Benign Prostatic Hypertrophy (BPH)

What is BPH?

BPH is a non-cancerous condition characterized by growth of the prostate gland. It is a common condition that occurs as men age, and it can cause urinary symptoms due to compression of the urethra. The prostate is an organ in men which is responsible for producing fluid that contributes to semen.

What are the risk factors for developing BPH?

The biggest risk factor for BPH is advancing age, as it can be prevalent in as many as 50% of men in their sixth decade of life, and as many as 80% of men in the ninth decade of life. Other risk factors include a family history, hormonal imbalances, and medical conditions such as obesity and diabetes.

What are the common symptoms of BPH?

The symptoms of BPH can vary from mild to severe and may include: frequent urination, difficulty initiating and stopping urination, weak urine flow, dribbling after urination, incomplete bladder emptying, and nocturia (frequent urination at night).

How is BPH diagnosed?

To diagnose BPH, a provider will typically perform a physical exam, including a digital rectal exam to assess the size and character of the prostate gland. Additional tests may include a urine flow study, a prostate-specific antigen blood test, an ultrasound, and a cystoscopy to evaluate the urinary tract.

Can BPH lead to complications?

In most cases, treating BPH is driven by improving the patient’s quality of life. However, in severe cases there are several complications which can arise. These include urinary tract infections, bladder stones, urinary retention (inability to empty the bladder completely), as well as bladder and kidney damage.

Is BPH a precursor to prostate cancer?

BPH is not considered a precursor to prostate cancer. Although both conditions can occur simultaneously, having BPH does not increase the risk of developing prostate cancer. However, the symptoms of BPH can rarely mask the presence of prostate cancer, so it is important to rule out cancer through appropriate screening.

What medications are used to treat BPH?

Alpha blockers

Tamsulosin (Flomax) is the most common alpha blocker which is prescribed. Alpha blockers work by relaxing the smooth muscles in the prostate and bladder neck, which help to improve urine flow and relieve the symptoms associated with BPH. Common side effects of alpha-blockers can include dizziness, lightheadedness, fatigue, nasal congestion, and retrograde ejaculation (semen going backward into the bladder instead of out through the penis). These effects are usually mild and tend to improve over time. Tamsulosin is typically taken once per day, at bedtime, and its effects can be seen as soon as a few days after starting the medication.

5-alpha reductase inhibitors

Finasteride and dutasteride are the commonly prescribed 5-alpha reductase inhibitors. They work by blocking the conversion of testosterone into dihydrotestosterone (DHT), a hormone that contributes to prostate gland growth. By reducing DHT levels, these medications can shrink prostate volume up to 20%, however takes between 3-6 months for effects to be seen. Common side effects may include decreased libido (sex drive), erectile dysfunction, breast enlargement or tenderness, and reduced ejaculate volume. These side effects are generally reversible upon medication discontinuation.

Can alpha blockers and 5-alpha reductase inhibitors be used together?

Yes, in some cases providers may prescribe a combination of these medications, as they target different pathways of BPH. In one study, the combination of these medications was shown to be superior than one medication alone in preventing clinical progression.

Are there any alternative or complementary medications for BPH?

There have been several alternative medications used for BPH, each with various evidence supporting their use. These include saw palmetto, pygeum africanum, pumpkin seed oil, and urtica dioica. Before starting these medications, patients should consult with a healthcare provider.

What are the surgical options for BPH?

Surgery is typically reserved for patients whose symptoms are not well controlled due to medications. It is also preferred for patients who continue to have recurrent urinary tract infections, bladder stones, urinary retention, and medical kidney disease due to their BPH. There are several surgical options available for the treatment of BPH. The choice of surgery depends on the severity of symptoms, prostate size, overall health, and patient preference.

• Transurethral resection of the prostate (TURP): This is the most common surgical procedure for BPH. It involves the removal of excess prostate tissue using a scope inserted through the urethra. TURP provides significant symptom relief and is considered the gold standard for surgical treatment of BPH.

• Transurethral incision of the prostate (TUIP): TUIP involves making small incisions in the prostate gland to relieve pressure on the urethra and improve urine flow. It is typically performed in cases where the prostate enlargement is less severe.

• Laser surgery: Various laser techniques can be used to treat BPH. Examples include photoselective vaporization of the prostate (PVP), holmium laser enucleation of the prostate (HoLEP), and GreenLight laser therapy. These procedures use laser energy to remove or vaporize excess prostate tissue, providing symptom relief.

• Prostatic Urethral Lift (PUL): PUL is a minimally invasive procedure that uses tiny implants to hold the enlarged prostate lobes away from the urethra, opening up the flow of urine. It is a relatively new procedure and may be suitable for men with moderate to severe BPH symptoms. PUL also has the advantage where it can be performed in the office.

• Rezum: Rezum is a minimally invasive procedure where a small device is inserted into the urethra, which can deliver bursts of heated water vapor directly into the enlarged prostate tissue. The vapor condenses and releases thermal energy, causing cell death and ablation of the prostate tissue. Just as with Urolift, Rezum, can be done either in the operating room or in the office.

• Prostate artery embolization (PAE): PAE is a minimally invasive procedure performed by interventional radiologists in which tiny particles are injected into the arteries supplying blood to the prostate, causing the prostate to shrink. It is currently considered an experimental treatment by the American Urologic Association, and is typically reserved for patients who cannot undergo other forms of treatment.

• Robotic prostatectomy: This surgery is typically reserved for extremely large prostates or if other surgical methods are not feasible. It involves using the Da Vinci robotic system to remove the enlarged prostate tissue.