Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland (a gland surrounding the neck of the bladder in men).

The condition is sometimes also called benign enlargement of the prostate (BEP), in cases where the enlarged prostate reaches or advances beyond a certain size of around 30 cubic cm.

The condition involves the development of nodules (small swellings) in a zone of the prostate called the transitional zone. These nodules impair the functioning of the urethra, the tube that carries urine out of the body. 1 This impairment often creates various difficulties when urinating.

BPH is common in older men and is, in most cases, a non-serious condition. There is no link to prostate cancer, as the cancer grows in a different zone (peripheral zone) of the prostate. A number of treatment options are available for BPH, and it can usually be managed successfully. 2

The most common symptoms of BPH are related to urination. They include: 3

• The need to urinate frequently, including at night
• Strong urges to urinate that appear suddenly and may lead to urinary leakage
• A weak or interrupted urine stream
• Urinary dribbling, which is where urine slowly leaks out after urination, due to incomplete emptying of the bladder
• The sensation that the bladder is never truly empty, also known as incomplete voiding
• Pain while urinating
• Red-tinted urine due to presence of small amounts of red blood cells in the urine

The symptoms of BPH can vary in severity. Some men will experience extremely mild symptoms that require no treatment. In rarer cases, others, typically those with a full blockage of the urethra, will find it impossible or extremely difficult to urinate.

Worried you may have this condition? Start a symptom assessment on the Ada app.

The exact cause of BPH is unknown, but it is thought mainly to be linked to hormonal changes. Many of these changes naturally affect older men, e.g., declining testosterone levels, which lead to a greater (relative) level of estrogen in the bloodstream. 1

Some experts believe that a family history of prostate irregularities puts some men at greater risk of developing BPH. Certain genetic factors also seem to play a role in the development of BPH. 3

Diagnosing BPH will typically begin with the doctor taking a medical history, including questions to find out if the affected person has a family history of prostate problems, followed by a full medical examination.

The examination will include a digital rectal examination (internal examination of the rectum), through which the doctor will be able to estimate the following about the prostrate:

• The size
• The shape
• The health

The rectal examination will also be used to check for the presence of prostate cancer, which, while unconnected to BPH, can be experienced simultaneously with the condition. Other exams and tests may include: 3

• Urinalysis: Testing a sample of urine to check for a bladder infection which may be causing the symptoms.
• Blood tests: To check the levels of prostate-specific antigen (PSA), a protein produced by the prostate that may increase in volume in men with BPH and prostate cancer. In some cases, blood tests may be carried out to check kidney function, as the kidneys can sometimes be affected, e.g., in cases of severe urinary obstruction.
• Uroflowmetry: To check the rate of urine flow during urination. The normal maximal urinary flow rate, the highest speed at which urine is released from the body during the test, is more than 15 milliliters per second. Maximal flow rates of less than 15 milliliters per second indicate an obstruction at the bladder outlet. Maximal flow rates of less than 10 ml per second (due to BPH) indicate the need for surgery. 1
• Abdominal ultrasound: This imaging technique may be used to detect factors such as increased total prostate volume, an elevated post-void residual urine volume (a higher than usual amount of urine, e.g. 100 ml, left in the body after urination), thickening of the bladder wall and hydronephrosis (swelling of a kidney due to a build up of urine). 1
• Transrectal ultrasound: This imaging technique requires insertion of an ultrasound probe into the rectum of the affected individual. It is carried out only if prostate cancer is suspected, for example, in cases of abnormal digital rectal exam results, or elevated serum PSA.

A variety of treatment options for BPH exist, including:

• Medication
• Minimally invasive therapy and surgery
• Surgery

The treatment route chosen will depend on: 4

• The severity of the condition
• Age
• General health
• The size of the prostate

In people affected by mildly symptomatic BPH, observation of the condition over time, accompanied by some behavioural changes may be sufficient. These behavioural changes may also be employed as a supplementary therapy for people undergoing medical treatment for BPH. Helpful behavioural changes include:

• Restricting fluid intake before bedtime and before leaving the house
• Choosing non-caffeinated and non-alcoholic beverages
• Ensuring the bladder is completely empty by passing urine in the sitting position and double voiding (emptying the bladder twice to ensure complete urination)

Medication is the most common method of treating BPH. Options include:

• Alpha blockers: These drugs relax bladder and urethra muscles, easing urination. They are generally more effective in men with smaller prostates and tend to work rapidly. Side-effects may include dizziness and retrograde ejaculation, a harmless condition in which semen is sent to the bladder instead of being released from the penis.
• 5-alpha reductase inhibitors: These drugs work by reducing the size of the prostate. They may take roughly six months to become effective and may also cause retrograde ejaculation.
• Phosphodiesterase type 5 inhibitors: e.g. Tadalafil. Although this drug is more typically prescribed to treat erectile dysfunction, it has also shown success in treating symptoms of BPH. It is generally only prescribed to those experiencing BPH and erectile dysfunction simultaneously.

In some cases, the doctor may prescribe a combination of drugs.

For those experiencing moderate to severe BPH, or in cases where medication has proven to be unsuccessful, a range of minimally invasive surgical therapies are available. These include:

• Transurethral incision of the prostate (TUIP): Incisions are made in the prostate by passing a lighted scope (tubular viewing instrument) up the urethra, allowing urine to pass more easily through the urethra.
• Transurethral microwave thermotherapy (TUMT): An electrode is passed into the prostate and microwaves are emitted in order to shrink the prostate. This therapy can ease urine flow. 5 6
• Transurethral needle ablation (TUNA): Radio waves are passed through needles which have been inserted into the prostate, heating and reducing excess tissue.
• Laser therapy: A laser is used to destroy excess prostate tissue, quickly relieving the symptoms of BPH.
• Interventions such as the Urolift® system, 7 a non-surgical proprietary device that uses tiny implants to lift the prostate away from the urethra and thereby relieve BPH symptoms that result from pressure on the urethra.

Those with severe symptoms or those for whom other treatment methods have proven unsuccessful may require surgery to treat BPH.

• Transurethral resection of the prostate (TURP): By passing a lighted scope up the urethra, a surgeon removes the majority of the prostate. This usually relieves the symptoms of BPH, however, a catheter may be required until the operation site has fully healed.
• Open prostatectomy: This is an inpatient procedure in which an incision is made in the abdomen or perineal area, allowing a surgeon access to the prostate to remove excess tissue. It is common for those with a very large prostate or other complicating factors that rule out other treatment options.

The two main causes of BPH, aging and genetics, cannot be avoided, meaning the condition is difficult to prevent. However, leading a healthy lifestyle may delay the onset of the condition or help manage its symptoms. Lifestyle choices that may help include: 8

• Maintaining a healthy diet: Fruits and vegetables are high in antioxidants, polyphenols, vitamins and minerals, which are all substances that may help fight inflammation and reduce the risk of an enlarged prostate. Avoiding fatty, sugary and additive-heavy foods may also help with this.
• Maintaining a healthy weight: Some studies have drawn a link between being overweight and BPH. Regular exercise can help with this.
• Managing stress: Some studies have suggested that hormonal changes associated with stress may contribute to the onset of BPH.
• Do not wait to urinate: Delaying urination may worsen the symptoms of BPH and can, in some cases, lead to a urinary tract infection.

Although these lifestyle factors may help delay or manage BPH, even very healthy men can develop BHP, and these preventative measures offer no guarantee against this condition.

Although BPH is usually a non-serious condition that can be managed effectively, in rare cases complications can arise. These include: 9

• Urinary tract infection (UTI): Those unable to fully empty their bladder as a result of BPH are at risk of infection. Frequent infection may necessitate the surgical removal of part of the prostate.
• Urinary retention: An inability to urinate may call for the insertion of a catheter to drain the urine from the bladder. Surgery may also be necessary.
• Bladder stones: These can lead to infection, irritation, blood in the urine and an inability to properly urinate. Bladder stones can be surgically removed.
• Bladder damage: BPH, especially when experienced for a prolonged period, can weaken the bladder significantly.
• Kidney damage: Built-up pressure from urinary retention can damage the kidneys and allow infections to spread to the kidneys.
• Retrograde ejaculation: Almost all of the surgical procedures listed above can lead to retrograde ejaculation into the bladder. This is because the bladder sphincter, the muscle that usually keeps semen out of the bladder, can be compromised during surgery. If the shape or function of the bladder sphincter is altered during surgery, it may lose its ability to create a complete seal.

BPH does not increase, or decrease, the risk of prostate cancer. The peripheral zone (in which prostate cancer can develop) is left intact during the TURP procedure. People who have been treated for BPH are therefore at the same risk of developing prostate cancer as the general male population, so normal prostate cancer screening protocol should be followed. 1

Q: Is BPH linked to erectile dysfunction?
A: BPH and erectile dysfunction (ED) are separate problems. However, certain medications used to treat BPH may lead to ED, while, conversely, certain medications used to treat ED can help with BPH. A doctor can help to outline the right treatment plan for an individual. 10

Q: Are there any natural treatment methods for BPH?
A: A number of natural products are thought by some to help treat BPH. These include: 11

• Saw palmetto: A herbal remedy that has historically been used to treat urinary problems.
• Beta-sitosterol: A mixture of plant extracts containing sitosterol, a cholesterol-like substance thought to help with the symptoms of BPH.
• Pygeum: The bark from the African plum tree which has historically been used to treat urinary problems.
• Rye grass pollen extract: An extract made from three types of grass pollen that is thought to help relieve the symptoms of BPH.

It is important to note that such natural treatments are not guaranteed to help prevent BPH or relieve its symptoms, nor should they be seen as an alternative to normal treatment methods. A doctor should always be consulted before using natural treatment methods.