Benign Prostatic Hyperplasia

Overview

Benign prostatic hyperplasia (BPH) is a common cause of lower urinary tract symptoms in males. It is the nonmalignant proliferation or hyperplasia of prostate tissue. The prevalence of disease has been demonstrated to rise with age. Indeed, the histological prevalence of BPH at autopsy is as high as 50% to 60% in men in their 60s, escalating to 80% to 90% in those over 70 years old.

Benign Prostatic enlargement (BPE) with Bladder Outflow Obstruction (BOO) is known as benign prostatic obstruction. Lower urinary tract symptoms (LUTS) are simple urine symptoms that are shared by bladder and prostate illnesses (when in reference to men). LUTS symptoms are classified as storage or voiding. These words have mostly superseded those that were formerly referred to as "prostatism."

BPH is characterized by stromal and epithelial cell proliferation in the prostate transition zone (surrounding the urethra), which leads to urethral compression and the development of bladder outflow obstruction (BOO), which can result in clinical manifestations of lower urinary tract symptoms (LUTS), urinary retention, or infections due to incomplete bladder emptying. Long-term untreated illness can result in persistent high-pressure retention (a potentially fatal emergency) and long-term alterations to the bladder detrusor (both overactivity and reduced contractility).

BPH treatment options vary from observation to medication and surgical intervention. Non-modifiable and modifiable risk variables include age, genetics, geographic location, and obesity, which have all been demonstrated to impact the development of BPH. It is consequently critical to be able to distinguish between people at risk of illness development and those who may be managed more conservatively to decrease morbidity and health-care costs.

What is the Prostate?

The prostate gland is a walnut-shaped gland in the male reproductive system. The prostate's primary role is to produce a fluid that enters sperm. Prostate fluid is required for male fertility. At the bladder's neck, the gland surrounds the urethra. The bladder neck is the junction of the urethra and the bladder. The lower urinary tract includes the bladder and urethra. The prostate is located in front of the rectum, right below the bladder, and has two or more lobes, or divisions, surrounded by an outer layer of tissue. The urethra is a tube that connects the bladder to the exterior of the body. In men, the urethra also transports sperm.

What Causes Benign Prostatic Hyperplasia?

In addition to the direct hormonal actions of testosterone on prostate tissue, the etiology of BPH is impacted by a wide range of risk factors.

Although they do not directly cause BPH, testicular androgens have a role in its development, with dihydrotestosterone (DHT) interacting directly with the prostatic epithelium and stroma. Testosterone generated in the testes is converted to dihydrotestosterone (DHT) in prostate stromal cells by 5-alpha-reductase 2 and accounts for 90% of total prostatic androgens. DHT regulates both cellular proliferation and apoptosis through having direct effects on stromal cells in the prostate, paracrine effects on neighboring prostatic cells, and endocrine effects in the bloodstream (cell death).

BPH is caused by a breakdown in the equilibrium between cellular proliferation and cell death, leading in an imbalance favoring cellular growth. This causes an increase in the number of epithelial and stromal cells in the prostate's periurethral region, which may be detected histopathologically.

• Risk Factors

Non-modifiable and modifiable risk factors also contribute to the development of BPH. These have been shown to include metabolic syndrome, obesity, hypertension, and genetic factors.

1. Metabolic syndrome: Hypertension, glucose intolerance/insulin resistance, and dyslipidemia are all symptoms of metabolic syndrome. According to a meta-analysis, those with metabolic syndrome and obesity have considerably larger prostate sizes. Further research into males with high levels of glycosylated hemoglobin (Hba1c) has revealed an increased risk of LUTS. These trials have limitations in that there were no following significant alterations in IPSS, and the effect of diabetes on LUTS has been shown to be multifactorial. More research is needed to determine causality in these people.
2. Obesity: In observational studies, it has been linked to an increased risk of BPH. The exact etiology is unknown, however it is likely complex in nature, as obesity is one component of the metabolic syndrome. Increased levels of systemic inflammation and estrogens are among the proposed causes.
3. Genetic: In one study, first-degree relatives had a four-fold increase in the incidence of BPH compared to controls, indicating a genetic susceptibility to BPH. These findings have shown consistency in twin studies looking at the severity of BPH, with monozygotic twins having greater rates of LUTS.

How Common is BPH?

The most prevalent prostate condition in males over the age of 50 is benign prostatic hyperplasia. In the United States in 2010, up to 14 million men reported lower urinary tract symptoms indicative with benign prostatic hyperplasia.  Although benign prostatic hyperplasia seldom produces symptoms before the age of 40, its prevalence and severity grow with age. Benign prostatic hyperplasia affects around 50% of men between the ages of 51 and 60, and up to 90% of men over the age of 80.

Signs & Symptoms

• Medical history:

A focused medical history in the elective situation should cover all elements of symptomatology, including onset, timing, aggravating, and relieving variables.

Lower urinary tract symptoms are classified as storage (frequency, nocturia, urgency) or voiding (stream, straining, hesitancy, prolonged micturition) and can aid in the diagnosis of other causes of urinary symptoms such as urinary tract infections/overactive bladder, as well as determining the affected site (bladder vs. prostate). Men with BPH are more prone to experience nocturia, a weak stream, hesitation, or prolonged micturition.

More dangerous causes of urine symptoms, such as bladder/prostate cancer, neurology, such as cauda equina, or persistent high-pressure retention, are indicated by red flags (which can lead to silent renal failure). These can be detected by inquiring about visible haematuria/bone pain/weight loss, neurology, and nocturnal enuresis/incontinence, in that order.

A complete medication history should be obtained, including any drugs they have tried as well as the usage of anticoagulants or antiplatelets, which may increase the risk of intra-operative bleeding or must be held prior to surgery.

The patient's general fitness should be determined to evaluate eligibility for any future treatments (fitness for anesthesia, independence, exercise tolerance, capacity to accomplish activities of daily living), as well as the symptom load on quality of life.

• Physical Examination:

The examination should include abdominal examination (searching for palpable bladder/loin discomfort) and inspection of external genitalia in the elective context (meatal stenosis or phimosis). The examination should then be concluded with a digital rectal examination, with special attention paid to the size, shape (number of lobes), and consistency (smooth/hard/nodular) of the prostate (BPH is characterized by a smooth enlarged prostate).

Further bedside evaluation includes:

• Urine dipstick (rule out other causes such as infection).
• Post-void residual volume (whether the bladder is emptied properly).
• IPSS (international prostate symptom score).
• Frequency-volume chart.

How is Benign Prostatic Hyperplasia Diagnosed? 

Standard BPH investigations may include bedside urine dipstick, post-void residual, IPSS, and urine flow examinations to determine if obstructive voiding is present. Depending on the patient/history, further testing may be recommended.

1. Blood Tests:

Blood testing, particularly renal function tests, can assist support the diagnosis of renal failure/acute kidney damage in those with chronic high-pressure retention or acute retention, for example.

2. Urinalysis:

Urine specimen testing can assist in the detection of infections, non-visible haematuria, and metabolic abnormalities (glycosuria). Leucocytes and nitrites are typical observations in infections; proteinuria may indicate nephrological problems. The American Urological Association recommends urinalysis using a dipstick test; further tests may be ordered if the dipstick results are abnormal (culture, etc.).

3. Prostate-Specific Antigen (PSA):

Testing for prostate-specific antigens has been found to predict prostatic volume. PSA testing, on the other hand, should be used with caution and should not be done frequently in the study of BPH. Levels can rise in a variety of circumstances (large prostate, infection, catheterization, prostate cancer) and give the patient excessive concern or further unneeded examinations. The author prefers to perform PSA testing in specified instances, such as when cancer is suspected (malignant feeling prostate, metastatic disease suspected), or when a historical baseline has been established.

4. Ultrasound:

Ultrasound scans are used to look for evidence of hydronephrosis and are indicated in patients with high residual volumes or renal impairment. Other indications include suspicion of urinary tract stones or the investigation of haematuria.

5. Flow Studies:

Urine flow studies are performed to calculate the amount of urine that is passed over time. This can aid in determining whether there is objective evidence of a flow restriction. Urodynamic investigations look at how the bladder empties and fills. They can assist in further evaluating individuals if the diagnosis is uncertain or a neurogenic/overactive bladder is suspected (i.e., neurological conditions that may affect the bladder, flow studies equivocal, diagnosis not clear).

6. Cystoscopy:

Flexible cystoscopy should be utilized to evaluate red flag symptoms such as visible haematuria/suspected bladder cancer, as well as to search for urethral strictures, which can result in poor flow/decreased urine flow studies. 

Treatment / Management

Treatment options for benign prostatic hyperplasia may include:

• lifestyle changes
• medications
• minimally invasive procedures
• surgery

A doctor will treat benign prostatic hyperplasia based on the severity of the symptoms, how much the symptoms interfere with a man's everyday life, and the man's preferences.

Men with a moderately enlarged prostate may not require treatment unless their symptoms are unpleasant and compromising their quality of life. A urologist may prescribe frequent checks instead of therapy in some circumstances. A urologist would usually prescribe therapy if the symptoms of benign prostatic hyperplasia become bothersome or pose a health concern.

Lifestyle Changes:

For males with mild or annoying symptoms, a health care provider may propose lifestyle adjustments. Lifestyle changes can include: 

• Reduced consumption of liquids, particularly before going out in public or before sleeping.
• Avoiding or closely controlling the use of decongestants, antihistamines, antidepressants, and diuretics training the bladder to retain more pee for extended periods of time.
• Exercising the pelvic floor muscles.
• Constipation prevention or treatment.

Medications:

A health care practitioner or urologist may prescribe drugs to slow or halt the development of the prostate or to alleviate the symptoms of benign prostatic hyperplasia:

• Alpha blockers: These medications relax the smooth muscles of the prostate and bladder neck to improve urine flow and reduce bladder blockage:

1. terazosin (Hytrin)
2. doxazosin (Cardura)
3. tamsulosin (Flomax)
4. alfuzosin (Uroxatral)
5. silodosin (Rapaflo)

• Phosphodiesterase-5 inhibitors: Urologists typically prescribe these drugs to treat erectile dysfunction. Tadalafil (Cialis) is a drug in this family that helps relieve lower urinary tract symptoms by relaxing smooth muscles in the lower urinary tract. Researchers are investigating the relevance of erectile dysfunction medications in the long-term management of benign prostatic hyperplasia.

• 5-alpha reductase inhibitors: These medications block the production of DHT, which accumulates in the prostate and may cause prostate growth:

1. finasteride (Proscar)
2. dutasteride (Avodart)

In some men, these drugs can slow the course of prostate growth or even cause the prostate to shrink. Finasteride and dutasteride have a slower action than alpha blockers and are only beneficial for moderately enlarged prostates.

• Combination medications: Several studies, like the Medical Therapy of Prostatic Symptoms (MTOPS) research, have demonstrated that combining two classes of drugs, rather than just one, can improve symptoms, urine flow, and quality of life more successfully. Among the combinations are:

1. finasteride and doxazosin
2. dutasteride and tamsulosin (Jalyn), a combination of both medications that is available in a single tablet
3. alpha blockers and antimuscarinics

For individuals with overactive bladder symptoms, a urologist may prescribe a combination of alpha blockers and antimuscarinics. Overactive bladder is a condition in which the bladder muscles contract involuntarily, resulting in urine frequency, urgency, and incontinence. Antimuscarinics are a type of drug that relaxes the muscles of the bladder.

Minimally Invasive Procedures:

Researchers have developed a number of minimally invasive procedures that relieve benign prostatic hyperplasia symptoms when medications prove ineffective. These procedures include:

• transurethral needle ablation.
• transurethral microwave thermotherapy.
• high-intensity focused ultrasound.
• transurethral electrovaporization.
• water-induced thermotherapy.
• prostatic stent insertion.

Minimally invasive procedures can help reduce obstruction and urine retention caused by benign prostatic hyperplasia by destroying enlarged prostate tissue or widening the urethra.

Urologists use the transurethral approach to undertake minimally invasive operations, which includes inserting a catheter (a thin, flexible tube) or cystoscope into the urethra to reach the prostate. Local, regional, or general anesthesia may be required for these operations. Although removing problematic prostate tissue alleviates many of the symptoms of benign prostatic hyperplasia, it does not cure the condition. Based on the man's symptoms and overall condition, a urologist will determine which surgery to undertake.

• Transurethral needle ablation. 

To damage prostate tissue, radiofrequency radiation is used to produce heat. A urologist inserts a cystoscope into the prostate through the urethra. A urologist then inserts tiny needles into the prostate through the end of the cystoscope. The needles emit radiofrequency radiation, which heats and kills specific areas of prostate tissue. Shields guard the urethra against heat injury.

• Transurethral microwave thermotherapy:

Microwaves are used in this therapy to destroy prostate tissue. A urologist inserts a catheter into the urethra and into the prostate, and an antenna transmits microwaves through the catheter to heat specific areas of the prostate. The temperature inside the prostate rises to the point where swollen tissue is destroyed. During the process, a cooling device protects the urinary tract from heat injury.

• High-intensity focused ultrasound:

 A urologist inserts a special ultrasonic probe into the rectum, near the prostate, for this treatment. The probe's ultrasound waves heat and destroy abnormal prostate tissue.

• Transurethral electrovaporization: 

A urologist performs this surgery by inserting a tube-like equipment called a resectoscope into the urethra to reach the prostate. A resectoscope-attached electrode slides over the prostate's surface, transmitting an electric current that vaporizes prostate tissue. The vaporizing action penetrates under the treated surface area and closes blood vessels, reducing the risk of bleeding.

• Water-induced thermotherapy: 

This technique destroys prostate tissue by using hot water. A urologist inserts a catheter into the urethra, allowing a therapy balloon to sit in the center of the prostate. Heats and eliminates the surrounding prostate tissue when heated water passes through the catheter into the therapy balloon. The therapy balloon can target a specific location of the prostate while protecting neighboring tissues in the urethra and bladder.

• Prostatic stent insertion: 

A urologist will put a tiny device called a prostatic stent through the urethra to the region restricted by the enlarged prostate. Once in position, the stent extends like a spring, pushing the prostate tissue back and opening the urethra. Temporary or permanent prostatic stents are available. Prostatic stents are often used by urologists in men who may not tolerate or be candidates for other operations.

Surgery:

For long-term treatment of benign prostatic hyperplasia, a urologist may recommend removing enlarged prostate tissue or making cuts in the prostate to widen the urethra. Urologists recommend surgery when:

• medications and minimally invasive procedures are ineffective.
• symptoms are particularly bothersome or severe.
• complications arise.

Although removing troublesome prostate tissue relieves many benign prostatic hyperplasia symptoms, tissue removal does not cure benign prostatic hyperplasia.

Surgery to remove enlarged prostate tissue includes:

• transurethral resection of the prostate (TURP).
• laser surgery.
• open prostatectomy.
• transurethral incision of the prostate (TUIP).

• Transurethral Resection of The Prostate (TURP): 

During TURP, a urologist inserts a resectoscope into the urethra to reach the prostate and uses a wire loop to remove sections of enlarged prostate tissue. The tissue fragments are carried into the bladder by a special fluid, and the urologist flushes them out at the end of the treatment. TURP is the most frequent procedure for benign prostatic hyperplasia and is considered the gold standard for addressing urethral obstruction caused by BPH.

• Laser Surgery: 

A urologist will use a high-energy laser to eliminate prostate tissue during this procedure. A cystoscope is used by the urologist to guide a laser fiber into the urethra and into the prostate. The swollen tissue is destroyed by the laser. Because the laser shuts blood arteries while it slices through the prostate tissue, the risk of bleeding is reduced than with TURP and TUIP. Laser surgery, on the other hand, may not be successful in treating severely enlarged prostates.

• Open Prostatectomy: 

A urologist performs an open prostatectomy by making an incision or cut through the skin to reach the prostate. Through the incision, the urologist can remove all or part of the prostate. This procedure is most commonly utilized when the prostate is very enlarged, difficulties arise, or the bladder is injured and requires repair. 

Open prostatectomy necessitates general anesthesia, a lengthier hospital stay, and a longer recovery period than other surgical techniques for benign prostatic hyperplasia. Retropubic prostatectomy, suprapubic prostatectomy, and perineal prostatectomy are the three open prostatectomy procedures. The recovery duration for open prostatectomy varies depending on the man undergoing the surgery.

• Transurethral Incision of The Prostate (TUIP):

A TUIP is a surgical procedure that is used to widen the urethra. The urologist inserts a cystoscope and an instrument that employs an electric current or a laser beam to reach the prostate during a TUIP. The urethra is widened by the urologist by making a few tiny incisions in the prostate and bladder neck. Some urologists feel that TUIP provides the same relief as TURP, but with less side effects.

Complications of BPH

1. Urinary Retention:

According to international research, BPH accounts for more than two-thirds of instances of acute urine retention. Furthermore, 15% of people who suffer acute urinary retention have another episode in the future, with 75% requiring surgery when compared to those with precipitating factors (only 26 percent).

Men suffering from BPH may also have persistent retention. Chronic high-pressure retention is mainly caused by high voiding detrusor pressures in the bladder as a result of outflow restriction. Because of the inability to properly empty the bladder, the pressure within the bladder might rise, resulting in hydronephrosis and subsequent impairment in renal function, eventually leading to renal failure. Urgent catheterization and urgent surgery to release the blockage (TURP) or long-term catheterization are thus used to manage certain categories of patients (those with high-pressure retention should not undergo TWOC).

2. Urinary Tract Infections:

This happens as a result of partial bladder emptying, which results in incomplete bladder emptying and stagnant urine. Recurrent infections may signal that therapy or long-term antibiotics are required to prevent related co-morbidity (admissions with urosepsis).

3. Haematuria:

This is a common complication of BPH and a common reason for additional examination. Because of the increased vascularity of bigger prostate arteries, bleeding may occur.  Finasteride has been demonstrated to reduce vessel density and hence assist manage troublesome BPH-related haematuria.

Conclusion

BPH, or benign prostatic hyperplasia, is a disorder in which the prostate gland enlarges but is not malignant. BPH is sometimes referred to as benign prostatic hypertrophy or benign prostatic obstruction.

As a man matures, his prostate goes through two major growth stages. The first is when the prostate doubles in size throughout puberty. The second stage of development begins at the age of 25 and lasts for the rest of a man's life. The second growth phase is frequently associated with benign prostatic hyperplasia.

As the prostate grows in size, it pushes on and compresses the urethra. The bladder's wall thickens. The bladder may eventually weaken and lose its capacity to completely empty, leaving some pee in the bladder. Many of the issues connected with benign prostatic hyperplasia are caused by urethral constriction and urine retention (the inability to completely empty the bladder).

The intensity of symptoms in men with prostate gland enlargement varies, but they tend to increase over time. The following are some of the most common indications and symptoms of BPH: frequent or urgent need to urinate, (nocturia), difficulty starting urination, weak urine stream or a stream that stops and starts, dribbling at the end of urination, inability to completely empty the bladder.