Benign prostatic hyperplasia (BPH) is the medical term referring to a non-malignant enlargement of the prostate gland which can lead to obstructive lower urinary tract symptoms (LUTSs). It is the most common benign tumour in men and is responsible for urinary symptoms in the majority of males over the age of 50 years.
It is estimated that about 50% of males have significantly enlarged prostates by age 60 and 80% by age 90. Generally, it increases in prevalence with age.
As the prostate enlarges, it can compress the urethra and this, together with increased adrenergic tone, can lead to bladder outflow obstruction (BOO) and lower urinary tract symptoms (LUTSs). Therefore, the term BPH includes benign prostatic enlargement (BPE), the clinical features associated with urinary obstruction and LUTSs.
Basically, prostate enlargement is directly related to the ageing process and to hormone activity. Within the prostate, testosterone is converted by 5α-reductase enzyme to dihydrotestosterone (DHT). DHT is five times more potent than testosterone and is responsible for stimulating growth factors that influence cell division leading to prostatic hyperplasia and enlargement.
Most men over the age of 50 years exhibit some of the symptoms of BPH. These men can develop bothersome LUTSs that can impact negatively on their quality of life.
LUTSs can be divided into symptoms of failure of urine storage (irritative) and those caused by failure to empty the bladder (obstructive or voiding).
- Frequent urination
- Frequent urination during night
- Urgency and urge incontinence (urge to urinate)
- Poor urinary flow (weak urine stream)
- Leakage of urine (overflow incontinence)
- Hesitancy in initiation of urination
- Dribbling after urination
- Sensation of incomplete emptying of the bladder
- Occasional acute retention of urine requiring emergency treatment
A focussed medical history of all men with LUTSs should be taken to clarify the cause of their symptoms. LUTSs should be evaluated using a validated scoring tool such as the international prostate symptom score (IPSS). This can be used to monitor the severity and progression of the disease and assess the impact of therapy on LUTSs.
All patients who present with suspected BPH should undergo a digital rectal examination (DRE). A DRE is performed to exclude the presence of prostate cancer (PC) and can also be used to estimate the shape and size of the prostate; transrectal ultrasonography (TRUS) provides a more accurate measurement of prostate volume.
Imaging procedures such as Prostatic ultrasound scan are also relevant for diagnosis.
The range of treatment options for the management of BPH includes watchful waiting, medical therapies and surgical interventions. The key issue, therefore, is deciding who should be treated and when.
Men with mild or moderate and not significantly bothersome LUTSs should be offered a trial of watchful waiting. This management strategy does not include any medical or surgical treatment but involves regular active monitoring. In some cases, symptoms remain unchanged for years and no further interventions are necessary since disease progression is minimal. Patients that adopt this modality should be offered education and lifestyle advice to manage their urological symptoms together with a review of their medication, particularly diuretics or other medicines known to affect the urinary system.
The principal treatment options are α-adrenoceptor blocking drugs (e.g Tamsulosin), 5α-reductase inhibitors (e.g Dutasteride) and combination therapy; other drugs of different pharmacological classes have been approved… These drugs are prescription medicines, and patients must be assessed and counselled properly before initiation of treatment.
α-Adrenoceptor blocking drugs are effective in reducing symptoms. 5α-Reductase inhibitors reduce prostate size, improve symptoms, increase urinary flow rates and reduce the risk of developing complications such as acute urinary retention (AUR) or the need for prostate surgery. Both classes are usually combined for better results.
Common side effects of common drugs for BPH include: orthostatic hypotension, impotence/ low libido, ejaculatory dysfunction, and dizziness.
Phytotherapy is also used in the management of BPH, although the benefits are yet to be proven beyond reasonable doubt. For the record, they include saw palmetto, African plum tree, stinging nettle, rye pollen extract. Nutritional supplements like vitamin E and selenium are widely used in management of BPH.
Advice for the management of lower urinary tract symptoms
- Limit fluid consumption before going out and before going to bed (to reduce urinary frequency and nocturia)
- Reduce alcohol and caffeine intake
- Schedule toilet visits
- Manage constipation
- Review medication (including diuretics and other medicines that can affect the urinary system)
- Bladder training (encourage patient to go longer between voiding and increase the volume voided)
- Use distraction techniques (practice breathing exercises and penile squeezing to control symptoms of irritation)