Benign Prostatic Hyperplasia

What is benign prostatic hyperplasia (BPH)?

Benign prostatic hyperplasia (BPH) is an enlarged prostate gland. The prostate gland surrounds the urethra, the tube that carries urine from the bladder out of the body. As the prostate gets bigger, it may squeeze or partially block the urethra. This blockage often causes problems urinating. The prostate gland begins enlarging during puberty and continues throughout a man’s life. Men can begin experiencing urinary symptoms caused by BPH as early as age 40. The older a man gets, the more likely he is to experience BPH-related symptoms. Approximately half of all men older than 75 years old have some symptoms.

What causes BPH?

Benign prostatic hyperplasia is a normal part of the aging process in men, caused by changes in hormone balance and in cell growth.

What are the symptoms?

BPH causes urinary problems such as:

Trouble getting a urine stream started (hesitancy)
Trouble stopping (dribbling).
A weak or slow urine stream.
A sense of not emptying the bladder (retention)
Needing to wake up from sleep to urinate (nocturia)
Having to urinate often (frequency)
Having to urinate abruptly (urgency)
Leaking urine (incontinence)

In some instances, BPH may completely block the urethra, making it impossible or extremely hard to urinate. This problem may cause backed-up urine (urinary retention), leading to bladder infections, bladder stones or kidney damage.

Erectile dysfunction, orgasmic dysfunction and diminished ejaculatory volume are experienced more often in men who have BPH.

BPH does not cause prostate cancer.

How is BPH diagnosed?

Your doctor can diagnose BPH by asking questions about your symptoms and past health and by doing a physical exam. The AUA Symptom Score Index (available at the end of this site) is a questionnaire that determines the severity of symptoms. Initial tests may include a urine test (urinalysis), blood tests (serum creatinine, PSA), and a digital rectal exam. To further evaluate BPH, a transrectal prostate ultrasound can accurately measure the size of the prostate gland and determine its precise shape. Uroflow is a simple test to measure how well the urine flows out. Urodynamics is a more advanced assessment of the bladder’s function. Cystoscopy allows the doctor to directly examine the internal anatomy of the lower genito-urinary tract.

When is BPH treated?

As a general rule, a man doesn’t need treatment for BPH unless the symptoms are consistently bothersome. There are 5 complications of BPH that mandate treatment:

Complete urinary retention
Development of bladder stones
Recurrent bladder/prostate infections
Recurrent prostatic bleeding
Kidney injury due to bladder dysfunction

Treatment Overview

Benign prostatic hyperplasia (BPH) cannot be cured, so treatment focuses on reducing symptoms. Treatment is based on symptom severity, degree of patient bother, and presence of complications.

Initial Treatment

The American Urological Association (AUA) makes the following treatment recommendations for benign prostatic hyperplasia treatments based on the severity of your symptoms.

Symptoms that are mild or that do not bother you (AUA score of 0 to 7) may be best treated by watchful waiting. This means you may make small changes to your lifestyle to control your symptoms, but you do not take medicines or have surgery. You have regular checkups to be certain your symptoms are not getting worse.
The treatment of moderate to severe symptoms (AUA score of 8 or more) depends on how much you are bothered by them. If the symptoms are not greatly affecting your quality of life, you may choose watchful waiting or treatment with medicine. If the symptoms are bothersome or you want more aggressive treatment, you may be offered surgery.
Severe symptoms, such as ongoing inability to urinate, bladder stones, kidney damage, or ongoing blood in your urine, should be treated with surgery.

What to Think About

Unless surgery is required because of a complication, choosing a treatment is largely up to you and your doctor. If complications arise, surgery may be necessary.

The extent to which treatment improves your symptoms depends partly on how bad your symptoms are and how much you are bothered by them. If you are not bothered by your symptoms before treatment, you are less likely to notice much improvement after treatment.

Surgery offers the best chance for improving the symptoms but also has the risk of causing other problems. For more information, see the Surgery section of this topic.

Medications

Medicines are sometimes used to help relieve bothersome, moderate to severe urination problems caused by benign prostatic hyperplasia (BPH). If you stop using medicine, the symptoms will usually return.

Alpha-blockers include doxazosin (Cardura) and terazosin (Hytrin), tamsulosin (Flomax), alfuzosin (Uroxatral), and silodosin (Rapaflo). These agents relax the smooth muscle tissue in the prostate and the opening to the bladder. Symptom improvement typically begins within one week. Alpha-blockers do not stop the process of prostate enlargement. Potential side effects include dizziness, nasal stuffiness, fatigue and retrograde ejaculation.
• 5-alpha reductase inhibitors, such as dutasteride (Avodart) or finasteride (Proscar), may reduce the size of an enlarged prostate but may take 6 to 9 months to achieve maximal improvement of symptoms. Potential side effects include diminished semen volume and reduced libido (sex drive).
• Using a combination of an alpha-blocker with a 5-alpha reductase inhibitor may symptoms more than either medicine alone.

Surgery

Most surgeries for BPH are performed endoscopically: the surgical instrument is passed up the urinary opening in the penis to the location of the prostate. This is described as a transurethral surgery.

Transurethral resection of the prostate (TURP). The obstructing portion of the prostate gland is removed endoscopically with an electrocautery cutting instrument. A patient typically is hospitalized for 24-48 hours after this procedure for monitoring of post-operative bleeding. If a man is taking a blood thinner such aspirin, warfarin (Coumadin), or clopidogrel (Plavix), this surgery cannot be safely performed. The surgeons at Central Bucks Urology have collectively performed more than 2,000 of these procedures.

Transurethral Laser Vaporization of the Prostate. The most commonly used laser is the Greenlight laser. During this procedure the obstructing portion of the prostate gland is vaporized, sealing the blood vessels in the process. A patient typically goes home on the day of the surgery with a bladder catheter maintained overnight. Bleeding is typically minor during and after this procedure. This surgery can be performed even if the patient is on blood-thinners. Go to the following website for more information: www.greenlighthps.com.

The surgeons at Central Bucks Urology have collectively performed more than 500 of these procedures.

Open Surgery. Typically reserved for very large prostate glands or if bladder stones are also present, this surgery is performed through an abdominal incision. A patient is hospitalized for 3-7 days afterward and has a bladder catheter for 10-14 days.

A number of office-based, minimally- invasive procedures have been available since the early 1990’s. The effectiveness of these procedures is far inferior to those options listed above. Based upon their strong, collective opinion that these procedures represent decidely inferior options, the surgeons of Central Bucks Urology do not offer nor recommend them. Three examples of such procedures:

Transurethral microwave therapy (TUMT): microwave energy is used to destroy a portion of the prostate through heating.
Transurethral needle ablation (TUNA): a heated needle is used to destroy a portion of the prostate.
Interstitial Laser Coagulation (Indigo Laser): a puncturing laser is used to destroy prostate tissue.

What to Think About

Medical therapy typically is tried as the first line of benign prostatic hyperplasia treatment. For many men, medical therapy provides satisfactory and durable improvement in their voiding pattern. Medical therapy must be maintained indefinitely to remain effective.

Surgery is the most reliable way to maximally relieve symptoms. But surgery may not relieve all your symptoms, and it puts a man at risk for certain surgical complications, including infection, bleeding, urinary retention, and urinary incontinence and ejaculation of semen into the bladder instead of out through the penis (retrograde ejaculation).

Men who have severe symptoms often notice great improvement in the quality of life following surgery. Men whose symptoms are mild may find that surgery does not greatly improve quality of life; men with mild symptoms should think carefully before deciding to have surgery to treat BPH.

The benefits of surgery typically prove to be life-long.

AUA Symptom Score Index

Fill out the form below to evaluate your BPH symptoms:

Symptoms over the past month	Less than 1 time in 5	Less than half the time	About half the time	More than half the time	Almost always
Sensation of not emptying the bladder completely after urinating	1	2	3	4	5
Had to urinate within two hours of a previous urination	1	2	3	4	5
Needed to stop and start again several times while urinating	1	2	3	4	5
Found it difficult to postpone urination	1	2	3	4	5
Had a weak urinary stream	1	2	3	4	5
Needed to strain to urinate	1	2	3	4	5
Number of times needed to urinate during bedtime at night	1	2	3	4	5