Benign Prostatic Hyperplasia (BPH)

Benign prostatic hyperplasia or BPH is the non-cancerous enlargement of the prostate gland. The prostate gland is a walnut-sized gland part of the male reproductive system whose function is to add fluid to the semen. It is located beneath the urinary bladder, and the penile urethra passes through it. Therefore, the enlargement of this gland results in the obstruction to the flow of urine, causing the symptoms of difficulty passing urine, incomplete emptying of the bladder, increased urinary frequency, especially at night, etc. Enlargement of the prostate gland is part of the normal aging of men, and hence a widespread problem.

The exact cause of this enlargement is unknown. However, it is thought to result from hormonal changes with increasing age. The testosterone, a male hormone, is converted to Dihydrotestosterone (DHT) by an enzyme called 5α-reductase, which acts locally on the gland and causes it to grow. Although the testosterone level decreases as the man ages, other agents may also influence the growth. BPH is also linked to metabolic syndrome, a combination of diabetes mellitus, obesity, hypertension, and dyslipidemia.

The prevalence of BPH is similar in white and African-American men; however, it is more severe and progressive in African-American men, possibly due to higher levels of testosterone, 5α-reductase, and DHT.

Age: Aging is the most crucial risk factor for developing BPH. Most of the men older than 50 have enlarged prostates.

Genetics: a family member with BPH increases your risk also.

Obesity: obesity and reduced exercise also puts you at the risk of BPH

Metabolic Syndrome: the presence of diabetes, hypertension, dyslipidemia, heart disease can also increase your risk of BPH.

The prevalence of BPH is similar in white and African-American men; however, it is more severe and progressive in African-American men, possibly due to higher levels of testosterone, 5α-reductase, and DHT.

The signs and symptoms usually result from the pressing of the urethra by the enlarged prostate gland.

• Urinary urgency: you may feel the sudden, urgent need to urinate. 
• Urinary frequency: you may have an increased need to pee, although the amount of urine may be minimal.
• Nocturia: you may have an increased frequency to urinate at night.
• Hesitancy: you may have difficulty initiating the urine, and the stream may be weak.
• Straining: you may need to test for urine.

Incomplete bladder emptying: no matter how many times you urinate, you may still feel residual urine in the bladder, and dribbling may occur.

Your doctor will ask you questions about your symptoms and examine you for physical signs.

Digital Rectal Examination (DRE): your doctor will insert gloved, lubricated fingers through your anus into the rectum to feel the prostate gland for enlargement, hardness, lumps, or pain.

Urinalysis and Urine Culture: your urine may be collected to check for abnormalities and rule out other conditions.

Blood Tests: Bun, creatinine, and electrolytes can be checked for kidney functions

Prostate-Specific Antigen (PSA): It is a protein made by the prostate. It can be raised in BPH, prostatitis (prostate infection), or prostate cancer.

Some other tests may aid in diagnosing and determining the severity of BPH.

Urine Flow Rate: this test measures the speed and strength of the urinary stream.

Post-Void Residual Urine Volume: this test measures the amount of urine left in the bladder after urination.

Urodynamic Studies: this test measures the pressure in your bladder.

Ultrasound Scans: these scans are done to determine bladder and prostate size.

Cystoscopy: a flexible tube is inserted into the bladder to see the interior and take a biopsy.

CT/MRI Scans: these are not usually recommended for uncomplicated cases but may give a clearer picture of the size and position of the gland when needed or before surgery.

Symptoms similar to BPH can be caused by some other conditions also like:

• Cystitis (bladder infection)
• Prostatitis (prostate infection)
• A Prostate abscess (pus accumulation in the prostate)
• Prostate cancer
• Overactive or neurogenic bladder
• Strictures or stones in the bladder
•  Bladder cancer

Symptoms of BPH are irrespective of its size. Some people with larger glands have fewer symptoms, while others may have more. The treatment, therefore, depends upon the severity of the disease, available treatment options, and your preferences.

Watchful Waiting: Sometimes, the condition is tolerable, and no treatment is needed 

Interventional Therapy: Your doctor may discuss with you a wide variety of interventional procedures like ablative procedures, lasers, mechanical lifting, minimally invasive surgeries, and open surgeries if medications do not control the symptoms, or there are complications of BPH like urinary tract obstruction, stones, blood in urine, or you wish to discontinue medications for other reasons. They include the following procedures,

• Transurethral Resection of the Prostate (TURP): It is a commonly used procedure in which a lighted scope is inserted through penile urethra under local or general anesthesia, and all or part of the prostate is cut and removed by using current or laser. This relieves the symptoms quickly. Significant side effects include bleeding, retrograde ejaculation, and impotence. 
• Transurethral Incision of the Prostate (TUIP): In this procedure, a scope is inserted through the urethra, and one or two small incisions are made in the prostate gland to ease the flow of urine. 
• Transurethral Needle Ablation (TUNA): In this procedure, a scope is passed through the urethra to place needles on the gland, which delivers high-frequency radio waves to produce heat and destroy the prostate tissue under local anesthesia
• Transurethral Microwave Therapy (TUMT): includes applying microwave therapy that delivers heat to the prostate via a transurethral catheter.
• Radiofrequency Generated Water Thermotherapy: in this procedure, sterile water is converted into vapor or steam using The Rezum system and is delivered into the prostate tissue.
• Laser Therapy: Different types of lasers are used to deliver heat to the prostate tissue and destroy it through various mechanisms. Potassium-titanyl-phosphate (KPT) and holmium lasers are used to cut part (transurethral vaporization) or whole of the prostate (enucleation). The laser procedures cause lesser side effects of bleeding, impotence and can be used for patients who cannot undergo TURP or other systems.
• Automated Procedure: Flexible stents can improve urine flow; however, they can cause pain, incontinence, and overgrowth of tissue across the stent.
• Prostatic Artery Embolization: This procedure remains experimental, and the safety and efficacy of its use have yet to be established. It blocks the blood supply of the prostate to shrink its size.
• Open prostatectomy: If your prostate is vast or there are complications and other procedures cannot be used, open prostatectomy is done. A cut is made through your abdomen, and prostate tissue is removed. Side effects include bleeding, impotence, incontinence, and retrograde ejaculation.

Alpha-Blockers: these medicines relax the muscles at the neck of the bladder and improve the urinary symptoms. They include prazosin, alfuzosin, tamsulosin, terazosin. Side effects may include dizziness, lightheadedness, headaches, sexual problems.

5- Alpha-Reductase Inhibitors: these medicines stop the conversion of testosterone into DHT and reduce the prostate’s size. They include finasteride, dutasteride. Adverse effects include ejaculation back into the bladder instead of the penis.

Combination Therapy: alpha-blockers and five alpha-reductase inhibitors are often combined to treat BPH.

Phosphodiesterase Enzyme Inhibitors: this class includes tadalafil and is known to cause smooth muscle relaxation.

The condition itself is benign but may cause serious discomfort and affect the quality of life. If left untreated may result in chronic urine outflow obstruction, urinary infections, urinary stones, and damage to the bladder or kidneys.

There are some changes that you can make to your daily routine to improve BPH symptoms.

• Avoid taking fluids at night.
• Reduce the amount of caffeine, alcohol. 
• Encourage physical activity. 
• Maintain avoiding routine.
• Avoid certain medications like antihistamines, decongestants, opioids.
• Eat a high-fiber, low-fat diet.