Benign Prostatic Hyperplasia (BPH) – Diagnosis, Symptoms, and Treatment

What is Benign Prostatic Hyperplasia?

Benign prostatic hyperplasia is a medical condition characterized by prostate enlargement. This results in urinary symptoms such as difficulty passing urine, incomplete bladder emptying, or frequently urinating at night.  This condition only affects men as women do not have prostate glands.  This condition increases in prevalence with age.  Progressive enlargement of the prostate may cause significantly bothersome symptoms and can increase the risk of urinary tract infections.

What Causes Benign Prostatic Hyperplasia (BPH)?

The prostate is a male organ that rests beneath the bladder – here, and it wraps around the urethra.  The urethra is the urinary tract region that connects the bladder to the tip of the penis.

Benign prostatic hyperplasia is caused by progressive enlargement of the prostate gland.  It generally affects older men.  Testosterone is converted into dihydrotestosterone (DHT) in tissues such as the prostate and scalp tissue.  The enzyme 5-alpha reductase performs this.  DHT acts on prostate tissue to promote its enlargement.  As the prostate enlarges, it becomes more difficult for urine to travel from the bladder out of the penis.  The prostate constricts the urethra.

When urethral constriction becomes severe enough, patients may retain urine in the bladder and have a higher risk of developing urinary tract infections.  Sometimes patients develop severe urinary retention that results in kidney injury.  This often requires placement of a Foley catheter or emergency placement of a suprapubic catheter to relieve bladder pressure.

How Common is Benign Prostatic Hyperplasia (BPH)?

Benign prostatic hyperplasia is a widespread condition that is frequently evaluated in the primary care clinic.  This disease often requires referral to a urology specialist.

Its prevalence is increasing due to the rise of older men in the United States.  It affects about 50% of American men in their 50s and 80% of men age 80 or older.

Signs and Symptoms

Benign prostatic hyperplasia primarily causes urinary symptoms.  The most common symptoms include:

• Urinary frequency
• Frequent urination at night (nocturia)
• Urinary hesitancy – trouble passing urine
• Incomplete bladder emptying
• Suprapubic or pelvic pain

Your doctor will often evaluate for specific findings on your physical examination such as:

• Enlarged prostate on rectal examination
• Abdominal distension or pain on abdominal palpation
• Genital examination evaluating for urethral strictures or structural abnormalities such as Peyronie disease

Diagnosis

Benign prostatic hyperplasia is diagnosed based on symptoms and physical examination.  The palpation of an enlarged prostate on rectal examination is the classic feature.

Your doctor will also likely order blood tests such as a CMP (comprehensive metabolic panel), CBC (complete blood cell count), and urine analysis.  They may send urine for a bacterial culture as well.

If you are over the age of 50, your doctor may consider checking a serum PSA level.  This blood test is usually elevated in prostate cancer but can also increase in the setting of prostate infection or inflammation.

Benign Prostatic Hyperplasia Medication and Treatment

If your prostate enlargement has gotten severe enough to block off the urinary tract completely, this is a medical emergency.  Acute urinary retention often requires a Foley catheter placement to relieve pressure off the urinary tract and bladder.  If a Foley catheter cannot be placed, a suprapubic catheter may need to be inserted by a urologist.

In mild to moderate cases of prostate enlargement, patients often benefit from the use of medications.  The most commonly prescribed drugs for benign prostatic hyperplasia include:

Alpha-blockers:

• Uroxatral (alfuzosin)
• Cardura (doxazosin)
• Flomax (tamsulosin)
• Rapaflo (silodosin)

5-alpha reductase inhibitors:

• Proscar (finasteride)
• Avodart (dutasteride)

Alpha-blockers work by relaxing the smooth muscles around the urinary tract and prostate gland – allowing urine to pass through the prostate and flow more easily.  They may cause dizziness upon standing very early on in treatment, but this typically improves.  It should be used with caution in individuals at risk for falls.

5-alpha reductase inhibitors work by reducing the conversion of testosterone to dihydrotestosterone (DHT).  DHT is responsible for enlarging prostate tissue over time – so 5-alpha reductase inhibitors work by lowering DHT and prostate size.  Side effects may include low sexual desire, impotence, and projects ejaculating.  These are relatively uncommon and improve with drug discontinuation.

If patients do not respond to these medications or are not interested in drug therapy, they may be candidates for prostate surgery.  Their urologist will often recommend a minimally invasive procedure called a transurethral resection of the prostate (TURP) - where they remove prostate tissue by entering through the urethra.  They may also recommend a more invasive procedure called radical prostatectomy, which involves complete removal of the prostate gland.

References:

1. Pearson R, Williams PM. Common questions about the diagnosis and management of benign prostatic hyperplasia. Am Fam Physician. 2014 Dec 1;90(11):769-74. - https://www.semanticscholar.org/paper/Common-questions-about-the-diagnosis-and-management-Pearson-Williams/a5eb15aa972cfa16f0b8fd06dea9b9f1dba740c1
2. Sarma AV, Wei JT. Clinical practice. Benign prostatic hyperplasia and lower urinary tract symptoms. N Engl J Med. 2012 Jul 19;367(3):248-57. - https://www.ncbi.nlm.nih.gov/pubmed/22808960
3. McVary KT. BPH: epidemiology and comorbidities. Am J Manag Care. 2006 Apr;12(5 Suppl):S122-8. - https://www.ajmc.com/journals/supplement/2006/2006-04-vol12-n5suppl/apr06-2288ps122-s128