Hyperplasia is a general medical term referring to an abnormal increase in cells. Benign prostatic hyperplasia (BPH) is noncancerous cell growth of the prostate gland. It is the most common noncancerous form of cell growth in men and usually begins with microscopic nodules in younger men. BPH is not a precancerous condition and does not lead to prostate cancer.
As BPH progresses, it can lead to enlargement of the prostate gland (a condition called benign prostatic enlargement [BPE]). About half of men with BPH go on to develop an enlarged prostate. As the prostate grows, it can squeeze the urinary tube (urethra), causing urinary symptoms. These urinary difficulties are part of a group of symptoms called collectively lower urinary tract symptoms (LUTS).
The size of the prostate gland in patients with an enlarged prostate is not always directly related to a patient’s symptoms. Not all men with BPH have LUTS, and not all men with LUTS have BPH. About a third of men with BPH have symptoms that interfere with their quality of life.
Description of the Prostate Gland. The prostate is a walnut-shaped gland located below the bladder and in front of the rectum. It wraps around the urethra (the tube that carries urine through the penis).
Functions of the Prostate Gland. The prostate gland provides the following functions:
Changes During the Lifespan. The prostate gland undergoes many changes during the course of a man's life. At birth, the prostate is about the size of a pea. It grows only slightly until puberty, when it begins to enlarge rapidly. It reaches normal adult size and shape, about that of a walnut, when a man is in his early 20s. The gland generally remains stable until about the mid-40s, when, in most men, the prostate begins to grow again through a process of cell multiplication.
The process of urination is more complicated than it appears:
The causes of benign prostatic hyperplasia are not fully understood. Several theories have been proposed to explain benign cell growth in older men.
Male Hormones. Androgens (male hormones) most likely play a role in prostate growth. The most important androgen is testosterone, which is produced in the testes throughout a man''s lifetime. The prostate converts testosterone to a more powerful androgen, dihydrotestosterone (DHT). DHT stimulates cell growth in the tissue that lines the prostate gland (the glandular epithelium) and is the major cause of the rapid prostate enlargement that occurs between puberty and young adulthood. DHT is a prime suspect in prostate enlargement in later adulthood.
Female Hormones. The female hormone estrogen may also play a role in BPH. (Some estrogen is always present in men.) As men age, testosterone levels drop, and the proportion of estrogen increases, possibly triggering prostate growth.
Another theory focuses on cells in a certain section of the gland that may become active late in life, signaling other prostate cells to replicate or causing them to be sensitive to growth-stimulating hormones.
Lower urinary tract symptoms (LUTS) are categorized either as voiding (formerly called obstructive) or storage (formerly called irritative) symptoms. BPH is often, but not always, the cause of LUTS, especially the voiding symptoms. Other medical conditions, such as bladder problems, can also cause these symptoms.
Some men with BPH may have few or no symptoms. The size of the prostate does not determine symptom severity. An enlarged prostate may be accompanied by few symptoms, while severe LUTS may be present with normal or even small prostates.
Voiding symptoms can be caused by an obstruction in the urinary tract. They are often due to BPH. (Obstruction is the most serious complication of BPH and requires medical attention.) Voiding symptoms include:
Storage symptoms, also referred to as filling symptoms, include:
Urinary retention (inability to void) is a serious symptom of severe BPH that requires immediate medical attention. Urinary retention can be a sign of obstruction in the bladder. Bladder obstruction can cause bladder stones, urinary tract infections, blood in the urine, and incontinence.
A doctor makes a diagnosis of BPH based on description of symptoms, medical history, physical examination, and various blood and urine tests. The doctor may recommend that the patient sees a urologist for complex test procedures.
Some diagnostic tests are used to rule out cancers of the prostate or bladder as the cause of symptoms. In some cases, symptoms of prostate cancer can be similar to those of BPH. Tests may also be performed to see if BPH has caused any kidney damage.
The doctor will ask about the patient’s personal and family medical history, including past and present medical conditions. The doctor will also ask about any medications the patient may be taking that could cause urinary problems
Digital Rectal Exam. The digital rectal exam is used to detect an enlarged prostate. The doctor inserts a gloved and lubricated finger into the patient''s rectum and feels the prostate to estimate its size and to detect nodules or tenderness. The exam is quick and painless. The test helps rule out prostate cancer or problems with the muscles in the rectum that might be causing symptoms, but it can underestimate the prostate''s size. It is never the sole diagnostic tool for either BPH or prostate cancer.
Other Physical Examinations. The doctor will usually press on and manipulate (palpate) the abdomen and sides to detect signs of kidney or bladder abnormalities. The doctor will also check for signs of swelling in the legs and arms. Certain procedures that test reflexes, sensations, and motor response may be performed in the lower extremities to rule out possible neurologic causes of bladder dysfunction.
A PSA test measures the level of prostate-specific antigen (PSA) in the patient''s blood. It is a widely used but controversial screening test for prostate cancer. High PSA levels may indicate prostate cancer, but BPH itself usually raises PSA levels. [For more information, see In-Depth Report #33:
A urinalysis can detect signs of bleeding or infection. A urinalysis involves a physical and chemical examination of a urine sample. A urinalysis also helps rule out bladder cancer.
To determine whether the bladder is obstructed, an electronic test called uroflowmetry measures the speed of urine flow. To perform this test, the patient urinates into a special toilet equipped with a measuring device. A reduced flow may indicate BPH. However, bladder obstruction can also be caused by other conditions including weak bladder muscles and problems in the urethra.
Cystoscopy, also called urethrocystoscopy, is a test performed by a urologist to check for problems in the lower urinary tract, including the urethra and bladder. The doctor can determine the presence of structural problems including enlargement of the prostate, obstruction of the urethra or neck of the bladder, anatomical abnormalities, or bladder stones. The test may also identify bladder cancer, and causes of blood in the urine and infection.
In this procedure, a thin tube with a light at the end (cytoscope) is inserted into the bladder through the urethra. The doctor may insert tiny instruments through the cytoscope to take small tissue samples (biopsies). Cytoscopy is typically performed as an outpatient procedure. The patient may be given local, spinal, or general anesthesia.
Ultrasound is a painless procedure that can give an accurate picture of the size and shape of the prostate gland. Ultrasound may also be used for detecting kidney damage, tumors, and bladder stones. Ultrasound tests of the prostate generally use one of two methods:
The postvoid residual urine volume (PVR) test measures the amount of urine left after urination. Normally, about 50 mL or less of urine is left; more than 200 mL is a sign of abnormalities. Measurements in between require further tests. The most common method for measuring PVR is with a catheter, a soft tube that is inserted into the urethra within a few minutes of urination. PVR can also be measured using transabdominal or suprapelvic ultrasonography.
In addition to prostate cancer, other conditions and factors can cause lower urinary tract symptoms similar to those associated with BPH:
Structural Abnormalities. Abnormalities in the urinary tract can cause BPH-like symptoms. These abnormalities include narrowing of the urethra, weakened bladder, and prostate muscle contractions. Such conditions can produce obstruction, impairor weaken the detrusor muscles surrounding the bladder, or cause other damage that impacts the urinary tract.
Prostatitis. Prostatitis is an inflammation of the prostate gland that can be caused by bacterial or nonbacterial factors. (The most common form of prostatitis is nonbacterial, a condition also called prostatosis.) Symptoms include urgent need to urinate, frequent urination, and the need to urinate at night. Pain may occur in the lower back or rectum, or it may develop after ejaculation.
Medications. A number of medications can cause lower urinary tract symptoms or urinary retention, and can worsen symptoms of BPH. These medication classes include antihistamines, decongestants, diuretics, opiates, and tricyclic antidepressants.
Age is the major risk factor for BPH. Over half of men develop BPH by age 60 and about 85% of men have BPH by age 85. It is uncommon for BPH to cause symptoms before age 40.
A family history of BPH appears to increase a man's chance of developing the condition.
Some evidence indicates that the same risk factors associated with heart disease may increase the risk of developing BPH. These risk factors include obesity, high blood pressure, low levels of HDL (“good”) cholesterol, diabetes, and peripheral artery disease (PAD). Lifestyle factors that are unhealthy for the heart (lack of physical activity, cigarette smoking, poor diet) may also possibly increase BPH risk or worsen its symptoms.
Because BPH rarely causes serious complications, men usually have a choice between treating it or opting for watchful waiting:
The choice between watchful waiting and treatment usually depends on symptoms severity. The American Urological Association’s BPH Symptom Score uses seven questions to evaluate a patient’s urinary symptoms during the past month. (The International Prostate Symptoms Score is another index that is also used.) The questions are:
Responses for the first six questions are scaled from “not at all” to “almost always.” (The last question uses answers ranging from “none” to “5 or more times”.) Each response is assigned a number on a scale of 0 to 5, and totaled into a symptom score. The symptom score can fall anywhere between 0 and 35.
Patients with mild symptoms will have low scores and may decide to delay treatment. Higher scores indicate more severe symptoms. Treatment can reduce the score:
Your doctor can discuss with you the various treatment options and the likelihood of symptom relief they may provide. All treatments have various side effects, which need to be taken into consideration. Quality of life is as important as symptom severity.
Medications. In general, there is no reason to treat BPH with medications unless symptoms become very uncomfortable. The size of the prostate, determined by exam or ultrasound, cannot indicate the need for medications. Evidence suggests that:
Surgery. A quarter of men with moderate symptoms, and even more men with severe symptoms, eventually need surgery. If a man chooses surgery, there are many choices. Transurethral resection of the prostate (TURP) is the standard procedure, but less invasive procedures, particularly those using heat or lasers to destroy prostate tissue, are becoming more common.
The most common reason for choosing surgery is obstruction of the bladder outlet, which causes urinary retention. Surgery is also typically a reasonable option when BPH is clearly related to one or more of the following conditions:
Increased urinary flow and reduced urine retention are the greatest improvements resulting from surgery. Often, however, the benefits of surgery are not permanent.
Certain lifestyle changes may help relieve symptoms and are particularly important for men who choose to avoid surgery or drug therapy. They include:
Decongestants and Antihistamines. Men with BPH should avoid, if possible, the many medications for colds and allergies that contain decongestants, such as pseudoephedrine (Sudafed). Such drugs, known as adrenergics, can exacerbate urinary symptoms by preventing muscles in the prostate and bladder neck from relaxing to allow urine to flow freely. Antihistamines, such as diphenhydramine (Benadryl), can also slow urine flow in some men with BPH.
Diuretics. Men who are taking diuretics, which increase urination, may want to talk to their doctor about reducing the dosage or switching to another drug. These are important drugs for many people with high blood pressure, with a proven track record for saving lives. No one should go off these medications without medical supervision.
Other Drugs. Other drugs that may worsen symptoms are certain antidepressants and drugs used to treat spasticity.
Pelvic floor muscle exercises, first developed to help women with childbirth, may also help men prevent urine leakage, particularly after surgical procedure. These exercises strengthen the pelvic floor muscles that both support the bladder and close the sphincter.
Performing the Exercises. Since the muscle is internal and sometimes hard to isolate, doctors often recommend practicing while urinating:
A heart-healthy diet rich in vegetables and fruit may help reduce BPH risk. Some evidence indicates that fruits and vegetables rich in beta-carotene and vitamin C may help protect against BPH. Dietary choices should also focus on increasing intake of healthy fats, such as omega-3 fatty acids, and limiting intake of saturated fats and trans-fatty acids.
Generally, manufacturers of herbal remedies and dietary supplements do not need approval from the Food and Drug Administration to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been several reported cases of serious and even lethal side effects from herbal products. Patients should check with their doctor before using any herbal remedies or dietary supplements.
Popular herbal and dietary supplement treatments for BPH include:
The two primary drug classes used for BPH are:
Because these two types of drugs work in different ways, combinations of the two may control symptoms in select patients more effectively than either drug alone. The combination treatment may work best for patients with larger prostate glands and higher PSA readings. Many men, however, can control their condition with a single drug.
General Guidelines for Alpha-Blockers. Alpha-adrenergic antagonists, commonly called alpha-blockers, were originally used to treat high blood pressure. They are prescribed for BPH to relax smooth muscles in the prostate. The muscle cells in the prostate are stimulated by molecules called alpha adrenergic receptors. This can cause lower urinary tract symptoms.
Drugs that block these receptors relax the muscles in and around the prostate, increase urinary flow and improve symptoms, sometimes significantly. Improvement occurs within days to weeks. Because these drugs are short-acting, symptoms return very quickly once a man stops taking the medication. They neither affect PSA levels nor shrink the size of the prostate.
Alpha-blockers are prescribed for most men with BPH symptoms whose prostates are not significantly enlarged. Even men with moderately enlarged prostates might try alpha-blockers before more intense treatments because these drugs work fairly quickly, have no effect on sexual drive, and are the least expensive treatment for BPH. Some doctors now recommend alpha-blockers as first-line treatment for patients with moderate-to-severe symptoms.
These drugs are generally referred to as either nonselective or selective alpha-blockers. Nonselective alpha-blockers relax all smooth muscles in the body that surround blood vessels. Selective alpha-blockers target more specifically the smooth muscles of the prostate, but they can also affect other areas of the body, such as the eyes. Drugs in both categories are similar in effectiveness for reducing symptoms and improving urinary flow. There are some differences, however. Discuss with your doctor which alpha-blocker is best for your individual condition.
Brands. Nonselective alpha-blockers (also referred to as alpha-specific antagonists) for treatment of BPH include:
Selective alpha-blockers for treatment of BPH are:
Side Effects. Alpha-blockers can reduce blood pressure, which may cause dizziness lightheadedness, and fainting. Orthostatic hypotension, a sudden drop in blood pressure when standing, can occur and increases the risk of falling. Taking the medication close to bedtime can help reduce these side effects. Because of the reduced blood pressure side effect, do not take phosphodiesterase inhibitors [such as sildenafil (Viagra)] at the same time, at least without advice from a doctor.
Alpha-blockers can also cause headache, and stuffy or runny nose. Men may also experience a decreased ejaculate. (Erectile dysfunction is not a usual side effect of alpha-blockers, as it is with finasteride and dutasteride.)
A special concern for tamsulosin (Flomax), and other selective alpha-blockers, is that they are associated with a condition called intraoperative floppy iris syndrome (IFIS). IFIS is a loss of muscle tone in the iris that can cause complications during eye surgery. Patients who are planning cataract or other eye surgery should be sure to inform their doctors prior to the surgery. IFIS appears more likely to occur with the newer, selective alpha-blockers than non-selective alpha blockers.
The prostate gland contains an enzyme called 5 alpha-reductase that converts testosterone to another androgen called dihydrotestosterone. Finasteride (Proscar) and dutasteride (Avodart), known as 5-alpha-reductase inhibitors (5-ARIs), block this enzyme and thus reduce dihydrotestosterone in the prostate. This process helps to shrink an enlarged prostate and prevent future growth of the prostate. These drugs can also help prevent against urinary retention, and possibly reduce the need for future prostate surgery.
5-alpha-reductase inhibitors are not as effective as alpha-blockers in improving BPH and urinary tract symptoms, but they can help modestly reduce symptoms for some men. However, these drugs take several months before they have an effect so men may not notice any signs of improvement for 3 - 6 months. The 5 alpha-reductase inhibitors are most effective in reducing symptoms in men with enlarged prostates.
Side Effects. The main side effects of finasteride and dutasteride are erectile dysfunction, lowered sexual drive (libido), and reduced semen release during ejaculation. These side effects generally subside within a year or two of treatment. (A positive side effect of finasteride is possible reduction of hair loss related to male hormones and, in some cases, hair growth in men with mild-to-moderate male pattern baldness.)
There is ongoing debate on whether 5-alpha-reductase inhibitors can help prevent prostate cancer. The American Society of Clinical Oncology and American Urological Association recently issued guidelines concerning the pros and cons of 5-ARIs for prostate cancer prevention. Men who take these drugs for BPH should discuss this issue with their doctors.
These drugs decrease prostate-specific antigen (PSA) levels, which may mask the presence of prostate cancer. To resolve this problem, doctors calculate PSA levels in men taking these drugs by doubling the PSA values. This doubling equation helps provide an accurate measurement
PDE5 Inhibitors. Phosphodiesterase-5 (PDE5) inhibitors are used to treat erectile dysfunction (ED). They include sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). Because lower urinary tract symptoms (LUTS) and ED often occur together in older men, researchers are investigating whether PDE5 inhibitors may help improve BPH symptoms. Some studies indicate that sildenafil improves urinary symptoms in men who have both ED and LUTS. It is also being evaluated in combination with selective alpha-blocker drugs.
Several surgical approaches are available for treating BPH. Reasons for performing prostate surgery include:
Invasive Procedures. The most effective surgical procedure, transurethral resection of the prostate (TURP) is also the most invasive. It has the highest risk for serious complications, including blood loss, erectile dysfunction, and urinary incontinence. However, because it is more effective than less invasive procedures, TURP remains the procedure of choice for many doctors. When considering invasive surgery, the patient should be sure that the surgeon is experienced in performing these procedures.
Less Invasive Procedures. Minimally invasive procedures use some form of heat to destroy excess prostate tissue. The heat may be delivered by:
Although some of these minimally invasive procedures may be an appropriate choice for patients depending on the circumstances, none of them to date have proven superior to TURP. Over 5 - 10 years of follow-up, a higher percentage of patients receiving these less invasive procedures need surgery again. Minimally invasive procedures may be appropriate for certain patients, such as:
Transurethral resection of the prostate (TURP) involves surgical removal of the inner portion of the prostate, where BPH develops. It is the most common surgical procedure for BPH, although the number of procedures has dropped significantly over the past decades because of the availability of effective medications.
Procedure. TURP usually requires a 1 - 3 day hospital stay. The surgeon inserts a fiberoptic endoscope, which is a thin tube, into the urethra. No incision is needed. The surgeon uses the endoscope to cut away excess prostatic tissue, and water solutions are used to flush away the excised matter.
Risk of Water Intoxication. If the fluids used during TURP build up, water intoxication can develop, which can be serious. This condition is referred to as the transurethral resection (TUR) syndrome and includes abdominal cramps, nausea, vomiting, lethargy, and dizziness. It occurs in about 2% of patients and is a temporary condition occurring immediately after surgery, which can be treated with diuretics to remove excess fluid.
Postoperative Catheterization. A Foley catheter generally remains in place for 3 - 5 days after surgery to allow urination. This device is a tube inserted through the opening of the penis to drain the urine into a bag. The catheter can cause bladder spasms that can be painful, but they eventually cease.
Recuperation. Urine flow is stronger almost immediately after most TURP procedures. After the catheter is removed, patients often feel some pain or sense of urgency as the urine passes over the surgical wound. These sensations gradually subside. Complete healing takes about 2 months. The following are some tips for hastening recovery and avoiding complications:
Postoperative Complications. Complications after TURP can be high, depending on the skill of the surgeon and other factors, but their incidence has decreased considerably over the past decades because of advances in surgical technique and more widespread expertise.
Repeat Operations. Symptomatic relief is usually maintained for at least 15 years after surgery, but BPH may return or patients may need a second operation for other reasons. Up to 10% of TURP patients need a repeat operation within 10 years. Sometimes, scarring in the bladder severe enough to cause obstruction occurs within a year of the procedure and may require transurethral incision (TUIP). More often, the urethra is scarred and narrows, but usually this condition can be corrected by a simple stretching procedure performed in the doctor's office.
Transurethral Incision of the Prostate (TUIP). In TUIP, the surgeon makes only one or two incisions in the prostate, causing the bladder neck and the prostate to spring open and reduce pressure on the urethra. TUIP is generally used only for men with minimally enlarged prostates (30 grams or less) who have obstruction of the neck of the bladder.
TUIP is less invasive than TURP, has a lower rate of the same complications, particularly retrograde ejaculation, and usually does not require a hospital stay. More studies are still needed, however, to determine whether they are comparative in long-term effectiveness.
Open Prostatectomy. In open prostatectomy, the enlarged prostate is removed through an open incision in the abdomen using standard surgical techniques. This is major surgery and requires a hospital stay of several days. Open prostatectomy is used only for severe cases, about 2 - 3% of BPH patients, when the prostate is severely enlarged, the bladder is damaged, or other serious problems exist. Up to 14% of patients need a second operation because of scarring. In making a decision about prostatectomy, it is essential that the doctor explains the consequences of a diminished sexual capacity that occurs after this procedure. Prostatectomy should be considered a last resort if the patient still has an active sex life. Other complications are similar to those of TURP.
Procedures. Laser technology is used for removal of prostate tissue. Laser procedures can usually be done as an outpatient procedure, and there is little risk for bleeding.
These procedures have a faster recovery time and less risk of incontinence than invasive surgical procedures, but their longterm effectiveness is unclear. Laser surgery may not be appropriate for men with larger prostates. Different procedures are used to provide different degrees of thermal cell destruction that range from coagulation to complete vaporization:
These minimally invasive procedures carry less risks for incontinence or problems with sexual function than invasive procedures, but it is unclear how effective they are in the long term.
Transurethral Microwave Thermotherapy (TUMT). Transurethral microwave thermotherapy delivers heat using microwave pulses to destroy prostate tissue. A microwave antenna is inserted through the urethra with ultrasound used to position it accurately. The antenna is enclosed in a cooling tube to protect the lining of the urethra. Computer-generated microwaves pulse through the antenna to heat and destroy prostate tissue. When the temperature becomes too high, the computer shuts down the heat and resumes treatment when a safe level has been reached. The procedure takes 30 minutes to 2 hours, and the patient can go home immediately afterward.
Transurethral Needle Ablation (TUNA). Transurethral needle ablation is a relatively simple and safe procedure, using needles to deliver high-frequency radio waves to heat and destroy prostate tissue.
Transurethral Electrovaporization (TUVP). Transurethral electrovaporization uses high voltage electrical current delivered through a resectoscope to combine vaporization of prostate tissue and coagulation that seals the blood and lymph vessels around the area. Deprived of blood, the excess tissue dies and is sloughed off over time.
Water-Induced Thermotherapy (WIT). A device called Thermoflex, which circulates heated water through a catheter to destroy prostatic tissue, has been approved for treating BPH. Another technique uses a balloon filled with hot water to destroy tissue around the urethra.
Prostatic stents used for BPH are flexible mesh tubes that are inserted into the urethra. Typically, the insertion procedure takes only 15 minutes. Patients need only regional anesthetic and mild sedation. There is minimal recuperation and no overnight hospital stay. Unfortunately, stents often need to be removed later because of poor placement or complications, including irritation when urinating, urinary tract infections, and treatment failure. At this point, stents seem best suited for high-risk surgical patients or those with a limited life expectancy.
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