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BPH, benign prostatic hypertrophy, enlarged prostate, prostatism
Benign prostatic hyperplasia (BPH) is the enlargement of the prostate gland. It is caused by excess growth of cells in the prostate. This condition does not represent cancer.
What is going on in the body?
The prostate gland surrounds the urethra as it exits the bladder in men. The urethra is the tube that carries urine from the bladder to the outside of the body. The job of the prostate is to secrete substances into semen that aid in fertility. The prostate responds to testosterone, the main male hormone, and after puberty it slowly increases in size. By the time men reach their fifties or sixties, almost all have some evidence of BPH. This harmless enlargement can cause a blockage of the bladder outlet, known as prostatism. Although the actual causes are more complex, it is helpful to think of BPH as a blockage of urine flow by an enlarging prostate.
What are the signs and symptoms of the condition?
Symptoms may be mild or severe, and include:
What are the causes and risks of the condition?
- difficulty starting the stream of urine
- a weak force of the urinary stream
- frequent urination
- difficulty controlling urination, with a sense of urgency to urinate
- getting up at night to urinate, known as nocturia
- a feeling of incomplete emptying of the bladder
- an urge to urinate soon after emptying the bladder
- incontinence, or an involuntary loss of urine
BPH is probably partly inherited. The exact cause is not known. Men who have close family members with BPH before the age of 60 have a four times greater risk of early BPH themselves.
The primary risk of BPH is that urine flow may be blocked. This can sometimes cause kidney damage and other life-threatening problems, such as infections.
What can be done to prevent the condition?
There are no widely accepted ways to prevent BPH.
How is the condition diagnosed?
Symptomatic BPH is usually diagnosed on the basis of the symptoms. A doctor often uses his finger to examine the rectum and prostate. This helps to make sure there are no growths called nodules, which are small, hard lumps, on the prostate. These lumps might suggest prostate cancer. An older man who has the typical symptoms of BPH and an enlarged prostate is assumed to have the condition. A prostate-specific antigen (PSA) blood test is often done. If this value is abnormal, a biopsy sample of the prostate may be advised to look for prostate cancer.
Other tests may be done in certain cases. These may include measuring the rate of urine flow, and checking with a catheter or special x-ray test to see how much urine is left in the bladder after voiding. A pressure-flow study (urodynamics) combines measuring the urine flow and the pressure in the bladder during voiding. Cystoscopy is a procedure that uses a tiny telescope to look inside the urethra, prostate, and bladder for the amount of blockage. Ultrasound, a type of x-ray test, may be used to measure the exact size of the prostate. This can be important in making choices about therapy. A symptom questionnaire can help to measure both the symptoms and the response to treatment.
What are the long-term effects of the condition?
Long-term effects are generally due to chronic, incomplete emptying of the bladder and may include:
What are the risks to others?
- a bladder that fails to adequately hold urine, called bladder decompensation or decreased capacity
- bladder stones, also called calculi
- urinary tract infections
- a type of damage to the kidney, known as hydronephrosis, which can rarely lead to kidney failure
BPH is not contagious.
What are the treatments for the condition?
Prostatism is usually treated first with drugs called alpha-blockers, such as prazosin. These drugs relax the muscle in the prostate and at the bladder neck, which allows better urine flow. Since the prostate responds to testosterone, suppressing this hormone can reduce the size of the prostate and improve symptoms. Unfortunately, this has a variety of unwanted side effects, such as impotence. There is one drug, finasteride, that can reduce testosterone levels in the prostate without causing symptoms of hormone loss in the rest of the body. Some studies have suggested that finasteride can shrink the prostate by about thirty percent (30%). This may take several months, and often the improvement is not as dramatic as that seen with alpha-blockers.
If drugs do not work, or cannot be taken, surgery is an option. The traditional operation has been transurethral resection of the prostate (TURP). This involves passing a special tiny telescope, called an endoscope, through the urethra. The endoscope has an electrified loop, which is passed into the area of the prostate that surrounds the bladder neck. Under anaesthesia, the electrified loop is used to scoop out tissue from the prostate and free the flow of urine. This surgery has a success rate of about 85 %.
Because TURP can cause bleeding, there has been a great effort to find other ways to do the surgery. A variety of energy sources have been tried, including high-intensity sound waves, lasers, heat, and radio waves. Sometimes tubes called stents are placed in the urethra to hold it open. Some of these procedures require a small amount of anaesthesia, and others require none at all. In general, these procedures are less risky than TURP, but do not work as well.
When the prostate is very enlarged, many surgeons recommend open prostatectomy. This is surgical removal of the obstructing portion of the prostate. TURP and other techniques may be less effective or even dangerous in such a large gland.
What are the side effects of the treatments?
Medications used to treat BPH may all cause side effects, such as dizziness, low-blood pressure, and impotence. Specific side effects depend on the drug used.
What happens after treatment for the condition?
- Dangerous complications after TURP are unusual.
- The most common side effect of TURP, in about four to six percent (4% to 6 %) of people who undergo the procedure, is a need to place a urinary catheter for longer than 2 days after the operation.
- Bleeding used to be more of a concern following TURP. Now, transfusion is needed less than two to three percent (2% to 3%) of the time.
- Incontinence of urine, or the inability to control urination is unusual. Impotence can occur in 5-10% of men. These complications are more common with removal of the prostate.
- Retrograde ejaculation or loss of ejaculation with intercourse occurs in over 90% of patients.
Those treated with medications often need treatment for life or until symptoms get bad enough to require surgery.
Recovery from TURP is usually fairly quick. Blood in the urine gradually disappears over the first week or so. Symptoms of bladder obstruction are usually relieved immediately. Bladder irritation symptoms take one to two months after the procedure to go away. Rarely, men can develop abnormal narrowing of the urethra. This is usually noticed when the force of the urine stream weakens two or three months after the procedure. Some fifteen percent (15%) of men do not have their symptoms relieved by TURP. If someone's bladder does not contract very well before a TURP, the urinary flow may not be much improved by the procedure. Sometimes, a second TURP or other prostate surgery may be needed at a later date.
How is the condition monitored?
Those treated with medications can often monitor their own symptoms at home. After TURP or prostate surgery, the person is seen periodically by the doctor, and watched for a return of symptoms.
Reviewer: HealthAnswers Australia Medical Review Panel
Editor: Dr David Taylor, Chief Medical Officer HealthAnswers Australia
Last Updated: 1/10/2001
Potential conflict of interest information for reviewers available on request