Benign prostatic hyperplasia (BPH)

 

Symptoms of Benign Prostatic Hyperplasia (BPH)

The symptoms of BPH, often collectively referred to as Lower Urinary Tract Symptoms (LUTS), are primarily related to the impaired outflow of urine due to prostate enlargement. Symptoms can be broadly categorized into obstructive (voiding) and irritative (storage) symptoms.

Early (Obstructive) Symptoms

The initial manifestations of BPH typically include:

• Weak or Sluggish Urine Stream (Reduced Flow Rate): The force of urination is diminished.
• Hesitancy: Difficulty initiating urination, even with a full bladder.
• Intermittency: Urine flow starts and stops during urination.
• Straining to Urinate: The need to push or strain with abdominal muscles to begin or maintain urination and completely empty the bladder.
• Prolonged Micturition Time: Urination takes longer than usual.
• Terminal Dribbling: Leakage of urine at the end of urination.

These obstructive symptoms of BPH tend to develop slowly and may go unnoticed by the patient for a considerable time or be attributed to normal aging.

Later (Irritative and Storage) Symptoms

As the prostate continues to grow and the bladder muscle works harder to overcome the obstruction, the bladder may become overactive or may not empty completely. This leads to the accumulation of residual urine in the bladder post-voiding. If there is a significant amount of residual urine, a feeling of incomplete bladder emptying occurs, and other BPH symptoms, caused by functional bladder disorders and a decrease in its effective storage capacity, appear:

• Urinary Frequency: The need to urinate more often than usual during the day.
• Urgency: A sudden, strong, and often overwhelming urge to urinate that is difficult to defer.
• Nocturia: The need to wake up one or more times during the night to urinate.
• Urge Incontinence: Involuntary leakage of urine preceded by or accompanied by a strong urge to urinate.

Advanced Stage Symptoms

In the later stages of untreated or progressive BPH, symptoms can become more severe:

• Overflow Incontinence: Urine leaks out drop by drop from an overfilled bladder (ischuria paradoxa), often without a preceding urge. The normal urge to urinate may disappear.
• Acute Urinary Retention (AUR): A sudden and painful inability to pass urine, requiring emergency catheterization.
• Chronic Urinary Retention: Persistent inability to empty the bladder completely, leading to large volumes of residual urine.

 

Diagnosis of Benign Prostatic Hyperplasia (BPH)

A thorough diagnostic evaluation is essential if BPH is suspected, not only to confirm the diagnosis but also to assess symptom severity, rule out other conditions (like prostate cancer), and guide treatment decisions.

Diagnostic Tests

• Medical History and Symptom Assessment: Detailed discussion of urinary symptoms, their impact on quality of life (often using standardized questionnaires like the International Prostate Symptom Score - IPSS), medical history, and medications.
• Digital Rectal Examination (DRE): The physician inserts a gloved, lubricated finger into the rectum to feel the prostate gland, assessing its size, consistency, and any nodules or irregularities.
• Urinalysis: To check for signs of infection, blood, or other abnormalities in the urine.
• Prostate-Specific Antigen (PSA) Blood Test: PSA is a protein produced by the prostate gland. Elevated levels can indicate BPH, prostatitis (prostate inflammation), or prostate cancer. It is used as a screening tool for prostate cancer, and its interpretation requires consideration of age, prostate size, and other factors.
• Transrectal Ultrasound (TRUS) of the Prostate Gland: This imaging technique uses sound waves to create detailed pictures of the prostate. TRUS allows for accurate assessment of prostate size (volume) and its internal structure, helping to differentiate BPH from other prostate pathologies (e.g., cysts, calcifications, suspicious areas for cancer). It can also guide prostate biopsies if needed.
• Uroflowmetry: Measures the rate and volume of urine flow during urination. A reduced flow rate can indicate obstruction.
• Post-Void Residual (PVR) Urine Measurement: Uses ultrasound or catheterization to determine the amount of urine left in the bladder immediately after urination. Elevated PVR indicates incomplete bladder emptying.
• Pressure-Flow Studies (Urodynamics): More invasive tests that measure bladder pressure during voiding, used in complex cases to differentiate between bladder outlet obstruction and impaired bladder contractility.
• Cystoscopy: Involves inserting a thin tube with a camera (cystoscope) through the urethra to visualize the urethra, prostate, and bladder lining. It may be used if other conditions are suspected or before certain surgical procedures.

Impact on the Urinary System

As BPH progresses, the enlarged prostate gland squeezes the urethra, leading to impaired urodynamics (the mechanics of urine flow) at all levels of the urinary system (kidneys, ureters, bladder, and urethra). This impaired passage and stagnation of urine are major contributing factors to several complications:

• Urolithiasis (Urinary Stones): Stagnation of urine, particularly in the bladder, can promote the formation of bladder stones.
• Urinary Tract Infections (UTIs): Incomplete bladder emptying provides a favorable environment for bacterial growth, leading to recurrent or chronic cystitis (bladder infection) and potentially pyelonephritis (kidney infection).
• Bladder Dysfunction: Chronic obstruction can lead to bladder muscle hypertrophy (thickening) initially, then decompensation (weakening) and diverticula (outpouchings) formation.
• Hydronephrosis and Renal Impairment: Severe, prolonged obstruction can cause back-pressure on the kidneys, leading to hydronephrosis (swelling of the kidneys) and, ultimately, impaired kidney function or renal failure.

 

Treatment Options for Benign Prostatic Hyperplasia (BPH)

Any degree of prostate enlargement due to BPH can potentially cause acute urinary retention, a condition requiring urgent medical intervention to restore urine outflow. Currently, a fairly large number of surgical and medical treatments are available for BPH (prostate adenoma). The choice of treatment depends on symptom severity, prostate size, patient comorbidities, and patient preference.

The main treatment approaches for BPH include:

Watchful Waiting (Observation)

For men with mild symptoms that do not significantly impact their quality of life, a strategy of watchful waiting or active surveillance may be appropriate. This involves regular monitoring of symptoms and prostate health without active medical or surgical intervention. Lifestyle modifications (e.g., fluid management, avoiding caffeine/alcohol) may be recommended.

Medical (Drug) Therapy

Several classes of medications are used to manage BPH symptoms:

• Alpha-Blockers (Adrenergic Blockers): (e.g., tamsulosin, alfuzosin, silodosin, doxazosin, terazosin). These drugs relax the smooth muscles in the prostate gland and bladder neck, improving urine flow and reducing obstructive symptoms. They work relatively quickly.
• 5-Alpha-Reductase Inhibitors: (e.g., finasteride, dutasteride). These drugs block the conversion of testosterone to dihydrotestosterone (DHT), a hormone that promotes prostate growth. They can shrink the prostate over time (usually 6 months or more), reduce the risk of AUR and BPH progression, and improve symptoms, particularly in men with larger prostates.
• Combination Therapy: Using an alpha-blocker and a 5-alpha-reductase inhibitor together can be more effective than either drug alone for men with moderate to severe symptoms and larger prostates.
• Phosphodiesterase-5 (PDE5) Inhibitors: Tadalafil (daily dose) is approved for treating BPH symptoms, often in men who also have erectile dysfunction.
• Antimuscarinics/Beta-3 Agonists: May be used to treat overactive bladder (storage) symptoms if they persist despite treatment for obstruction, but with caution in men with significant bladder outlet obstruction.
• Phytotherapy (Herbal Remedies): Some plant extracts (e.g., saw palmetto) are used, but scientific evidence for their efficacy is often limited or inconsistent.
• Other fortifying agents might be considered as supportive.

Minimally Invasive Surgical Therapies (MIST)

These procedures are less invasive than traditional surgery and can often be done on an outpatient basis:

• Transurethral Microwave Thermotherapy (TUMT): Uses microwave energy to heat and destroy excess prostate tissue.
• Transurethral Needle Ablation (TUNA): Uses radiofrequency energy delivered via needles to ablate prostate tissue.
• Prostatic Urethral Lift (PUL) (e.g., UroLift): Implants are used to lift and hold enlarged prostate tissue away from the urethra, opening the channel.
• Water Vapor Thermal Therapy (e.g., Rezūm): Uses steam to ablate prostate tissue.
• Balloon Dilatation of the Prostate Gland (Historical/Less Common): Involves expanding the narrowed urethral area by inflating a balloon inserted into the urethra. This is less commonly performed now due to limited long-term efficacy compared to other methods.
• Placement of Prostatic Stents: Small devices inserted into the prostatic urethra to keep it open. Usually reserved for men who are not candidates for other surgeries.

Surgical Treatments

Surgery is typically recommended for moderate to severe BPH symptoms that do not respond to medical therapy, or if complications develop (e.g., recurrent AUR, bladder stones, renal insufficiency due to BPH).

• Transurethral Resection of the Prostate (TURP): Long considered the gold standard. An instrument (resectoscope) is inserted through the urethra, and the surgeon removes the part of the prostate that is obstructing urine flow using an electrical loop.
• Transurethral Incision of the Prostate (TUIP): For smaller prostates; one or two small cuts are made in the prostate and bladder neck to widen the urethra.
• Laser Therapies: Various laser techniques (e.g., Holmium laser enucleation of the prostate - HoLEP; GreenLight laser photoselective vaporization of the prostate - PVP) are used to remove or vaporize obstructing prostate tissue via the urethra. These often have fewer bleeding complications than TURP.
• Open Adenomectomy (Prostatectomy): Involves surgically removing the inner part of the prostate gland through an incision in the lower abdomen or perineum. This is typically reserved for men with very large prostates (>80-100 grams) or if other conditions (e.g., large bladder stones) need to be addressed simultaneously.

Other Therapeutic Approaches

• Transrectal Hyperthermia of the Prostate and other methods of physiotherapy: These involve applying heat to the prostate, often via a transrectal probe, with the aim of reducing tissue volume or symptoms. Their efficacy and role in standard BPH management are less established than other therapies.

Individualized Treatment Approach

All of these methods of treating BPH (prostate adenoma) have both advantages and disadvantages, as well as specific indications and potential side effects. Therefore, for the most effective treatment, an individualized approach to each patient is required, considering factors such as symptom severity, prostate size, overall health, patient preferences, and potential risks and benefits of each option. A thorough discussion with a urologist is essential to select the most appropriate treatment tactics.

 

Potential Complications of Untreated BPH

If BPH is left untreated and progresses, it can lead to several serious complications:

• Acute Urinary Retention (AUR): Sudden inability to urinate, requiring emergency catheterization.
• Chronic Urinary Retention: Persistent inability to empty the bladder fully.
• Recurrent Urinary Tract Infections (UTIs): Stagnant urine is a breeding ground for bacteria.
• Bladder Stones (Calculi): Formed from concentrated urine due to incomplete emptying.
• Bladder Damage: Chronic straining can lead to bladder muscle thickening (trabeculation), loss of elasticity, and diverticula formation.
• Kidney Damage (Hydronephrosis, Renal Insufficiency/Failure): Prolonged back-pressure from retained urine can damage the ureters and kidneys.
• Hematuria (Blood in Urine): From strained bladder vessels or an enlarged, congested prostate.

 

Differential Diagnosis of Lower Urinary Tract Symptoms (LUTS) in Men

While BPH is a very common cause of LUTS in aging men, other conditions can cause similar symptoms and must be considered in the differential diagnosis:

Condition	Key Differentiating Features
Benign Prostatic Hyperplasia (BPH)	Gradual onset of obstructive and/or irritative LUTS in aging men; enlarged prostate on DRE/TRUS; PSA may be mildly elevated.
Prostate Cancer	Can cause LUTS similar to BPH; prostate may feel hard, nodular on DRE; PSA often significantly elevated or rapidly rising; diagnosis by biopsy.
Prostatitis (Acute or Chronic)	Pain (perineal, pelvic, ejaculatory), irritative LUTS, +/- fever (acute); prostate may be tender on DRE; urine/prostatic secretion cultures may be positive.
Urethral Stricture	Narrowing of the urethra, often due to prior trauma, infection, or instrumentation; causes obstructive symptoms; diagnosed by urethrography or cystoscopy.
Bladder Neck Contracture/Sclerosis	Narrowing at the bladder outlet, can be post-surgical or idiopathic; causes obstructive LUTS; diagnosed by cystoscopy/urodynamics.
Overactive Bladder (OAB) Syndrome	Primarily irritative symptoms (urgency, frequency, nocturia, +/- urge incontinence) without significant obstruction. Urodynamics may be needed.
Neurogenic Bladder	Bladder dysfunction due to neurological conditions (e.g., stroke, Parkinson's disease, spinal cord injury, diabetes); varied LUTS depending on type of neurogenic bladder.
Urinary Tract Infection (UTI)	Irritative LUTS (frequency, urgency, dysuria), +/- fever, suprapubic pain; positive urinalysis and urine culture.
Bladder Cancer or Stones	Can cause irritative LUTS, hematuria; stones may cause intermittent obstruction or pain; diagnosed by cystoscopy and imaging.

 

Prevention and When to Consult a Urologist

While there are no definitive measures to prevent BPH due to its strong association with aging and hormonal factors, maintaining a healthy lifestyle (healthy diet, regular exercise, weight management) may have some general benefits for prostate health.

Men should consult a urologist or their primary care physician if they experience:

• Any bothersome lower urinary tract symptoms (as listed in Section 2).
• Changes in urination patterns that affect their quality of life.
• Blood in the urine (hematuria).
• Recurrent urinary tract infections.
• Inability to urinate (acute urinary retention - this is an emergency).

Regular prostate health check-ups, including DRE and PSA testing as appropriate for age and risk factors, are important for early detection of prostate conditions, including BPH and prostate cancer.