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Health Education

Benign Prostatic Hyperplasia

What is benign prostatic hyperplasia?
Benign prostatic hyperplasia is a term for noncancerous enlargement of the prostate, the walnut-sized gland located at the base of the urinary bladder in men. Literally, benign prostatic hyperplasia means nonmalignant (benign) enlargement (hyperplasia) of the prostate (prostatic).

The role of the prostate is to produce fluids found in semen, and as such the gland is closely associated with the urethra, the duct through which urine (and semen) flows for discharge at the glans of the penis.

Anatomically, the prostate wraps around the urethra, and it has a natural tendency to increase in size as men age. For a substantial proportion of men, this enlargement not only grows outward to increase the overall size of the gland, but inward to constrict the urethra passing through it, resulting in problems primarily involving the ability to pass urine — including difficulty starting urination, weak urine stream, a need for frequent urination, an inability to completely empty the bladder and dribbling as urination ends.

BPH is a gradually developing problem, and to an extent the need to treat it is a matter of choice for each man. Whether or when to treat depends to a large degree on your level of discomfort and dissatisfaction with your situation.

Whether treatment is desirable or not, if the symptoms of benign prostatic hyperplasia are present it's important to have your situation evaluated by a physician. For one thing, the same symptoms can be indicative of prostate cancer or other problems. And although prostate cancer is much less common than BPH, it's essential to have it ruled out (other than having some symptoms in common, BPH does not have any relationship to prostate cancer).

Options for dealing with BPH range from "watchful waiting" (taking no action but monitoring its course closely) to treatment with medications, minimally invasive therapies and surgery.

The physicians of Hartford HealthCare Medical Group have extensive experience in the treatment of benign prostatic hyperplasia, using a range of state-of-the-art approaches.

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How common is benign prostatic hyperplasia?
Most men can expect to experience some enlargement of their prostate gland as they age. The question is whether or how much they will be adversely affected by this growth.

The natural course of prostate development is that it is about a quarter-inch in diameter at birth, grows slowly throughout childhood, experiences dramatic growth during puberty and reaches a diameter of about one-and-a-half inches at full development.

At about age 25, the prostate begins growing again, and it is this second stage of growth that can cause problems later in life.

As stated, BPH is a developing problem we experience as we age. While BPH only rarely causes symptoms before age 40, it's estimated that half of all men in their 60's and more than 80 percent of all men in their 70's and 80's are affected by the consequences of BPH.

In the United States, some 375,000 men are admitted to the hospital each year because of problems with BPH.

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What is the anatomy of the prostate gland?
The prostate is a walnut-sized gland located at the base of the urinary bladder. It surrounds the urethra, the duct running from the bladder to the opening at the glans of the penis for the elimination of urine. Located at the base of the pelvis, it is situated just behind the pubic bone and in front of the rectum.

The role of the prostate is to produce approximately 20 percent of the semen fluids that contribute to the delivery and vitality of sperm as it is discharged into the vagina during sexual intercourse. This reduces the acidity of vaginal secretions that might otherwise destroy sperm cells.

Nerves associated with the sphincter that controls urinary flow and the corpora cavernosa of the penis (the spongy structure that fills with blood to create erections) are located close-by. Damage to these nerves during some surgical treatments are a concern. This is potentially the time when the entire prostate is removed for cancer.

Interference with erectile function or urinary continence resulting from BPH treatment is usually temporary. Also a potential side effect to treatment is retrograde ejaculation — a condition in which sperm passes backwards into the bladder rather than being forced through the urethra during intercourse. This can significantly reduce the numbers of sperm in the semen and result in infertility.

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What causes benign prostatic hyperplasia?
The factors that cause the prostate to grow larger are unclear. One theory notes that men's bodies produce both the male hormone (testosterone) and a small amount of the female hormone (estrogen). In this view, the natural decline in the level of testosterone that occurs as men age results in the presence of higher levels of estrogen — that increase cell growth.

Another theory sees a relationship between prostate growth and the continued presence of DHT — dihydrotestosterone, a substance produced by testosterone reaching the prostate — even after testosterone production by the body has declined. Some studies have indicated that men who lack DHT do not experience BPH.

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What are the risk factors for BPH?
Aging is obviously the most prominent risk factor for developing benign prostatic hyperplasia. As noted, BPH only rarely causes symptoms before age 40, but it's estimated that half of all men in their 60's and more than 80 percent of all men in their 70's and 80's are affected by the consequences of PBH.

Benign prostatic hyperplasia appears to run in families, so that if a father or grandfather has experienced BPH, there is an increased risk for it for you.

Race and ethnicity appear to be factors in your risk for BPH, with Caucasian men experiencing it at higher rates than those of African and Asian descent.

Additionally, being married appears to be a factor, although the reasons are not understood. Married men are more likely to develop BPH than single men.

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How does BPH progress?
It's worth noting that the degree of prostate enlargement does not always dictate the degree of problems or symptoms. It's possible to have a significantly enlarged gland with little obstruction and only minor symptoms, or a relatively small enlargement with significant problems.

As the prostate gland increases in size, it is likely to begin pressing against the urethra, narrowing the channel through which urine passes. This may result in a weak stream flow in itself.

In fact, it's estimated the only about half of all men with BPH experience symptoms significant enough to cause them to seek treatment. That said, the development of benign prostatic hyperplasia with serious consequences follows a predictable course.

Over time, the wall of the urinary bladder can become thicker and irritable. The bladder itself starts contracting when stimulated by even a small amount of urine, leading to a need for frequent urination. After a period, the bladder may become weak and lose the ability to become completely empty.

More serious consequences that can emerge as the problems become more severe include urinary tract infections, bladder and kidney damage, bladder stones and loss of continence. A condition in which urination is not possible at all is called acute urinary retention. The larger the gland, the higher the risk of urinary retention.

And you should be aware that many over-the-counter cold and allergy medications contain decongestants called sympathomimetics (Sudafed®, pseudoephedrine) that can aggravate urination difficulties by preventing the bladder sphincter from relaxing to permit the flow of urine. Alcohol and cold temperatures can have similar effects.

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What are the symptoms of benign prostatic hyperplasia?
Since only about half of all men with BPH experience symptoms significant enough to lead them to seek treatment, each case has to be evaluated by itself. And since it's usually a progressively developing problem, each man has to decide when the symptoms become bothersome enough to warrant seeking evaluation and when to begin treatment.

The most common symptoms include:
  • Difficulty beginning urination
  • Weak stream during urination
  • A feeling that your bladder isn't empty
  • A need for frequent urination
  • Increased frequency of urination at night
  • Feelings of an urgent need to urinate
  • Dribbling at the end of urination

Especially serious symptoms are:
  • Blood in the urine (or in semen)
  • Urinary tract infections
  • Urinary retention or near-retention

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How is benign prostatic hyperplasia diagnosed?
If you're a male over 40, the basic screening tools for benign prostatic hyperplasia should already be part of your regular physical examination routine — digital rectal examination (DRE) and measurement of prostate specific antigen (PSA) in your blood.

Although they're more commonly promoted in connection with screening for prostate cancer, DRE's are important tools as well for assessment of prostate enlargement. In fact, positive results for either DRE or PSA screening are far more likely to indicate the presence of BPH than of cancer.
  • Digital Rectal Examination. With the prostate located directly adjacent to the rectum, digital rectal examination is literally a physical-touch test in which your doctor inserts a gloved, lubricated finger into your rectum to feel your prostate for abnormalities in size, texture or shape.
  • Prostate Specific Antigen Measurement. The same is basically true of prostate specific antigen measurement — it's most often performed for prostate cancer screening, but it's a valuable tool for assessing prostate size as well. PSA is a substance produced by the prostate gland that is normally confined within the gland. While a certain level of PSA invariably escapes into the bloodstream, elevated levels may be present in the blood if the prostate is undergoing change — whether cancer, BPH, inflammation, increased size or infection. Additional PSA will be secreted into your bloodstream in these circumstances.
  • Your level of PSA is measured in nanograms of PSA per milliliter of blood (ng/ml). Generally, a rating of less that 4 ng/ml is normal. A rating between 4 ng/ml and 10 ng/ml is generally considered a medium elevation and more than 10 ng/ml is high. This is a highly complex and changing discussion. Younger men commonly have a lower PSA rating.

If your DRE or PSA tests are suggestive, your doctor might order other tests of increasing complexity. These could include:
  • AUA Symptom Index. The AUA Symptom Index is a relatively simple questionnaire developed by the American Urological Association to assess your prostate disease symptoms. By rating the severity and frequency of symptoms such as stream flow, your doctor can both gain information about your condition and monitor it over time. To review the AUA Symptom Index, click here.
  • Urinalysis. While analysis of your urine doesn't diagnose either benign prostatic hyperplasia or prostate cancer, it can help in identifying or ruling out other factors that may have produced the DRE or PSA results, such as infection or kidney disease.
  • Urinary Flow Study. In this test, you are asked to urinate into a special device that measures the strength and amount of your urine flow. In addition to providing information about your current condition, it provides a tool for monitoring changes over time.
  • Transrectal Ultrasound. Generally restricted to men with high PSAs or those with irrgularities in the prostate exam, this is another test designed to address the possibility of prostate cancer versus benign prostate enlargement. In this test, a small ultrasound probe is inserted into your rectum — and adjacent to the prostate — to use sound waves to obtain an image of your prostate gland and any abnormalities that may be detectable (not all are). It also helps in estimating the size of your prostate.
  • Intravenous Pylogram. An intravenous pylogram (IVP) obtains x-ray images of the urinary tract system, using a medical dye to visualize the urinary tract and any obstructions that may be present. This is rarely needed unless other problems (blood in the urine, infection, etc.) are present.
  • Cystoscopy. Cystoscopy is the insertion of a thin, video-equipped catheter into the urethra to enable visual examination of the inside of the urethra and bladder. Performed under local anesthetic, cystoscopy enables your doctor to visualize the degree of compression in the urethra due to the enlarged prostate, any obstructions of the urethra or bladder or other problems.

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How is benign prostatic hyperplasia treated?
Treatment options for BPH can range from watchful waiting to surgery to reduce the urethral obstruction caused by the enlarged gland. Options in between include treatment with medications and minimally invasive therapies using heat, ultrasound or lasers.

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What is watchful waiting?
When enlargement of the prostate is detected in its early stages and no serious symptoms are apparent, watchful waiting may be the best course. Watchful waiting simply means taking no action to deal with your BPH in the absence of any serious symptoms or complications. It's estimated that the symptoms disappear or diminish in as many as one-third of all mild cases (an active exercise program also seems to help with these symptoms). The goal here is to use digital rectal examinations and PSA testing to monitor the prostate's progress.

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What are the medical approaches to treating BPH?
Drug therapies for treating BPH take two different approaches — Finasteride shrinks the prostate gland to relieve pressure on the urethra and bladder and Alpha blockers relax the muscles at the neck of the bladder to make it easier to release urine.
  • Finasteride. Finasteride is probably best known by its heavily marketed brand names, Proscar and Propecia. The drug is modestly effective for men with greatly enlarged prostates, and is less effective for those whose prostates are only moderately enlarged. Drawbacks are its high cost and the fact that it must be used indefinitely; otherwise symptoms will recur. Also, it can take as long as six months to a year to achieve maximum effect. Side effects can include impotence and decreased libido.
  • Alpha Blockers. Alpha blockers originated as drugs for treating high blood pressure, but they have also been found to relax the smooth muscle tissue of the prostate and neck of the bladder, reducing obstruction and improving urine flow. The most commonly prescribed brand names are Hytrin, Cardura and Flomax. Alpha blockers usually take effect within several days, and reports are that as many as 75 percent of men who take them find them helpful. Side effects can include headaches, dizziness, fatigue and, to a lesser extent, impotence.



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What is sawtooth palmetto?
An alternative medical approach is the use of a number of herbs sold in health food stores as treatments for BPH. By and large, these are untested and their claims not evaluated by any government agencies in the United States.

The exception is saw palmetto, an herb extract that has undergone long-term trials and that is generally concluded to be as effective as Finasteride, with fewer side effects. It's believed to work by preventing testosterone from breaking down into a form that encourages prostate tissue growth.

The major drawback is that it works slowly, taking as long as three months to demonstrate any significant benefit. Long-term effects are unclear. It should be noted that it can interfere with the accuracy of PSA tests for prostate cancer, usually reducing the measured PSA values to half of prior levels. This consistent effect on the laboratory value levels can be taken into account by your doctor. If you take it, be certain to tell your doctor before any tests are ordered.

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What are minimally invasive therapies for BPH?
A number of technologies have been developed in recent years for minimally invasive treatment of BPH. By and large, they are all transurethral — that is, they utilize a thin, hollow catheter inserted into the urethra to deliver heat, electrical energy or laser energy at the site of the obstructing prostate. Some involve the use of anesthesia and some can be performed without it. Most are performed on an outpatient or day-surgery basis.
  • Transurethral microwave therapy (TUMT) uses computer-controlled microwaves to treat damaged prostate tissue with heat (a built-in cooling system protects the urethra). Frequently used systems include TherMatrx®, TargisTM and Prostatron®. Usually performed as an outpatient or day procedure, TUMT offers the advantages of avoiding major surgery and anesthesia with low rates of impotence or incontinence side effects. It shows good short-term results in as many as 70 percent of patients, but long-term results appear to be lower. It appears to work best in men with milder cases, and may take several weeks for the initial results to be apparent.
  • Transurethral radiofrequency needle ablation (TUNA) heats the obstructing prostate tissue with radio waves sent through needles inserted into the tissue. TUNA appears to be less effective in cases of very large prostates, and its long-term effectiveness is not yet clear. It involves the use of mild anesthetics and appears to avoid serious side effects.
  • Transurethral Electrovaporization (TUVP) uses a high frequency electrical current to cut and vaporize obstructing tissue. Its advantages include the fact that tissue is actually removed and bleeding is minimized by sealing remaining tissue off as it cuts. A relatively new treatment, its long-term effectiveness is not yet clear.
  • Water-Induced Thermotherapy (WIT) is a new treatment approach that places an inflatable balloon that can circulate heated water at the site of the obstructing prostate. Conductive heat from the water within the balloon destroys prostate tissue. As a relatively new procedure, its long-term effectiveness is unclear.
  • High Intensity Focused Ultrasound (HIFU) uses an ultrasound transducer placed in the rectum adjacent to the prostate to bombard it with ultrasound waves, producing heat that destroys prostate cells. After initially swelling, the prostate shrinks. National statistics show low usage.
  • Noncontact visual laser ablation (VLAP) is an approach that uses laser energy to dry up the cells of obstructing prostate tissue. In this approach, the body then sloughs off these dead cells over a period of weeks. This approach may require you to wear a drainage catheter during this period. Irritive voiding symptoms may persist until healing is complete.
  • Interstitial laser coagulation (IndigoTM) involves the use of laser energy delivered to the interior of obstructing prostate tissue rather than the surface layers. This approach reduces the size of the prostate. Advantages are the minimal bleeding associated with it and the doctor's ability to visually observe the area of work and treat specific segments of the prostate. It can be used in patients taking coagulants such as Coumadin©.

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What are the surgical approaches to BPH?
Each treatment approach has its advantages and disadvantages — usually in terms of effectiveness and potential side effects.

Surgery is still considered to be the "gold standard" and the most effective option for dealing with the problems of an enlarged prostate. The potential for side effects is higher, however. All involve one or two days of hospitalization and approximately one month of progressive healing.

That said, surgery is safe and reliable in the hands of experienced practitioners. The urologists of Hartford HealthCare Medical Group have a strong background in surgery for BPH as one of the treatment options for symptomatic BPH.

Currently, there are three types of surgical procedures for BPH: transurethral resection of the prostate, transurethral incision of the prostate and open prostatectomy.

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What is transurethral resection of the prostate?
Transurethral resection of the prostate (TURP) is the surgical excision of obstructing prostate tissue, accomplished with the use of a resectoscope inserted through the urethra to the site of the obstructing prostate tissue.

The resectoscope is fitted with fiber-optic capabilities, a channel for circulating irrigating fluids and an electrical loop that cuts tissue. Essentially, with the resectoscope the surgeon can shave off sections of the obstructing prostate tissue from within the urethra and flush them out with the irrigating fluid.

Following the procedure, 88 percent of patients experience symptom relief and a strong urine flow within several days. TURP carries with it a small risk of causing impotence (widely debated, but one to three percent) or urinary incontinence (less than one percent). When they occur, these are usually temporary, generally resolving in a matter of weeks or months, although complete recovery can take as long as a year. For incontinence, pelvic floor muscle exercises can speed up the recovery process. Retrograde ejaculation occurs in a high percentage of patients — 73 percent — resulting in a "dry ejaculation").

TURP is the most commonly performed surgical procedure for BPH, with some 200,000 procedures performed in the United States each year. It usually involves a hospital stay of one to three days and use of a catheter for several days.

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What is transurethral incision of the prostate?
Rather than shaving out tissue from the enlarged prostate, transurethral incision of the prostate (TUIP) involves making small incisions in the prostate and in the bladder where the urethra joins the bladder. The goal here is to reduce pressure on the urethra and ease the flow of urine.

TUIP may be more appropriate for men with smaller prostates or prostates that are only moderately enlarged. TUIP involves fewer risks of complications, but also is often less effective. It may require repetitive procedures. It involves a one-to-three day hospital stay and a short period of catheter drainage at home.

Statistically, TUIP has been shown to improve the patient's condition in 80 percent of cases, with an impotence rate of one to two percent, a short-term incontinence rate of less than one percent and a retrograde ejaculation rate of 25 percent.

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What is open prostatectomy?
Open prostatectomy is surgery in which a transurethral approach is not appropriate and that requires a traditional, external incision in the lower abdomen. Open prostatectomy is likely to be performed only in cases in which the patient's prostate is excessively large and difficult to remove through a transurethral approach, when large bladder stones or large bladder diverticulae are present, or when other complications exist.

The procedure is actually the safest and most effective surgical approach for patients with very large prostates, but it also carries the highest risks of impotence, incontinence and retrograde ejaculation side effects. It usually involves a hospital stay of three to five days and approximately one month of surgical recovery.

Statistically, open prostatectomy has been shown to improve the patient's condition in 98 percent of cases, with a short-term impotence rate of about three to five percent, an incontinence rate of less than one percent and a retrograde ejaculation rate of 77 percent.

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What can I do to lower my risk of benign prostatic hyperplasia?
To some extent, prostate enlargement is an inevitability for a man, but there are some measures you can take to reduce your risk of developing symptoms of benign prostatic hyperplasia, or to slow its development.
  • Limit caffeine and alcohol. These substances can cause bladder irritation, increase urine output and irritate your bladder, aggravating symptoms of frequency and urge to void.
  • Be cautious with over-the-counter medications. As stated, many medications for colds and flu contain substances that seriously aggravate symptoms of prostate enlargement.
  • Exercise. Regular physical activity — even moderately strenuous walking — can held reduce your symptoms. Inactivity, on the other hand, encourages your retention of urine.
  • Screening. Regular screening in the form of a doctor's digital rectal examination and PSA testing are important steps you can take to catch benign prostatic hyperplasia early.

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For additional information
You can find additional information about benign prostatic hyperplasia at web sites sponsored by government agencies, societies and healthcare institutions. It should perhaps be noted that the World Wide Web is open to many sources posting questionable information and promises, and you are encouraged to seek information from established, reputable organizations.

Likely sources include:

American Urological Association Health Guide
www.urologyhealth.org

National Institutes of Health
www.nih.org

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