Benign Prostatic Hyperplasia (BPH)
What is it?
BPH is a gradually progressive disease that commences in men who are around 40 years of age. It's
prevalence increases with age. 40% of men over 60 have lower urinary tract symptoms (LUTS), about
half of whom have an impaired quality of life, owing to BPH. The cause is unknown. There is a non-
malignant growth (usually of the transition zone) of the prostate. This process reduces the distensibility
of the urethra when passing urine.
What are the symptoms?
BPH can produce bladder outflow obstruction (BOO). This increase in outflow resistance can cause
changes to the bladder. The walls of the bladder, which are muscular, thicken and become stronger.
These changes may lead to the development of lower urinary tract symptoms such as frequency,
nocturia (the passing of urine at night) and a reduced flow. The high pressure that the bladder
thickened walls generate cause pouches or 'diverticula' to form, and can lead to back pressure on the
kidneys-causing kidney problems. Overall the efficiency of the bladder to void is impaired. This leads to
the inability to completely empty the bladder of urine. Having an increasing post-void residual (PVR)
can lead to infections and the formation of bladder stones.
The table below outlines the common lower urinary tract symptoms associated with BPH:
How is BPH diagnosed?
A lot of emphasis is put on the patient's symptoms and history. The International Prostate Symptom
Score (IPSS) is a way of quantitatively evaluating patient symptoms. However it does not diagnose
BPH.
Below is the IPSS:
The results from this questionnaire will help your doctor to assess if you have an enlarged prostate.
The results do not help to diagnose prostate cancer. In general, a score of:
The physician will also do a digital rectal examination (DRE). This allows him to assess the size and
shape of the prostate gland. Also your abdomen may be felt. This is to see whether a palpable bladder
is present. This may indicate that you are retaining urine.
You are likely to have a urine and blood test. The urine test will look for infection and possibly unusual
cells. The blood test will check the function of the kidneys. A PSA (prostate specific antigen) may also
be measured. PSA is a marker that indicates damage to the prostate, most often rising in prostate
cancer but can also be elevated in BPH.
A combination of imaging and urine flow tests will be carried out
Urine flow tests (or uroflowmetry) measure a number of parameters of obstruction, but the most
important one is probably the peak flow rate. Normally, the bladder fills to a volume of around 400mls
and then empties completely with a maximum flow rate of more than 15 mls/sec. However in older
men (70-80) the peak flow rate may be reduced. A peak flow rate of less than 15mls/sec suggests
obstruction (provided an adequate amount of urine has been passed i.e. at least 150mls).
Unfortunately, uroflowmetry cannot distinguish between obstruction or poor bladder contractility as the
cause of a low urine flow rate.
Measurement of post-void residual urine is also a useful test in assessing BPH. This is measured by
a non-invasive trans-abdominal ultrasound that calculates the volume of urine left in the bladder after
voiding. It can identify patients who are likely to respond less well to watchful waiting or medical
therapy. In general volumes of 200-300 mls or more indicate a higher likelihood of conservative therapy
failing.
You may also have a trans-rectal ultrasound performed. This is normally done if the PSA is elevated or
the DRE is abnormal. This allows an accurate measurement of the volume of the prostate. This may
be needed to guide the physician in choosing the correct therapy.
How is BPH managed?
There are a number of options in the management of BPH. The choice of medical or surgical
treatment, as well as watchful waiting, should take into account:
the nature and severity of the symptoms
Medical treatment of BPH
Medical treatment is suitable for patients with moderate to severe symptoms of BPH. However there
are limitations to their use. They should not be used in patients who have urinary retention and
complications of BPH such as bladder stones or damage to the kidneys.
The two principal approaches to the medical management of BPH are the use of α1-blockers and
5α-reductase inhibitors.
α1-blockers
α1-blockers, such as doxazosin, tamsulosin and alfuzosin, can all be administrated once a day and
produce a rapid and sustainable improvement of LUTS and flow. This improvement is seen in about
60% of patients with symptomatic BPH. However α1-blockers do not prevent the progression of BPH or
the complications of BPH; neither do they prevent the eventual need for surgical treatment.
How do they work? : α1-blockers act by blocking α1-adrenoceptors in prostatic smooth muscle and in
the bladder neck. This reduces the outflow obstruction without affecting the bladder contractility.
Symptoms usually improve within 2-3 weeks and they can be use as a long-term option.
What are the side effects? : the main side effects, which effect 10-15% of patients, include tiredness,
headaches and dizziness
5α-reductase inhibitors
Examples of 5α-reductase inhibitors include finasteride and dutasteride. They improve both symptom
scores and urine flow rates. Unlike α1-blockers, 5α-reductase inhibitors are capable of reversing the
natural history of BPH. Patients who respond best tend to be those with large prostates and elevated
PSA levels.
How do they work? : 5α-reductase inhibitors act by inhibiting an enzyme that converts testosterone to a
compound called dihydrotestosterone (DHT). DHT is known to play an important role in the growth of
the prostate. Therefore this inhibition actually causes regression of the overgrowth in the prostate
gland. However the main clinical effects of 5α-reductase inhibitors take 3-6 months to become
apparent. Also serum PSA levels are reduced by approximately 50% after 6-12 months of treatment.
What are the side effects? : 3-5% of men experience a reduced libido and weak erections. These
effects return to normal after stopping the treatment. About 1% of men develop breast tenderness.
Women who are, or who might be pregnant should avoid touching crushed or broken tablets
Combination treatment
A recent large study has indicated that the use of both an α1-blocker and a 5α-reductase inhibitor were
significantly more effective than the use of either agent alone. The risk of acute retention and
symptomatic progression was reduced more with combination treatment than with either agent alone.
Surgical treatment of BPH
Surgical intervention is normally indicated for patients who have complications of BPH, lack of
response to medical therapy or those who elect to have surgery as part of a definitive treatment.
The three most common procedures are:
However there are a number of novel procedures that will supercede the above in due time.
Transurethral resection of the prostate
This is the most surgical procedure carried out for BPH
What does it involve? : under a general anaesthetic or a spinal epidural a resectoscope (a type of
telescope instrument) is inserted down the urethra (the pipe from the bladder to the outside world).
This allows the prostate surrounding the urethra to be visualised. Then with a wire loop, through which
an electric current is passed, the prostate is scraped away. These bits of prostate tissue (chips) are
then removed via the resectoscope sheath. Afterwards a catheter is inserted and is left in place for 36-
48 hours post-operatively.
What are the possible complications? : erectile dysfunction has been reported in 2-4% of men.
However, a reported 4% of men experience post-operative impotence even in general surgical
procedures. Most men will have retrograde ejaculation after the procedure. During a TURP the bladder
neck sphincter mechanism is damage (this should not cause incontinence). Normally during
ejaculation this sphincter closes to send the semen down the urethra. After a TURP the semen instead
passes upwards into the bladder. So at orgasm no ejaculation occurs. However, the sensation
remains the same. Men should be aware that they will not be able to have children after this procedure.
A very small number (less than 1%) experience some incontinence. Bleeding is another problem that
can be encountered, it normally resolves by itself but may need a return to theatre or a transfusion.
What the outcomes? : symptoms are improved in 70-90% of patients. Peak urine flow rates of 15-20
ml/s can be achieved reliably. It should be noted that prostatic re-growth is common and may
necessitate a further TURP to improve symptoms.
Transurethral incision of the bladder neck
This is often the choice of procedure in patients who although having a small prostate, nevertheless
causing obstruction. It is suitable for those with a small prostate, a high bladder neck and no middle
lobe hyperplasia.
What does it involve? : under a general anaesthetic or a spinal epidural a cystoscope (a type of
telescope instrument) is inserted down the urethra (the pipe from the bladder to the outside world).
Under direct vision an incision is made from inside the bladder to a point just above where the
prostatic ducts enter the urethra. This has the effect of relieving the obstruction and allowing the
bladder neck to spring apart. A catheter will be inserted and left for 24-48 hours.
What are complications? : overall the incidence of side effects are lower than for TURP. Incontinence
and the risk of strictures are lower. Furthermore, retrograde ejaculation is seen in about 10 % only.
However it should be realised that further treatment will eventually be necessary and will be probably
involve a TURP.
What are the outcomes? : an incision of the bladder neck is almost as effective as TURP in relieving
symptoms, and may produce similar increases in urine flow rates.
Open Prostatectomy
Open prostatectomy is often considered for very large prostates (i.e. over 100 cc). It can also be
considered for complications of BPH such as bladder stones.
What does it involve? : under a general anaesthetic a low midline or a transverse suprapubic (like a
caesarean scar) incision is made. Most prostatectomies are carried out are retropubic. This means
that the prostate is removed without incising the bladder. The prostatic capsule is incised and the
growth is "shelled out" by the Urologist's finger. A catheter will be inserted that will remain for 3-4 days.
You will be in hospital for 5-7 days and unlike the other two operations, you will be left with a scar.
What are the complications? : owing to the more invasive nature of this operation, there is scope for
blood loss that may need replacing in the form of a transfusion. Retrograde ejaculation is present in
about 7 out of ten men. The risk of incontinence is comparable to that of a TURP but the risk of
impotence/erectile dysfunction is higher (about 2 in 10).
What are the outcomes? : the results of this surgery are comparable to that seen in TURP. Peak urine
flow rate normally increases to over 20 ml/sec. Moreover, patients are less likely to warrant further
surgery after this procedure has been carried out.
Other therapies for BPH
There are a number of novel techniques being used for the treatment of BPH. Owing to their recent
invention little is known about their long-term efficacy and they are not widely found throughout the UK.
Below is brief description of the more commonly found therapies.
Laser therapy
In a procedure similar to a TURP, a green light laser is used to remove prostatic tissue. The laser
effectively vaporizes the tissue and as a result of this there is very little blood loss. However no tissue
can be removed so a definitive diagnosis of BPH can not be made. Most patients report little pain
afterwards and the catheter is normally removed less than 12 hours after the procedure; meaning that
this procedure can be done as a day case operation. The risks of incontinence and impotence are very
low. Furthermore the risk of retrograde ejaculation is less than that in TURP.
Transurethral needle ablation
This technique uses radio-frequency energy to apply high temperatures to the prostate. This destroys
the prostatic overgrowth without damaging the urethra. Unlike other techniques it can be carried out
under local anaesthesia. Although bleeding is minimal, the catheterisation period is usually longer
than compared with a TURP. However increases in peak urine flow rates are comparable with a TURP.
Watching waiting
In patients with very mild BPH symptoms or those whose quality of life is not unduly affected then a
strategy of 'watchful waiting' can be observed. This option involves:
Further information
Your local GP surgery is the best place for you to find information on Benign Prostatic Hyperplasia
(BPH), especially if you have specific concerns about your symptoms and treatment. The following
websites can also be useful sources of information and support.
Prostate Research Campaign UK www.prostate-research.org.uk
UK Prostate Link www.prostate-link.org.uk
