Benign Prostatic Hyperplasia (BPH)

What is Benign Prostatic Hyperplasia?

The prostate gland is part of the male reproductive system, and its main job is to produce fluid in semen that provides nutrition for the sperm. The development of the prostate gland is controlled by testosterone, a male hormone.

The prostate gland is about the size of a walnut and it lies below the bladder and in front of the rectum.
The urethra, emerging from the bladder, passes through the prostate tissue and serves to carry urine from the bladder out through the penis.

The prostate gland usually goes through 2 phases of growth during a man’s life — the first begins early on during puberty when the prostate gland doubles in size. The second phase starts around age 25 and continues as they age. The condition in which the prostate gland enlarges to more than 20-25 g is known as benign prostatic hyperplasia (BPH).

Prevalence

Benign prostatic hyperplasia is a very common condition affecting most males worldwide. Its prevalence increases after the age of 50 and reaches around 70-80% at the age of 90. Additionally, according to a study conducted on benign prostatic hyperplasia in Singapore, it was observed that with the population ageing, there is potential for the condition to become one of the most common urological conditions in the country.

Causes

While the causes of BPH are unknown, it is often suggested that BPH may be influenced by genetics, diet, and lifestyle. Recent reports have also suggested a correlation of BPH with metabolic syndrome (i.e., diabetes, hypertension, hyperlipidemia, obesity), erectile dysfunction, and inflammation.

Does BPH cause cancer?

BPH is a benign condition, which means it is not cancerous and will not increase the risk for prostate cancer. BPH itself may not need any treatment, but it can often cause several serious urinary symptoms that may warrant medical intervention when it affects your daily life.

What are the symptoms of Benign Prostatic Hyperplasia?

BPH can lead to lower urinary tract symptoms (LUTS) as the enlarging prostate begins to obstruct the urethra. Symptoms of BPH include:

Lower urinary tract symptoms (LUTS):

Frequency – having to urinate more often than normal
Urgency – feeling more frequent urges to urinate
Nocturia – getting up in the middle of the night to urinate
Weak urine stream
Intermittency – a urine stream that starts and stops
Straining to pass urine
Hesitancy – difficulty in starting urination
Dribbling of urine at the end of urination
The sensation of incomplete bladder emptying

In advanced BPH, these LUTS may lead to complications such as:

Having frequent urinary tract infections (UTIs) as the bladder fails to empty urine completely
Bladder stones
Blood in the urine (haematuria)
Inability to urinate (acute urinary retention) and kidney function impairment

When to visit the doctor

Although benign prostatic hyperplasia is not cancerous, the LUTS symptoms may get severe and affect urination and daily life. If you are experiencing any of the urinary problems described above, it would be prudent to visit a doctor to discuss the possible causes of your symptoms as well as further treatment plans. Even if these symptoms are not bothersome, it is important to identify and rule out any underlying causes of LUTS.

Possible causes of LUTS may include:

Overactive / underactive bladder
Benign prostatic obstruction
Distal ureteric stone/bladder stone
Bladder cancer
Urethral stricture
Urinary tract infection
Neurogenic bladder

If you experience acute urinary retention (sudden inability to pass urine and completely empty the bladder) seek medical attention immediately.

What can I expect during my first consultation?

During your initial consultation, the urologist will discuss your symptoms and signs and will take a detailed medical history, including your family history and past medical history, so that they get a good understanding of your condition.

The urologist may also perform a physical examination to assess the cause of your symptoms. Physical examination usually includes abdominal and digital rectal examinations (see below). A brief neurological physical examination may also be performed if indicated.

Following this, further investigations may be required to confirm the diagnosis and rule out any complications. The majority of these diagnostic tests can be carried out in the clinic.

How is BPH diagnosed?

There are many ways to evaluate benign prostatic hyperplasia. These include:

Physical examination — A digital rectal examination (DRE) is often the next step after taking your medical history to help confirm the diagnosis of BPH.
The DRE is a fairly quick process where the doctor inserts a gloved, lubricated finger into the anus to examine the prostate gland’s posterior (back) wall.
The doctor will look out for any prostate enlargement, pain, and lumps/hard spots which may occur due to prostate cancer. A DRE usually lasts for about 20 seconds, and it is relatively painless, although some patients may experience slight discomfort. Overall, a DRE is an essential investigation in detecting any issues quickly and early.

Bladder diary – This is an important assessment tool that allows patients to record the amount of fluid they intake, how often they urinate (volume and time), and if they experience any urine leakage as well. Other parameters that can be derived include day and night-time voiding frequency and the proportion of urine production during the night compared to the day. It is important that patients fill it out completely so that the urologist will be able to help them manage their symptoms effectively.

Urine tests are also a useful adjunct to rule out other differential diagnoses.
- Urinalysis — This involves collecting a sample of urine to check for any blood, signs of infection, glucose/sugar, proteins, and other components that may help doctors point to a diagnosis.
- Uroflow — This is a device that objectively measures the speed of urine flow.
- Post-Void Residual Urine (PVRU) — This test helps to measure the amount of urine left in the bladder and is performed with the help of an ultrasound scan. A high PVRU may necessitate early treatment.

Scans
- Ultrasound scans — This scan can be carried out to examine the prostate and to determine its size, shape, and surface. In addition, a kidney ultrasound is typically performed to rule out any swelling of the upper urinary tract that may occur as a result of prostate enlargement.
- Cystoscopy — This involves using a flexible, long, thin tube with a small video camera attached to the end of it, known as a cystoscope. The cystoscope is inserted into the urethra (which will be numbed with local anaesthetic beforehand), and the video camera at the end allows the surgeon to visualise the inside of the genitourinary tract, especially the urethra and bladder. This may be performed in patients with microscopic/gross haematuria (blood in the urine) to rule out bladder tumours.
- MRI/CT scans — These imaging tests are used to obtain a more detailed view of the body cavity. If any differential diagnoses, such as urinary stones or cancer are indicated, they can be ruled out with the help of these scans.

Blood tests may be done if cancer is suspected.
- Prostate-Specific Antigen (PSA) is used to screen for prostate cancer. A high PSA may be a sign that there is something amiss and may require further investigation to rule out prostate cancer.

How is Benign Prostatic Hyperplasia treated?

BPH leading to bothersome lower urinary tract symptoms can be treated in several ways, ranging from medical methods to surgery.

Medical treatment

Alpha-blockers are one of the most common drugs taken to help treat BPH. They act by relaxing the smooth muscles in the prostate gland and bladder neck and widening the outflow tract during the passage of urine from the bladder. They are generally very safe, although a small minority of patients may experience giddiness, a drop in blood pressure or ejaculation issues.
5-alpha reductase inhibitors act to prevent the conversion of testosterone into a more active form, which is responsible for the growth and development of the prostate gland. By inhibiting this conversion of testosterone, these drugs can help to shrink the prostate (by about 20%) and slow down the growth and progression of BPH. The most common side effects are erectile dysfunction and a decrease in libido.

Surgical treatment

Transurethral resection of the prostate (TURP) is safe and effective and is commonly used in managing BPH. It involves removing the part that obstructs the prostate gland with an instrument known as a resectoscope, which is inserted into the bladder through the urinary passage in the penis. The procedure is typically performed under spinal or general anaesthesia and may involve an inpatient stay of one to two days.
Laser therapy can be used to destroy and remove overgrown prostate tissue. It has a low side effect profile and is known to be effective in helping to reduce BPH symptoms in a safe and non-invasive manner. Laser therapy is offered to some patients, such as those on blood thinners for whom surgery is not recommended.
Novel methods such as convective water vapour energy ablation is injected into the prostate to shrink the prostate. It can be performed very quickly with sustained effect, and ejaculatory function can also be preserved. Additionally, an alternative treatment option known as Prostatic Urethral Lift (Urolift) can be performed in suitable patients, and it also has a lower incidence of sexual side effects.
Robot-assisted simple prostatectomy is a minimally invasive surgery where the entire prostate adenoma (benign tumour/BPH) is removed. This surgery is rarely performed and is reserved only for very large prostates.

What are the complications of Benign Prostatic Hyperplasia treatment?

While many complications do not usually occur with benign prostatic hyperplasia treatment, some patients may face the following:

Painful urination or difficulty with urinating – While this may occur at the start of the treatment, symptoms will usually resolve with time. Some patients may even experience urinary retention, frequency, or urgency, but these effects are temporary and will return to normal after a few months.

Urinary tract infection (UTI) – Patients who struggle with urination or are not able to empty the bladder completely may have a higher risk of getting a UTI. Additionally, the use of catheters in a number of benign prostatic hyperplasia treatments may result in UTIs.

Bladder and kidney damage – If the patient is not able to empty the bladder properly, the wall of the bladder may weaken over time, and as a result, the bladder wall muscles may not be able to contract properly. This contraction is essential to pass urine. The pressure of an overly distended bladder due to not being able to urinate properly can damage the kidneys as well.

Can Benign Prostatic Hyperplasia be prevented?

While there is no definite strategy to prevent BPH, adopting certain practices such as being more active, controlling type 2 diabetes, eating a well-balanced diet rich in fruits and vegetables, and limiting alcohol intake may have a positive impact on improving your urinary symptoms.

Summary

In conclusion, benign prostatic hyperplasia is a common condition among men as they age. Most men with an enlarged prostate do not develop many complications, and BPH can be readily treated with medication. If you suffer from BPH symptoms, ensure that you consult your urologist for a proper diagnosis and personalised treatment plan.

Benign Prostatic Hyperplasia (BPH)