Benign Prostatic Hyperplasia

Benign prostatic hyperplasia(BPH), also known as benign prostatic hypertrophy, is a very common degenerative disease among the older men in Hong Kong. The incidence rate increases with age. About half of all men over age 50 start to develop BPH. Almost 90% of men over age 80 get BPH, and around half of them have the symptom of urinary obstruction.

BPH can cause constriction of the urethra, which may lead to severe urinary problems. Although BPH is not a life-threatening disease, it can seriously affect quality of life.

The aging of population significantly increases the number of men with prostate problems. Most men over age 50 may have experienced some of the following symptoms: frequent urination at night; increased urination during the day; sudden urge to urinate; interrupted or weak urinary stream; dribbling at the end of urinating; and feeling that the bladder is not empty even after urinating. All these are warning signs of BPH. If you have any of these symptoms, you should see you doctor as soon as possible.

Most older men have BPH problems. Men with BPH should not delay seeking treatment because of embarrassment. Early diagnosis and treatment can help relieve symptoms effectively. 

(Special thanks to Dr W. C. YIP, Chief of Service and Consultant Surgeon, Kwong Wah Hospital for reviewing the information of this page.)

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The prostate gland is a male organ about the size of a walnut. It is located below the bladder and surrounds the urethra. Its major function is to produce the fluid in semen that transports sperm out of the body.

The size of adult prostate generally remains stable until middle-age, when hormonal changes may cause enlargement of the prostate. Since the enlargement is non-cancerous, it is called benign prostatic hyperplasia.

When the prostate enlarges, it presses down on the urethra. This pressure can lead to difficult urination and other urinary problems. Clinical statistics show that BPH affects around 50% of men between the ages 51 and 60, 70% of men at the age of 70, and up to 90% of men over the age of 80.

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BPH is mainly produced by age-related hormonal changes and non-cancerous overgrowth of prostate tissue. Urinary infections can increase the severity of BPH symptoms. Besides, obesity, stress, depression, alcohol abuse, smoking, medications, diet habits and poor hygiene can increase the risk of BPH.

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The risk of getting BPH increases with age. It is still uncertain what might prevent the condition. However, the following can help to reduce the risk of developing BPH:

  • Regular checkups
    According to the American Cancer Society, men over 50 years of age should have an annual prostate examination for early detection and treatment of BPH.
  • Digital rectal examination (DRE)
    Men over 50 years of age should have a DRE at least once a year. The test examines the size and shape of the prostate, and checks for abnormal nodules or inflammation.
  • Maintaining a healthy diet and adopting a healthy lifestyle
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The actual cause of BPH is still unknown. However, clinical studies show that the prostate of most men by the age of 50 will enlarge gradually due to hormonal changes that lead to overgrowth of the prostate tissue. The muscle tissue in the prostate will also contract and constrict the urethra. It can block the normal flow of urine and lead to difficulty in urination.

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相片 BPH usually begins with slow urine flow. Since there is no pain or obvious nuisance, most men tend to ignore it. When the condition becomes more serious, there is difficulty in starting urination. This is because the enlarged prostate presses down on the urethra and causes the urethra to constrict, the bladder is then forced to press harder to push the urine out. The bladder wall becomes thicker and thicker while the bladder can hold less and less urine. It can lead to the following symptoms:

  • Frequent urination. Having an urge to urinate many times during the day and getting up more often at night to urinate.
  • Difficulty starting urination or delayed start while trying to urinate
  • Hesitant, intermittent, weak or slow urine stream. Stopping and starting or even dribbling while urinating. 
  • Dribbling at the end of urination
  • Feeling that the bladder is not completely emptied after urinating. Straining to urinate
  • Having strong or sudden urge to urinate quite often, especially at night
  • Urge incontinence, i.e. inability to control urination
  • Urinary incontinence
  • Acute urinary retention: A sudden, painful inability to urinate that leads to acute retention of urine in the bladder
  • Lower abdominal discomfort
  • Blood in the urine (hematuria)

Although BPH is not a seasonal affective condition, incidence of BPH occurs more often in winter. The reason is that cold weather stimulates the sympathetic nerves and strengthens muscle contraction of the prostate, which further constricts the urethra and brings on some of the symptoms. Besides, as people get flu more often in winter, some sinus medicines also strengthens muscle contraction of the prostate and increases the symptoms such as difficult urination.

The symptoms and severity of BPH vary from person to person, and do not necessarily correspond with the size of the prostate.

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相片

To diagnose BPH, doctors generally use the International Prostate Symptom Score questionnaire (IPSS) to evaluate the severity of symptoms. Designed by the American urological Association (AUA), the IPSS is an important tool to determine prostate problems at the early stage, to follow the progression of BPH and to track the treatment effects.

The IPSS consists of 7 questions, scored on a scale from 0-5:

The symptoms are graded as:
mild:         score 1 to 7
moderate:  score 8 to 19
severe:      score 20 to 35

Besides, doctors may also do some of the following tests to diagnose the condition:

Digital rectal examination (DRE)
The doctor inserts a gloved finger through the patient's anus into the rectum to assess the size, shape, symmetry and consistency of the prostate, to feel for nodules and hardness, and examine the rectum and anus at the same time. However, this test alone is not sufficient for diagnosing the degree of obstruction or the severity of the condition.

Urine test (urinalysis)
A urine test checks if there is blood in the urine, infection or proteinuria.

Prostate-specific antigen (PSA) blood test
PSA is a protein produced by the prostate. Elevated PSA levels may indicate prostate problems. PSA blood test can help screen for prostate cancer.

Uroflowmetry
Uroflowmetry measures the urine flow rate, the degree of obstruction and help to monitor treatment effects.

Transrectal ultrasound (TRUS)
An ultrasound test provides measurements of the prostate and reveals the amount of residual urine in the bladder.

Bladder function test
Straining to force out the urine due to difficult urination may cause weak bladder over time. Bladder function test is needed to check how well the bladder is working.
 
Urodynamics tests
Urodynamics tests measure the urine volume and pressure in the bladder, the urine flow rate and the residual urine in the bladder.

Cystoscopy
A lighted flexible telescope (cystoscope) is inserted into the urethra to examine the bladder for signs of obstruction or abnormalities.

In some cases, further tests may be needed to confirm the diagnosis. These tests include postvoid residual urine test, ultrasonography, intravenous urogram, magnetic resonance imaging (MRI), X-rays or intravenous pyelogram (IVP).

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相片

BPH is most commonly treated with medications or minimally invasive surgery. Depending on the severity of the conditions, doctors will recommend appropriate treatments to relieve symptoms, reduce the risk of complications or stop BPH progression.

Medications

Doctors generally use medications to treat moderate symptoms of BPH. There are two main classes of medicine: 5-alpha-reductase inhibitors and alpha –receptor blockers. Usually, these medicines have to be taken for long periods of time. In most cases, medications can improve the symptom of difficult urination caused by BPH.

  • 5-alpha-reductase inhibitors
    These medications shrink the prostate by blocking the production of a hormone called dihydrotestosterone (DHT) that causes the prostate to enlarge. They do this by blocking an enzyme called 5-alpha-reductase. These medicines help reduce the severity of BPH and the need for surgery. It may take 3 to 6 months for them to be effective. The anti-androgen finasteride is a 5-alpha-reductase inhibitor commonly used to treat BPH.

  • Alpha-receptor blockers/Alpha blockers
    These medications can lower blood pressure and widen blood vessels. They help relax bladder neck and urethral muscles and make it easier to urinate. However, they cannot reduce the size of the prostate. Hence, the prostate will continue to enlarge. These medications should be used long-term. The symptom of difficult urination will return and may become more severe if the medication is stopped. These medicines work quickly to alleviate symptoms. 70- 80% of patients have improvement within a few days. However, patients who experience serious side-effects should not use them. The most common alpha-receptor blockers are terazosin, doxazosin and tamsulosin.

Surgery

Doctors may recommend surgery if the patients have severe symptoms or are unwilling to take long-term medication, or if medication is not effective or complications have occurred. The purpose is to remove part of the excess prostate tissue. The following are several common types of surgery for BPH:

(a) Transurethral incision of the prostate (TUIP)

This is an endoscopic procedure. It is performed by inserting an endoscope through the urethra to the prostate. Then a small incision is made in the prostate tissue to enlarge the opening of the urethra and bladder outlet. TUIP is a pretty safe procedure and there is no exterior wound after surgery. The procedure takes about 40-50 minutes.

(b) Transurethral resection of the prostate (TURP)

This is also an endoscopic procedure. It is performed by inserting an endoscope through the penis and removing the obstructing prostate piece by piece with an electric current. The heat of the electric current can stop bleeding quickly as well. The procedure takes about 60-90 minutes and may be done under general or regional anesthesia.

(c) Open prostatectomy

This is a more traditional operation. An incision is made in the lower abdomen to remove prostate tissue. It is generally performed when the prostate is very large.

Minimally invasive treatments

Minimally invasive treatments are comparatively newer and less traumatic. They generally can be done under regional anesthesia and do not require hospitalization. .

Some of the minimally invasive treatments are:

  • Transurethral microwave thermotherapy (TUMT): TUMT uses microwave heat to destroy enlarged prostate tissue.
  • Transurethral needle ablation (TUNA): TUNA uses low levels of radiofrequency energy to heat and destroy overgrown prostate tissue.
  • Visual laser ablation of the prostate (VLAP): VLAP uses high-energy lasers to destroy excess prostate tissue.
  • Balloon Dilation: This treatment uses an expandable balloon to widen the urethra.
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Some men with BPH may not notice any symptoms. They may not know they have prostate problems until they suddenly experience painful inability to urinate. This condition is known as acute urinary retention. It demands immediate treatment. Otherwise, other complications may occur.
 
Common complications of BPH include:

(a) Acute urinary retention
This is a sudden inability to urinate. The bladder becomes swollen and painful. It is an emergency that demands immediate medical attention.

(b) Urinary tract infections
Residual urine caused by BPH may lead to recurrent urinary tract infections.

(c) Bladder stones
BPH can increase the risk of bladder stone formation.

(d) Blood in the urine
BPH may cause bleeding.

(e) Impaired bladder function
BPH can cause bladder outlet obstruction. When the bladder has to work harder to push the urine out for a long period of time, the muscular wall of the bladder stretches and weakens and no longer contracts properly.

(f) Impaired kidney function
Severe BPH can cause urine to back up in and damage the kidneys. Hydronephrosis, uremia and even kidney failure may result.

(g) Prostatitis, an inflammation of the prostate gland.

It is believed that BPH does not lead to cancer, but both conditions can exist together.

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  • Go for health checkup regularly. Receive a digital rectal exam (DRE) and prostate-specific antigen (PSA) test at least once a year.
  • Avoid prolonged sitting and don't delay urination.
  • Maintain a healthy diet. Reduce consumption of high cholesterol or hot stimulating foods.
  • Exercise regularly.
  • Don't drink too much caffeine or alcohol.
  • Avoid drinking a lot of fluids before bedtime to help relieve nocturia symptoms.
  • Try not to take over-the-counter cold, cough or sinus medicines. These medicines can tighten the urethra and thus increase BPH symptoms.
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