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BENIGN PROSTATIC HYPERPLASIA (BPH)

 

What is the prostate?

The prostate is a gland in men which sits between the bladder and the urethra (water pipe). It forms part of the male urinary and reproductive tracts. It is essential for normal fertility and produces some of the fluid that makes up semen.

 

What is BPH (Benign Prostatic Hyperplasia)?

  • BPH is a benign (non-cancerous) enlargement (hyperplasia) of the prostate.

  • The part of the prostate that tends to be affected by BPH is called the transition zone. The transition zone wraps around the urethra.

  • As the prostate enlarges around the urethra, it causes obstruction by progressively compressing and occluding the urethra

How common is BPH?

  • BPH is the commonest cause of male urinary symptoms

  • All men’s prostates will grow to some degree with ageing, however, some prostates grow faster or in such a way that it will increase the degree of bladder obstruction

  • BPH causing urinary symptoms will affect >50% men over 60 years age

  • The severity of symptoms may range from mild to severe

 

What are the symptoms of BPH?

Symptoms attributed to BPH are also known as LUTS (lower urinary tract symptoms). LUTS include 2 broad categories of symptoms:

 

  1. Voiding (obstructive) symptoms:

  • Slow flow – reduced pressure of urinary stream

  • Dribbling

  • Intermittent flow (start/stop)

  • Difficulty initiating urine stream – hesitancy

  • Incomplete emptying – feeling of residual urine or measured on an ultrasound after voiding

  • Urinary retention – inability to urinate

   2. Storage (irritative) symptoms:

  • Frequency – frequent passage of urine (usually > than every 2 hours)

  • Urgency – sudden and compelling desire to urinate

  • Nocturia – need to wake from sleep to pass urine (more than once)

 

Other symptoms that may be as a result of BPH include:

  • Blood in urine – haematuria

  • Urinary tract infections – UTI’s

  • Incontinence

 

How is BPH diagnosed?

BPH is usually diagnosed after taking a history of your symptoms, preforming an examination of the abdomen and prostate (digital rectal examination) and preforming some or all of the following tests:

  • Urine culture – to exclude infection

  • Blood tests – including kidney function

  • PSA – tumour marker for prostate cancer. May also be elevated in men with enlarged benign prostates. 

  • Kidney bladder and prostate ultrasound

    • Estimated prostate size/volume

    • Post void residual volume – remaining urine volume in bladder after voiding

    • Rule out bladder stones and other bladder abnormalities

  • Bladder diary – a diary recording the volume of urine passed and  fluids consumed over a 24-48 hour period

  • Flow rate/bladder scan – performed in the office at Geelong urology

  • Cystoscopy – to look for other causes of symptoms and assess the shape of the prostate

  • Urodynamics – may be used in selected men with LUTS to help dictate treatment

 

How is BPH treated?

As BPH is a non-cancerous condition, treatment is elective, and depends on the degree of bother and severity of symptoms for each individual.

 

  1. Conservative management: reserved for those with mild symptoms not causing significant bother and involves:

  • Modifying fluid intake

  • Decreasing bladder irritants – caffeine, alcohol

  • Weight loss

  • Changes to other medications

    2. Medications: first line option for men with mild to moderate symptoms

  • Alpha blockers – Tamsulosin (Flomaxtra), Prazosin (Pressin), Alfuzosin (Xatral)

    • “relax” the muscles within the prostate and improve urinary flow

    • start working quite quickly (within 48 hours)

  • 5 alpha reductase inhibitors – Finasteride (Proscar), Dutasteride (Avodart)

    • lower the testosterone level within the prostate, progressively causing shrinkage of the prostate

    • take at least 3 months to begin improving symptoms

  • Combination of the above 2 – Tamsulosin and Dutasteride (Duodart)

    • Offer both rapid symptom relief and progressive shrinkage of the prostate

    • Most effective medication at improving urinary symptoms caused by BPH

 

     3. Surgical options: most effective way of improving symptoms caused by BPH

  • Urolift – stapling the prostate

    • Novel procedure with less side effects than TURP and slightly better outcomes than medications

  • TURP (Transurethral resection of the prostate)

    • Gold standard for BPH and involves the removal of the obstructive growth of the prostate to create wide outflow channel for the bladder

  • Green light laser prostatectomy

    • A newer technique using a high power laser to vaporise prostate tissue. 

    • Much like a TURP, this creates a wider channel to pass urine through.

 

What if I elect not to treat my enlarged prostate?

Not all men with BPH left untreated will progress or worsen.

 

Men with the following characteristics are at an increased risk of progression:

  • Older

  • Larger prostates (>40cc)

  • Higher PSA’s (>2.5)

  • Severe baseline urinary symptoms

  • Lower starting urine flow rates

 

Complications of BPH, for which surgical treatment is usually indicated, include:

  • Inability to void – urinary retention

  • Kidney impairment/failure

  • Formation of bladder stones

  • Urinary tract infections (often recurrent)

  • Blood in urine – haematuria

  • Development of bladder diverticula (out-pouches in the bladder wall)