What is benign prostatic hyperplasia?

Benign prostatic hyperplasia (also called BPH) is a condition that affects the prostate
gland in men. The prostate is a gland found between the bladder (where urine is stored)
and the urethra (the tube urine passes through). As men age, the prostate gland slowly
grows bigger (or enlarges). As the prostate gets bigger, it may press on the urethra and
cause the flow of urine to be slower and less forceful. "Benign" means the enlargement
isn't caused by cancer or infection. "Hyperplasia" means enlargement.

What are the symptoms of BPH?

Most symptoms of BPH start gradually. One symptom is the need to get up more often at
night to urinate. Another symptom is the need to empty the bladder often during the day.
Other symptoms include difficulty in starting the urine flow and dribbling after urination
ends. The size and strength of the urine stream may decrease.

These symptoms can be caused by other things besides BPH. They may be signs of more
serious diseases, such as a bladder infection or bladder cancer. Tell your doctor if you
have any of these symptoms, so he or she can decide which tests to use to find the
possible cause.

How will my doctor know if I have BPH?

After your doctor takes a complete history of your symptoms, a rectal exam is the next
step. In a rectal exam, your doctor checks your prostate by putting a gloved, lubricated
finger into your rectum to fee the back of your prostate gland. This exam allows your
doctor to feel the size of the prostate gland.

To make sure that your prostate problem is benign, your doctor may need to look at a
sample of your urine for signs of infection. Your doctor may also do a blood test. An
ultrasound exam or a biopsy of the prostate may help your doctor make the diagnosis.

How will my doctor treat my BPH?

Once your doctor is sure that your symptoms are caused by benign growth of the prostate
gland, treatment can be recommended. However, your doctor may suggest that you wait
to see if your symptoms get better. Sometimes mild symptoms get better on their own. If
your symptoms get worse, your doctor may suggest another treatment option.

Surgery is considered the most effective treatment and is used in men with strong
symptoms that persist after other treatments are tried. This is also the best way to
diagnose and cure early cancer of the prostate. Surgery is usually done through the
urethra, leaving no scars. Surgery does have risks, such as bleeding, infection or
impotence. These risks are generally small.

Are there any drugs I can take?

Drug treatments are available. Finasteride (brand name: Proscar) and dutasteride (brand
name: Avodart) blocks a natural hormone that makes the prostate enlarge, but it does not
help all patients. The side effects of finasteride are rare and mild, but they usually have to
do with sexual function. They go away when the medicine is stopped. The prostate may
enlarge again when the medicine is stopped, so your doctor may suggest another
treatment.

Another kind of medicine, called alpha-blockers, also can help the symptoms of BPH.
Alpha-blockers have been used for a long time to treat high blood pressure, but they can
also help the symptoms of BPH, even in men with normal blood pressure. Some of these
drugs are terazosin (brand name: Hytrin), doxazosin (brand name: Cardura), tamsulosin
(brand name: Flomax) and alfuzosin (brand name: Uroxatral). These medicines may not
work in all men. The side effects of alpha-blockers include dizziness, fatigue and
lightheadedness. The side effects go away if you stop taking the medicine.

Written by familydoctor.org editorial staff.

Source

American Academy of Family Physicians

Reviewed/Updated: 12/06
Created: 09/00
Copyright © 2000-2007 American Academy of Family Physicians
This article provides a general overview on this topic and may not apply to everyone. To find out if this article applies to
you and to get more information on this subject, talk to your family doctor.

What is the prostate gland?

The prostate is a small organ about the size of a walnut. It lies below the bladder
(where urine is stored) and surrounds the urethra (the tube that carries urine from
the bladder). The prostate makes a fluid that becomes part of semen. Semen is
the white fluid that contains sperm.
 Prostate problems are common in men 50 and older. Most can be treated
successfully without harming sexual function. A urologist is a specialist in
diseases of the urinary system, including diagnosing and treating problems of the
prostate gland.

How does the doctor detect prostate enlargement?

A doctor usually can detect an enlarged prostate by rectal exam. The doctor also
may examine the urethra, prostate, and bladder using a cytoscope, an instrument
that is inserted through the penis.

What is benign prostatic hyperplasia?

Benign prostatic hyperplasia is nonmalignant (noncancerous) enlargement of the

prostate gland, a common occurrence in older men. It is also known as benign
prostatic hypertrophy and abbreviated as BPH and as nodular hyperplasia of the
prostate.

BPH
Benign Prostatic Hyperplasia and Benign Prostatic Hypertrophy are both non-cancerous
conditions that cause a constriction of the urethra, due to the increase in the size of the prostate.
BPH commonly affects middle aged to elderly men. About 43% of men with BPH are over 65.
Although the two conditions are scientifically quite distinct from each other they are both called
BPH by doctors, and have the same methods of diagnosis and treatment.

This fact sheet is about the causes, symptoms, diagnosis and treatment of BPH.

What is BPH
Benign Prostatic Hyperplasia describes the abnormal increase in the number of non-cancerous
cells within the transition zone of the prostate.

Most cancers of the prostate start in the peripheral zone, whilst the central zone tends to be free
from changes.

Benign Prostatic Hypertrophy is the abnormal increase in the size of non-cancerous cells within
the transition zone of the prostate.

What causes BPH?

As men get older, there is a surplus in the amount of testosterone produced by the testicles. This
excess testosterone is absorbed by the prostate. Testosterone causes an increase in the growth
of prostate cells, and how long those cells live. The result of this is growth of the prostate. Since
the prostate surrounds the urethra this growth slowly begins to strangle the urethra as it exits the
bladder. This can cause obstruction and reduce the flow of urine from the bladder.
Signs & Symptoms
The degree of ‘bother’ symptoms cause will differ from man to man as will the type of symptoms
experienced and length of time they last. The signs and symptoms experienced are often referred
to by health professionals as Lower Urinary Tract Symptoms (LUTS).

Symptom Description
Poor stream Urine flow is weak and slow
Frequency Peeing more than 10 times a day
Urgency The sudden almost uncontrollable need to pee
Hesitancy Difficulty and delay starting to pee
Nocturia Waking up more than twice a night to pee
Dribbling Being unable to stop completely the flow of urine
Incomplete emptying of the bladder
Burning/pain on peeing

Effects of BPH
How and when you decide to seek advice for your symptoms will usually depend on the ‘bother’
factor of symptoms and their impact upon you and your partners work and social life. Some men
find that their activities are limited due to the need to be near toilet facilities. Work, driving,
outdoor activities and attending social events can become difficult.

If left unchecked problems that are more serious can develop:

Some men find that they have a sudden and painful inability to pass urine. This is Acute
Retention of Urine. This requires urgent medical treatment by means of draining the bladder
with a urinary catheter and probably a short period of hospitalisation.

Other men find it becomes increasingly more difficult, though usually painless, to empty the
bladder and they retain more urine than they pass. This is Chronic Retention of Urine. Chronic
retention will cause an overstretching of the bladder as it tries to cope with the increase in
capacity and pressure. The increase in pressure can lead to back pressure which left unchecked
can result in kidney failure as the kidneys become ‘waterlogged’. As the lining and muscles of the
bladder become fatigued through the constant stretch of chronic retention small tears and
pockets may develop and give rise to urinary tract infections as well as the formation of bladder
stones.

Bladder stones are collections of crystallised urine that form into semi-soft ‘putty like’ and hard
‘rock like’ stones. Although not life threatening bladder stones can be painful and contribute to a
worsening of symptoms.

Diagnosis

• An initial diagnosis can be made by your GP who may perform the following
tests. If not completed by your GP they will be done by an Urologist or Specialist
Nurse at your local hospital.
• You will be asked about your symptoms. A scorecard may be used to rate your
symptoms.
 • You may be asked to record your drinking and urination over a series of days to
assess the frequency and amount of urine you pass.
• A rectal examination will indicate if the prostate is enlarged. The prostate can be
felt through the wall of the rectum.
• Usually your urine will be tested to find any possible infection.
• A blood test to check kidney function should be performed.
• You may be given a PSA test.
• More specialist tests will be required and these are usually carried out in a more
specialist setting:

Flow rate

Assesses the force of urination by recording the speed and energy of flow of urine when passed
into a recording device.

Ultrasound scan

This records the amount of urine that the bladder retains following urination. A scan to check the
size and shape of the urinary system may also be performed.

X-rays

Depending on symptoms, other x-ray examinations such as dye tests (Intravenous Urogram IVU)
may be performed to ascertain the effects upon the kidneys and the bladder.

Treatment Options
The type of treatment you require will be based upon the severity of your symptoms, the
presence of any complications and your general health. All treatments have advantages and
disadvantages. You should discuss the most appropriate treatment with your specialist.

Treatment options are:

• Watchful Waiting and lifestyle changes

• Permanent catheterisation
• Drug treatments and alternative medicines
• Non surgical interventions
• Surgery

Watchful Waiting

If there are no complications and minimal inconvenience from the symptoms it may be more
appropriate to wait and see how your condition develops over a period of time. You should have
regular checks on your symptoms.

Lifestyle Changes
If you who wish to avoid surgery and drug therapies relief from symptoms may be increased by
some simple changes to your lifestyle:

• Avoid drinks that are high in caffeine

• Avoid alcohol or reduce your alcohol intake
• Decrease the amount you drink in the evening
• Avoid cold and allergy medicines such as anti-histamines and decongestants,
which can affect the muscles in the bladder (this should be done in consultation
with your GP)
• Drink Green tea, it contains flavonoids that may be of benefit to the prostate
• Increase the amount of fibre and fruit you eat to avoid constipation

Urinary Catheterisation

Urinary catheterisation may be used for some men for medicines are not suitable as a treatment
choice or those who cannot endure surgery. The catheter may be placed via the urethra or via the
abdominal wall. This will allow urine to drain continually with minimal inconvenience.

Catheterisation is not without its disadvantages. Men with a catheter are more susceptible to
infection and may find it interferes with their sex life.

Drug Treatments & Alternative Medicines

The continual development in conventional drug therapies, and the greater awareness of
‘alternative medicines’, has reduced the number of men undergoing surgery for BPH. They have
also had a part in delaying the eventual need for surgery in those with symptoms that are more
aggressive.

Conventional drug therapies fall into two type of drugs:

• Alpha-blockers
• 5 a-reductase inhibitors.

Alpha-blockers

A drug that relaxes smooth muscles, alpha-blockers have previously been used to treat high
blood pressure. They are effective in treating the symptoms of BPH in men who don’t have
significantly enlarged prostates. By relaxing the smooth muscles surrounding the prostate alpha-
blockers increase the flow of urine and improve symptoms.

Types of alpha-blockers
Drug Brand Name
Alfuzosin Xatral SR & Xatral XL
Doxazosin Cardura
Indoramin Doralese
Prazosin Hypovase
Tamsulosin Flomax MR
Terazosin Hytrin BPH
Advantages of alpha-blockers

• Improve urinary flow

• Quick to work
• No adverse effect upon sexual drive

Disadvantages of alpha-blockers

• Short acting
• Usually only delays the need for surgery, no evidence for preventing the
progression of BPH
• Only effective on moderately enlarged prostates
• Lower blood pressure and dizziness
• Short acting
• Can cause fatigue, nasal congestion, headache
• Can decrease ejaculate

5 Alpha-reductase Inhibitors

5 a-reductase inhibitors block the conversion of testosterone within the prostate cells. 5 a-
reductase inhibitors are more effective in men with larger prostate glands than alpha-blockers and
have been found to reduce prostate volume by 20% resulting in an improvement in symptoms.

Types of 5 a–reductase inhibitors

Drug Brand Name

Finasteride Proscar

Advantages of Finasteride

• More effective on larger prostates

• Longer acting
• Less side effects than alpha blockers
• Can reverse male pattern balding

Disadvantages of Finasteride

• Not effective on slight and moderately enlarged prostates

• Slow to act - can take up to six months to work
• Can affect sexual function
• Can cause breast swelling
• Can be transmitted in semen and cause birth defects, users should have protected
sex
Alternative Therapies
Although there are as yet no conclusive studies to the true value of herbal and non-traditional
therapies many men have found relief from the symptoms of BPH. If you intend trying any
alternate treatments it is advisable to discuss this with your doctor before you start.

The more widely available alternative therapies include Saw palmetto, Beta-sitosterol plant
extracts and Rye Grass pollen extract.

Surgery
For the majority of men with BPH whose symptoms are becoming unbearable or who develop
complications surgery is the recommended treatment.

Transurethral Resection of Prostate (TURP)

This is the most widely available surgery. TURP involves stripping away the enlarged prostate via
the urethra, under anaesthetic. This procedure is ideal for most degrees of enlargement. TURP is
performed under anaesthetic and via the urethra, so no incision is required. Using fibre-optic
equipment small scrapings of the enlarged prostate tissue are made until a clear passage is be
made. A catheter can then be inserted to help drain the bladder and evacuate any debris.

Smaller prostates can be removed in a similar fashion. This is often called Bladder Neck Incision
or Transurethral Incision. Larger prostates may require an open prostatectomy where the
enlarged prostate is removed via an incision in the abdomen.

It is common for the symptoms of BPH to persist for several weeks after TURP, they should settle
with time and if required performing pelvic floor exercises to strengthen the muscles of the pelvis.
Most men are discharged within five days of admission and return to the clinic within three
months of the operation for a check up.

Open Prostatectomy

Open Prostatectomy is only carried out on men with very large prostate glands. The gland is
removed through an incision in the lower abdomen. Open Prostatectomy is a major operation and
requires a hospital stay of 7 days or more. A catheter will be inserted at the time of the operation
that will stay in place for about two weeks. Recovery following this surgery is slower than TURP
because of the wound, and men are advised to avoid strenuous activity for several months. The
complications are similar to TURP with 10% requiring further surgery within 8 years.

Different hospitals and specialists have different ways of achieving the same results so always
check their treatment plan for your procedure.

Advantages of surgery

• TURP is widely available

• 90% probability of symptom improvement

Disadvantages of surgery
 • Blood Loss
• 20% of men will need a second TURP within 8 years (5)
• Disruption of sexual function
• Risk of scarring (stricture) in the urethra
• Hospital stay of five – seven days
• Temporary incontinence
• Infection
• Wound (open prostatectomy)

Non Surgical Interventions

Non Surgical Techniques are not widely available in the UK and many are still under study to see
if they are effective compared to TURP. It will be several years before any conclusive evidence of
their value is available.

Non surgical interventions

• Transurethral Microwave Therapy (TUMT)

• Transurethral Needle Ablation (TUNA)
• Transurethral Electrovaporisation (TUEVP)
• Laser Surgery
• Prostatic Stenting

Transurethral Microwave Therapy (TUMT)

TUMT, or thermotherapy, is the destruction of enlarged prostatic tissue by heating it to around 45

– 55 C. Microwave heat is delivered via a probe inserted via the urethra with a temperature
regulator placed in the rectum.

Advantages of TUMT

• Little or no bleeding
• Reasonable urinary flow improvement
• Less effect on sexual function compared to standard surgery

Disadvantages of TUMT

• May need repeated sessions

• Requires general anaesthetic
• High risk of retention of urine after treatment
• Cannot be performed if you have a pacemaker, or other metal implant
• Not widely available

Transurethral Needle Ablation (TUNA)

Destruction of enlarged prostatic tissue is achieved by using radio-frequency energy applied to

the centre of the prostate gland at temperatures of 120 C. It is applied to the core of the prostate
to avoid damage to the urethra and is reported to be more effective on moderately enlarged
prostates.

Advantages of tuna

• Can be performed under local anaesthetic

• Little bleeding
• Low risk of incontinence
• Urine flow improvement comparable to surgery

Disadvantages of tuna

• Not effective on large prostates

• High risk of retention of urine after treatment
• Disruption to sexual function
• Painful urination after procedure
• Not widely available

Transurethral Electrovaporisation of Prostate (TUEVP)

A modification of the standard surgery TURP. The prostate tissue is vaporised by a high electrical
current rather than cut away. The electrical current also seals any bleeding.

Advantages of TUEVP

• Similar results to surgery

• Minimal blood loss compared to surgery

Disadvantages of TUEVP

• Not widely available

• Effectiveness of surgery can be delayed
• Hospital stay of around 5 days

Laser Surgery

There are various methods of laser-based surgery being used and studied at present. All require
the insertion of a laser probe or wire into the urethra to rest on the surface of the prostate.
Treatments tend to be short in duration compared to conventional surgery. Men receiving laser
surgery usually see an immediate improvement in their symptoms and urine flow, whereas those
treated by the laser coagulation method find the response is delayed.

Advantages of laser surgery

Minimal bleeding compared to standard surgery

• Symptoms may improve immediately

Disadvantages of laser surgery

• High risk of retention of urine following treatment

• Symptom improvement may be slow
• Not Widely available

Prostatic Stenting

For men whom surgery, medicines and catheterisation is not advisable prostatic stenting may be
an option. The obstruction caused by the enlarged prostate can be held back by the insertion,
usually under a local anaesthetic, of a cylinder shaped mesh structure, called a stent. This is
made from flexible metals such as titanium alloy. Stents are advantageous in the reducing the
symptoms of BPH by having the instant effect of improving symptoms without any