Benign Prostatic Hyperplasia

The prostate gland is located just below a male’s bladder and surrounds the top portion of the tube that drains urine from the bladder (urethra). The gland’s primary function is to produce most of the fluids in semen, the fluid that nourishes and transports sperm. From birth to young adulthood, the prostate grows from about the size of a pea to about the size of a walnut.

What is prostate gland enlargement (BPH)?

The prostate gland is located just below a male’s bladder and surrounds the top portion of the tube that drains urine from the bladder (urethra). The gland’s primary function is to produce most of the fluids in semen, the fluid that nourishes and transports sperm. From birth to young adulthood, the prostate grows from about the size of a pea to about the size of a walnut. For most men, the prostate gland undergoes a second phase of growth around mid to late 40s. At this time, cells in the central portion of the gland — where the prostate surrounds the urethra — begin to reproduce more rapidly. As tissues in the area enlarge, they often compress the urethra and partially block urine flow. Benign prostatic hyperplasia (BPH) is the medical term for this condition. Prostate gland enlargement affects about half of men in their 60s and up to 90 percent of men in their 70s and 80s. There is no correlation between prostate gland enlargement and the growth of prostate cancer.
Treatment depends on your signs and symptoms and may include medications, surgery or nonsurgical therapies.

Prostate gland enlargement diagnosis & Screening

To diagnose prostate gland enlargement, your doctor will likely begin by asking you what your symptoms are, when they developed and how often they occur. During your visit, your doctor may inquire about any other medical conditions you have, the medicines you are taking and if anyone in your family has a history of prostate-related issues. Over-the-counter (OTC) drugs, such as aspirin, decongestants and antacids, are considered medications, so tell your doctor about those too. The history of when you start and stop medications is also important for your doctor to know about. In addition, your checkup may include:

To perform this exam, your doctor puts on an examination glove, applies a lubricant to one finger, and then gently inserts the lubricated finger into your rectum. Because the prostate gland is located adjacent to the rectum, your doctor can feel the back wall of the gland. Through this procedure, medical providers can tell if your prostate is enlarged and help determine if you have prostate cancer.

Having a sample of your urine analyzed in the laboratory can help your doctor rule out an infection or other conditions that can produce symptoms similar to those of prostate gland enlargement, such as prostatitis, cystitis and kidney disease.

Prostate-specific antigen is naturally produced in your prostate gland to help liquefy semen. A small amount circulates in your blood. Higher-than-normal levels in your blood can indicate BPH, prostate cancer or prostatitis.

If the results of these tests suggest prostate gland enlargement, your doctor may want to perform additional exams. The following can help confirm the diagnosis of prostate gland enlargement and determine its severity:

Questionnaire

A short questionnaire, developed by the American Urological Association (AUA), asks you about specific urinary symptoms associated with prostate gland enlargement and how often they occur. In addition to helping determine the severity of prostate gland enlargement, this symptom index is helpful in monitoring the progression of the condition over time.

Urinary flow test

This test measures the strength and amount of your urine flow. By charting the results of this test, your doctor can determine if your urinary flow patterns change over time and at what rate. Keep in mind that your peak flow rate normally decreases as you age. Restricted urine flow can also be a sign of other problems, such as a weakened bladder muscle.

Post-void residual volume test

This test measures whether you can empty your bladder. The test is done one of two ways: by inserting a thin, soft tube (catheter) into your urethra and up into your bladder or by using ultrasound imaging to see inside your bladder.

The ultrasound method is more common and less uncomfortable, but often less accurate. Because the results of this test can vary, you may need to have it done more than once to get an accurate reading.

Ultrasound

Imaging through ultrasound is used to estimate the size of your prostate gland.

In addition, it can help detect problems such as an obstruction of your kidney, stones in your kidneys or prostate, or a tumor in the prostate.

Urodynamic studies

If your doctor suspects that your symptoms may be related to a bladder problem rather than prostate gland enlargement, he or she may recommend a series of tests to measure bladder pressure and function. These tests are done by threading a small catheter through the urethra and into your bladder. Water is gently injected into your bladder to measure internal bladder pressure and to determine how effectively your bladder contracts. Bladder pressure is measured during bladder filling and urination.

Cystoscopy

This procedure involves the use of a thin tube containing a lens with a light system (cystoscope) that’s gently inserted into the urethra under local anesthesia. It allows your doctor to see inside the urethra and bladder. The procedure can detect problems including enlargement of the prostate, compression of the urethra due to enlarged prostate, obstruction of the urethra or bladder neck, an anatomical abnormality, and the development of stones in your bladder. These disorders may cause your bladder to weaken.

Intravenous pyelogram

An intravenous pyelogram is an X-ray image of the urinary tract used to help detect an obstruction or abnormality. Dye is injected into a vein, and an X-ray is taken of your kidneys, bladder and tubes that attach your kidneys to your bladder (ureters). The dye makes it possible to identify urinary stones, tumors or a blockage above your bladder.

Benign Prostate Hyperplasia Treatment

Treatment for benign prostate hyperplasia is determined by your signs and symptoms and their severity. If you have significant problems, such as urinary bleeding, persistent urinary tract infections, bladder and kidney damage, your doctor generally will recommend treatment. If your prostate is enlarged but you experience little or no discomfort, treatment often isn’t necessary.

A wide variety of treatments are available to ease the signs and symptoms of an enlarged prostate. They include medications, other nonsurgical therapies and surgical procedures.

Medications are the most common method for controlling moderate symptoms of prostate gland enlargement. Doctors use a variety of medications to treat prostate gland enlargement:

Alpha blockers

Initially, these drugs were invented for the purpose of managing high blood pressure levels. These medications help to loosen the muscles at the neck of your bladder, allowing you to pass urine more easily. The Food and Drug Administration has approved four alpha blockers for prostate gland enlargement: terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax) and alfuzosin (Uroxatral).

Alpha blockers are effective in about two-thirds of men who take them. The drugs work quickly. Within a day or two, most men notice an increase in urinary flow and a decrease in how often they need to urinate. You may need to take an alpha blocker indefinitely.
Doctors are uncertain about the long-term benefits and risks of alpha blockers. To reduce your risk of side effects, your doctor may start with a low dose of medication and gradually increase the dosage. Alpha blockers taken with drugs for impotence, such as sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis), may interact and cause low blood pressure. Discuss with your doctor the possible side effects of these medications before taking them.

Finasteride (Proscar, Propecia)

This drug relieves symptoms in a totally different manner than alpha blockers do. Instead of relaxing your muscles, it shrinks your prostate gland. Men suffering from enlarged prostates may see some immediate improvement in symptoms upon taking this drug. It’s generally not effective, though, if you have only a moderately enlarged or normal-sized prostate.

A few of men who take finasteride experience side effects, such as impotence and decreased sex drive. But in most men, the drug produces only slight side effects. Finasteride also takes a long time to work. You may notice some improvement in urinary flow after three months, but it generally takes up to a year for complete results. However, the long-term effects of this medication have yet to be determined.
Finasteride has two other drawbacks. It’s more expensive than alpha blockers, and although it generally lowers your baseline PSA level, finasteride doesn’t affect or change your risk of prostate cancer. This can interfere with the effectiveness of the PSA screening test for prostate cancer. Be sure to tell your doctor if you are taking finasteride or have taken it in the past.

Combination drug therapy

A study published in the Dec. 18, 2003, issue of the New England Journal of Medicine found that taking doxazosin and finasteride together significantly reduced the risk of further prostate gland enlargement to the point where invasive surgery was not needed. This therapy also appears to decrease urination problems often caused by an enlarged prostate.

Nonsurgical therapies

Several nonsurgical treatment methods are available to reduce the size of the prostate. These therapies focus on enlarging the urethra, making it easier for you to urinate.

Heat therapy. Heat therapy uses heat energy delivered through the urethra to destroy excessive prostate tissue. It is a non-invasive, medication-free solution for many ailments. It’s the perfect middle ground between medication and surgery. It’s more effective than medications for moderate to severe symptoms, and it doesn’t produce as many side effects as surgery.

Heat therapy is often performed on an outpatient basis. But depending on the procedure, your doctor and how quickly you’re able to urinate on your own, you may need to stay in the hospital overnight. Heat therapy ordinarily requires only a few days’ recovery time. An exception is laser therapy. With certain laser treatment methods, it may be necessary to wear a catheter for an extended duration of up to three weeks. Newer techniques often require use of a catheter for only 24 hours.

Several types of heat therapy are available. These may include:

Microwave therapy

Transurethral microwave therapy (TUMT) uses computer-controlled heat in the form of microwave energy to safely destroy the inner portion of the enlarged gland.

The size and shape of an enlarged prostate are critical to the success of microwave therapy. If your prostate is very large or growing in an unusual shape into your bladder, this treatment generally isn’t effective.
During the procedure, a machine emits microwave energy through a urinary catheter. The catheter includes a tiny internal microwave antenna to deliver a dose of microwave energy that heats the enlarged cells and destroys them. To safeguard the urethra from intense heat, cool water is circulated around the tip and sides of the antenna while performing the procedure.
A local anesthetic helps control pain. It is possible to experience mild warmth in the region of the prostate and bladder. You may also have a strong desire to urinate and may experience bladder spasms. These responses usually disappear after the treatment is finished. You can go home when you have normal urination, typically on the same day.
It may take several weeks before you begin to see a noticeable improvement in your symptoms. Men who experience mild symptoms of a condition at the beginning tend to show the best responses over time. The long-term effectiveness of the procedure is uncertain.
It’s normal to have urgent, frequent urination and small amounts of blood in your urine during recovery. There may be changes in the amount of semen you ejaculate. However, unlike more invasive surgery, TUMT generally doesn’t produce impotence, incontinence or retrograde ejaculation. With retrograde ejaculation, semen flows backward into the bladder during ejaculation instead of out through the penis and can result in infertility.
TUMT isn’t recommended if you have a pacemaker or any metal implants.

Radiofrequency therapy

Transurethral needle ablation (TUNA) works by sending radio waves through needles that are inserted into your prostate gland, heating and destroying the tissue. As in TUMT, a special catheter is inserted through your urethra. The needles are inserted into your prostate by maneuvering the catheter.

TUNA typically is less effective than traditional surgery in reducing symptoms and improving urine flow. Its long-term effectiveness also isn’t known. Another drawback of the procedure is that it doesn’t work as well in men with very large prostates. Side effects may include urine retention, blood in your urine, painful urination and a small risk of retrograde ejaculation.

Electrovaporization

Transurethral electrovaporization of the prostate (TVP) involves a special metal instrument that emits a high-frequency electrical current to cut and vaporize excess tissue while sealing off the remaining tissue to prevent bleeding. This procedure is especially useful for men at higher risk of complications, including those who take a blood-thinning (anticoagulant) medication. As with other, newer treatments, its long-term benefits aren’t yet known.

Laser therapy

This procedure is performed similarly to other heat therapies, except it uses a laser instead of microwave energy, radio waves or electrical current to produce heat. It is generally believed that it doesn’t lead to impotence or long-term incontinence. However, some laser procedures require lengthy use of a catheter. Laser therapy includes transurethral evaporation of the prostate (TUEP), noncontact visual laser ablation of the prostate (VLAP) and interstitial laser therapy.

TUEP is similar to electrovaporization. The difference is that your doctor destroys prostate tissue with laser energy instead of electrical current. The procedure is generally secure and results in minimal bleeding. The procedure produces speedy results, often showing an enhancement in urine flow shortly after.
VLAP is a laser procedure that involves targeting and removing extra prostate cells, resulting in their destruction. Due to the effect of swelling and shedding dead skin, you may have difficulty passing urine over a few days and require catheterization. You may also experience a burning sensation during urination for days to weeks.
Interstitial laser therapy directs laser energy inside the prostate growths rather than at the urethral surface. This treatment helps to improve urinary flow while safely minimizing the size of the prostate. Additionally, it appears to be effective for individuals with large prostates. It is possible that after treatment, there will be a large amount of inflammation in the tissues which may necessitate the usage of a catheter for up to three weeks. Uncomplicated urinary tract infections also are common. Interstitial laser therapy is a good option if you can’t have surgery because of other health complications. It doesn’t cause any blood loss and uses a combination of local anesthesia and intravenous sedation to control pain during the procedure.

A drawback of heat therapies is that no tissue is taken (biopsied) from your prostate gland. During surgical treatments for an enlarged prostate, a small sample of your prostate generally is taken by your doctor and examined by a pathologist for possible cancer.

Prostatic stents

A prostatic stent is a tiny metal coil. During this procedure, it is inserted into your urethra to widen the urethra and keep it open. Stents are securely held in place by tissue growth after placement. This treatment produces little or no bleeding and doesn’t require a catheter. It may be an option for men who are unwilling or unable to take medications or who are reluctant or unable to have surgery. Stents often aren’t ideal for older men who have difficulty wearing or maintaining them, or who are unable to tolerate the procedure.

Some men find that the stents don’t improve their symptoms. Many individuals suffer from a burning sensation when they urinate or experience recurrent urinary tract infections. These complications, along with the high cost and potential difficulties in removing the stents, have reduced the popularity of this treatment.

Surgical and other procedures

At one time surgery was the most common treatment for benign prostatic hyperplasia (BPH). Due to advances in medications and other less traumatic methods of treatment, surgeries are declining in popularity as more people embrace alternative methods. Today it’s used mainly for more severe signs and symptoms or if you have complicating factors, such as:

Frequent urinary tract infections
Kidney damage from urinary retention
Bleeding through the urethra
Stones in the bladder

Among all treatments for an enlarged prostate, surgery is the most effective in providing relief from symptoms. This treatment is known to be the benchmark of other treatments, and physicians have a long-standing record of familiarity with it. Despite its great benefits, it has the potential to cause some side effects.

Fortunately, most men experience few problems. Among those with certain health conditions, such as uncontrolled diabetes, cirrhosis of the liver, a major psychiatric disorder, or a serious lung, kidney or heart condition, surgery isn’t usually recommended unless absolutely necessary.

Surgery for an enlarged prostate requires a hospital stay. After a surgical procedure, it may be necessary to take time off work for recovery, ranging from a few days to a month. You’ll also need to avoid heavy lifting, jarring to your lower pelvic area or straining of your lower abdominal muscles for up to two months.

The types of surgery for an enlarged prostate include:

Transurethral resection of the prostate (TURP)

An enlarged prostate is commonly treated with surgical procedures, the most frequently used of which is this one. During the procedure, you’re given general anesthesia or anesthetized from the waist down with a spinal block. During a surgical procedure, a slender tool known as a resectoscope is carefully inserted into the urethra and then used to cut away excess prostate tissue. You can expect to stay in the hospital for one to three days after surgery. During your recovery, you’ll have a urinary catheter in place for a few days.

TURP is effective and relieves symptoms quickly. Most men experience a stronger urine flow within a few days. You can expect some blood or small blood clots to appear in your urine afterward. Before you leave the hospital, you should be able to urinate on your own. Initially, when you urinate, you may experience some discomfort or a burning sensation in the area where the surgery was performed. This discomfort should gradually improve. In some cases, you may be sent home from the hospital with a catheter that is later removed in your doctor’s office.
In certain scenarios, TURP may result in impotence and inability to control urinary excretion. Generally, these conditions are only temporary. Pelvic floor muscle exercises (Kegel exercises) often help restore bladder control. Typically, sexual functioning will go back to normal within a couple of weeks up to several months. However, it can take up to one year to make a full recovery from these side effects.
A commonly reported side effect of surgery is retrograde ejaculation TURP may also produce scarring and narrowing in the urethra or bladder neck. Outpatient stretching of scar tissue can often help alleviate this issue. In some cases, men who have undergone Transurethral Resection of the Prostate (TURP) may need to repeat the surgery due to regrowth of the prostate or removal of scar tissue from prior operations.

Transurethral incision of the prostate (TUIP)

Surgery may be considered if you have a medium to the low-sized prostate gland. Additionally, this is an ideal choice for those men who are not suitable for major surgery due to health concerns or fear of potential infertility.

TUIP, similar to TURP, mandates the utilization of special tools which are inserted through the urethra. Rather than removing the entire prostate gland, the surgeon opts for making one or two tiny incisions in it. The cuts help enlarge the opening of the urethra, making it easier to urinate.
Compared to other types of surgery, this procedure comes with fewer risks and complications. This particular treatment is not an overnight hospital stay, however, its success rate is lower and oftentimes has to be done again. For some men, an enhancement in urinary flow is observed but it can be quite minimal.

Open prostatectomy

This type of surgery is generally performed only if you have an excessively large prostate, bladder damage or other complicating factors, such as bladder stones or urethral strictures. It’s called open because the surgeon makes an incision in your lower abdomen to reach the prostate rather than going up through the urethra. An open prostatectomy typically involves the removal of the inner section of your prostate gland, preserving the outer portion.

Open prostatectomy is the go-to therapy for men with severe prostate enlargement since it is secure and successful. But it poses the greatest risk of side effects. The procedure carries the same risks as TURP, but the complications may be more severe in nature. Generally, patients need to stay in the hospital for three to five days for this procedure.