Benign Prostatic Hyperplasia (BPH)

Introduction, Symptoms and Complications

The prostate gland is present only in males. Enlargement of the prostate gland causes problems in urination in elderly male. (usually over the age of 60 years). With increase in life expectancy, the incidence of benign prostatic hyperplasia (also called BPH) has also increased.

What is the prostate gland? What is its function?

The prostate gland is a small organ about the size of a walnut and is part of the male reproductive system.

The prostate gland is situated just underneath the bladder and in front of the rectum. It surrounds the initial portion of the urethra (the tube that carries urine from the bladder). In other words, the initial portion of the urethra (about 3 cm. long) runs through the prostate.

The prostate is a male reproductive organ. It secretes fluid that nourishes and carries sperm into the urethra during ejaculation.

What is benign prostatic hyperplasia (BPH)?

“Benign prostatic” means the prostatic problem is not caused by cancer and “hyperplasia” means enlargement.

Benign prostatic hyperplasia or benign prostatic hypertrophy (BPH) is a non-cancerous prostatic enlargement that occurs in almost all men as they get older. As men age, the prostate gland slowly grows bigger (or enlarges). An enlarged prostate compresses the urethra, blocks the urine stream and causes problems in urination. Because of narrowing of the urethra, flow of urine becomes slower and less forceful.

Symptoms of BPH

The symptoms of BPH usually begin after age 50. More than half of men in their 60s and up to 90% of men in their 70s and 80s have symptoms of BPH. Most symptoms of BPH start gradually and worsen over the years. The most common symptoms of BPH are:

• Frequent urination, especially at night. This is usually a very early symptom.
• Slow or weak stream of urine.
• Difficulty or straining in starting the urine flow, even when the bladder feels full.
• Urge to urinate immediately is the most bothersome symptom.
• Straining to urinate.
• Interrupted urine flow.
• Leaking or dribbling at the end of urination. Drops of urine are expelled even after urination causing wetting of underclothes.
• Incomplete emptying of bladder.

Complications of BPH

Severe BPH can cause serious problems over a time in a few patients, if left untreated. Common complications of BPH are:

• Acute urinary retention: untreated severe BPH over time can cause sudden, complete and often painful blockage of urine flow. Such patients require insertion of a tube called a catheter to drain urine from the bladder.
• Chronic urinary retention: partial blockage of urine flow for a prolonged period can cause chronic urinary retention. Chronic urinary retention is painless and is characterized by an increased residual urine volume. The amount of urine which remains in bladder after normal urination is called residual urine. Its usual presentation is incomplete bladder emptying or frequent voiding of small amount of urine (overflow of urine).

• Damage to bladder and kidney: chronic urinary retention causes stretching of the muscular wall of the bladder. In the long term the bladder becomes weak and no longer contracts properly.

  Large residual urine volume leads to increased pressure in the bladder. High bladder pressure may lead to a back pressure of urine through the ureters and into the kidneys. Resultant fullness of the ureters and the kidneys eventually may lead to kidney failure.

• Urinary tract infection and bladder stones: inability to completely empty the bladder increases the risk of urinary tract infection and formation of bladder stones.
• Remember, BPH does not increase the risk for prostate cancer.

Diagnosis of BPH

When history and symptoms suggest BPH, the following tests are performed to confirm or rule out the presence of an enlarged prostate.

• Digital rectal examination (DRE) In this examination, a lubricated, gloved finger is gently inserted into the patient’s rectum to feel the surface of the prostate gland through the rectal wall. This examination gives the doctor an idea of the size and condition of the prostate gland.

  In BPH, on DRE, the prostate is enlarged, smooth, and firm in consistency. Hard, nodular and irregular feel of the prostate on DRE suggests cancer or calcification of prostate gland.

• Ultrasound and post-void residual volume test An ultrasound can estimate the size of the prostate and detect other problems such as malignancy, dilatation of the ureter and the presence of a kidney abscess.

  Ultrasound imaging is also used to determine the quantity of urine left in the bladder after urination. Post-void residual urine volume less than 50 ml indicates adequate bladder emptying. Post-void residual urine volume of 100 to 200 ml or higher is considered to be significant and further evaluation is needed.

• Prostate symptom score or index The International Prostate Symptom Score (IPSS) or AUA (American Urological Association) symptom index helps in the diagnosis of BPH. In this diagnostic modality, patients are asked about the presence or absence of common symptoms of benign prostatic hyperplasia. The answers are then scored and, on the basis of the calculated prostate symptoms score, the severity of the urinary problem is judged.
• Laboratory tests Laboratory tests do not help diagnosing of BPH. But they help in the diagnosis of associated complications and excluding problems with similar presentation. Urine is tested for infection and blood is tested for kidney function.
• Prostate Specific Antigen (PSA) is a screening blood test for cancer of the prostate.
• Other investigations Different investigationsperformed to diagnose or exclude the diagnosis of BPH are uroflowmetry, urodynamic studies, cystoscopy, prostate biopsy, intravenous pyelogram or CT urogram and retrograde pyelography.

Yes. Many symptoms of prostate cancer and BPH are similar, so on the basis of clinical symptoms it is not possible to differentiate between the two conditions. But remember, BPH is not related to prostate cancer. Three most important tests which can establish the diagnosis of prostate cancer are digital rectal examination (DRE), blood test for prostate- specific antigen (PSA) and prostate biopsy.

Life style changes and Medical treatment

Factors determining treatment options of BPH are severity of symptoms, the extent to which daily life is affected due to symptoms, and the presence of associated medical conditions. Goals of treatment of BPH are to reduce symptoms, improve quality of life, reduce post void residual urine volume and prevent complications of BPH.

Three different treatment options of BPH are:

A. Watchful waiting and lifestyle changes (no treatment)
B. Medical Treatment
C. Surgical Treatment

“Wait and watch” without any treatment is the preferred approach for men with mild symptoms or symptoms that don’t bother them. But watchful waiting does not mean to simply wait and do nothing to reduce symptoms of BPH. During watchful waiting, the person should make

changes in life style to reduce symptoms of BPH and also have regular yearly checkups to see if the symptoms are improving or getting worse. · Make simple changes in the habits of urination and in consumption of liquids.

• Empty bladder regularly. Do not hold back urine for long. Urinate as soon as the urge arises.
• Double void. This means urine is passed twice in succession. First empty the bladder normally in a relaxed way, wait for a few moments, and try to void again. Do not strain or push to empty.
• Avoid drinking alcohol and caffeine containing beverages in the evening. Both can affect the muscle tone of the bladder, and both stimulate the kidneys to produce urine, leading to night-time urination.
• Avoid excessive intake of fluid (take less than 3 liters of fluid per day). Instead of consuming a lot of fluid all at once, spread out intake of fluids over the day.
• Reduce fluid intake few hours before bedtime or going out.
• DO NOT take over-the-counter cold and sinus medications that contain decongestants or antihistamines. These medications can worsen symptoms or cause urinary retention.
• Change the timing of medications which increases volume of urine (e.g. diuretics).
• Keep warm and exercise regularly. Cold weather and lack of physical activity may worsen symptoms.
• Learn and perform pelvic strengthening exercises as they are useful to prevent urine leakage. Pelvic exercises strengthen the muscles of the pelvic floor which support the bladder and help in closing the sphincter. The exercises consist of repeatedly tightening and releasing the pelvic muscles.
• Bladder training focused on timed and complete voiding. Try to urinate at regular times.
• Treatment of constipation.
• Reduce stress. Nervousness and tension can lead to more frequent urination.

Medications are the most common and preferred way to control mild to moderate symptoms of BPH. Medications significantly reduce major symptoms in about two-thirds of treated men. There are two classes of drugs, alpha-blockers and anti-androgens (5-alpha-reductase inhibitors), for an enlarged prostate.

• Alpha-blockers (tamsulosin, alfuzosin, terazosin, and doxazosin) are prescription medicines that relax the muscles in and around the prostate, relieve urinary obstruction and allow urine to flow more easily. The most common side effects of alpha-blockers are light headedness, dizziness and fatigue.
• 5-alpha-reductase inhibitors (finasteride and dutasteride) are medicines that can reduce the size of the prostate gland. These drugs increases urine flow rate, and decreases symptoms of BPH. They do not work as quickly as alpha-blockers (improvement is seen within six months of starting treatment) and generally work best on men with severe prostate enlargement. The most common side effects of 5-alpha-reductase inhibitors are problems with erection and ejaculation, decreased interest in sex and impotence.
• Combination treatment: An alpha blocker and an alpha-reductase inhibitor work differently and have an additive effect when given simultaneously. Therefore combination of both drugs leads to significantly greater improvement in the symptoms of BPH, than taking either drug by itself. Combination treatment is recommended in men with severe symptoms, large prostate and inadequate response to the highest dose of an alpha blocker.

Surgical treatment

Surgical treatment is recommended in persons with:

• Bothersome, moderate to severe symptoms refractory to medical treatment.
• Acute urinary retention.
• Recurrent urinary tract infections.
• Recurrent or persistent blood in the urine.
• Kidney failure due to BPH.
• Bladder stones along with BPH.
• Increasing or significant post void residual urine in bladder.

Surgical treatment can be divided into two groups: surgical therapies and minimally invasive treatment. The standard surgical method is a transurethral resection of the prostate (TURP). Currently several newer methods are evolving in the surgical management of small to medium sized glands, which aim to achieve results comparable to TURP with less morbidity and cost.

Surgical Therapies

Surgical Therapies

Specific surgical procedures commonly used are transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP) and open prostatectomy.

1. Transurethral Resection of the Prostate (TURP)

TURP remains the gold standard treatment of prostate surgery and is more successful than medication. It relieves urinary obstruction in at least 85% to 90% of cases, and the improvement is usually long-lasting. TURP is a minimally-invasive operation, performed by urologists to remove part of the prostate gland blocking urine flow. TURP does not require any skin incision or stitches, but requires hospitalization.

Before surgery

• Before the procedure, fitness of the person is ensured.
• The patient is asked to stop smoking as smoking increases the risk of getting a chest and wound infection, and can delay recovery.
• The patient is asked to discontinue blood-thinning medications (warfarin, aspirin and clopidogrel).

During the procedure

• TURP generally takes about 60 to 90 minutes.
• TURP is usually done using spinal anesthesia. Antibiotics are given to prevent infection.
• During TURP, an instrument (resectoscope) is inserted in the urethra through the tip of the penis to remove the prostate.
• The resectoscope has a light and camera for vision, an electrical loop to cut tissue and seal blood vessels, and a channel which carries irrigating fluid into the bladder.
• Prostate tissue removed during the procedure is sent to a laboratory for histopathological examination to exclude prostate cancer.

After surgery

• The hospital stay is usually 2 to 3 days after TURP.
• Following surgery, a large triple lumen catheter is inserted through the tip of the penis (through the urethra) into the bladder.
• A bladder irrigation solution is attached to the catheter and the bladder is irrigated and drained continuously for about 12–24 hours.
• Bladder irrigation removes blood or blood clots that may result from the procedure.
• When the urine is free of significant bleeding or blood clots, the catheter is removed.

Advice after surgery

Following measures after TURP help in early recovery:

• Drink more fluids to flush out urine from the bladder.
• Avoid constipation and straining during defecation. Straining can result in increased bleeding. If constipation occurs, take a laxative for a few days.
• Do not start blood-thinning medications without advice of the doctor.
• Avoid heavy lifting or strenuous activity for 4-6 weeks.
• Avoid sexual activity for 4-6 weeks after surgery.
• Avoid alcohol, caffeine, and spicy foods.

Possible complications

• Immediate common complications are bleeding and urinary tract infection; while less common complications are TURP syndrome and problems from surgery.
• Subsequent complications of TURP are narrowing (stricture) of the urethra, retrograde ejaculation, incontinence and impotence.
• Ejaculation of semen into the bladder (retrograde ejaculation) is a common sequel a of TURP, occurring in about 70% of cases. This does not affect sexual function or pleasure but causes infertility.
• Factors which can increase the risk of complications are obesity, smoking, alcohol abuse, malnutrition and diabetes.

After discharge from the hospital, contact the doctor if the patient has:

• Difficulty or inability to void.
• Severe pain which persists even after medications.
• Bleeding with large blood clots that block the catheter.
• Signs of infection, including fever or chills.

2. Transurethral Incision of the Prostate (TUIP)

Transurethral incision of the prostate (TUIP) is an alternative to TURP for men with smaller prostates or very poor health and therefore, not suitable for TURP.

The set-up for TUIP is similar to TURP, but rather than removing tissue from the prostate, two or more deep lengthwise incisions (cuts) are made in the prostate. The cuts widen the urethral passage, relieve pressure on the urethra and improve the flow of urine.

Benefits of TUIP are less blood loss, less surgery-related complications, shorter hospital stay and recovery time; and less risk of retrograde ejaculation and urinary incontinence as compared to TURP.However, TUIP is less effective in providing symptom relief and/or symptoms return faster over a shorter period of time in some patients requiring a follow up treatment with TURP. TUIP is not the most effective method of treatment for a large-sized prostate.

3. Open Prostatectomy

Open prostatectomy is a type of surgery where an incision is made in the abdomen to remove the prostate. With availability of many effective and less invasive options, open prostatectomy is rarely used in the treatment of BPH.

An open prostatectomy is reserved only for very few men with severely enlarged prostates and in patients suffering from other problems that need simultaneous correction during surgery.

Minimally Invasive Treatments (MITs)

Minimally invasive methods are those that hurt the least. With modern technology and research, minimally invasive treatments are aimed at treating BPH through simpler procedures with less complications. These treatment modalities generally use heat, laser, or electrovaporization to remove excess tissue from the prostate. All of these treatments use a transurethral approach (going up through the urethra in the penis).

Benefits of minimally invasive treatments are: shorter hospital stay, need for minimal anaesthesia, less risks and complications than standard prostate surgery, and shorter patient recovery times. Disadvantages of these methods are: less effectiveness than standard TURP, more likely to need surgery again after 5 or 10 years, non availability of prostate tissue for histopathological examination (to exclude hidden prostate cancer) and fewer long-term studies for their safety and efficacy. Important additional drawback is that minimally invasive treatments (MITs) are not available in majority of developing countries and are currently more expensive.

Different minimally invasive treatments used in BPH are transurethral microwave thermotherapy (TUMT), transurethral needle ablation (TUNA), water-induced thermotherapy (WIT), prostate stents and transurethral laser therapy.

1. Transurethral Microwave Thermotherapy (TUMT): In this procedure,microwave heat is used to burn excess prostate tissue blocking urine flow.
2. Transurethral Needle Ablation of the Prostate (TUNA): In this procedure, radiofrequency energy is used to coagulate and necrose excess prostate tissue blocking urine flow.
3. Water-Induced Thermotherapy (WIT): In this technique, hot water causes heat-induced coagulation and necrosis of the excess prostate tissue.
4. Prostatic Stents: In this technique, a stent is placed within the narrowed area of the prostatic urethra. The stent keeps the channel open and allows easy urination. Stents are flexible, self-expanding titanium wire devices shaped like small springs or coils.
5. Transurethral Laser Therapy: In this technique, laser energy destroys the obstructing portions of the prostate by heating.

When should a patient with BPH consult a doctor?

Patients with BPH should consult a doctor in case of:

• Complete inability to urinate.
• Pain or burning during urination, foul-smelling urine, or fever with chills.
• Blood in the urine.
• Loss of control of urination causing wetting of underclothes.