BENIGN PROSTATIC HYPERPLASIA (BPH)

1. WHAT IS BPH?

BENIGN PROSTATIC HYPERPLASIA (BPH) is a condition affecting men, in which the prostate (a gland) becomes enlarged as part of the aging process.

2. DEFINITION:

BENIGN - NON-CANCEROUS

PROSTATIC - OF THE PROSTATE GLAND

HYPERPLASIA - INCREASE IN SIZE

From puberty until middle age, prostate growth is negligible. However, around the age of 40 years hormonal changes in men trigger prostate growth usually through the activity of a key hormone, dihydrotestosterone (DHT). This non-cancerous ("benign") growth is called "hyperplasia". While having BPH does not seem to increase a man's risk of prostate cancer, both conditions can be present at the same time. Therefore, it is recommended that all men over the age of 50 talk with their doctors about having an examination once a year to screen for prostate cancer.

3. THE PROSTATE (AND ITS FUNCTION)

The prostate is an organ about the size of a walnut (15 grams) and is situated at the base of the bladder in front of the rectum. It surrounds part of the urethra, the tube that carries urine from the bladder during urination, and seminal fluid during ejaculation. Its function is to secrete fluid into the semen, which helps to carry and nourish sperm, aiding in the process of conception.

4. HOW BPH DEVELOPS

As a man gets older the prostate tends to enlarge and often compresses against the bladder and urethra, thereby restricting the flow of urine. The more the prostate grows, the more the urethra is constricted and the harder the bladder muscles have to squeeze to allow the flow of urine. The muscles of the bladder wall thicken and become more sensitive, creating the need to urinate frequently, even when the bladder only contains a small amount of urine. Over time, this can cause urinary tract infections (UTI's). Also, the abdomen becomes swollen and painful. The bladder muscles can begin to weaken and urinary incontinence (a "weak bladder") can occur with only small dribbles of urine. In most men this usually requires surgery to repair the damaged bladder.

About one-tenth of men with BPH go on to develop Acute Urinary Retention (AUR), a condition characterized by a sudden and unexpected inability to pass urine. It can be extremely painful and inconvenient. Nearly one in three men over 80 years will go on to develop AUR. AUR is most often caused by increased resistance to urinary flow - i.e. blockage. Hence, BPH is the most common cause of AUR.

5. WHO GETS BPH?

The risk of BPH increases with age. If you have a family member who has BPH you are more likely to develop this condition. Interestingly, married men are more inclined to experience BPH than single men. It is one of the most common diseases to affect men over 40, with almost half of men over 65 experiencing problems associated with an enlarged prostate. Studies have found enlarged prostates in about 40% of men over 55, rising to 70% in men over 70, and to 90% in men aged 85 and over.

6. SYMPTOMS OF BPH

Symptoms of BPH develop slowly over time, and eventually begin to impact on the sufferer's quality of life. Common symptoms of BPH include:

Difficulty in starting to pass urine - getting the flow going

Frequent urination

Weak flow of urine despite a strong urge

Burning sensation while urinating

Waking during the night with a strong urge to urinate

Continuing pain in the lower back, pelvis or upper thighs.

Passing urine may be a stop-start process, with a feeling that the bladder hasn't been fully emptied. The bladder may then leak urine. Sometimes the need to pass urine will be very urgent and you will want to urinate more often. Over half of men with symptoms of BPH feel that their symptoms worsen with time, with only about one-third finding they remain stable. Some men learn to live with their symptoms if they are not too severe.

In the initial stages, men rarely need to alter their lifestyle, but with time, as the condition progresses, there are social consequences, such as staying close to a toilet and wearing dark trousers to conceal leakage.

It may happen that you will not be able to urinate if the bladder muscle has become over-stretched and cannot pass urine. Your doctor will have to insert a catheter to drain the bladder, after which you are likely to need an operation to correct the problem. In addition to the possibility of developing a UTI, the symptoms of BPH can lead to:

Kidney or bladder damage
Bladder stones
Incontinence

7. SEEING THE DOCTOR

If you are experiencing these symptoms your doctor will have to do various tests to confirm you have BPH. These tests include:

Digital Rectal Examination (DRE) examine your prostate by putting his/her finger in your rectum
Rectal ultrasound - rule out prostate cancer
Urine flow study - determine the emptying capacity of your bladder
Intravenous Pyelogram (IVP) - check your kidney function
Urine test - test for blood or infection in the urine
PSA (Prostate-Specific Antigen) test - rule out cancer

Often it may be necessary for the doctor to do a cytoscopy - a thin tube with a telescope at the end is inserted into the urethra. In this way, any conditions affecting the bladder, the urethra or the prostate can be identified, diagnosed, and the appropriate procedure/s accurately recommended.

8. TREATMENT OF BPH

BPH is more likely to affect a man's quality of life, rather than his "quantity" of life. It is therefore the degree to which the patient's symptoms bother him that will determine the need for, and extent of treatment. Treatment can be either surgical or non-surgical, but thanks to advances in various therapies and drugs, treatment has become less surgery-oriented.

SURGICALWhile surgical procedures are not 100% successful in all patients, more than two-thirds of men who have the operation are very pleased with the results.

The most common operation for BPH is called: Trans-Urethral Resection of the Prostate (TURP). The prostate and the bladder is examined through a very thin telescope inserted in the urethra (cytoscopy). Prostate tissue that may be blocking the passage of urine is "burnt" away with an electrical current to restore flow. If the prostate is very enlarged and the blockage is more severe, the whole prostate may need to be removed. The operation to relieve the obstruction is called a "prostatectomy". This procedure is only likely to be performed if there is complete blockage of urine or if there are complications, such as infection or bleeding. This will be done through a cut in the lower abdomen in a separate operation.

Another operation that is commonly performed is a Trans-Urethral Incision of the Prostate (TUIP), in which a cut is made in the bladder neck or along the length of the prostate to relieve the pressure on the urethra. A TUIP is usually performed if the prostate gland is only moderately enlarged.

Microwave and laser therapy are two procedures that are also being conducted but these forms of therapy are still being investigated and not yet widely practiced.

NON-SURGICALNon-surgical procedures are naturally a preferred option. Firstly, you can "watch and wait" if the prostate is only slightly enlarged. Symptoms need to be watched to see if there is any worsening of the condition. If not, treatment may not be necessary at this time. Secondly, there are drugs that can be safely used. A class of agents called alpha-blockers can be used to reduce muscular spasms at the base of the bladder, allowing urine to flow more freely. Another type of agent, the 5 a-reductase inhibitor, blocks the male hormone, testosterone, thereby shrinking the prostate. An advantage of using an alpha-blocker to counter the symptoms of BPH is that it is also prescribed for high blood pressure (hypertension). This is useful if a male patient has both BPH and hypertension at the same time, which is often the case.

Treatment for the more advanced condition, AUR (Acute Urinary Retention), will involve similar treatment options as BPH; however, there is a higher likelihood of surgery needing to be performed.

9. THINGS YOU CAN DO TO HELP

Rather than wait until you experience the uncomfortable and inconvenient symptoms of BPH, there are some common-sense things you can do to help yourself:

Eat a well-balanced diet - fruit/vegetables
Exercise more
Avoid smoking and excessive alcohol intake
Reduce stress in your life and sleep more
Go to your doctor if you have blood in your urine or a stinging sensation when you urinate
Take note of how much liquid you are drinking during the day and avoid strong tea/coffee

And, if you are over the age of 50, it might be a good idea to visit your doctor to have these basic tests done. After all, a gram of prevention is worth a kilogram of cure!

DISCLAIMER:

The health information contained herein is provided for educational purposes only and is not intended to replace discussions with a healthcare provider. All decisions regarding patient care must be made with a healthcare provider, considering the unique characteristics of the patient.

The Merck Manual of Medical Information. Second Home Edition Online. Access Date: 12 September 2005.
www.hsc.stonybrook.edu. Access Date: 12 September 2005.
www.uclaurology.com. Access Date: 12 September 2005.
www.jr2.ox.ac.uk/bandolier. Access Date: 12 September 2005.

22/CAR/09/05/PA