Benign Prostatic Hyperplasia (BPH) is a very common disease among older men in Hong Kong, affecting around 50% of all men over the age of 50 in the Chinese population. BPH is not cancer but it can lead to urinary problems and affect the quality of life. Early diagnosis and treatment can help relieve symptoms of BPH effectively. Men should not delay seeking treatment for BPH.
BPH pathophysiology: What is BPH?
Benign Prostatic Hyperplasia (BPH) is a condition in which the prostate and its surrounding tissue enlarge. Prostate is usually the size of a walnut, made of glandular and muscular tissue. The main function of the prostate gland is to produce fluid in semen that transports sperm out of the body. The size of the prostate generally remains stable until middle-age. Under the influence of male hormones (androgen), the prostate gland can enlarge slowly. The enlargement is non-cancerous, it is therefore called Benign Prostatic Hyperplasia.
The prostate is located in the pelvis, between the penis and bladder. It surrounds part of the urethra, a tube that carries urine and sperm out of the body. When the prostate becomes enlarged, it can compress the urethra and hence obstruct the flow of urine, making it more difficult to pass urine and to empty the bladder completely.
Benign Prostatic Hyperplasia: BPH symptoms and signs
Not all men with BPH experience symptoms. For those who have symptoms, commonly include:
- Urgency – difficult to postpone urination
- Frequency – have to urinate more often than previously
- Nocturia – need to get up at night to urinate
- Urge incontinence – inability to control urination
- Hesitancy – have to wait before starting to urinate
- Weak or intermittent urine flow
- Sense of incomplete emptying or post-void dribbling
- Burning sensation or pain while urinating (when men experience a UTI)
In severe cases, the bladder cannot pass urine and may result in urinary retention, causing swelling and pain in the lower abdomen. It is a serious condition that requires immediate medical attention.
Many symptoms of BPH are similar and overlapped to those found with prostate cancer, but the two are not related. Based on research to date, having BPH does not automatically increase your risk of prostate cancer.
Benign Prostatic Hyperplasia: BPH causes and risk factors
The exact cause of prostate enlargement is unknown, but it is believed to be linked to male hormones which can lead to overgrowth of the prostate tissue as men get older.
There are several factors found to be associated with higher risk for BPH include:
Benign Prostatic Hyperplasia: BPH diagnosis and detection
Your doctor will take a thorough medical history by asking about your symptoms and concerns, and how the symptoms might have an impact on your quality of life. Doctors will generally use the International Prostate Symptom Score questionnaire (IPSS) to evaluate the severity of symptoms and detect prostate problems at the early stage.
Besides, doctors may also perform the following tests to aid the diagnosis of BPH:
- Digital rectal examination (DRE) – Doctors will insert a gloved, lubricated finger through the patient’s anus into the back passage (rectum), to assess the consistency and size of the prostate gland
- Urine test (urinalysis) – Check if there is blood, signs of infection or protein in the urine
- Prostate-specific antigen (PSA) blood test – PSA is a protein produced by the prostate gland. A rise in PSA level may be a sign of a prostate problem, however, it is not specific to BPH. Other prostate problems such as inflammation of the prostate (prostatitis), or more seriously, prostate cancer can also lead to a rise in PSA
- Uroflowmetry – Non-invasive test to measure the urine flow rate
- Urodynamic Test – Insertion of thin tubes into the urethra and back passage (rectum), to measure the bladder’s ability to store urine and empty steadily and completely
- Ultrasound of prostate and bladder – Use of ultrasound to measure the prostate size and reveal the amount of residual urine in the bladder after urination
- Cystoscopy – Insert a lighted flexible telescope into the urethra to examine the bladder for signs of obstruction or abnormalities
Benign Prostatic Hyperplasia: BPH treatment
Benign Prostatic Hyperplasia (BPH) treatment typically consists of active surveillance, medications, minimally invasive surgery or more invasive surgery.
Your doctor will recommend the optimal treatment depending on the severity of the condition, patients’ general health status, along with how the condition is affecting the patient’s quality of life.
BPH Treatment: Acute surveillance and lifestyle changes
Often, BPH will only require acute surveillance (sometimes called “watchful waiting”). Meaning in patients with mild to moderate symptoms and are not bothered by the impact of BPH, they may not require treatment other than continued active observation to make sure their condition doesn’t get worse.
Appropriate education and lifestyle changes would also be advised, including reduction of fluid intake before bedtime, avoidance of caffeinated beverages, urethral milking to prevent dribbling after urination.
If your symptoms get worse, or if new symptoms appear, affecting your daily activity, your doctor may suggest that you begin active treatment with the following options:
BPH Treatment: Medication
Medication is commonly used for moderate symptoms of BPH. In most cases, medication can improve the urinary symptoms caused by BPH. Medication can be used alone or in combination, to decrease the size of the prostate or reduce the severity of symptoms. There are two main classes of medication for BPH:
- 5-alpha-reductase inhibitors (Such as Finasteride, Dutasteride) – These medications work by decreasing the production of the hormone that promotes prostate growth, therefore resulting in shrinkage of the prostate gland. It may take 3 to 6 months for the medications to be effective. Adverse effects include a decrease in libido (sexual desire), erectile dysfunction, enlargement of breast tissue (gynecomastia).
- Alpha-blockers (Such as Tamsulosin, Doxazosin, Terazosin) – These medications can widen blood vessels and lower blood pressure, which will help to relax the muscle in the prostate and make it easier to urinate. It is, therefore, more suitable for patients with predominant difficulty in urinating (voiding symptoms). However, these medications cannot reduce the size of the prostate and it will continue to enlarge. The most common side effects are lightheadedness and low blood pressure, others include drowsiness, dry mouth, erectile disorder.
BPH Treatment: Minimally invasive treatments
Doctors may recommend minimally invasive treatments or surgery if the patients suffer from severe symptoms or if medications are not effective. The aim is to remove part of the excess prostate tissue.
Minimally invasive treatments are comparatively newer and carry less surgical risk. They can be done under local anesthesia and do not require hospitalization. Some of the minimally invasive treatments include:
- Prostatic Urethral lift (UroLift) – The doctor will insert a special device through the urethra to access the prostate. Small implants are then placed to lift and hold the enlarged prostate tissue away from the urethra, increasing the urethra opening.
- Water Vapor Thermal Therapy (Rezum) – A small tube will be inserted through the urethra to the prostate, then the sterile steam will be injected to destroy the enlarged prostate tissue. HKUMed is the first to introduce Water Vapor Thermal Therapy to treat BPH in Asia, with promising results seen.
- Transurethral microwave thermotherapy (TUMT) – Uses microwave heat to destroy the enlarged prostate tissue, a cooling system is used to protect the urinary tract from heat damage
BPH Treatment: Surgery
The following are common options of surgery for BPH:
- Transurethral resection of the prostate (TURP) – Performed by inserting an endoscope through the urethra and removing the obstructing prostate gland with an electric current. This procedure may be done under general or local anesthesia.
- Laser prostatectomy: the obstructive prostate gland was removed or vaporized by laser energy.
- Prostatectomy – Incision is made in the lower abdomen to remove excess prostate tissue, it is traditionally done through open surgery. In a few cases, minimally invasive laparoscopic surgery is used. Nowadays, robotic prostatectomy is also available.
Benign Prostatic Hyperplasia: BPH Complications
Some men with BPH may not have noticed any symptoms until they suddenly experience a painful inability to pass urine. This condition is known as acute urinary retention. It is an emergency that demands immediate medical attention.
Other complications of BPH include:
- Urinary tract infections
- Inflammation of the prostate gland (Prostatitis)
- Bladder stones
- Blood in urine
- Impaired bladder function
- Impaired kidney function
To date, it is believed that BPH does not lead to cancer, however, both conditions can co-exist together.
Benign Prostatic Hyperplasia: How to prevent BPH?
Inevitably, the risk of getting BPH increases with age. However, the following can help to reduce the risk of developing BPH:
- Regular check ups – Early symptoms of BPH may be very subtle and overlapped with those found in prostate cancer, the American Urological Association recommends all men aged 50 or above to undergo regular prostate exam even in the absence of symptoms
- Maintain a healthy diet and lifestyle – Stop smoking, reduce in consumption of alcohol, exercise regularly and maintain healthy body weight
There is a large variety of treatment options for Benign Prostatic Hyperplasia. Typically consists of active surveillance, medications, minimally invasive surgery or more invasive surgery. Your doctor will recommend the optimal treatment depending on the severity of the condition, patients’ general health status, along with how the condition affects the patient’s quality of life.
This article was medically reviewed by Dr. Vera Chung 鍾楊醫生. Dr. Chung is a female urologist practicing at the Hong Kong Urology Clinic. She qualified in 2003 from the University of Hong Kong and was trained as a urologist in Queen Elizabeth Hospital and obtained the Fellowship of Royal College of Surgeons of Edinburgh in 2011. Dr. Chung was promoted to associate consultant in Pamela Youde Nethersole Eastern Hospital in 2012. From 2013 to 2015 she has completed a two-year European Board of Urology (EBU) Fellowship in endourology and laparoscopy at Nuffield Department of Surgical Sciences, University of Oxford. In Oxford, Dr. Chung also consolidated her training in the management of continence and prolapse problems in the Department of Gynecology.
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This article was independently written by Healthy Matters and is not sponsored. It is informative only and not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be relied upon for specific medical advice.