Benign prostatic hyperplasia  (BPH) is the enlargement of the prostate gland, which can give rise to bothersome lower urinary tract symptoms and cause discomfort to the patient.

It is essentially benign (noncancerous) and affects men over the age of 45 years. Though the cause is not yet known, risk factors have been identified, the main being age, metabolic syndrome, and a familial tendency.

There are various criteria to diagnose benign hyperplasia of the prostate and treatment guidelines offer several options to manage this condition. Your urologist who will treat this condition will evaluate your prostate size, the severity of your symptoms, and your overall health to choose the right treatment option.

In some men, the symptoms may improve on their own, and as such a wait and watch option and correcting your diet and lifestyle has produced satisfactory results.

BPH diagnosis guidelines

Symptoms provide a very valuable hint of prostate involvement. However, a confirmed diagnosis of BPH has to made and for that, the following steps are adopted.

  • Family history can be useful as BPH tends to run in families.
  • A digital rectal examination (DRE) provides valuable information to the urologist about the enlargement of the prostate gland.
  • A routine urine analysis gives information about the presence of urinary tract infection or the presence if bladder stones.
  • Renal function blood tests provide information about the state of the kidneys and their function.
  • PSA blood test. Prostate-specific antigen (PSA) is a protein made by the prostate and is present in small quantities when the prostate is healthy. This test is done before the DRE. High levels can indicate prostate enlargement. Elevated PSA levels can also be due to recent surgery or procedures, infection, and prostate cancer.

Sometimes, further tests may be required to arrive at a conclusive diagnosis. They include:

  • Urinary flow test or the uroflow test. You’ll need a full bladder for the test. You urinate into a container connected to a measuring device. It measures the amount of urine, the rate of urine flow in seconds, and the length of time to pass all of the urine. This gives an idea to the urologist as to how well your lower urinary tract is functioning. A slow flow might mean you have weak bladder muscles or a blockage in your urinary tract that could be due to an enlarged prostate.
  • Postvoid residual volume test. The ultrasound or a catheter inserted into your bladder measures the amount of urine that remains in your bladder after you have urinated. A volume less than 50 mL is normal and less than 100 mL is usually acceptable in patients above 65 years but abnormal in younger patients.
  • 24-hour voiding record diary. This test records the frequency and amount of urine you pass during the 24 hour period. With BPH, you pass more than one-third of your daily urinary output at night.

In more complicated cases, your doctor may recommend additional tests.

  • Transrectal ultrasound. The ultrasound probe is inserted into your rectum and the ultrasound measures the size of your prostate.
  • Prostate biopsy. Under transrectal ultrasound guidance, the urologist inserts the biopsy needle into the prostate to take out pieces of suspicious tissue from the prostate. Histopathology then helps to rule out prostate cancer.
  • Urodynamic and pressure-flow studies. A catheter is threaded through the urethra into your bladder and water or air is slowly injected. This helps to measure bladder pressure and determine how well your bladder muscles are working.
  • Cystoscopy. A cystoscope is inserted into the bladder through the urethra and the inside is viewed to check for any abnormality.

BPH treatment guidelines

Therapeutic considerations for BPH consist of the following:

  • Watchful waiting
  • Drug therapy
  • Interventional therapy

Your treating urologist will identify the best treatment option for you after a careful evaluation of your prostate condition, symptoms, and overall health.

Watchful waiting

Watchful waiting is recommended in men with mild symptoms of BPH and those with moderate to severe symptoms who are not bothered by their symptoms and in whom no complications have developed.

These are the identified men in whom medicines are not likely to improve the symptoms. These men are, however, examined periodically every few months. An enlarged prostate often develops gradually, and symptoms may not bother you for some time.

Men with BPH carry risk factors such as metabolic syndrome. Such men should address this or any other such risk by medication and improving their lifestyle.

Men who have associated metabolic syndrome should postpone the progression of BPH by lowering blood glucose, improving insulin resistance, and reducing inflammation through an improved lifestyle and clinical treatment of the comorbidities.

Suggested lifestyle changes:

  • Avoid caffeine, alcohol, artificial sweeteners, and aerated drinks because they can irritate the bladder and worsen your urinary symptoms.
  • If you are taking any long-term medication, make sure it does not worsen your LUTs because certain medicines such as antidepressants can do so.
  • Eat more fruits, vegetables, and foods with fiber as it helps avoid constipation that makes urinary symptoms worse.
  • Exercise regularly as it helps reduce the symptoms.

Some men experience the ease of symptoms without medication, by improving lifestyle and by addressing the comorbidities.

Drug therapy for BPH

The medical therapeutic options for BPH have changed significantly over the years, with the development of receptor-specific alpha-blockers that form the first line of therapy, and the approval of 5-alpha-reductase inhibitors.

  • Alpha-blockers. Alpha-blockers relax the bladder neck sphincter, the urethra, and the smooth muscle fibers of the prostate making it easier to pass urine. They act fast and effects are seen more quickly in men with smaller prostate. Side effects include dizziness and retrograde ejaculation. This is a harmless condition in which the semen goes back into the bladder instead of out of the penis during ejaculation. Examples include alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax), and silodosin (Rapaflo).
  • 5-alpha reductase inhibitors. 5-alpha-reductase inhibitors reduce the size of your prostate by inhibiting the hormonal changes that cause prostate enlargement. They reduce DHT levels by more than 80%, thereby improving symptoms, reducing urinary retention, and the likelihood of surgery for BPH. They act slowly and may take up to six months to show effect. They can reduce serum PSA values by as much as 50%. Examples include finasteride (Proscar) and dutasteride (Avodart). Side effects include decreased libido and retrograde ejaculation.
  • Combination drug therapy. In cases where one of the drugs above is not effective, your doctor may prescribe you both drugs in combination for better therapeutic effect.
  • Tadalafil (Cialis). The long-acting PDE5 inhibitor tadalafil (Cialis) produces significant improvement in symptoms of BPH/LUTS. It can be used alone or with finasteride. It has also been approved for regular use in patients with both BPH and erectile dysfunction (ED).

Most men need to take medication for long term often for life to keep the symptoms away.

Minimally invasive procedures for BPH

Indications for surgical intervention include:

  • Moderate to severe symptoms that are bothersome
  • Medication has not given relief
  • Presence of urinary tract obstruction
  • Formation of bladder stones
  • Hematuria (blood in urine)
  • Kidney problems

Contraindications for surgical intervention for BPH include:

  • Urethral stricture
  • Presence of untreated urinary tract infection
  • History of previous surgery on the urinary tract
  • You suffer from a neurological disorder, such as Parkinson’s disease or multiple sclerosis

There are several options your surgeon has when you decide to go for intervention therapy. He has to choose from the minimally invasive procedures, endoscopic, or open surgeries to treat your symptoms, which may be moderate to severe.

Minimally invasive procedures do not remove or cut into the prostate. Your doctor will evaluate your prostate size and your overall health to decide if minimally invasive surgery is the right option for you.

Advantages include

  • They relieve BPH symptoms better than medicines.
  • Recovery is faster and there is less pain than traditional, open surgery
  • There are fewer risks than open surgery

Transurethral resection of the prostate (TURP)

This is the most common type of surgery to treat BPH. The urologist inserts a scope into your urethra and removes all but the outer part of the prostate that is pressing on to the urethra and obstructing your urine flow. There is a possibility of retrograde ejaculation occurring after TURP

Transurethral incision of the prostate (TUIP)

In this procedure, the surgeon inserts a scope into the urethra and makes a couple of incisions into the prostate tissue to relieve the pressure on the urethra. This is useful in men whose prostate enlargement is small. Symptomatic relief is equal to that of TURP, the risk of retrograde ejaculation is much less as compared to TURP but there is a possibility that some men may require a repeat TUIP.

Laser surgery

The doctor uses a laser beam to remove excess prostate tissue and reduce the size of the gland. This type of surgery gives you symptomatic relief and good urine flow similar to TURP. The risk of bleeding is considerably reduced.

Invasive surgery for BPH

Invasive surgery is the best long-term solution for the relief of urinary symptoms that are really bothering you. It involves taking out the enlarged portion of the prostate.

Indications

  • Complete urinary retention. You are not able to pass urine at all.
  • Watchful waiting, improvement of lifestyle, and medication have not worked for you.
  • Blood in the urine does not respond to treatment
  • You develop bladder stones.
  • You have recurrent urinary tract symptoms.
  • Your kidney starts showing damage.

Types of invasive surgeries

  • Open prostatectomy. In this type of surgery, the surgeon removes the prostate gland. It is done under general or spinal anesthesia. Usually, the surgeon makes an incision through the lower abdomen, although sometimes he may make the incision between the rectum and the base of the penis. This surgery is indicated when the prostate is greatly enlarged, complications have developed, or when the bladder is damaged and needs repair.
  • Laparoscopic and Robotic Prostatectomy.  In laparoscopic or robotic surgery four small incisions are made as opposed to one large one to remove the enlarged tissue of the prostate.

Complications of prostate surgery

Any type of prostate procedure can cause side effects. Complications might include:

  • Retrograde ejaculation
  • Temporary difficulty in passing urine
  • Urinary tract infection
  • Bleeding
  • Erectile dysfunction
  • Very rarely urinary incontinence

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