Discover symptoms, causes, and treatment options for benign prostatic hyperplasia (BPH). Get informed and find support on Meri Sehat.

Benign Prostatic Hyperplasia

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Iqra Mazhar

Overview

Non-cancerous enlargement of the prostate gland in men is known as benign prostatic hyperplasia (BPH), benign prostatic hypertrophy, or benign prostatic obstruction<a href="#accordion">[1]</a>. 
&nbsp;

Benign prostatic hyperplasia is a common condition, especially in older men. Due to the enlargement of the prostate gland, it is easily confused for cancer, but the enlargement of the gland is completely non-cancerous. Moreover, it does it impact the growth of pre-existing cancer or increase the chances of getting cancer. The main issue often lies in how less it is talked about due to the stigma around prostate issues. Men feel uncomfortable getting screened or checked for such issues because it is somehow made to relate to diminished masculinity. This has led to not only several benign prostatic hyperplasia cases going undiagnosed but also other problems like cancer worsening, too<a href="#accordion">[2]</a>.&nbsp;

Worldwide, the prevalence of benign prostatic hyperplasia varies from 20% all the way up to 62% in men that are over the age of 50<a href="#accordion">[3]</a>. When it comes to Pakistan, a study done by Dow University of Health and Sciences in 2013 reported the prevalence of BPH to be around 87.5% whereas King Edward Medical University reported their stats to be 77%<a href="#accordion">[4]</a>. These statistics are alarming and indicate the need for increasing awareness about BPH. 
&nbsp;

Signs And Symptoms

Symptoms of benign prostatic hyperplasia include:

<ul>
	<li>Urination at least 8 or more times a day</li>
	<li>Inability to hold in urine (urinary urgency)</li>
	<li>Difficulty starting urination</li>
	<li>Weak and interrupted urine stream</li>
	<li>Dribbling at the end of urination</li>
	<li>Nocturia (frequent urination at night while asleep)</li>
	<li>Urinary tract infection&nbsp;</li>
	<li>Inability to urinate</li>
	<li>Urinary retention</li>
	<li>Discomfort or pain after urination or ejaculation</li>
	<li>Blood in urine 
	&nbsp;</li>
</ul>

Causes

The prostate is a gland in the male reproductive system responsible for producing fluid that goes into semen and is essential for <a href="https://www.merisehat.pk/disease/infertility-in-men" target="_blank">fertility</a>. In benign prostatic hyperplasia, this gland enlarges. The exact reason why it occurs is still unknown, but in most cases, only older men are affected by it. Men who have their testicles removed before puberty have no sign of getting BPH. Hence, it is believed that the occurrence of the disease may be connected to testicles and age factors.

Some studies suggest that the presence of active testosterone in the blood decreases with age; thus, leaving back a higher percentage of estrogen in the blood. Estrogen is believed to indirectly promote prostate cell growth.&nbsp;

Another theory suggests that dihydrotestosterone is the culprit. In men when there is a drop in testosterone levels, dihydrotestosterone is still produced. This accumulates in the body and stimulates the growth of prostate cells, and this has been seen in some studies, wherein men who did not produce DHT also did not get BPH<a href="#accordion">[1]</a>.&nbsp; 
&nbsp;

Methods to screen for benign prostatic hyperplasia are not widely used. Due to the stigma surrounding prostate exams, not many men willingly get screened for prostate issues. However, the screening is a very easy process involving a digital rectal exam (DRE), wherein a physician inserts their gloved finger into the lower rectum from where the size of the prostate can be felt<a href="#accordion">[5]</a>.&nbsp;

Certain screening tests are under research e.g. benign prostatic enlargement (BPE)/ benign prostatic obstruction (BPO) screening tool that is applied along with prostate-specific antigen test to confirm BPH in men<a href="#accordion">[6]</a>.&nbsp; 
&nbsp;

Diagnosis

The diagnosis starts with taking the patient&rsquo;s history. A few initial tests are done including:

<ul>
	<li>Digital Rectal Exam &ndash;&nbsp;This involves the insertion of a finger in the rectal area to check for prostate inflammation.</li>
	<li>Prostate-Specific Antigen (PSA) Blood Test &ndash; PSA is produced in your prostate. Not every man may have increased levels of this antigen when suffering from benign prostate hyperplasia, but in most cases, higher levels are observed. Hence, the levels are tested for confirmation</li>
	<li>Blood Test &ndash;&nbsp;This is to assess kidney functioning.</li>
</ul>

&nbsp;

After this initial testing, based on the results, your doctor may also suggest some of the following tests:

<ul>
	<li>Flow Test &ndash;&nbsp;The patient is required to urinate in a receptacle attached to a machine which assesses the strength and the volume of urine flow.</li>
	<li>Postvoid Residual Volume Test &ndash;&nbsp;This test determines the ability of the patient to empty their bladder completely.</li>
	<li>Voiding Diary &ndash;&nbsp;A&nbsp;diary is required to be maintained by the patient that has records of their urination frequency throughout the day and helps in determining the possibility of nocturia.</li>
</ul>

&nbsp;

If these further tests turn out severe or complex in any case, then the patient is recommended:

<ul>
	<li>Cystoscopy &ndash;&nbsp;This involves the insertion of a flexible instrument in your urethra that allows the physician to observe the insides of the urethra and bladder.</li>
	<li>Prostate Biopsy &ndash;&nbsp;Performed along with transrectal ultrasound where tissue&nbsp;samples are taken from the prostate for examination.</li>
	<li>Urodynamic And Pressure Flow Studies &ndash;&nbsp;Bladder pressure is measured through the insertion of a catheter into the urethra. Water or air is injected into your bladder and then the pressure is determined by observing how the muscles are responding.</li>
	<li>Transrectal Ultrasound &ndash;&nbsp;Ultrasound is done by the insertion of a probe in the rectum for prostate examination.</li>
</ul>

<div>&nbsp;</div>

Treatment

Due to the common nature of the disease, there is a wide range of treatments available, ranging from medications to therapies and even surgeries. The treatment right for you is determined on the basis of:

<ul>
	<li>Age</li>
	<li>Other health complications</li>
	<li>Level of discomfort</li>
	<li>Size of your prostate</li>
</ul>

&nbsp;

Often no treatment is required in very mild cases, but if symptoms occur very frequently and the quality of life of the patient is affected adversely, along with the disease progressing towards severity then the following treatments are prescribed. Treatment can also be given to prevent harmful complications.&nbsp; 
&nbsp;

<h5>1. Medication</h5>

This is the go-to treatment choice for patients experiencing mild to moderate symptoms. The medicines used include:

<ul>
	<li>Alpha-Blockers (ABs) &ndash; These medicines are responsible for relaxing the bladder neck muscles&nbsp;</li>
	<li>Tadalafil &ndash;&nbsp;This medicine is used to treat erectile dysfunction, but also exerts anti-inflammatory effects on the prostate gland</li>
	<li>5-Alpha Reductase Inhibitors (5-ARIs) &ndash;&nbsp;They treat BPH by targeting the hormones responsible for the overgrowth of prostate</li>
	<li>Combination Therapy &ndash;&nbsp;Alpha-blockers and 5-alpha reductase inhibitors are often used in combination if either one of the drugs is not effective on its own</li>
	<li>PDE5 Inhibitors &ndash;&nbsp;They treat BPH symptoms by increasing the flow rate 
	&nbsp;</li>
</ul>

<h5>2. Supplements</h5>

Saw palmetto is one of the most commonly used and most deeply researched supplements with regard to benign prostatic hyperplasia. However, there are still doubts about its efficiency because while several small studies have reported a therapeutic effect, studies on a larger scale reported no change in the size of the prostate<a href="#accordion">[7]</a>. Some other supplements used for this purpose include:

<ul>
	<li>Pygeum</li>
	<li>Ryegrass</li>
	<li>Beta-sitosterol</li>
</ul>

Note: Supplements are not a replacement for medication. Please consult your doctor for the best advice on different treatment options. 
&nbsp;

<h5>3. Invasive Surgical Therapy</h5>

This includes:

&nbsp;

<ul>
	<li>
	TUNA &ndash; Transurethral needle ablation (TUNA) involves the insertion of a scope in your urethra. The scope allows the physician to place needles in the prostate gland and send radio waves through the heated needles to destroy the excess tissue. However, this procedure is not used anymore.
	</li>
</ul>

&nbsp;

<ul>
	<li>TUMT &ndash; Transurethral microwave thermotherapy (TUMT) process in a noninvasive procedure that involves the insertion of an electrode through the urethra. Microwave energy is sent from the electrode to the prostate gland to destroy the inner portion of the prostate gland, causing the gland to reduce in size and allowing proper urine flow. TUMT is employed in moderate cases of prostate enlargement and it takes a while before an improvement in symptoms can be noticed.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>TURP &ndash; A scope with a light is inserted in the patient&rsquo;s urethra in transurethral resection of the prostate (TURP). The surgeon removes the outer part of the enlarged prostate. The symptoms are relieved much more quickly, and a significant improvement in urine flow is noticed</li>
</ul>

&nbsp;

<ul>
	<li>TUIP &ndash; Similar to TURP, transurethral incision of the prostate (TUIP) involves the insertion of a lighted scope. However, in this procedure, the surgeon puts cuts on the prostate gland to allow a better flow of urine.&nbsp;</li>
</ul>

<div>&nbsp;</div>

Following are the complications of benign prostatic hyperplasia:

<ul>
	<li>Urinary tract infections</li>
	<li>Chronic or partial urinary retention</li>
	<li>Blood in urine</li>
	<li>Bladder stones</li>
	<li><a href="https://www.merisehat.pk/disease/kidney-stones-66" target="_blank">Kidney stones</a></li>
	<li>Bladder damage 
	&nbsp;</li>
</ul>

Benign Prostatic Hyperplasia is very common in men and the majority of the male population is expected to suffer from it at some point in their lives. It is believed that by the age of 80, 90% of men would have had BPH<a href="#accordion">[1]</a>. However, the risk factors involve:

&nbsp;

<ul>
	<li>Age &ndash; It is very rare for men under the age of 40 to suffer from benign prostatic hyperplasia</li>
	<li>Family History &ndash; A variety of genes tend to have an impact on the early onset of BPH</li>
	<li>Ethnicity &ndash; BPH is noticed to be more common in African American and Hispanic men, as compared to Caucasian men. But no clear connection has been established to date.</li>
	<li>Heart Issues</li>
	<li><a href="https://www.merisehat.pk/disease/obesity" target="_blank">Obesity </a>&ndash; Higher body fat content in men leads to higher levels of estrogen. Hence, earlier possible onset of BPH</li>
	<li><a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2" target="_blank">Diabetes </a>&ndash; Insulin-like growth factor (IGF) secretion is stimulated during diabetes when the pancreas is secreting more insulin to bring down the blood sugar level. IGF induces prostate growth and diabetes is also responsible for inflammation and inadequate levels of sex hormones&nbsp;</li>
	<li><a href="https://merisehat.pk/disease/erectile-dysfunction" target="_blank">Erectile Dysfunction</a> (DE) &ndash; ED is not responsible for BPH, but the conditions are believed to go hand-in-hand</li>
	<li>Physical Inactivity&nbsp; 
	&nbsp;</li>
</ul>

Benign prostatic hyperplasia cannot really be prevented, but with the right care, you can avoid the severity of the problem. Following are some measures that you can take to maintain your prostatic health:

<ul>
	<li>Physical activity</li>
	<li>Weight loss</li>
	<li>Quitting alcohol</li>
	<li>High vegetable consumption</li>
	<li>Controlling diabetes&nbsp;&nbsp; 
	&nbsp;</li>
</ul>

Researchers at Beaumont Health recently uncovered the relationship between benign prostatic hyperplasia and prostate cancer. The findings suggested that BPH serves as a protective factor against prostate cancer. The study states that BPH tends to have a protective effect against prostatic cancer and there is no way for BPH to further increase the chances of getting prostate cancer<a href="#accordion">[8]</a>.

A study published in The Journal of Urology suggested that the drugs used for the treatment of benign prostatic hyperplasia tend to increase the chances of patients developing heart issues and are believed to have a slight impact on increasing the risk of heart failure. This was especially noticed in men who were treated using 5-ARIs and ABs<a href="#accordion">[9]</a>.&nbsp;

&nbsp;

Key Points

<ul><li>Benign prostatic hyperplasia is a very common issue in men of age older than 50. It is characterized by the non-cancerous enlargement of the prostate gland&nbsp;</li><li>In Pakistan, the prevalence of recorded cases of BPH ranges from 77%-87%</li><li>As people age, levels of testosterone decrease and increased levels of estrogen are observed. Estrogen tends to indirectly increase the growth of cells in the prostate gland</li><li>The most common symptom of BPH is difficulty in urinating and frequent urination</li><li>There are no robust methods for screening so far. The digital rectal exam involves the insertion of the physician’s gloved finger in the lower rectal area. There is a lot of taboo surrounding this and often leads to men not getting themselves tested for BPH</li><li>Alpha-blockers, tadalafil, 5-ARIs are commonly used on their own or in combination as drug therapy for the treatment of BPH</li><li>BPH may lead to complications like UTIs, blood in urine, kidney stones, bladder stones and several other bladder issues</li></ul><div> </div>

[1] Prostate enlargement (benign prostatic hyperplasia). National Institute of Diabetes and Digestive and Kidney Diseases.

[2] Zlatopolsky A. Prostate cancer's impact on Mental Health. Healthline..

[3] Yeboah ED. PREVALENCE OF BENIGN PROSTATIC HYPERPLASIA AND PROSTATE CANCER IN AFRICANS AND AFRICANS IN THE DIASPORA. J West Afr Coll Surg. 2016 Oct-Dec;6(4):1-30. PMID: 29181363; PMCID: PMC5667727.

[4] Frequency and trends of prostatic diseases in a subset of Karachi population: A retrospective study. Pakistan Journal of Medicine and Dentistry. 2021. doi:10.36283/pjmd10-1/004

[5] Screening for benign prostatic hyperplasia (BPH). Winchester Hospital.

[6] Benign prostatic hyperplasia (BPH) screening tool case finding study in subjects &gt;=50 years - Full Text view. Full Text View - ClinicalTrials.gov.

[7] BPH treatment: Options for treating benign prostatic hyperplasia. WebMD.

[8] Nandalur KR, Colvin R, Walker D, et al. Benign prostate hyperplasia as a potential protective factor against prostate cancer: Insights from a magnetic resonance imaging study of compositional characteristics. The Prostate. 2021;81(14):1097-1104. doi:10.1002/pros.24207

[9] Lusty A, Siemens DR, Tohidi M, Whitehead M, Tranmer J, Nickel JC. Cardiac failure associated with medical therapy of benign prostatic hyperplasia: A population based study. Journal of Urology. 2021;205(5):1430-1437. doi:10.1097/ju.0000000000001561