long-term data for this procedure.

Robot-guided prostatectomy is another newer technique. However, the technology is not widely available, and surgeon experience should be taken into consideration. In addition, there are no long-term studies of this surgery.

Another form of treatment is prostatic stents.

For more information, see prostate surgery.

Support Groups

Several national groups provide information on BPH. See BPH support groups.

Possible Complications

Men who have had long-standing BPH with a gradual increase in symptoms may develop:

• Sudden inability to urinate
• Urinary tract infections
• Urinary stones
• Damage to the kidneys
• Blood in the urine

Even after surgical treatment, a recurrence of BPH may develop over time.

When to Contact a Medical Professional

Call your doctor right away if you have:

• Less urine than usual
• Fever or chills
• Back, side, or abdominal pain
• Blood or pus in your urine

Also call your doctor if:

• Your bladder does not feel completely empty after you urinate
• You take medications that may cause urinary problems, like diuretics, antihistamines, antidepressants, or sedatives. DO NOT stop or adjust your medications on your own without talking to your doctor
• You have taken self-care measures for 2 months without relief

Hormone Foundation. Hormones & you. Patient information page. Benign prostatic hyperplasia (enlarged prostate). J Clin Endocrinol Metab. 2005; 90(10):2.

AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. J Urol. 2003 Aug; 170:530-47.

Bent S, Kane C, Shinohara K, et. al. Saw Palmetto for Benign Prostatic Hyperplasia. NEJM. 2006; 354:557-566.