BPH: Benign Prostatic Hyperplasia

What is BPH?

The prostate is a gland in men that helps produce semen, the fluid that contains sperm. Over many years, the cells of this gland have a tendency to become enlarged (or hypertrophy). Fortunately, this enlargement is not itself dangerous. As the name “benign” implies, BPH is not prostate cancer and does not increase the risk of prostate cancer. In fact, BPH is rarely harmful, usually more of an inconvenience than anything else.

The problems it does cause result from compression of the urethra, which passes through the prostate as it carries urine out of the body. An enlarged prostate can obstruct the flow of urine making it difficult to empty the bladder, which in turn leads to frequent urination and nighttime awakening to urinate.

BPH is a chronic, progressive disease, meaning that the symptoms are mild at first and slowly get worse over many years. Serious complications can occur when there is significant obstruction of the urinary tract, though this is relatively uncommon.

You should visit your primary care physician who may coordinate care with a specialist called a urologist. While some prescription medication may be used, no treatment is also an option. Depending on the severity of your symptoms, your physician may choose to wait and follow-up if symptoms worsen.

BPH symptoms

The main symptoms of BPH relate to the obstruction of urine, which makes it difficult to empty your bladder. There are also a few secondary symptoms and complications of advanced BPH which result from chronic inability to empty the bladder. That said, the main problems experienced by most men with BPH are urinary difficulties such as the following.

• Weak flow of urine: This leads to a stuttering or slow stream.
• Difficulty starting urination: This is known as urinary hesitancy.
• Sudden urge to urinate: This is known as urinary urgency.
• Frequent urination, particularly at night: This is caused by an inability to fully empty the bladder each time.
• Incomplete voiding: This describes the feeling of not being able to fully empty the bladder.

In addition to the urinary symptoms themselves, BPH causes some important secondary symptoms that result from chronic inability to empty the bladder. These fall into two main camps: lack of sleep caused by frequent nighttime awakenings, and increased risk of infection from retained urine.

Symptoms caused by impaired sleep

Though not directly related to urinary tract obstruction, men with BPH often suffer symptoms caused by their frequent nighttime awakenings and lack of sleep, such as the following.

• Daytime sleepiness
• Lack of energy
• Cognitive changes: Such as difficulty concentrating or irritability

Infection risk

While BPH is rarely dangerous, there are a few serious complications which can occur when there is significant or complete obstruction of urinary outflow. The most significant of these is an increased risk of infection starting in the urinary tract. Such infections are more common in anyone who cannot fully empty their bladder since bacteria grow better in stagnant or slow-moving liquid.

Most urinary tract infections are generally mild and easy to treat, though they can become dangerous. This is particularly true for at-risk groups such as the elderly and those with impaired immune systems due to immunosuppressive medications or diseases such as HIV/AIDS. Specific infections more common in those with BPH include the following.

• Urinary tract infections (UTIs): These are the most common and mild form of infection seen in BPH. They involve infection of the bladder (known as cystitis) by bacteria that has had time to grow in the retained urine. The main symptoms are pain and burning with urination. UTIs are extremely common even in those without BPH, and most are easily treatable.
• Pyelonephritis: This refers to infection of the kidney, most often due to upward spread of bacteria from an infected bladder. Unlike the UTI that likely caused it, a kidney infection can be extremely serious. Severe back or flank pain is common, as are high fevers and shaking chills.
• Urosepsis: This is the most severe and advanced form of infection beginning in the urinary tract. Sepsis occurs when bacteria or other bugs leak into the bloodstream, spread to all areas of the body and cause an overwhelming inflammatory response. Urosepsis describes sepsis that began as a UTI or pyelonephritis. It is most common in the elderly and immunocompromised; it is a life-threatening medical emergency requiring prompt and intensive care.

What causes BPH?

The urethra is a thin tube that carries urine from the bladder to the outside world. In men, it also carries semen, much of which it picks up when passing through the prostate. Unfortunately, the region of the prostate which tends to overgrow (known as the transitional zone) sits immediately around the urethra, making it prone to compression and obstruction. This zone is rarely affected by prostate cancer, which is why urinary symptoms are rare in prostate cancer until the disease is relatively advanced. This may seem purely academic but it underscores an important point: an older man with trouble urinating is far, far more likely to have BPH than prostate cancer.

Who is most likely to be affected

The precise cause of BPH remains poorly understood despite ongoing research. That said, a number of contributors and risk factors have been identified, including the following.

• Males only
• Age: This is the (next) most significant risk factor for BPH. It is almost unheard-of in young men, while post-mortem studies suggest more than 80 percent of men over 80 years old have at least some BPH.
• Hormones: Particularly androgens (“male hormones”) such as testosterone and dihydrotestosterone (DHT) are known to contribute to BPH development and progression. This is based on the knowledge that blocking these hormones can treat BPH while supplementing them can worsen BPH or even trigger it. However, these hormones are also part of normal biology and most men with BPH have normal hormone levels.
• Race: This may play a role in BPH risk, though the evidence for this is somewhat unclear. Some studies have found that black men are more likely to need surgery for BPH than white men, while Asian men are less likely than either group to require prostate surgery.

Various other possible risk factors such as obesity have been proposed, though evidence for these is conflicted.

BPH treatment

Initial management

Treatment usually is not needed for the early stages of BPH. For men who are not particularly bothered by their symptoms, it is often appropriate to adopt a “watchful waiting” strategy. It can often be helpful to keep a urinary frequency log to track the progression of BPH symptoms. Decreasing fluid intake and alcohol consumption, particularly in the evening, can also significantly improve urinary frequency and nighttime awakening.

Medications

Once symptoms become significantly bothersome or complications develop, there are several medications which are effective at controlling the symptoms of BPH. While they do not reverse or cure BPH, they are often sufficient to significantly relieve urinary symptoms. These medications fall into two main camps: alpha blockers and 5-alpha reductase inhibitors.

• Alpha blockers: Alpha blockers are considered the first-line option when medications are needed to treat BPH [2,3,5]. This group includes medications such as tamsulosin (Flomax), doxazosin, terazosin and prazosin. Alpha blockers work by relaxing the smooth muscle which surrounds the urethra and bladder neck. This opens up the urinary tract, allowing urine to flow more easily. Known side effects include dizziness and lightheadedness, particularly in those with low blood pressure.
• 5-alpha reductase inhibitors: Medication such as finasteride (Proscar) represent the other main class used to treat BPH. These medications block the synthesis of the male hormone DHT, which contributes to prostate growth in BPH. This means that unlike alpha blockers, 5-alpha reductase inhibitors may be able to slow the progression of BPH. However, they are significantly less effective at improving urinary symptoms and have been known to cause sexual dysfunction. They are therefore mainly used in conjunction with alpha blockers for men with worsening BPH.

Anticholinergics such as tolterodine (Detrol) and oxybutynin (Ditropan) are occasionally used to treat urinary urgency associated with BPH. They can be used alone or in combination with other medications, though they risk worsening urinary retention and should not be used in men with incomplete voiding.

Unsupported alternative medicine and supplements

Several alternative medications and herbal supplements have been studied as treatment options for BPH. To date, data supporting their use is extremely limited so most professional organizations do not consider them effective treatments. For example, practice guidelines from the American Urological Association conclude that no dietary supplement or other non-conventional therapy is recommended for the treatment of BPH.

• Supplements: Studies have found supplements containing pygeum, cernilton, and beta-sitosterols to be no better than placebo at relieving BPH symptoms, which is to say that they do not work.
• Acupuncture: Similar results were found in a scientific study of acupuncture for BPH.
• Saw palmetto: Supplements containing saw palmetto have shown some efficacy in alleviating BPH symptoms. In some parts of Europe, many urologists saw palmetto a reasonable alternative for patients with mild BPH who are not interested in prescription medications. However, more recent literature reviews have found the studies supporting saw palmetto to be of poor quality, so most professional organizations consider the data insufficient to recommend its use.

Surgery

Unfortunately, these medications cannot cure or reverse the progression of BPH. Surgery is the best option to definitively reduce the size of a significantly enlarging prostate. While several surgical options have been attempted, the mainstay of treatment is known as transurethral prostate resection (TURP). As the name suggests, the TURP procedure involves accessing the prostate via the urethra and removing part of the enlarged prostate. While this can sound quite intimidating to many men, TURP is usually very well tolerated with minimal discomfort. That said, known complications include bleeding, sexual dysfunction, electrolyte imbalances, and incomplete resolution of urinary obstruction. While most men experience significant improvement in BPH symptoms following TURP, a small percentage need repeat intervention within the coming years.

A plethora of other surgical techniques have been used with varying degrees of success, ranging from minimally invasive needle resections to complete removal of the prostate (known as prostatectomy). The details of those procedures fall beyond the scope of this article, but as always it’s worth discussing all options with your doctor when considering surgery.

Prevention

Unfortunately, there is currently little that can be done to prevent the development of BPH. While a handful of risk factors have been identified, most of them are “non-modifiable” risk factors such as age and race which are outside of our control. Some evidence suggests that maintaining a healthy weight and blood pressure may decrease the risk of BPH, but other studies showed no significant relationship between BPH and overall health. Certain medications such as diuretics and first-generation antihistamines can worsen urinary symptoms, but they do not themselves contribute to the development of BPH.

When to seek further consultation

Most cases of BPH are mild and can be managed on a routine basis by a primary care physician. As mentioned above, difficulty urinating is extremely common in older men and is not a cause for alarm. That said, it is not a part of “normal aging” as many men assume. Complications can occur, so trouble urinating is worth mentioning at your next doctor's appointment.

If you have pain or burning with urination, foul-smelling urine, or a fever

There are a few urinary symptoms that can occur in men with BPH that merit seeking medical care more promptly. BPH should not cause pain or burning with urination, foul-smelling urine, or fever. Those symptoms are more likely related to urinary tract infection and should be reported to your doctor.

If you have brown or bloody urine

Brown or bloody urine may be signs of a more serious condition and therefore warrant seeking professional medical care. The same is true for complete inability to urinate or feelings of significant abdominal distension, both of which can be seen in a complete urinary obstruction requiring professional intervention. Those with advanced BPH causing significant discomfort or disability should seek the specialized care of a urologist.