Prostate Enlargement / Benign Prostatic Hypertrophy/hyperplasia (BPH)
What does the prostate do?
The main function of the prostate is to secrete an alkali fluid that makes up a large proportion of semen. This alkalinity aims to combat normal acidity within the vagina so as to protect sperm and allow fertilisation.
What is it?
BPH is enlargement of the prostate gland which invariably will happen to all men by a certain age. 50% of men will demonstrate signs and symptoms of BPH by age 60 and jumps to 95% by age 85. It is not associated with cancer, which itself is a completely separate topic.
Since the urethra (the tube connecting the bladder to the penis tip) runs through the prostate it can be compressed in BPH (Fig 1 and 2). This leads to bladder outlet obstruction and further results in lower urinary tract symptoms, which will be detailed below. Should bladder outlet obstruction worsen it can have effects on other parts of the urinary system – the back pressure can lead to urinary retention, poor kidney function, recurrent urine infections and even the formation of kidney stones.
How can it be diagnosed?
Usually history and examination are enough to formally diagnose BPH. Classical symptoms (below) may be present and a rectal examination can help to determine the size of the prostate.
If the diagnosis is in doubt then a transrectal ultrasound can be performed. This involves placing a small ultrasound probe into the rectum which is pushed up against the prostate. This gives a clear image regarding the size of the prostate.
Sometimes a biopsy can be taken of the prostate, which is examined under the microscope. This will confirm the presence of BPH or whether something else like cancer may be causing an enlarged prostate.
What are the symptoms?
The most common symptoms include:
- Incomplete emptying – this means that you have passed urine but you feel that there is more inside the bladder that you cannot pass out.
- Increased frequency – this means that you need to go to the toilet more regularly than normal.
- Intermittency – this means that you can pass urine as normal but find that your urine stream is interuppted and requires a few start/stop periods in order to empty the bladder fully.
- Urgency – this means that when you have a sudden urge to pass urine you must get to the toilet immediately. Whereas normally you would be able to hold onto the urine until a convenient time.
- Weak stream – this means that the normally strong stream of urine becomes much weaker and can sometimes dribble out instead.
- Straining – this means that you have to push hard in order to get the urine to pass. Previously you may have had no issue and the urine passes smoothly without much straining.
- Nocturia – this means needing to get up at night (or being woken up at night) needing to go to the toilet more often.
A table with a score is deatiled below, titled International Prostate Symptom Score (IPSS).
Those with a mild to moderate score with no significant troubling symptoms or complications often can be managed with watchful waiting – nothing more may be required. Medications may not improve symptoms and actual side effects from these medicines may outweigh any benefit.
For those with bladder outlet obstruction or severe symptoms a transurethral resection of the prostate can be performed (TURP). This involves a specialist introducing a camera and surgical tool into the urethra until it reaches the prostate. From there they cut away as much of the prostate as is necessary in order to relieve compressions on the urethra itelf.
For those in between where surgery may not yet be indicated but symptoms are troublesome there are medical treatments available:
- Alpha 1 receptor blockade – these medications target the smooth muscle in the bladder and prostate and bladder and sim to relax them. This can result in a reduction of pressure and can help symptoms. An example of this medicine would include Tamsulosin (Flomax).
- Phosphodiesterase 5 enzyme inhibitors (PDE5) – these medications include viagra as well cialis. They have been approved for use in treatment of BPH with erectile dysfunction and have proven effective. The are known to mediate smooth muscle relaxation in the urinary tract. An example of this would include Tadalafil (Cialis).
- 5-alpha reductase inhibitors – these reduce the conversion of testosterone to dihydrotestosterone (DHT), which is the hormone responsible for prostate growth. So by reducing the hormone the prostate has shown to reduce in size. An example of this includes Finasteride (Proscar).
- Natural remedies – one such remedy includes Saw Palmetto derived from the American dwarf palm tree. Several studies have shown this to be effective at relieving symptoms of BPH and has minimal side effects. The volatile oil is the important component of this and must be included to be useful. The effective dose is 320mg once per day.
BPH is a disorder that will affect most men. Symptoms are problematic and can have a marked impact on quality of life. Diagnosis is usually clinical but tests are available to aid diagnosis. The IPSS helps determine the severity of the disorder and this in turn helps decide upon potential treatment; this ranges from watchful waiting and certain medication to possible surgery.
For more info on BPH click here.
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