Benign Prostatic Hyperplasia (BPH)

Introduction

Are you a man that is experiencing a weak or interrupted urine stream, dribbling after urinating, or the urge to urinate even after voiding? These symptoms may be a result of benign prostatic hyperplasia (BPH), or enlargement of the prostate. As a man ages, the prostate gland progressively becomes larger causing constriction of the urethra and obstruction of the flow of urine. This obstruction to the flow of urine may be the reason for such symptoms.

What is it?

Benign prostatic hyperplasia (BPH) is enlargement of the prostate gland - a gland found only in men, which produces the milky fluid in which sperm are ejaculated. The enlargement results from uncontrolled growth of the gland. As the prostate gland progressively becomes larger, the urethra - a tube through which urine is passed out of the body - may become constricted because it is surrounded by the prostate gland. This constriction can obstruct the flow of urine out of the bladder and this constriction and/or obstruction is thought to cause the urinary symptoms characteristic of BPH.

What causes it?

The exact cause of benign prostatic hyperplasia (BPH) is unclear, although researchers believe it may be caused by hormonal changes that occur during the aging process. One theory is that as a man ages, the amount of testosterone in his blood decreases, leaving a higher proportion of estrogen in his blood. The disproportion of estrogen may contribute to cell growth within the prostate gland. Another possible hormonal change involves dihydrotestosterone (DHT), a by-product of testosterone. If levels of DHT accumulate in the prostate, overgrowth of cells in the prostate can occur.

Who has it?

As a man ages, his likelihood for developing benign prostatic hyperplasia (BPH) increases. Only 10% of men younger than the age of 40 years have BPH, whereas 50% of men in their sixties and 90% of men over the age of 80 years have prostate gland enlargement. Even though so many men have BPH, less than 5% receive treatment, mainly because many men think that urinary difficulties are a normal sign of aging and don't realize that effective treatments exist.

What are the risk factors?

Risk factors are characteristics that can predispose you to developing a condition. Currently, aging is the only identifiable risk factor for the development of benign prostatic hyperplasia (BPH). BPH is the most common disease of the aging male. Obesity, heredity, and race may also play a role in determining your risk for BPH. Although symptoms of advanced prostate cancer are similar to symptoms of BPH, BPH is not a precursor to the development of prostate cancer.

What are the symptoms?

The symptoms associated with benign prostatic hyperplasia (BPH) are often the result of the enlarged gland obstructing the urethra. Common symptoms include the following:

  • Weak, interrupted urine stream
  • Difficulty starting urination
  • Dribbling after urinating or voiding
  • Frequent urge to urinate even after voiding
  • Frequent urination, especially at night
  • Leakage of urine
  • Need to strain to initiate urination
  • Not being able to completely empty bladder
  • Urinary tract infections
  • Blood in the urine

By the age of 55 years, 25% of men experience a weak and interrupted urine stream. This symptom frequency increases to 50% by the age of 75 years. An important point to consider is that a larger prostate does not necessarily correlate with more severe symptoms of BPH.

If BPH is severe, it may result in the inability to urinate. This can cause severe pain and discomfort. In addition, if urine is retained in the bladder for long periods of time, this can lead to urinary tract infections, bladder or kidney damage, or bladder stones. The inability to urinate may be due to triggers that prevent the bladder opening from relaxing. They include the following:

  • Holding urine for a long time
  • Over-the-counter cold or allergy medications (e.g. decongestants or antihistamines)
  • Some prescription drugs (eg. ipratropium, albuterol, epinephrine)
  • Alcohol consumption
  • Cold temperatures
  • Long periods of inactivity

How is it treated?

Treatment options for BPH include lifestyle changes, "watchful waiting," drug therapy, non-surgical procedures and major surgery. The goals of treatment are to improve urinary flow and decrease the symptoms an individual may be experiencing. Treatment should also delay or prevent the progression of BPH.

If symptoms are mild and do not affect a man's quality of life, "watchful waiting" is often recommended. Individuals may also select this treatment option if the symptoms are not bothersome or they feel drug therapy may be a greater inconvenience than the symptoms of BPH. During "watchful waiting," men receive regular checkups and report any intolerable BPH symptoms to the doctor. If symptoms occur and cause discomfort, affect activities of daily living, or endanger the man's health, drug treatment is recommended.

Drugs are used to relieve the common urinary symptoms associated with BPH by either reducing the size of the prostate gland or slowing the growth of the prostate. Common drug classes that are used to treat urinary symptoms include alpha blockers, such as doxazosin (Cardura) or tamsulosin (Flomax), and 5-alpha reductase inhibitors, such as finasteride (Proscar) or dutasteride (Avodart). You can learn more about these medications by clicking on the drug class links below. However, if drug therapy does not provide adequate relief of symptoms, surgery may be needed to help correct the prostate gland overgrowth. If a man experiences more severe symptoms of BPH such as recurrent urinary retention, recurrent blood in the urine, recurrent urinary tract infections or bladder stones, then drug therapy should not be initiated. These symptoms indicate that surgery is most likely needed to correct the problem.

The National Institute of Health has sponsored the Medical Therapy of Prostatic Symptoms Trial (MTOPS). Researchers studied whether finasteride (Proscar) and doxazosin (Cardura) taken alone or together would delay or prevent the progression of prostate growth in men with benign prostate hyperplasia (BPH). Follow-up visits for this study continued through November 2001. After an average follow-up time of more than 4 years, combination therapy with doxazosin and finasteride was found to be superior than taking either drug alone for the prevention of BPH-related disease progression. This combination therapy is now a recommended option by the American Urologic Association for patients with lower urinary tract symptoms associated with BPH.

Helping Yourself

The severity and discomfort of symptoms of benign prostatic hyperplasia (BPH) may be lessened by various lifestyle changes:

  • Eat whole, fresh, unrefined, and unprocessed foods. Include fruits, vegetables, whole grains, soy, beans, seeds, nuts, olive oil, and cold-water fish (salmon, tuna, sardines, halibut, and mackerel). Eating organic food helps reduce exposure to hormones, pesticides, and herbicides.

  • Decrease fluid intake, especially at dinnertime or before bedtime. This may help decrease the number of wake-up trips to the bathroom.

  • Limit or avoid the consumption of alcohol and caffeine. These can increase urine production and worsen symptoms.

  • Avoid common cold and allergy over-the-counter medications; talk to your doctor before taking any of these medications. These medications can cause the bands of muscles that control urine flow from your urethra to tighten, making urination more difficult.

  • Perform pelvic floor exercises (called Kegel exercises) to help prevent urine leakage. The exercises are repetitive contractions of the muscles used to stop urinary flow. These exercises will strengthen the floor of the pelvis, which helps support the bladder and the bladder's opening. To learn how to perform Kegel exercises, go to www.urologychannel.com/education.

  • Schedule your bathroom breaks every 4 to 6 hours throughout the day. This will help to ?retrain? the muscles of the bladder, and can be very useful in patients with severe frequency and urgency.

  • Empty your bladder by trying to urinate all that you can each time you go to the bathroom. For some men, sitting on the toilet is more effective than standing.

  • Stay active or exercise. Inactivity can lead to urinary retention, so even the smallest amount of exercise may improve the symptoms of BPH.

What is on the horizon?

In recent years many new drug therapies have been under development. Many of these new drugs work in ways that no other drugs for this condition work. This means in the future we will probably see more combination drug therapies for BPH. Some of the most interesting data has come from Europe.

In August 2003, Italian physicians showed that injection of Botox into the prostate appears to be a safe and effective treatment for BPH. Currently, Botox is approved by the US Food and Drug Administration only for cosmetic applications. However, animal experiments recently showed that Botox injected into the prostate causes it to shrink. However, it is important to realize that currently the use of Botox in the urinary tract is clearly investigational and it should be strongly emphasized that more research looking at its use in the BPH population is needed.

In December 2007, researchers concluded a four year study investigating the effect of dual therapy with dutasteride (Avodart) and tamsulosin (Flomax) on treating lower urinary tract symptoms associated with BPH. The results of this study showed that, compared with monotherapy, combination therapy resulted in significantly greater improvements in lower urinary tract symptoms. Although dual therapy appeared more efficacious than montherapy, it was also associated with more adverse effects.

References

Roehrborn C, McConnell J, Barry M, et. al. Guideline on the management of benign prostatic hyperplasia (BPH). American Urologic Association Education and Research Inc. 2003

McConnell J, Roehrborn C, Bautista O, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med. 2003; 349:2387-2398.

Benign Prostatic Hyperplasia. Mayo Clinic. Diseases and Conditions. Available at URL: http://www.mayoclinic.com/health/prostate-gland-enlargement/DS00027. (Accessed January 2008)

Botox Can Relieve Urination Difficulties for Men. http://www.nlm.nih.gov/medlineplus/news/fullstory_13796.html. (Accessed April 2006).

Dull P, Reagan RW, and Bahnson RR. Managing Benign Prostatic Hyperplasia. American Family Physician 2002; 66(1): 77-84.

Dutasteride/Tamsulosin May Be Helpful for Benign Prostatic Hyperplasia. http://www.medscape.com/viewarticle/568033 (Accessed January 2008).

Lee M. Management of Benign Prostatic Hyperplasia. In: DiPiro JT, Talbert RL, Yee GC and others, eds. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. New York: McGraw-Hill; 2005: 511-529.

National Institute of Diabetes and Digestive and Kidney Diseases. Prostate enlargement: benign prostatic hyperplasia. http://kidney.niddk.nih.gov/kudiseases/pubs/prostateenlargement/index.htm (Accessed January 2008)

Lepor H. Natural history, evaluation, and nonsurgical management of benign prostatic hyperplasia. In: Campbell's urology. 7th ed. Walsh PC, Retik AB, Vaughan ED et al., eds. Philadelphia: W.B. Saunders Company;1998:1453-77.

McConnell JD. Epidemiology, etiology, pathophysiology, and diagnosis of benign prostatic hyperplasia. In: Campbell's urology. 7th ed. Walsh PC, Retik AB, Vaughan ED et al., eds. Philadelphia: W.B. Saunders Company;1998:1429-52.

Letran JL, Brawer MK. Disorders of the prostate. In: Principles of geriatric medicine and gerontology. 4th ed. Hazzard WR, Blass JP, Ettinger WH, et al., eds. New York: McGraw Hill;1999:809-21.

Urology Channel. Prostate/BPH. http://www.urologychannel.com/prostate/ (Accessed February 2007)

Prostate Institute. BPH. http://www.prostateinstitute.org. (Accessed April 2006)

WebMD. Benign prostatic hyperplasia: a very thorough review of BPH, with an emphasis on treatments, including medications, surgery, and complementary medicine. http://my.webmd.com/content/dmk/dmk_article_40011 (Accessed April 2006)

Benign Prostatic Hyperplasia (BPH) Health Condition Last Updated: March 2008

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

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