What is Benign Prostatic Hyperplasia (BPH)?
Benign prostatic hyperplasia, or BPH, is a condition that affects the prostate gland in men. It is characterized by an enlarged prostate, which can press against the urethra and cause problems with urination. The prostate gland typically goes through two periods of growth in a man’s life. The second phase is from around age 25 until the end of a man’s life. BPH is most commonly seen during this second growth phase. Because of this, up to 90% of men over the age of 80 experience it.
BPH is benign and not cancerous. However, it is still important to seek medical attention if you have symptoms, as prostate cancer can present similarly.
What is the Prostate?
The prostate is a small gland located in the male reproductive system. It’s approximately the size of a walnut and weighs about an ounce. It sits below the bladder and in front of the rectum. The prostate encircles the urethra, which is the tube that carries urine from the bladder through the penis.
The primary function of the prostate is to produce fluid for semen. During ejaculation, sperm from the testicles mix with fluid from the prostate and seminal vesicles. They travel through the urethra and are expelled through the penis as semen.
Symptoms
An enlarged prostate can cause problems with urination due to its pressure on the bladder. The most common symptom of BPH is frequent urination, often occurring every 1 to 2 hours, especially at night.
Other symptoms of BPH include:
- A feeling of fullness in the bladder even after urinating
- An urgent need to urinate
- A weak flow of urine
- Difficulty starting and stopping urination
- The need to strain or push to urinate
In severe cases of BPH, a person may be unable to urinate at all, which is a medical emergency that requires immediate treatment.
BPH Causes
The exact cause of BPH is not fully understood. Some researchers believe that aging and hormonal factors may play a role in its development. For example, BPH does not occur in men who have had their testicles removed before puberty.
As men age, their levels of testosterone, a male hormone, decrease. At the same time their levels of estrogen, which men do produce naturally, increase. Some studies have suggested that the higher levels of estrogen in the prostate may contribute to the growth of prostate cells.
Another theory involves dihydrotestosterone (DHT), a male hormone that plays a role in prostate growth. Research shows that even when testosterone levels drop, high DHT levels can accumulate in the prostate. This can stimulate the growth of prostate cells. Men who do not produce DHT do not develop BPH.
Who is at Risk for BPH?
While age is the most significant risk factor for BPH, other factors may also increase a person’s risk of developing the condition.
These may include:
- Having a family history of BPH
- Being overweight or obese
- Consuming a diet high in animal fats
Can BPH be Prevented?
While it is not possible to completely prevent BPH, there are steps that may help reduce the risk of developing it. One way to keep the prostate healthy is to eat a balanced diet. Eating lots of fruits and vegetables helps maintain a healthy weight. This is important because too much body fat can raise hormone levels and boost prostate cell growth.
Engaging in regular physical activity can also help control weight and hormone levels. While these steps cannot guarantee the prevention of BPH, they can contribute to overall health and well-being.
BPH Diagnosis
If you are experiencing symptoms of BPH, it is important to see a healthcare provider.
Seek medical attention immediately if you have blood in your urine, pain or burning while urinating, or if you are unable to urinate.
Your doctor can diagnose BPH through a combination of:
- Review your personal and family medical history
- Performing a physical examination, which may include a digital rectal exam (DRE)
- Running additional medical tests, such as:
- Cystoscopy – to view the inside of the urethra and bladder
- Post-void residual volume measurement – to measure the amount of urine left after urinating
- Prostate-specific antigen (PSA) blood test – to measure markers of prostate cancer
- Ultrasound of the prostate – to look at the size and structure of the prostate
- Urinalysis – to check for signs of infection or other problems
- Uroflowmetry – to measure the speed of urine flow
- Urodynamic pressure testing – to test the bladder pressure during urination
- Urinary blood test – to screen for bladder cancer
PSA Blood Test
Prostate-specific antigen (PSA) is a protein produced exclusively by the prostate gland. In a healthy prostate, only small amounts of PSA can be detected in the blood. The PSA blood test measures the level of PSA in the bloodstream and can be conducted at a laboratory, hospital, or doctor’s office.
No special preparation is required for the test, although it is important to avoid ejaculating for 2 days prior to the test. Ejaculation can temporarily increase PSA levels for 24 to 48 hours.
A low PSA level is generally considered to be a positive indicator of prostate health, while a rapid increase in PSA may indicate a problem. BPH, prostatitis, and prostate cancer are potential causes of high PSA levels.
Digital Rectal Exam
A digital rectal exam (DRE) is a procedure in which a healthcare provider inserts a gloved and lubricated finger into the rectum to feel the prostate gland. A DRE is an easy and non-invasive way to check the prostate. This is because the prostate is just behind the rectum and can be felt through the anus.
During the exam, your urologist will feel the size, shape, and texture of the prostate. Any abnormalities can be signs of BPH, prostate cancer, or prostatitis. A DRE is generally quick and painless and can provide valuable information about the health of the prostate.
Treatment
There are a variety of treatment options available for BPH. The best course of treatment will depend on the severity of the condition and the patient’s specific needs and preferences. In some cases, a combination of treatments may be most effective.
Mild cases of BPH may not require any treatment at all.
The main types of treatment for BPH include:
- Watchful waiting / active surveillance
- Medical therapies
- Minimally invasive surgery
- Traditional surgery
Watchful Waiting/Active Surveillance
Watchful waiting, or active surveillance, means keeping a close eye on BPH. You monitor its progress without treating it right away. This approach may involve changes to diet and the use of medication to control symptoms.
Regular check-ups with your urologist will be necessary to track the condition. If symptoms worsen or new symptoms appear, active treatment may be recommended.
Watchful waiting has benefits. There are no side effects from medications or treatments. However, it can be harder to manage symptoms later. Men with mild to moderate BPH symptoms that do not significantly impact their quality of life may be good candidates for this approach.
It is important to discuss the potential risks and benefits of watchful waiting to determine if it is the right option for you.
Medical Therapies
1. Alpha Blockers
Alpha blockers are a type of medication that can be used to treat BPH. These pills work by relaxing the muscles of the prostate and bladder, improving urine flow, and reducing blockage of the urethra. While they do not shrink the size of the prostate, they can help alleviate BPH symptoms.
Some common alpha-blocking drugs include:
- Alfuzosin (Uroxatral)
- Terazosin (Hytrin)
- Doxazosin (Cadura)
- Famsulosin (Flomax)
One benefit of alpha-blockers is that they begin to work quickly. However, they may also cause side effects such as:
- Dizziness
- Lightheadedness
- Fatigue
- Difficulty ejaculating.
Alpha blockers may be a good treatment option for men with moderate to severe BPH who are bothered by their symptoms. They are not recommended for men who are preparing for cataract surgery.
2. 5-Alpha Reductase Inhibitors
5-alpha reductase inhibitors are another type of medication that can be helpful in treating BPH. These pills work by blocking the production of dihydrotestosterone (DHT). DHT is a male hormone that can accumulate in the prostate and stimulate its growth.
5-alpha reductase inhibitors shrink the prostate and improve urine flow. They may be taken in the form of finasteride (Proscar) or dutasteride (Avodart). These drugs can reduce the risk of complications from BPH and may also decrease the likelihood of needing surgery. However, they can cause side effects such as erectile dysfunction and reduced libido.
To maintain the benefits of treatment, it is necessary to continue taking 5-alpha reductase inhibitors. They may be most effective for men with very large prostate glands and older men.
3. Combination Therapy
Combination therapy involves the use of both an alpha-blocker and a 5-alpha reductase inhibitor. Using two types of medication together can be more effective. This combination may improve symptoms, urine flow, and overall quality of life better than a single medication.
Possible combinations include:
- Finasteride (Proscar) and doxazosin (Cadura)
- Dutasteride (Avodart) and tamsulosin (Jalyn)
Both combinations are available in a single tablet.
A urologist may also prescribe a combination of alpha-blockers and antimuscarinic drugs for patients with overactive bladder symptoms (OAB). OAB involves involuntary contractions of the bladder muscles. It can cause urinary frequency, urgency, and incontinence.
The benefits of combination therapy include improved symptoms and the prevention of BPH progression. However, it may also increase the risk of side effects. Common side effects are:
- Dizziness
- Erectile dysfunction
- Weakness or lack of energy
- A drop in blood pressure when standing up
Combination therapy may be a good option for men with larger prostates.
Phytotherapies
Phytotherapy, also known as herbal treatment, is a form of self-treatment for BPH. These treatments are not prescribed by a healthcare provider and are instead purchased over the counter as dietary supplements. One popular herb used in phytotherapy is saw palmetto.
However, these treatments are not recommended, as several studies have shown that they are not effective in treating BPH. Additionally, herbal treatments do not undergo the same testing and manufacturing processes as drugs. This means that the quality and purity of over-the-counter supplements can vary.
Urologists do not currently recommend the use of phytotherapies for the treatment of BPH.
Minimally Invasive Surgeries
Minimally invasive surgery is a type of surgery that is performed with minimal anesthesia and often involves a shorter recovery time. It may be performed in a doctor’s office or an outpatient center.
The type of minimally invasive surgery that is best depends on factors such as the size of the prostate, overall health, and personal preferences.
There are several types of minimally invasive procedures available for the treatment of BPH, including:
- Aquablation
- UroLift
- Rezum
- Prostatic Artery Embolization (PAE)
- GreenLight Laser Therapy
- Catheterization
Minimally invasive surgery can provide symptom relief and improve urinary control for some men. However, there is a risk that additional surgery may be necessary in the future.
Possible side effects of minimally invasive surgery may include:
- Urinary tract infection (UTI)
- Blood in the urine
- Burning with urination
- Increased urinary frequency
- Sudden urges to urinate
In rare cases, erectile dysfunction and retrograde ejaculation (semen flowing backward into the bladder instead of out of the penis) may also occur.
Good candidates for minimally invasive surgery include men with:
- Moderate to severe BPH symptoms
- Urinary tract obstruction
- Bladder stones
- Blood in the urine
- Difficulty emptying the bladder completely
- Bleeding from the prostate
- Slow urination
- Lack of response to medications
Aquablation
Aquablation uses a heat-free water jet controlled by robotic guidance to remove excess prostate tissue. This approach is designed to treat BPH while lowering the risk of side effects that affect urinary control or sexual function.
UroLift
UroLift opens the blocked urethra by placing small implants that hold prostate tissue out of the way. It relieves symptoms without removing or destroying tissue.
Rezum Water Vapor Therapy
Rezum uses steam (water vapor) therapy to shrink excess prostate tissue. The treatment can improve urinary flow and is usually done in the office with minimal downtime.
Prostatic Artery Embolization (PAE)
PAE is a minimally invasive procedure that shrinks the prostate by reducing its blood supply. This procedure is performed by an interventional radiologist. It can be an option for men who want to avoid surgery or are not good candidates for it.
GreenLight Laser Therapy
GreenLight uses laser energy to vaporize excess prostate tissue and open the urethra. It offers symptom relief similar to TURP but with less bleeding and a quicker recovery.
Catheterization
Catheterization is a procedure that involves the insertion of a thin, hollow tube into the bladder to drain urine. This can be done through the urethra or through a small puncture in the bladder called a suprapubic catheter. A catheter may be temporary or indwelling, depending on the severity of the urinary blockage.
Catheterization is often for men who can’t fully empty their bladders. It may serve as a temporary solution until other treatments start. Some men may need this option if they have multiple medical conditions that make them poor candidates for medications or surgery.
Side effects associated with catheterization include irritation of the bladder or urethra, frequent urination, and a burning sensation.
The main benefit of using a catheter is that it can provide temporary relief of symptoms, but there are also risks involved. The biggest risk is the potential for infection, as bacteria can accumulate on the surface of the catheter. Using a catheter for a long period of time can also increase the risk of bladder cancer and cause irritation and tissue damage to the penis.
BPH Surgery
If you are experiencing severe symptoms or if other treatments have failed, surgery may be necessary. There are several types of surgery that can be performed for BPH, ranging from least to most invasive:
- Transurethral Incision of the Prostate (TUIP)
- Transurethral Resection of the Prostate (TURP)
- Holmium Laser Enucleation of the Prostate (HoLEP)
- Thulium Laser Enucleation of the Prostate (ThuLEP)
Transurethral Incision of the Prostate (TUIP)
Transurethral incision of the prostate (TUIP) is a surgical procedure used to treat symptoms of an enlarged prostate. It is typically used in men with smaller prostates but significant blockage of the urethra. Instead of removing prostate tissue, TUIP widens the urethra by making small cuts in the prostate and bladder neck using a laser or electrical current. This reduces pressure on the urethra and makes urination easier. The procedure is usually performed as an outpatient procedure, with a hospital stay of one to three days.
The benefits of TUIP include improved ability to urinate and reduced symptoms. However, there are also risks and potential side effects, including:
- Temporary urine retention
- Urinary tract infection (UTI)
- Dry orgasm
- Incontinence
- Erectile dysfunction
In some cases, additional treatment may be needed after TUIP.
Good candidates for TUIP include men with smaller prostates who do not want a more complete prostate resection but still need surgery. The procedure is less likely to interfere with ejaculation than more invasive surgeries, such as transurethral resection of the prostate (TURP). However, it may not be suitable for men with larger prostates or more severe symptoms.
Transurethral Resection of the Prostate (TURP)
TURP is also a very common surgery for BPH. About 150,000 men in the United States have TURP each year.
The procedure is performed under general anesthesia. A surgeon inserts a thin, tube-like instrument (a resectoscope) through the tip of the penis into the urethra. The resectoscope has a light, valves for irrigating fluid, and a thin wire loop. An electrical current is passed along the wire. The surgeon uses the electrified wire to cut away prostate tissue that is blocking the urethra and seal blood vessels. The removed tissue is flushed into the bladder and then out of the body. You will need to use a catheter for 1 to 2 days after the procedure.
The benefits of TURP include long-term symptom improvement, minimal blood loss, and no incisions. However, there are also risks and side effects associated with this surgery. These may include retrograde ejaculation, erectile dysfunction, urinary tract infections, and urinary incontinence. It typically takes about four to six weeks for patients to fully recover from the procedure.
Good candidates for TURP are men who have moderate to severe BPH symptoms and require surgery.
Holmium Laser Enucleation of Prostate (HoLEP)
HoLEP is a minimally invasive procedure that involves the use of a laser to remove excess prostate tissue. The procedure is performed through the urethra using a thin, tube-like instrument called a resectoscope.
The benefits of HoLEP include rapid recovery, minimal blood loss, and a shorter hospital stay. However, like any surgery, HoLEP is associated with risks and side effects. These may include urinary incontinence, blood in the urine, frequent or painful urination, and the risk of anesthesia.
Good candidates for HoLEP are men with larger prostates who want to avoid invasive surgery. It also includes men at higher risk of bleeding from blood-thinning meds.
Transurethral Electroevaporation of the Prostate (TUVP)
TUVP is a less invasive alternative to more traditional surgical procedures such as TURP.
During the procedure, the surgeon inserts a resectoscope (a thin, tube-like instrument) into the urethra and uses an electrical current to destroy excess prostate tissue. The heat from the electrical current seals small blood vessels, which helps to reduce the risk of bleeding. TUVP is typically performed on an outpatient basis, and most patients are able to go home the same day without the need for a catheter.
There are several potential benefits to TUVP, including:
- Low risk of bleeding and fluid absorption
- A short hospital stay (usually just one night)
- The ability to return home without a catheter in most cases
However, as with any surgery, TUVP carries some risks, including the risks associated with anesthesia.
Candidates for TUVP are typically men with larger prostates who want to avoid more invasive surgery.