Benign Prostatic Hyperplasia (BPH)

Overview

Benign prostatic hyperplasia (BPH) is not simply a case of too many prostate cells. Prostate growth involves hormones, occurs in different types of tissue (e.g., muscular, glandular), and affects men differently. As a result of these differences, treatment varies in each case. There is no cure for BPH and once prostate growth starts, it often continues, unless medical therapy is started.

The prostate grows in two different ways. In one type of growth, cells multiply around the urethra and squeeze it, much like you can squeeze a straw. The second type of growth is middle-lobe prostate growth in which cells grow into the urethra and the bladder outlet area. This type of growth typically requires surgery.

Anatomy

The prostate is a walnut-sized gland located beneath the bladder and in front of the rectum. It is surrounded by a capsule of fibrous tissue called the prostate capsule. The urethra (tube that transports urine and sperm out of the body) passes through the prostate to the bladder neck. Prostate tissue produces prostate specific antigen and prostatic acid phosphatase, an enzyme found in seminal fluid (the milky substance that combines with sperm to form semen).

Incidence and Prevalence 
It is difficult to establish incidence and prevalence of BPH because research groups often use different criteria to define the condition. According to the National Institutes of Health (NIH), BPH affects more than 50% of men over age 60 and as many as 90% of men over the age of 70.

Risk Factor

BPH is a condition of aging. Nearly all men over the age of 50 have an enlarged prostate.

Causes

The cause of benign prostatic hyperplasia is unknown. It is possible that the condition is associated withhormonal changes that occur as men age. The testes produce the hormone testosterone, which is converted to dihydrotestosterone (DHT) and estradiol (estrogen) in certain tissues. High levels of dihydrotestosterone, a testosterone derivative involved in prostate growth, may accumulate and cause hyperplasia. How and why levels of DHT increase remains a subject of research.

Signs and Symptoms

Common symptoms of benign prostatic hyperplasia include the following:

  • Blood in the urine (i.e., hematuria), caused by straining to void
  • Dribbling after voiding
  • Feeling that the bladder has not emptied completely after urination
  • Frequent urination, particularly at night (i.e., nocturia)
  • Hesitant, interrupted, or weak urine stream caused by decreased force
  • Leakage of urine (i.e., overflow incontinence)
  • Pushing or straining to begin urination
  • Recurrent, sudden, urgent need to urinate

In severe cases of BPH, another symptom, acute urinary retention (the inability to urinate), can result from holding urine for a long time, alcohol consumption, long period of inactivity, cold temperatures, allergy or cold medications containing decongestants or antihistamines, and some prescription drugs (e.g., ipratropium bromide, albuterol, epinephrine). Any of these factors can prevent the urinary sphincter from relaxing and allowing urine to flow out of the bladder. Acute urinary retention causes severe pain and discomfort. Catheterization may be necessary to drain urine from the bladder and obtain relief.

Diagnosis

A physical examination, patient history, and evaluation of symptoms provide the basis for a diagnosis of benign prostatic hyperplasia. The physical examination includes a digital rectal examination (DRE), and symptom evaluation is obtained from the results of the AUA Symptom Index.

Digital rectal examination (DRE) 
DRE typically takes less than a minute to perform. The doctor inserts a lubricated, gloved finger into the patient's rectum to feel the surface of the prostate gland through the rectal wall to assess its size, shape, and consistency. Healthy prostate tissue is soft, like the fleshy tissue of the hand where the thumb joins the palm. Malignant tissue is firm, hard, and often asymmetrical or stony, like the bridge of the nose. If the examination reveals the presence of unhealthy tissue, additional tests are performed to determine the nature of the abnormality.

AUA Symptom Index 
The AUA (American Urological Association) Prostate Symptom Index is a questionnaire designed to determine the seriousness of a man's urinary problems and to help diagnose BPH. The patient answers seven questions related to common symptoms of benign prostatic hyperplasia. How frequently the patient experiences each symptom is rated on a scale of 1 to 5. These numbers added together provide a score that is used to evaluate the condition. An AUA score of 0 to 7 means the condition is mild; 8 to 19, moderate; and 20 to 35, severe.

PSA and PAP Tests 
Blood tests taken to check the levels of prostate specific antigen (PSA) and prostatic acid phosphatase (PAP) in a patient who may have benign prostatic hyperplasia helps the physician eliminate a diagnosis of prostate cancer.

Prostate-specific antigen (PSA) is a specific antigen produced by the cells of the prostate capsule (membrane covering the prostate) and periurethral glands. Patients with benign prostatic hyperplasia (BPH) or prostatitis produce larger amounts of PSA. The PSA level also is determined in part by the size and weight of the prostate.

The test measures the amount of PSA in the blood in nanograms per milliliter (ng/mL). A PSA of 4 ng/mL or lower is normal; 4–10 ng/mL is slightly elevated; 10–20 is moderately elevated; and 20–35 is highly elevated. Most men with slightly elevated PSA levels do not have prostate cancer, and many men with prostate cancer have normal PSA levels. A highly elevated level may indicate the presence of cancer.

The PSA test can produce false results. A false positive result occurs when the PSA level is elevated and there is no cancer. A false negative result occurs when the PSA level is normal and there is cancer. Because of this, a biopsy is usually performed to confirm or rule out cancer when the PSA level is high.

Free and total PSA (also known as PSA II) PSA in the blood may be bound molecularly to one of several proteins or may exist in a free, or unbound, state. Total PSA is the sum of the levels of both forms; free PSA measures the level of unbound PSA only. Studies suggest that malignant prostate cells produce more bound PSA; therefore, a low level of free PSA in relation to total PSA might indicate a cancerous prostate, and a high level of free PSA compared to total PSA might indicate a normal prostate, BPH, or prostatitis.

Age-specific PSA Evidence suggests that the PSA level increases with age. A PSA of up to 2.5 ng/mL for men age 40–49 is considered normal, as is 3.5 ng/mL for men age 50–59, 4.5 ng/mL for men age 60–69, and 6.5 ng/mL for men 70 and older. The use of age-specific PSA levels is not endorsed by all medical professionals.

Use the PSA Age/Race Quiz or the PSA Velocity Quiz to deterimine your risk of prostate cancer.

Urodynamic Testing 
Urodynamic tests, usually performed in a physician's office, are used to measure the volume and pressure of urine in the bladder and to evaluate the flow of urine. They are particularly useful for the diagnosis of Intrinsic sphincter deficiency and uncertain cases of mixed, overflow, urgency, or total incontinence. Additional tests may be conducted if symptoms indicate that blockage is caused by a condition other than BPH.

Uroflowmetry is a simple test performed to record urine flow, to determine how quickly and completely the bladder can be emptied, and to evaluate obstruction. With a full bladder, the patient urinates into a device that measures the amount of urine, the time it takes for urination, and the rate of urine flow. Patients with stress or urge incontinence usually have a normal or increased urinary flow rate, unless there is an obstruction in the urinary tract. A reduced flow rate may indicate BPH.

pressure flow study measures pressure in the bladder during urination and is designed to detect a blockage of flow. It is the most accurate way to evaluate urinary blockage. This test requires the insertion of a catheter through the urethra in the penis and into the bladder. The procedure is uncomfortable and rarely may cause urinary tract infection (UTI).

Post-void residual (PVR) test measures the amount of urine that remains in the bladder after urination. The patient is asked to urinate immediately prior to the test and the residual urine is determined by ultrasound or catheterization. PRV less than 50 mL generally indicates adequate bladder emptying and measurements of 100 to 200 mL or higher often indicate blockage. Nervousness and other types of stress may affect the result; therefore, the test is often repeated.

Treatment Options

Treatment options for enlarged prostate, or benign prostatic hyperplasia (BPH), may include the following:

  • Medical
    • Watchful waiting
    • Medications (e.g., alpha blockers)
    • Prostatic stents
  • Minimally invasive treatments (thermotherapy)
    • Laser (e.g., non-contact, contact, interstitial types)
    • Microwave (e.g., TUMT)
    • Other thermotherapies (e.g., Prostiva™ RF therapy [previously known as TUNA])
  • Surgical treatments
    • Transurethral resection of the prostate (TURP)
    • Holmium laser enucleation of the prostate (HoLEP)
    • Prostatectomy
    • Transurethral incision of the prostate (TUIP)
    • Transurethral ultrasound-guided laser incision of the prostate (TULIP)
  • Alternative treatments
    • Nutrition
    • Supplements
    • Herbal remedies
    • Hydrotherapy

Medical Treatment

There are several treatment options for men with benign prostate hyperplasia, depending on the severity of symptoms. If symptoms do not threaten the man's health, he may choose not to be treated. If symptoms are severe enough to cause discomfort, interfere with daily activities, or threaten health, treatment is usually recommended.

Watchful waiting 
Men with mild symptoms may choose to return for annual examinations. The physician will perform an examination that includes a DRE, PSA tests, and a urinary flow rate. The patient will be asked to describe symptoms in order to determine if the condition is worsening.

Medication 
5-Alpha reductase inhibitors such as finasteride (Proscar®) and dutasteride (Avodart®) prevent the conversion of testosterone to the hormone dihydrotestosterone (DHT). In many cases, a treatment period of 6-month is necessary to see if the therapy is going to work. These drugs are taken orally, once a day. Finasteride is available in tablet form and dutasteride is available as soft gelatin capsules. Patients should see their physician regularly to monitor side effects and adjust the dosage, if necessary.

Side effects include reduced libido, impotence, breast tenderness and enlargement, and reduced sperm count. Long-term risks and benefits have not been studied.

Women who may be pregnant must avoid handling dutasteride capsules and broken or crushed finasteride tablets because exposure to the drugs may cause serious side effects to the fetus. Intact tablets are coated to prevent absorption through the skin during normal handling. Patients should wait at least 6 months after dutasteride treatment to donate blood to prevent pregnant women from being exposed to the drug through blood transfusion.

Alpha blockers relax smooth muscle tissue in the bladder neck and prostate, which increases urinary flow. They typically are taken orally, once or twice a day.

Commonly prescribed alpha blockers include the following:

  • alfuzosin (UroXatral®), extended-release tablet taken once daily
  • doxazosin (Cardura®), tablet taken once daily
  • prazosin (Minipress®), capsule taken 2 or 3 times daily
  • tamsulosin hydrochloride (Flowmax®), capsule taken once daily
  • terazosin (Hytrin®), capsule taken once daily

Patients taking an alpha blocker require follow-up during the first 3 or 4 weeks to evaluate the effect on symptoms and adjust the dosage, if necessary. Side effects include headache, dizziness, low blood pressure, fatigue, weakness, and difficulty breathing. Long-term risks and benefits have not been studied.

Prostatic stents 
Although a prostatic stent is not a medical treatment, neither does it fall under the classification of a surgical procedure. Prostatic stents are used most often for patients with significant medical problems that prohibit medication or surgery. It is a tiny, springlike device inserted into the urethra. When expanded, it pushes back the surrounding tissue and widens the urethra. Prostatic stents have several advantages:

  • They can be placed in less than 15 minutes under regional anesthesia.
  • Bleeding during and after surgery is minimal.
  • The patient can be discharged the same day or the next morning.

There are also several disadvantages:

  • Prepositioning can be difficult.
  • They may cause irritation and frequent urination.
  • They may cause pain or incontinence.
  • Removing them (necessary in one-third of cases) can be difficult.

Minimally Invasive Treatment

Minimally invasive BPH treatments use state-of-the-art tools and techniques to reduce or eliminate symptoms. Men are treated on an outpatient basis in a urologist's office or the hospital. Other advantagesof minimally invasive treatments are

  • less pain,
  • faster recovery,
  • lower costs, and
  • local anesthesia and mild sedative.

Usually, heat is used to destroy excess prostate tissue. Techniques differ in heat source, heat delivery method, side effects, and number of treatments. Delivery methods include:

Laser (e.g., non-contact, contact, interstitial)

  • Indigo®
  • PVP
  • HoLAP

Microwave

  • CoreTherm®
  • Cooled ThermoTherapy™/TUMT™
  • TherMatrx®
  • Prolieve™

Other

  • AquaTherm™ System
  • Prostiva™ RF Therapy, previously known as TUNA
  • TUVP
  • HIFU

Patients who want to stop taking medication or whose medication no longer improves symptoms may elect to have one of these procedures. However, patients with severely enlarged prostates and whose bladders do not work properly may not be good candidates.

Prior to diagnosis and treatment of BPH, a prostate-specific antigen (PSA) test and digital rectal examination (DRE) are performed to rule out prostate cancer. A transrectal ultrasound and cystoscopy also may be performed to determine if prostatectomy or TURP is indicated.

 

Surgical Treatment

Surgery involves removing the enlarged part of the prostate that constricts the urethra. It is recommended for patients who experience serious complications, such as the following:

  • Bleeding through the urethra as a result of BPH
  • Damage to the kidneys caused by urine backing up
  • Frequent urinary tract infections
  • Inability to urinate
  • Stones in the bladder

TURP 
Transurethral resection of the prostate (TURP) is the gold standard to which other surgeries for BPH are compared. This procedure is performed under general or regional anesthesia and takes less than 90 minutes.

The surgeon inserts an instrument called a resectoscope into the penis through the urethra. The resectoscope is about 12 inches long and 3/8 of an inch in diameter. It contains a light, valves for controlling irrigating fluid, and an electrical loop to remove the obstructing tissue and seal blood vessels. The surgeon removes the obstructing tissue and the irrigating fluids carry the tissue to the bladder. This debris is removed by irrigation and any remaining debris is eliminated in the urine over time.

Patients usually stay in the hospital for about 3 days, during which time a catheter is used to drain urine. Most men are able to return to work within a month. During the recovery period, patients are advised to

  • avoid heavy lifting, driving, or operating machinery;
  • drink plenty of water to flush the bladder;
  • eat a balanced diet;
  • use a laxative if necessary to prevent constipation and straining during bowel movements.

Complications 
Blood in the urine (hematuria) is common after TURP surgery and usually resolves by the time the patient is discharged. Bleeding also may result from straining or activity. Postsurgical bleeding should be reported to the urologist immediately.

Some patients have initial discomfort, a sense of urgency to urinate, or short-term difficulty controlling urination. These conditions slowly improve as recovery progresses, but it is important to remember that the longer the urinary problems existed before surgery, the longer it takes to regain full and normal bladder function after surgery.

Up to 30% of men who undergo TURP experience problems with sexual function. Complete recovery of sexual function may take up to 1 year. The most common, long-term side effect of prostate surgery is retrograde ejaculation (dry climax), which results when the muscle that closes the bladder neck during ejaculation is removed along with the obstructing prostate tissue. Semen enters the wider opening to the bladder instead of being expelled through the penis, causing sterility but not affecting the man's ability to experience sexual pleasure. This complication is not an issue for most men requiring prostate surgery.

HoLEP 
Holmium laser enucleation of the prostate (HoLEP) produces results that are similar to TURP with fewer complications (e.g., less intraoperative bleeding). In this procedure, a holmium laser is used to remove obstructive prostatic tissue and seal blood vessels. HoLEP is usually performed as a day procedure in the hospital. Benefits of HoLEP over traditional surgery include the following:

  • Shorter hospital stay
  • Shorter catheterization time
  • Shorter recovery time

Approximately 10–15% of patients with large prostates (>100 gm) experience stress incontinence after undergoing HoLEP. In most cases, incontinence resolves within 6 weeks.

Prostatectomy 
If the prostate is greatly enlarged, if the bladder has been damaged, or if the patient has complications prohibiting transurethral surgery, prostatectomy (removal of the obstructing prostate) may be necessary. This procedure is sometimes the best and safest approach.

Prostatectomy is performed under general or regional anesthesia. The surgeon makes an external incision in the lower abdomen or in the perineum (area between the rectum and the scrotum). If the surgeon accesses the prostate from the abdomen, the procedure is called suprapubic or retropubicprostatectomy; surgery through the perineum is called perineal prostatectomy. Once access is gained, the prostate is removed.

After prostate surgery, a urinary catheter is inserted to ensure bladder emptying. Urine output and color and continuous bladder irrigation (CBI), if present, are monitored. Blood in the urine is an expected side effect of prostate surgery. CBI is used to maintain the effectiveness of the urinary catheter, remove blood clots, and cleanse the surgical area. If bladder spasms occur, the surgeon should be notified.

Once they have been discharged from the hospital, patients should abstain from sexual intercourse for 6 weeks after surgery. Strenuous activity and lifting is to be avoided throughout the recovery period, which can take up to 8 weeks.

Potential complications include incontinence and impotence. Depending on the procedure, stress urinary incontinence may result when pressure is put on abdominal muscles. Urge incontinence and involuntary passing of urine while asleep also may occur. Patients are encouraged to use Kegel exercises to strengthen pelvic floor muscles and to increase their water intake. Ejaculatory dysfunction and erectile dysfunction (impotence) may occur, depending on the procedure.

TUIP 
Transurethral incision of the prostate (TUIP) may be recommended to treat a prostate that is not greatly enlarged. The surgeon makes one or more cuts in the bladder neck where the urethra joins the bladder, extending into the prostate. This reduces the prostate's pressure on the urethra and makes urination easier. TUIP may provide relief with a lower incidence of retrograde ejaculation than TURP. However, its long-term benefits and risks compared to TURP have not been established.

TULIP 
Transurethral ultrasound-guided laser incision of the prostate (TULIP) is a new procedure that is similar to TUIP, except that the cuts are made with a laser.

Naturopathic Treatment

The goal of benign prostatic hyperplasia (BPH) treatment is to reduce excessive cell growth by inhibiting the conversion of testosterone into the more potent hormone dihydrotestosterone (DHT) and by preventing estrogen from attaching to receptors in prostate tissue. From a naturopathic viewpoint, this is accomplished through nutrition and the use of supplements and herbs.

Nutrition

  • Eat whole, fresh, unrefined, and unprocessed foods. Include fruits, vegetables, whole grains, soy, beans, seeds, nuts, olive oil, and cold-water fish (salmon, tuna, sardines, halibut, and mackerel). Eating organic food helps reduce exposure to hormones, pesticides, and herbicides.
  • Avoid refined sugar and flour, dairy products, refined foods, fried foods, junk foods, hydrogenated oils, alcohol (particularly beer), and caffeine.
  • Eliminate food sensitivities. Use an elimination and challenge diet to determine food sensitivities.
  • Drink 50% of your body weight in ounces of water daily (e.g., if you weigh 150 lbs, drink 75 oz of water daily).

Supplements 
Supplements are intended to provide nutritional support. Because a supplement or a recommended dose may not be appropriate for all persons, a physician (i.e., a licensed naturopathic physician or holistic MD or DO) should be consulted before using any product. Recommended doses follow:

  • Amino acids – The combination of glycine, alinine, and glutamic acid (200 mg of each daily) reduces urinary urgency, urinary frequency, and delayed micturition (initiation of flow).
  • Beta-sitosterol – 120 mg daily in 3 divided doses may help reduce symptoms. Beta-sitosterol also lowers cholesterol (a higher dose of 500 mg 3 times daily is required), which is important since high cholesterol levels can cause prostatic hyperplasia.
  • Flaxseed meal – Grind and eat 2-4 tbsp daily. An alternative is to take 1 tbsp of flaxseed oil daily. Flaxseed oil is a good source of the essential fatty acid (EFA) alpha-linolenic acid (an omega-3 fatty acid).
  • Flower pollen – Follow product directions. It has been used in Europe for over 25 years to treat BPH. Flower pollen is not the same as bee pollen.
  • Zinc picolinate – 30–50 mg daily. Zinc competes with copper for absorption; therefore, when supplementing long term with zinc, copper should also be supplemented. There are supplements available that contain both zinc and copper.

Herbal Medicine 
Herbal medicines usually do not have side effects when used appropriately and at suggested doses. Occasionally, an herb at the prescribed dose causes stomach upset or headache. This may reflect the purity of the preparation or added ingredients, such as synthetic binders or fillers. For this reason, it is recommended that only high-quality products be used. As with all medications, more is not better and overdosing can lead to serious illness and death.

These herbs may be used to treat BPH:

  • Saw palmetto (Serenoa repens) – Inhibits the conversion of testosterone to DHT in the prostate, has an antiestrogenic effect, and helps improve all symptoms of BPH. Recommended dosage is 320 mg of extract (standardized to contain approximately 85% fatty acids and sterols) daily.
  • Pygeum (Pygeum africanum) – Reduces BPH symptoms. Recommended dosage is 100-200 mg of extract (standardized to 14% triterpenes) 2 times daily.
  • Stinging nettles (Urtica dioica) – The concentrated extract reduces symptoms. Recommended dosage is 120 mg daily.

Hydrotherapy

  • Cold sitz bath and other hydrotherapy options