Benign prostatic hyperplasia

What is benign prostatic hyperplasia (BPH)

The prostate slowly increases in size from birth to puberty. It then expands rapidly until about age 30, after which time its size typically remains stable until about age 45, when further enlargement may occur, constricting the urethra and interfering with urine flow.

Benign prostatic hyperplasia (BPH) also called benign prostate gland enlargement or benign prostatic hypertrophy. Most men will get benign prostatic hyperplasia as they get older. Benign prostatic hyperplasia (BPH) occurs only in men; approximately 8 percent of men aged 31 to 40 have BPH. Symptoms often start after age 50. In men over age 80, more than 80 percent have BPH. Untreated, benign prostatic hyperplasia (BPH) can block the flow of urine out of the bladder and cause bladder, urinary tract or kidney problems.

The prostate is a chestnut-shaped structure that surrounds the urethra and ejaculatory ducts immediately inferior to the urinary bladder. It measures about 2 × 4 × 3 cm and is an aggregate of 30 to 50 compound tubuloacinar glands enclosed in a single fibrous capsule. These glands empty through about 20 pores in the urethral wall. The stroma of the prostate consists of connective tissue and smooth muscle, like that of the seminal vesicles. The thin, milky secretion of the prostate constitutes about 30% of the semen.

Benign prostatic hyperplasia (BPH) is not cancer and it does not seem to increase your chance of getting prostate cancer ¹. But the early symptoms are the same.

Many men with benign prostatic hyperplasia (BPH) have no symptoms. In men with symptoms, the most common include needing to urinate frequently (during the day and night), a weak urine stream, and leaking or dribbling of urine. These symptoms are called lower urinary tract symptoms. For men with bothersome symptoms, treatment with one or more medicines or surgery is available.

There are several effective treatments for prostate gland enlargement, including medications, minimally invasive therapies and surgery. To choose the best option, you and your doctor will consider your symptoms, the size of your prostate, other health conditions you might have and your preferences.

See your doctor if you have:

A frequent and urgent need to urinate, especially at night
Trouble starting a urine stream or making more than a dribble
A urine stream that is weak, slow, or stops and starts several times
The feeling that you still have to go, even just after urinating
Small amounts of blood in your urine

Severe benign prostatic hyperplasia (BPH) can cause serious problems over time, such as urinary tract infections, and bladder or kidney damage. If it is found early, you are less likely to develop these problems.

Tests for benign prostatic hyperplasia (BPH) include a digital rectal exam, blood and imaging tests, a urine flow study, and examination with a scope called a cystoscope. Treatments include watchful waiting, medicines, nonsurgical procedures, and surgery.

Figure 1. Prostate gland

Benign prostatic hyperplasia symptoms

The severity of symptoms in people who have prostate gland enlargement varies, but symptoms tend to gradually worsen over time.

Common signs and symptoms of BPH include:

Frequent or urgent need to urinate
Increased frequency of urination at night (nocturia)
Difficulty starting urination
Weak urine stream or a stream that stops and starts
Dribbling at the end of urination
Straining while urinating
Inability to completely empty the bladder

Less common signs and symptoms include:

Urinary tract infection
Inability to urinate
Blood in the urine

The size of your prostate doesn’t necessarily mean your symptoms will be worse. Some men with only slightly enlarged prostates can have significant symptoms, while other men with very enlarged prostates can have only minor urinary symptoms.

In some men, symptoms eventually stabilize and might even improve over time.

Other possible causes of urinary symptoms

Conditions that can lead to symptoms similar to those caused by enlarged prostate include:

Urinary tract infection
Inflammation of the prostate (prostatitis)
Narrowing of the urethra (urethral stricture)
Scarring in the bladder neck as a result of previous surgery
Bladder or kidney stones
Problems with nerves that control the bladder
Cancer of the prostate or bladder

When to see a doctor

If you’re having urinary problems, discuss them with your doctor. Even if you don’t find urinary symptoms bothersome, it’s important to identify or rule out any underlying causes. Untreated, urinary problems might lead to obstruction of the urinary tract.

If you’re unable to pass any urine, seek immediate medical attention.

What causes benign prostatic hyperplasia

The prostate gland is located beneath your bladder. The tube that transports urine from the bladder out of your penis (urethra) passes through the center of the prostate. When the prostate enlarges, it begins to block urine flow.

Most men have continued prostate growth throughout life. In many men, this continued growth enlarges the prostate enough to cause urinary symptoms or to significantly block urine flow.

It isn’t entirely clear what causes the prostate to enlarge. However, it might be due to changes in the balance of sex hormones as men grow older.

Risk factors for benign prostatic hyperplasia (BPH)

Risk factors for prostate gland enlargement include:

Aging. Prostate gland enlargement rarely causes signs and symptoms in men younger than age 40. About one-third of men experience moderate to severe symptoms by age 60, and about half do so by age 80.
Family history. Having a blood relative, such as a father or brother, with prostate problems means you’re more likely to have problems.
Ethnic background. Prostate enlargement is less common in Asian men than in white and black men. Black men might experience symptoms at a younger age than white men.
Diabetes and heart disease. Studies show that diabetes, as well as heart disease and use of beta blockers, might increase the risk of BPH.
Lifestyle. Obesity increases the risk of BPH, while exercise can lower your risk.

Complications of benign prostatic hyperplasia (BPH)

Complications of enlarged prostate can include:

Sudden inability to urinate (urinary retention). You might need to have a tube (catheter) inserted into your bladder to drain the urine. Some men with an enlarged prostate need surgery to relieve urinary retention.
Urinary tract infections (UTIs). Inability to fully empty the bladder can increase the risk of infection in your urinary tract. If UTIs occur frequently, you might need surgery to remove part of the prostate.
Bladder stones. These are generally caused by an inability to completely empty the bladder. Bladder stones can cause infection, bladder irritation, blood in the urine and obstruction of urine flow.
Bladder damage. A bladder that hasn’t emptied completely can stretch and weaken over time. As a result, the muscular wall of the bladder no longer contracts properly, making it harder to fully empty your bladder.
Kidney damage. Pressure in the bladder from urinary retention can directly damage the kidneys or allow bladder infections to reach the kidneys.

Most men with an enlarged prostate don’t develop these complications. However, acute urinary retention and kidney damage can be serious health threats.

Having an enlarged prostate doesn’t affect your risk of developing prostate cancer.

Tests and diagnosis for benign prostatic hyperplasia (BPH)

Your doctor will start by asking detailed questions about your symptoms and doing a physical exam. This initial exam is likely to include:

Digital rectal exam. The doctor inserts a finger into the rectum to check your prostate for enlargement.
Urine test. Analyzing a sample of your urine can help rule out an infection or other conditions that can cause similar symptoms.
Blood test. The results can indicate kidney problems.
Prostate-specific antigen (PSA) blood test. PSA is a substance produced in your prostate. PSA levels increase when you have an enlarged prostate. However, elevated PSA levels can also be due to recent procedures, infection, surgery or prostate cancer.
Neurological exam. This brief evaluation of your mental functioning and nervous system can help identify causes of urinary problems other than enlarged prostate.

After that, your doctor might recommend additional tests to help confirm an enlarged prostate and to rule out other conditions.

These additional tests might include:

Urinary flow test. You urinate into a receptacle attached to a machine that measures the strength and amount of your urine flow. Test results help determine over time if your condition is getting better or worse.
Postvoid residual volume test. This test measures whether you can empty your bladder completely. The test can be done using ultrasound or by inserting a catheter into your bladder after you urinate to measure how much urine is left in your bladder.
24-hour voiding diary. Recording the frequency and amount of urine might be especially helpful if more than one-third of your daily urinary output occurs at night.

If your condition is more complex, your doctor may recommend:

Transrectal ultrasound. An ultrasound probe is inserted into your rectum to measure and evaluate your prostate.
Prostate biopsy. Transrectal ultrasound guides needles used to take tissue samples (biopsies) of the prostate. Examining the tissue can help your doctor diagnose or rule out prostate cancer.
Urodynamic and pressure flow studies. A catheter is threaded through your urethra into your bladder. Water — or, less commonly, air — is slowly injected into your bladder. Your doctor can then measure bladder pressure and determine how well your bladder muscles are working.
Cystoscopy. A lighted, flexible cystoscope is inserted into your urethra, allowing your doctor to see inside your urethra and bladder. You will be given a local anesthetic before this test.
Intravenous pyelogram (IVP) or CT urogram. A tracer is injected into a vein. X-rays or CT scans are then taken of your kidneys, bladder and the tubes that connect your kidneys to your bladder (ureters). These tests can help detect urinary tract stones, tumors or blockages above the bladder.

Benign prostatic hyperplasia treatment

A wide variety of treatments are available for enlarged prostate, including medication, minimally invasive therapies and surgery. The best treatment choice for you depends on several factors, including:

The size of your prostate
Your age
Your overall health
The amount of discomfort or bother you are experiencing

If your symptoms are tolerable, you might decide to postpone treatment and simply monitor your symptoms. For some men, symptoms can ease without treatment.

Medication

Medication is the most common treatment for mild to moderate symptoms of prostate enlargement. The options include:

Alpha blockers. These medications relax bladder neck muscles and muscle fibers in the prostate, making urination easier. Alpha blockers — which include alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax), and silodosin (Rapaflo) — usually work quickly in men with relatively small prostates. Side effects might include dizziness and a harmless condition in which semen goes back into the bladder instead of out the tip of the penis (retrograde ejaculation).
5-alpha reductase inhibitors. These medications shrink your prostate by preventing hormonal changes that cause prostate growth. These medications — which include finasteride (Proscar) and dutasteride (Avodart) — might take up to six months to be effective. Side effects include retrograde ejaculation.
Combination drug therapy. Your doctor might recommend taking an alpha blocker and a 5-alpha reductase inhibitor at the same time if either medication alone isn’t effective.
Tadalafil (Cialis). Studies suggest this medication, which is often used to treat erectile dysfunction, can also treat prostate enlargement. However, this medication is not routinely used for BPH and is generally prescribed only to men who also experience erectile dysfunction.

Minimally invasive or surgical therapy

Minimally invasive or surgical therapy might be recommended if:

Your symptoms are moderate to severe
Medication hasn’t relieved your symptoms
You have a urinary tract obstruction, bladder stones, blood in your urine or kidney problems
You prefer definitive treatment

Minimally invasive or surgical therapy might not be an option if you have:

An untreated urinary tract infection
Urethral stricture disease
A history of prostate radiation therapy or urinary tract surgery
A neurological disorder, such as Parkinson’s disease or multiple sclerosis

Any type of prostate procedure can cause side effects. Depending on the procedure you choose, complications might include:

Semen flowing backward into the bladder instead of out through the penis during ejaculation
Temporary difficulty with urination
Urinary tract infection
Bleeding
Erectile dysfunction
Very rarely, loss of bladder control (incontinence)

There are several types of minimally invasive or surgical therapy.

Transurethral resection of the prostate (TURP)

A lighted scope is inserted into your urethra, and the surgeon removes all but the outer part of the prostate. TURP generally relieves symptoms quickly, and most men have a stronger urine flow soon after the procedure. After TURP you might temporarily need a catheter to drain your bladder, and you’ll be able to do only light activity until you’ve healed.

Transurethral incision of the prostate (TUIP)

A lighted scope is inserted into your urethra, and the surgeon makes one or two small cuts in the prostate gland — making it easier for urine to pass through the urethra. This surgery might be an option if you have a small or moderately enlarged prostate gland, especially if you have health problems that make other surgeries too risky.

Transurethral microwave thermotherapy (TUMT)

Your doctor inserts a special electrode through your urethra into your prostate area. Microwave energy from the electrode destroys the inner portion of the enlarged prostate gland, shrinking it and easing urine flow. This surgery is generally used only on small prostates in special circumstances because re-treatment might be necessary.

Transurethral needle ablation (TUNA)

In this outpatient procedure, a scope is passed into your urethra, allowing your doctor to place needles into your prostate gland. Radio waves pass through the needles, heating and destroying excess prostate tissue that’s blocking urine flow.

This procedure might be a good choice if you bleed easily or have certain other health problems. However, like TUMT, TUNA might only partially relieve your symptoms and it might take some time before you notice results.

Laser therapy

A high-energy laser destroys or removes overgrown prostate tissue. Laser therapy generally relieves symptoms right away and has a lower risk of side effects than does nonlaser surgery. Laser therapy might be used in men who shouldn’t have other prostate procedures because they take blood-thinning medications.

The options for laser therapy include:

Ablative procedures. These procedures vaporize obstructive prostate tissue to increase urine flow. Examples include photoselective vaporization of the prostate (PVP) and holmium laser ablation of the prostate (HoLAP). Ablative procedures can cause irritating urinary symptoms after surgery, so in rare situations another resection procedure might be needed at some point.
Enucleative procedures. Enucleative procedures, such as holmium laser enucleation of the prostate (HoLEP), generally remove all the prostate tissue blocking urine flow and prevent regrowth of tissue. The removed tissue can be examined for prostate cancer and other conditions. These procedures are similar to open prostatectomy.

Prostate lift

In this experimental transurethral procedure, special tags are used to compress the sides of the prostate to increase the flow of urine. Long-term data on the effectiveness of this procedure aren’t available.

Embolization

In this experimental procedure, the blood supply to or from the prostate is selectively blocked, causing the prostate to decrease in size. Long-term data on the effectiveness of this procedure aren’t available.

Open or robot-assisted prostatectomy

The surgeon makes an incision in your lower abdomen to reach the prostate and remove tissue. Open prostatectomy is generally done if you have a very large prostate, bladder damage or other complicating factors. The surgery usually requires a short hospital stay and is associated with a higher risk of needing a blood transfusion.

Follow-up care

Your follow-up care will depend on the specific technique used to treat your enlarged prostate.

Your doctor might recommend limiting heavy lifting and excessive exercise for seven days if you have laser ablation, transurethral needle ablation or transurethral microwave therapy. If you have open or robot-assisted prostatectomy, you might need to restrict activity for six weeks.

Whichever procedure you have, your doctor likely will suggest that you drink plenty of fluids afterward.

Home remedies for benign prostatic hyperplasia (BPH)

To help control the symptoms of an enlarged prostate, try to:

Limit beverages in the evening. Don’t drink anything for an hour or two before bedtime to avoid middle-of-the-night trips to the toilet.
Limit caffeine and alcohol. They can increase urine production, irritate the bladder and worsen symptoms.
Limit decongestants or antihistamines. These drugs tighten the band of muscles around the urethra that control urine flow, making it harder to urinate.
Go when you first feel the urge. Waiting too long might overstretch the bladder muscle and cause damage.
Schedule bathroom visits. Try to urinate at regular times — such as every four to six hours during the day — to “retrain” the bladder. This can be especially useful if you have severe frequency and urgency.
Follow a healthy diet. Obesity is associated with enlarged prostate.
Stay active. Inactivity contributes to urine retention. Even a small amount of exercise can help reduce urinary problems caused by an enlarged prostate.
Urinate — and then urinate again a few moments later. This practice is known as double voiding.
Keep warm. Colder temperatures can cause urine retention and increase the urgency to urinate.

What about alternative medicine ?

The Food and Drug Administration hasn’t approved any herbal medications for treatment of an enlarged prostate.

Studies on herbal therapies as a treatment for enlarged prostate have had mixed results. One study found that saw palmetto extract was as effective as finasteride in relieving symptoms of BPH, although prostate volumes weren’t reduced. But a subsequent placebo-controlled trial found no evidence that saw palmetto is better than a placebo.

Other herbal treatments — including beta-sitosterol extracts, pygeum and rye grass — have been suggested as helpful for reducing enlarged prostate symptoms. But the safety and efficacy of these treatments hasn’t been proved.

If you take any herbal remedies, tell your doctor. Certain herbal products might increase the risk of bleeding or interfere with other medications you’re taking.