Benign Prostatic Hyperplasia

Definition

The prostate is a male gland that secretes a fluid (a part of the semen) that carries sperm from the testicles during ejaculation.

The prostate is located just below the bladder and in front of the rectum. It surrounds the first inch of the urethra (the tube through which urine and sperm exit the body).

When the prostate becomes enlarged, this condition is called benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy.

Description

The prostate gland undergoes two growth spurts: once during adolescence and the other around the age of 50. Though the prostate continues to grow during most of a man's life, the enlargement does not usually cause problems until late in life. About 75 percent of men over the age of 50 and 90 percent of men in their 70s and 80s have had some symptoms of BPH.

The benign growth occurs when old cells do not die (as they once did) while new cells continue to grow. This accumulation of cells thickens the prostate, which can narrow the urethra, resulting in urination problems.

Causes and Risk Factors

The cause of BPH is not well understood, but researchers theorize that BPH could be caused by:

• the aging process

• testosterone levels - As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen. Studies with animals suggest that BPH may occur when a higher amount of estrogen (in the gland) increases the activity of substances that promote cell growth.

• Dihydrotestosterone (DHT) - DHT is a substance derived from testosterone in the prostate, which may help control its growth. Most animals lose their ability to produce DHT as they age, however, some research indicates that with a drop in blood testosterone level, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage the growth of cells. Scientists have also noted that men who do not produce DHT do not develop BPH.

• cell "instructions" - Some researchers suggest that BPH may develop as a result of "instructions" given to cells early in life. According to this theory, BPH occurs because cells in one section of the gland follow these instructions and "reawaken" later in life. These "reawakened" cells then deliver signals to other cells in the gland, instructing them to grow or making them more sensitive to hormones that influence growth.

Symptoms

The obstructive (problems with urethra and urination) symptoms of BPH are:

• difficulty initiating a urine stream

• a hesitant, interrupted and weak stream

• urgency and leaking or dribbling

• blood in the urine

As the urethra becomes narrower, the bladder wall becomes thicker and the bladder itself becomes smaller, causing:

• more frequent urination

• bladder irritability

• a sudden strong urge to urinate

• urge incontinence - (occurs when bladder muscles are too active.

People with urge incontinence lose urine as soon as they feel a strong desire to go to the bathroom.)

If a man suddenly becomes unable to pass any urine at all, this condition is called acute urinary retention.

The size of the prostate does not always determine how severe the obstruction or the symptoms will be. Some men with greatly enlarged glands have little obstruction and few symptoms, while others whose glands are less enlarged have more blockage and greater problems.

Diagnosis

The doctor will first take a detailed medical history to determine the severity of the symptoms. The results of this questionnaire will determine the course of treatment.

Additionally, a physical exam will be given (including a digital rectal exam - DRE). This procedure involves the doctor slipping a latex-gloved finger into the rectum and feeling the prostate for any lumps or hard spots (that may indicate cancer) and checking the size of the prostate to diagnose BPH. Based on the results of the DRE and the answers to the questionnaire, the doctor may suggest a urine test and a prostate-specific antigen (PSA) blood test.

It is important to tell the doctor about any urinary problems, such as those described in the SYMPTOMS and SIGNS section. Although these symptoms suggest BPH, they can also signal more serious conditions, such as a bladder infection, bladder stones, cancer, diabetes, multiple sclerosis and Parkinson's disease.

Treatment

If the score on the Symptom Index is low, the symptoms are considered mild and the usual procedure is "watchful waiting." No pharmaceutical or surgical treatment is recommended. Continue to have an annual exam so that the doctor can monitor the growth. The doctor will suggest the following lifestyle adjustments to ease symptoms:

• Reduce the intake of coffee, tea and cola drinks during the day.

• Eat dinner in the early evening so you have a chance to eliminate fluids.

• After 7 p.m., cut down on drinking fluids.

• Avoid over-the-counter (OTC) cold remedies that contain pseudoephedrine and antihistamines.

• Avoid spicy and salty foods.

• Stay regular - constipation may aggravate the urinary tract.

• Ejaculate regularly.

• Take hot baths.

• Avoid prolonged sitting.

If the score on the Symptom Index is in mid-range, the symptoms are considered moderate and the usual procedure is pharmaceutical intervention. There are two types of prescription drugs commonly used to treat BPH; alpha-receptor blockers and 5-alpha-reductase inhibitors (or hormone suppressor).

Alpha-receptor blockers (ordinarily prescribed for hypertension) relax the prostatic-urethral muscle thereby improving urinary flow. The most common alpha-receptor blockers are Hytrin, Cardura and Flomax. 5-alpha-reductase inhibitor helps shrink the prostate. The most common 5-alpha-reductase inhibitor is Proscar. Some physicians, particularly in Europe, recommend the use of saw palmetto extract to reduce this level of symptoms of BPH.

If the score on the Symptom Index is high, the symptoms are considered severe and the usual procedure is the use of invasive techniques. There are two types of invasive techniques, non-surgical and surgical.

Non-surgical invasive treatments include transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA).

For the TUMT (Prostatron) procedure, a catheter is threaded through the urethra into the prostate. A computer pulses microwaves through the catheter, heating the prostate, killing prostate tissue, and clearing room for the urethra to function normally.

In the TUNA procedure, a pencil-sized treatment wand is inserted into the urethra. Once in place, two small needles (from the tip of the wand) are pushed into the prostate. Radio waves from the needles heat the surrounding tissue, creating zones of dead BPH tissue that the body absorbs.

Surgical treatments include transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), and a prostatectomy. TURP is used for 90 percent of all prostate surgeries performed for BPH.

For a TURP procedure, an instrument called a resectoscope is inserted through the penis. The resectoscope (about 12 inches long and 1/2 inch in diameter) contains a light, valves for controlling irrigating fluid and an electrical loop that cuts tissue and seals blood vessels. During the operation, the surgeon uses the wire loop of the resectoscope to remove the obstructing tissue one piece at a time. The pieces of tissue are carried by fluid into the bladder and then flushed out at the end of the operation.

A variation of TURP is a laser ablation. Laser ablation uses a high-powered laser (instead of a surgical instrument) to slice away the BPH tissue. Instead of removing tissue (as with TURP) TUIP involves making a few small cuts in the prostate gland. This reduces the pressure on the urethra and permits urine to flow more freely. A prostatectomy is the removal of the inner portion of the prostate through an open incision in the lower abdomen.

Risks And Benefits Of Invasive Treatments

Risks and benefits exist with all forms of treatment for BPH. They are as follows:

TUMT is considered to be less effective than surgery, particularly when obstruction is at the center of the prostate. There is a risk of impotence, incontinence and *retrograde ejaculation. Though no hospitalization is required with this proceedure and relief can be experienced within in three to eight weeks, another TUMT may be necessary at a later date.

TUNA is less effective than surgery. There is the possiblity of impotence, incontinence and retrograde* ejaculation. Though no hospitalization is required with this proceedure and relief can be experienced within in three to eight weeks, another TUNA may be necessary in the future.

TURP presents a risk of retrograde ejaculation 80 percent of the time. There is the possiblity of impotence, incontinence, blood loss and urinary tract infection. This procedure provides instant relief of BPH and improved urination. One week of recovery time is needed. This is considered to be better than the other treatments.

TUIP surgery leaves the possiblity of impotence, incontinence, blood loss, urinary tract infection and retrograde ejaculation. This procedure provides instant relief of BPH. There is the possiblity of a hospital stay with a short recover time.

*Retrograde (backward) ejaculation occurs as a result of damage to the small muscles surrounding the urethra. Instead of clamping shut during ejaculation and forcing semen out through the penis, the muscles relax and allow semen flow into the bladder.

Questions to Ask Your Doctor

Would a more comprehensive exam or test be more appropriate?

Which treatment alternatives apply to this case?

Which treatment should I try first?

If treatment is not done now, will there be more serious problems in the future?

After treatment, will the problem return?

Will a change in diet, exercise, coffee or alcohol consumption, etc., make a difference?