Benign Prostatic Hyperplasia (BPH)

What is Benign Prostatic Hyperplasia (BPH)?

Benign Prostatic Hyperplasia (BPH) is the enlargement of the prostate gland. The prostate is a walnut-sized gland that forms part of the male reproductive system. It surrounds the urethra at the outlet of the bladder and produces fluid that carries the sperm during ejaculation. Prostate enlargement happens to virtually all men as they get older. This enlargement can place pressure on the urethra and cause urinary obstructive symptoms.

Note: BPH is not cancer and is not a risk factor for cancer either.

Symptoms

Common symptoms include:

• slowed or delayed start of the urinary stream
• weak urine stream
• dribbling after urination
• straining to urinate
• strong and sudden urge to urinate
• incomplete emptying of the bladder
• need to urinate more than two times at night
• urinary incontinence (loss of bladder control)
• pain with urination or bloody urine.

Diagnosis

After an assessment of the patient's medical history, a digital rectal exam (internal examination of the rectum) will be performed to feel the prostate gland.

Other tests include:

• urine flow rate test
• post-void residual urine test through an ultrasound
• bladder pressure flow studies
• an Intravenous Pyelogram (IVP) study - an X-ray test to confirm or look for blockage in higher urinary tracts
• urinalysis and urine culture test
• a Prostate-Specific Antigen (PSA) blood test to screen for prostate cancer
• cystoscopy to look directly into the urethra and bladder.

Treatment

Options for treatment include 'watchful waiting', lifestyle changes, medication or surgery. Minor symptoms may require self-care steps only. If you have BPH, annual examinations should be performed to monitor progression and changes in treatment.

Self care

• Urinate when you get the urge to do so; and go to the bathroom even if you don't feel the need to urinate.
• Avoid alcohol and caffeine, especially at night.
• Don't drink a lot of fluid at once, and avoid fluids just before bedtime.
• Medications like over-the-counter cold and sinus decongestants and antihistamines can increase BPH symptoms.
• Learn pelvic-strengthening exercises.

Medications

• Finasteride reduces prostate size; it increases urinary flow rate and decreases BPH symptoms. It may, however, take three to six months before you notice an improvement in symptoms. Side-effects include decreased sex drive and impotence (erectile dysfunction).
• Alpha-1 blockers (doxazosin, prazosin, tamsulosin and terazosin) also treat hypertension. They relax muscles in the bladder neck, allowing easier urination. A rate of 66% of patients report symptom improvement on these agents.
• Saw palmetto is used commonly as a herbal alternative. Evidence of its effectiveness is, however, lacking.

Surgery

Surgery is recommended for incontinence, recurrent blood in the urine, urinary retention and recurrent UTIs. Even after surgery, BPH may recur.

Choice of surgery varies from person to person, and includes:

• Transurethral resection of the prostate (TURP) - this is the most common treatment. It is performed by inserting a scope through the penis and removing prostate tissue piece by piece.

• Transurethral incision of the prostate (TUIP) - this is similar to TURP, but is more commonly chosen by men with smaller prostates. The patient is treated as an outpatient, and there is no hospital stay. As with TURP, it is done through a scope, but a small incision is made in the prostate to enlarge the urethral and bladder outlet opening.

• Opening prostatectomy - this surgery is done under spinal or general anaesthetic. The prostate is removed through incisions in the abdomen and perineum. This is a lengthy procedure and requires five to ten days of hospitalisation. Complications which may occur include impotence, retrograde ejaculation, infertility and urethral stricture (narrowing).

• Various minimally-invasive procedures are available - they destroy prostate tissue with heat by microwaves or laser. Photoselective vaporization (PVP) is a newer technology done as an outpatient treatment. The long-term effectiveness of this procedure is limited at this stage.

• Prostate stents are available but are not commonly used.

Long-term complications

• sudden inability to urinate (retention)
• urinary tract infections
• urinary stones
• kidney damage
• blood in the urine.

Call your doctor immediately if you have:

• less urine than usual
• fever or chills
• back, side or abdominal pain
• blood or pus in your urine
• your bladder does not empty completely after urination
• you take medications that can cause urinary symptoms
• self-care measures provide no relief after two months.