Benign Prostatic Hyperplasia, commonly referred to as BPH, is a non-cancerous enlargement of the prostate gland due to an overgrowth of prostate cells. The gland is a vital component of the male reproductive system, secreting a fluid into the urethra during ejaculation. It is located immediately below the neck of the urinary bladder, surrounding the urethra. While an official cause of BPH is unknown at this time, it’s believed to be due to the decrease in the hormone testosterone as a man ages and a predisposition through family history.
The incidence of BPH in American men is so high that nearly half of men at age 50 will have an enlarged prostate, and men at age 80 can expect an 80-90% chance of developing the condition. BPH is the most common disease among men beyond age 55 with approximately 2 million men treated for it annually in the United States. While symptoms of BPH and prostate cancer can be similar, BPH has never been shown to be a precursor to developing prostate cancer.
As the prostate enlarges it squeezes the urethra which runs through the center of the gland and, over time, restricts the flow of urine. Initially the symptoms are mild and, although annoying, are tolerated. As the condition increases in severity, the symptoms begin to affect daily activities.
Symptoms of BPH are:
- Urinary Frequency, especially at night
- Urgency – the need to urinate immediately
- Hesitancy – flow doesn’t start right away
- Intermittency – flow stops and goes
- Flow of urine is slow
- Blood in the urine
- A Feeling the bladder isn’t empty
- Dribbling after urination
- Pain or burning during or after urination
- Painful orgasms
With such symptoms, finding a restroom influences where one can go. Having to excuse oneself frequently and being uncomfortable a great deal of the time can be annoying if not embarrassing in social environments. At a certain point, it becomes necessary to see a urologist, a medical doctor specializing in diseases of the urinary and genital area. Once a diagnosis of BPH is confirmed, a treatment is recommended. There is no cure for this condition so finding relief from the symptoms is the goal of the treatment.
The precise cause of benign prostatic hyperplasia is unclear
Though research is ongoing, the root cause of benign prostatic hyperplasia has yet to be established. There are a few theories, none of which have gained complete agreement from researchers. Two factors stand out as predictors of the condition: increasing age and a family history of BPH. There does appear to be agreement that BPH results from the normal decrease in the hormone testosterone as men age. The higher concentration of another hormone, estrogen, may influence the increase in cell growth. In another theory, researchers believe they have identified a route by which a testosterone by-product called DHT (dihydrotestosterone) reenters the prostate gland encouraging the gland to grow just as testosterone did during puberty. Due to the vast population of men who suffer from this condition, much research is conducted to identify its cause and more effective, less invasive methods of treatment.
Treatment options for bph range from drug therapy to major surgery
For the majority of men with BPH the prostate will continue growing until it becomes necessary for medical intervention. With the help of a urologist each man will develop a treatment plan with which they are both comfortable. Below are the currently available treatment options.
Watch and Wait (along with Lifestyle Changes):
For relatively mild symptoms with no signif-icant effect on a man’s quality of life, for men with drug sensitivities, or when surgery presents undue risk, this can be a desirable strategy. With regular follow-ups, the physician monitors the progress of the disease and the man’s symptoms. This is often only a temporary option because the prostate will continue to grow and more advanced treatment will become necessary. Furthermore, advanced treatment may become advisable despite the level of the man’s discomfort because of the potential for harming the urogenital area. Over time, the wall of the bladder thickens and the muscles weaken to the point that it can not completely empty itself. This can result in urinary tract infections, retention of urine, bladder stones, damage to the urinary and reproductive organs, and, if these conditions persist, urine may back up to the kidney, eventually causing kidney stones and possibly renal disease.
Medications are separated into three groups: those which relax the muscles of the prostate and lower bladder allowing the urethra to open; those which retard and/or shrink the growth of the prostate; and those which increase bladder capacity. Some common names of these drugs are: Avodart, Proscar, Cardura and Flomax. This treatment option requires a man to take medication for the remainder of his life. The benefit of this option is that these medications are very effective. The downside is their side-effects, some of which are sexual functioning issues, making this option unacceptable to some men.
Surgical options are labeled invasive or minimally invasive depending on whether or not tissue is cut. The procedures discussed below are the most invasive, but also the most efficient and effective of all treatment options.
Historically, BPH was surgically treated by an operation called Open Prostatectomy which is a major abdominal surgery. Performed in a hospital under general anesthesia, the surgeon opens the patient’s abdomen and either removes the gland or cuts off the overgrowth. The patient leaves the operating room with two catheters which stay in for up to a week. This procedure requires a long-term rehabilitation period. Today, a prostatectomy is performed when the patient’s prostate has grown too large, there are bladder stones, or when the bladder needs to be repaired at the same time.
Less invasive than Open Prostatectomy is the more commonly performed TURP (Transurethral Resection of the Prostate). This procedure is done in a hospital or out-patient setting using general anesthesia, or an epidural or spinal anesthesia with sedatives. Using a resectoscope, the surgeon enters the urethra through the penis and cuts away pieces of the overgrown gland using electricity. At the end of the procedure, a urinary catheter is put in the patient and is removed either in recovery or the next day. This procedure takes about 90 minutes and the patient may be discharged on the day of or day after. The initial recovery period allows for a return to daily activities in about a month, delaying strenuous activity until considerably later. The benefit of this procedure is its safety and effectiveness in opening the urinary route. Possible side-effects directly after the procedure include uncomfortable and occasional difficulty urinating and blood in the urine. There is a possibility of long-term recovery issues, including impotence and retrograde ejaculation. TURP is considered to be the optimum treatment for BPH today.
Non-Surgical, Minimally Invasive Procedures:
Minimally invasive procedures focus high energy on the overgrown tissue, with each therapy using a different type of energy or a unique way of administering it. Lasers, microwaves, radio frequency waves, and ultrasound are energy forms which can be directed at the prostate by entering the urethra with a cystoscope or similar instrument. The effectiveness of using focused energy is positive for the short term with discharge on the same day, less discomfort urinating, and a quicker return to daily activities than with surgery. Longer term success needs further study before a comparison can be made between non-surgical and surgical treatment options.
Finding a urologist
Identifying a surgeon to perform any procedure is probably the most critical decision you can make in treating BPH. The first criteria for assuring a successful, complication-free procedure is to select a board-certified doctor – one who has shown a mastery of the knowledge and skills required in his/her field to the exacting standards of the certifying group.
David B. Samadi, MD is the Chairman of Urology, Chief of Robotic Surgery at Lenox Hill Hospital, and Professor of Urology at Hofstra North Shore-LIJ School of Medicine in New York City. He is a board-certified urologist and a specialist in the diagnosis and treatment of urologic diseases, kidney cancer, bladder cancer, and prostate cancer. Dr. Samadi is trained in oncology, open, laparoscopic, and robotic surgery and has performed over 7,000+ robotic laparoscopic prostate surgeries. He is actively involved in training and proctoring urologists throughout the United States and internationally.