+ Please select BPH/Enlarged prostate Prostate cancer Prostatitis

Benign prostatic hyperplasia (BPH), also known as prostate enlargement, is a condition commonly seen in men over 40 and particularly in the older men. According to the American National Institutes of Health (NIH), BPH affects more than 50% of men over 60 and as many as 90% of men over 70.

The prostate (click here to view the image) is a part of the male reproductive system. It is a walnut-shaped gland located in front of the rectum and below the bladder surrounding the urethra. It consists of three distinct zones:

• A central zone
• A transition zone (the usual site of development of BPH that leads to lower urinary tract symptoms as this zone surrounds the urethra), and
• A peripheral zone (the usual site of development of prostate cancer)

The main function of the prostate is to produce ejaculatory fluid, the milky substance that combines with sperm to form semen.

Causes
The cause of BPH is unknown. However, BPH is possibly associated with aging and hormonal changes. The testes produce the hormone testosterone, which is converted in turn to dihydrotestosterone (DHT) in certain tissues. DHT is involved in prostate growth and high levels of DHT may cause prostatic hyperplasia. How and why levels of DHT increase remains a subject of medical research.

Symptoms
Symptoms of BPH are associated with problems in holding or passing urine. This stems from obstruction of the urethra by the enlarged prostate that leads to a gradual deterioration of bladder function.

Symptoms include:

• Difficulty in starting the urine flow when urinating (hesitant in urination)
• A weak or interrupted flow of urine
• Dribbling of urine at the end of urination
• Feeling that the bladder is not emptied completely after voiding
• Urgency (a need to urinate right away)
• Frequent urination
• Need to wake up from sleep to void

Complications that may occur in severe BPH over time include:

• Blood in the urine that may result from straining
• Incontinence (involuntary discharge of urine)
• Acute retention of urine (inability to urinate with pain)
• Urinary tract infection
• Bladder damage, bladder stone formation
• Kidney damage

Diagnosis
A physical examination, patient history, and evaluation of symptoms by the International Prostate Symptoms Score (IPSS) may provide the basis for a diagnosis of BPH. The common examinations and tests are as follows:

• Digital rectal examination (DRE): This is the most important and simplest examination. During the examination, doctor will insert a lubricated, gloved finger into the patient¡¦s rectum to feel the surface of the prostate gland through the rectal wall and assess its size, shape, and consistency (click here to view the image).
• Urine tests: A urine test checks whether there are infections or bleeding in the urinary tract.
• Blood tests: A prostate specific antigen (PSA) blood test is usually recommended. PSA levels are elevated in patients with BPH or with prostate cancer. Further examination and tests are needed if PSA is highly elevated, in order to rule out the possibility of prostate cancer. Other blood tests may include blood sugar and kidney function tests.
• Ultrasound: This examination determines the size of the prostate gland, any evidence of tumor, amount of residual urine in the bladder, and the presence of stones in the bladder.
• Urine flow study: Sometimes the doctor will ask a patient to urinate into a special device that measures how quickly the urine is flowing. A reduced flow often suggests BPH.
• Cystoscopy: This procedure helps the doctor to see the inside of the urethra and the bladder. This investigation is used only when other pathology in the bladder is suspected as the cause of the patient¡¦s symptoms.

Treatment
There are several treatment options for BPH depending on the severity of symptoms. These treatments can be mainly divided into two categories: medical and surgical treatment. Patients with mild symptoms may choose not to be treated but to further closely monitor their symptoms (watchful waiting). Regular annual examinations are strongly advised.

1. Medical treatment
Medical treatment is relatively safe and effective. It is not invasive but the improvement can be less effective than surgery.

There are two types of medication for BPH:

• 5-Alpha reductase inhibitors: These drugs prevent the conversion of testosterone to dihyrotestosterone (DHT), inhibit the growth of the prostate and decrease the size of the gland. Two drugs are now available, finasteride and dutasteride. Currently only finasteride is marketed in Hong Kong. A treatment period of 6-months is necessary to see if the therapy is working. Patients should see their doctors regularly to monitor side effects such as reduced libido and erectile dysfunction. The size reduction required continuous drug treatment for maintenance and will be reversed if drug treatment is stopped.
• Alpha-blockers: These drugs relax smooth muscle tissue in the bladder and prostate, which increases urinary flow. Commonly prescribed alpha-blockers include alfuzosin, doxazosin, przosin, tamsulosin and terazosin. Patients need to be monitored for the first few weeks to evaluate the effect on their symptoms and to adjust the dose if necessary. Common side effects of alpha-blockers include headache, dizziness, low blood pressure, fatigue and weakness. Ejaculation may be affected. Continuous drug treatment is required for symptom control.

2. Surgical treatment
Surgical treatment is usually indicated for patients with severe symptoms or complications. Patients can either choose one of the following three procedures or consider minimally invasive therapy.

• Transurethral resection of the prostate (TURP): This is the most common surgical procedure for patients with BPH. It is performed under general or regional anesthesia and takes 60-90 minutes. An instrument called resectoscope is inserted through the penis. The resectoscope contains a light and an electrical loop that cuts enlarged prostate tissues. Patients usually stay in the hospital for about 3 days, and most of them are able to return to work within a month. Symptoms are improved in about 90% of patients, and likelihood of further surgery within 8 years is 16%-20%. The most common side effect of TURP is retrograde ejaculation, which means semen enters the bladder instead of being expelled through the penis during climax. This may cause sterility but usually will not affect a man¡¦s ability to experience sexual pleasure. In some patients erection may be impaired after the procedure.
• Transurethral incision of the prostate (TUIP): This procedure is indicated for patients with mild enlargement of the prostate but relatively severe symptoms. Instead of removing tissues, TUIP widens the urethra by making an incision in the bladder neck, thus relieving the symptoms. TUIP is performed under general or regional anesthesia. An instrument is inserted through the penis to make the incision, and the procedure takes less time than TURP. Symptoms are improved in about 80% of patients, retrograde ejaculation is markedly less common, but likelihood of further surgery within 8 years is more than 20%, as symptoms tend to recur.
• Open surgery: Open surgery is now indicated only for patients with a very large prostate and for those who have complications such as bladder stones. This procedure is performed under general anesthesia. An incision in the lower abdomen is made, and the surgeon scoops out the enlarged tissue from inside the prostate gland. Symptoms are improved in about 98% of patients and likelihood of further surgery within 8 years is less than 10%. However, patients require a longer stay in hospital than those after TURP. Postoperative complications are more common because the procedure is invasive.
• Minimally invasive therapy (keyhole surgery): A number of minimally invasive treatments of BPH have been developed in recent years. They included prostatic stents, laser ablation, trasurethral needle ablation (TUNA), transurethral microwave thermotherapy (TUMT) and electrovaporization. Advantages of these treatments include less bleeding and no need for hospitalization. However these new approaches are more expensive and in general less effective than TURP.

Prevention
There is no effective ways to prevent BPH. Men with urinary symptoms should consult a doctor as early as possible. Early diagnose and proper treatment are the most effective ways to ensure a healthy and quality filled life.