Overview of Enlarged Prostate, Benign Prostatic Hyperplasia (BPH)
Benign prostatic hyperplasia (BPH), also called benign prostatic hypertrophy, is not simply a case of too many prostate cells. Prostate growth involves hormones, occurs in different types of tissue (e.g., muscular, glandular), and affects men differently. As a result of these differences, treatment varies in each case. There is no cure for BPH and once prostate growth starts, it often continues, unless medical therapy is started.
The prostate grows in two different ways. In one type of growth, cells multiply around the urethra and squeeze it, much like you can squeeze a straw. The second type of growth is middle-lobe prostate growth in which cells grow into the urethra and the bladder outlet area. This type of prostate growth typically requires surgery.
Prostate Gland Anatomy
The prostate is a walnut-sized gland located beneath the bladder and in front of the rectum in men. It is surrounded by a capsule of fibrous tissue called the prostate capsule. The urethra (tube that transports urine and sperm out of the body) passes through the prostate to the bladder neck. Prostate tissue produces prostate specific antigen and prostatic acid phosphatase, an enzyme found in seminal fluid (milky substance that combines with sperm to form semen).
Incidence & Prevalence of BPH
It is difficult to determine the exact incidence and prevalence of BPH because research groups often use different criteria to define the condition. According to the National Institutes of Health (NIH), benign prostatic hyperplasia affects more than 50 percent of men over age 60 and as many as 90 percent of men over the age of 70.
Risk Factor for Benign Prostatic Hyperplasia (BPH), Enlarged Prostate
BPH is a condition of aging. Most men over the age of 50 have an enlarged prostate.
Causes of Benign Prostatic Hyperplasia (BPH), Enlarged Prostate
The cause for benign prostatic hyperplasia is unknown. It is possible that the condition is associated with hormonal changes that occur as men age. The testes produce the hormone testosterone, which is converted to dihydrotestosterone (DHT) and estradiol (estrogen) in certain tissues. High levels of dihydrotestosterone, a testosterone derivative involved in prostate growth, may accumulate and cause hyperplasia. How and why levels of DHT increase remains a subject of research.
Signs and Symptoms of Benign Prostatic Hyperplasia (BPH), Enlarged Prostate
Common symptoms of benign prostatic hyperplasia include the following:
- Blood in the urine (i.e., hematuria), caused by straining to void
- Dribbling after voiding
- Feeling that the bladder has not emptied completely after urination
- Frequent urination, particularly at night (i.e., nocturia)
- Hesitant, interrupted, or weak urine stream caused by decreased force
- Leakage of urine (i.e., overflow incontinence)
- Pushing or straining to begin urination
- Recurrent, sudden, urgent need to urinate
In severe cases of BPH, acute urinary retention (the inability to urinate) can result from holding urine in for a long period of time, alcohol consumption, a long period of inactivity, cold temperatures, allergy or cold medications containing decongestants or antihistamines, and some prescription drugs (e.g., ipratropium bromide, albuterol, epinephrine).
Any of these factors can prevent the urinary sphincter from relaxing and allowing urine to flow out of the bladder. Acute urinary retention causes severe pain and discomfort. In some cases, catheterization may be necessary to drain urine from the bladder.
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Diagnosis of Benign Prostatic Hyperplasia (BPH), Enlarged Prostate
A physical examination, patient history, evaluation of symptoms, laboratory tests, and other tests provide the basis for a diagnosis of benign prostatic hyperplasia (BPH). The physical examination includes a digital rectal examination (DRE).
Digital Rectal Examination (DRE)
DRE typically takes less than a minute to perform. In this procedure, the physician inserts a lubricated, gloved finger into the patient’s rectum to feel the surface of the prostate gland through the rectal wall to assess the size, shape, and consistency of the gland. Healthy prostate tissue is soft, like the fleshy tissue of the hand where the thumb joins the palm. Malignant tissue is firm, hard, and often asymmetrical or stony, like the bridge of the nose. If the examination reveals the presence of unhealthy tissue, additional tests are performed to determine the nature of the abnormality.
PSA and PAP Tests
Blood tests may be used to check the levels of prostate specific antigen (PSA) and prostatic acid phosphatase (PAP) in a patient who may have benign prostatic hyperplasia. These tests can help the physician rule out prostate cancer.
Prostate-specific antigen (PSA) is a specific antigen produced by the cells of the prostate capsule (membrane covering the prostate) and periurethral glands. Patients with benign prostatic hyperplasia (BPH) or prostatitis produce larger amounts of PSA. The PSA level also is determined in part by the size and weight of the prostate.
The test measures the amount of PSA in the blood in nanograms per milliliter (ng/mL). A PSA of 4 ng/mL or lower is normal; 4–10 ng/mL is slightly elevated; 10–20 is moderately elevated; and 20–35 is highly elevated. Most men with slightly elevated PSA levels do not have prostate cancer, and many men with prostate cancer have normal PSA levels. A highly elevated level may indicate the presence of cancer. However, the PSA test can produce false results. A false positive result occurs when the PSA level is elevated and there is no cancer. A false negative result occurs when the PSA level is normal and prostate cancer is present. Because of this, a biopsy usually is performed to confirm or rule out cancer when the PSA level is high.
PSA in the blood may be bound molecularly to one of several proteins or may exist in a free, or unbound, state. Total PSA (also known as PSA II) is the sum of the levels of both forms and free PSA measures the level of unbound PSA only. Studies suggest that malignant prostate cells produce more bound PSA; therefore, a low level of free PSA in relation to total PSA might indicate prostate cancer, and a high level of free PSA compared to total PSA might indicate a normal prostate, BPH, or prostatitis.
Evidence suggests that PSA levels increase with age (called age-specific PSA). A PSA of up to 2.5 ng/mL for men age 40–49 is considered normal, as is 3.5 ng/mL for men age 50–59, 4.5 ng/mL for men age 60–69, and 6.5 ng/mL for men 70 and older. The use of age-specific PSA levels is not endorsed by all medical professionals.
Urodynamic tests are used to measure the volume and pressure of urine in the bladder and to evaluate the flow of urine. These tests, which usually are performed in a physician’s office, are particularly useful for diagnosing intrinsic sphincter deficiency and uncertain cases of mixed, overflow, urgency, or total incontinence. Additional tests may be conducted if symptoms indicate that blockage is caused by a condition other than BPH.
Uroflowmetry is a simple test performed to record urine flow, to determine how quickly and completely the bladder can be emptied, and to evaluate obstruction. With a full bladder, the patient urinates into a device that measures the amount of urine, the time it takes for urination, and the rate of urine flow. Patients with stress or urge incontinence usually have a normal or increased urinary flow rate, unless there is an obstruction in the urinary tract. A reduced flow rate may indicate BPH.
Pressure Flow Study
A pressure flow study measures pressure in the bladder during urination and is designed to detect a blockage of flow. It is the most accurate way to evaluate urinary blockage. This test requires the insertion of a catheter through the urethra in the penis and into the bladder. The procedure is uncomfortable and rarely may cause urinary tract infection UTI).
Post-void Residual (PVR) Test
Post-void residual (PVR) test measures the amount of urine that remains in the bladder after urination. The patient is asked to urinate immediately prior to the test and the residual urine is determined by ultrasound or catheterization. PRV less than 50 mL generally indicates adequate bladder emptying and measurements of 100 to 200 mL or higher often indicate blockage. Nervousness and other types of stress may affect the result; therefore, the test is often repeated.
Treatments for Benign Prostatic Hyperplasia (BPH), Enlarged Prostate
Treatment options for enlarged prostate, or benign prostatic hyperplasia (BPH), may include the following:
- Medical treatment
- Watchful waiting
- Medications (e.g., alpha blockers)
- Prostatic stents
- “Mini” Incision Prostatectomy
- Minimally invasive BPH treatments use state-of-the-art tools and techniques to reduce or eliminate symptoms. Men are treated on an outpatient basis in an urologist’s office or the hospital.
- Other advantages of minimally invasive treatments are less pain, faster recovery, lower costs, and local anesthesia and mild sedative.
- Usually, heat is used to destroy excess prostate tissue. Techniques differ in heat source, heat delivery method, side effects, and number of treatments. Delivery methods include:
- Laser (e.g., non-contact, contact, interstitial)
- Cooled ThermoTherapy™/TUMT™
- Other treatment methods
- AquaTherm™ System
- Prostiva™ RF Therapy, previously known as TUNA
- Surgical treatments
- Transurethral resection of the prostate (TURP)
- Holmium laser enucleation of the prostate (HoLEP)
- Transurethral incision of the prostate (TUIP)
- Transurethral ultrasound-guided laser incision of the prostate (TULIP)
- Alternative treatments
- Herbal remedies