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What is BPH?
The exact diagnosis of BPH actually requires examination of prostate tissue to show excess prostate cell replication or multiplication. In everyday clinical practice, however, this term is more commonly used to imply prostate enlargement, for which the term prostatic hypertrophy should be used. On this basis, an initial working diagnosis of BPH is reasonable for any man who presents with bothersome urinary symptoms. It is estimated that 25 percent of men may experience bothersome urinary symptoms secondary to BPH during their lifetime.
Do men with "small" or "normal" size prostate ever have BPH symptoms?
In reality, prostate size does not correlate well with the degree of bothersome urinary symptoms. Furthermore, size alone is not a reliable predictor of the presence of bladder outlet obstruction. So the answer to this question is "yes."
How does the prostate cause obstruction of the bladder outlet?
The prostate gland wraps around the upper most portion of the urethra from the bladder neck to an area just above the voluntary urinary sphincter. In theory, a dense capsule surrounding the prostate prevents it from expanding outward, forcing the prostate tissue to press inward against the urethra like a closed fist, partially blocking urine flow or bladder emptying. A less distensible prostate capsule may explain why men with relatively smaller prostates can also have BPH symptoms or the so-called lower urinary tract symptoms (LUTS).
What are BPH symptoms or Lower Urinary Tract Symptoms (LUTS)?
These are symptoms commonly used to describe the difficulties men may have with urination. These symptoms can be categorized into two main groups to help define the source of the problem.
Obstructive voiding symptoms include weak or intermittent urinary stream, straining to urinate, a hesitation before urine flow starts, a sense that the bladder has not emptied completely, dribbling at the end of urination or leakage afterward, and painful urination. Obstruction is the most serious complication of BPH and requires medical attention.
Irritative voiding symptoms include the following: an increased frequency of urination (particularly at night), an urgent need to urinate, and bladder pain or irritation when urinating. These symptoms suggest a problem of bladder storage as a result of conditions such as an overactive bladder, prior surgery or radiation to the pelvic area, bladder infections, non-specific bladder inflammation, and bladder cancer. These irritative symptoms may also be the results of bladder outlet obstruction.
Is BPH the only cause of these bothersome symptoms?
No. Other conditions such as aging, inflammation of the bladder and/or prostate, infection and cancer are potential causes. Patients with spinal cord injuries, strokes, and diseases that affect the nervous system such as diabetes, multiple sclerosis and Parkinson's disease can also suffer from similar symptoms.
Who gets BPH?
Various studies have shown between 10% and 30% of men experience moderate to severe lower urinary tract symptoms (LUTS) when they are in their 50s. By age 80, the problem may be seen in over 50% of these men. Data also suggests that it is more prevalent in the U.S. and Europe, and less prevalent in Asian countries. It may be more common in married men than single men. There is also a correlation of family history, but it is unclear whether there is a genetic predisposition or other factors such as similarity in diet.
How serious is BPH and LUTS?
Problems with urination can be very distressing, although individual response to these symptoms varies widely. We do note that men are more apt to tolerate obstructive symptoms (intermittent flow, weak stream, hesitancy before urinating), but tend to seek help sooner for irritative symptoms (urgency, frequency, urination at night). Obstructive symptoms, however, may indicate the presence of bladder outlet obstruction, requiring the bladder to work harder to generate higher pressure for bladder emptying. Sometimes a man is unaware of an obstruction until he suddenly cannot urinate at all. This condition is called acute urinary retention. It is a dangerous complication that can damage the kidneys and bladder, and may even require emergency surgery. So, it is best to get evaluated early to avoid these acute complications.
What is involved in the evaluation of BPH or LUTS?
Like other medical conditions, an evaluation begins with your doctor taking a medical history and doing a physical examination. Questions regarding your urinary symptoms and habits will be asked. The physical examination will include a complete examination of the genitalia and a rectal exam to palpate the prostate. Laboratory testing may include an examination of urine (urinalysis), urine culture, urine cytology, and PSA testing for prostate cancer screening. If indicated, additional testing may also include post void residual urine check, ultrasound of the kidneys and bladder, urine flow test, cystoscopy (or cystourethroscopy), and urodynamic testing.
What are the general guidelines for treating or managing BPH or LUTS
The primary goals are to improve urinary flow and to reduce symptoms. Many treatment options are currently available, including medications, minimally invasive procedures, and major surgeries.
The decision between no treatment (or watchful waiting) and treatment usually depends on a number of factors, such as degree of bothersome symptoms, urine flow rates, and post void residual volumes. Some men with mild symptoms may opt for watchful waiting, and be followed with periodic examinations. It should be noted, however, that bladder outlet obstruction may be present in men even if they have no symptoms, although this is a relatively small group. Men with severe symptoms nearly always choose treatment. The choice is most difficult for men with moderate symptoms and may simply depend on a man's ability to tolerate them. Medications are usually the first line of therapy for men who choose to have any treatment.
What are the drugs used for BPH or LUTS?
Recent developments in drug therapy have reduced the number of prostate
surgery, especially for men with mild to moderate symptoms. The
two primary drug classes used for BPH or LUTS are alpha blockers
and 5-alpha-reductase inhibitors.
Alpha blockers are drugs that relax smooth muscles, like the muscles found in the areas of the bladder neck and the prostate. By relaxing these muscles in and around the prostate area, these drugs help to improve urinary flow and symptoms, sometimes significantly. When helpful, men should note improvement within days to weeks. Because of its quicker onset of action, this drug class is often chosen as the first-line drug therapy. Most men will require long-term use of this drug, but the beneficial effect may wane with time.
5-alpha-reductase inhibitors are drugs that block the conversion of testosterone to its active form, dihydrotestosterone. These drugs work by reducing the prostate size over time. However, it may take as long as 6 months for a man to notice a change in symptoms. The beneficial effect of prostate size reduction, however, is generally seen only in men with very large prostates. These drugs are most often used in combination with an alpha blocker.
What are the general guidelines for surgery?
The greatest improvements resulting from surgery are usually increased urinary flow and reduced urine retention. Surgery is usually chosen for men with moderate to severe symptoms, particularly if they failed to get satisfactory response to drug therapy. Surgery is usually the choice for men with bladder outlet obstruction presenting with intractable urinary retention, or if BPH is clearly related to recurrent urinary tract infections, blood in the urine, bladder stones, or kidney problems.
The most effective surgical procedures are transurethral resection of the prostate (TURP) and open prostatectomy, and are also the most invasive. Less invasive procedures tend to be less effective or less durable and include transurethral incision of the prostate (TUIP) and thermotherapy-type of prostate procedures.
* This information is not intended to substitute for a consultation with a urologist. It is offered to educate patients on the basis of urological conditions in order to get the most out of their office visits and consultations. Please see our web page disclaimer for addition information. |
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