Benign Prostatic Hyperplasia (BPH) or Enlarged Prostate

Benign prostatic hyperplasia (BPH), also known as an enlarged prostate, is a non-cancerous condition that affects many men as they age. While it's not usually a serious health threat, BPH can significantly impact quality of life due to its effects on urinary function. This comprehensive guide provides detailed information about BPH, including its causes, symptoms, diagnosis, treatment options, and tips for living with the condition.

The prostate is a small gland located below the bladder in men. It surrounds the urethra, the tube that carries urine from the bladder out of the body. The primary function of the prostate is to produce fluid that nourishes and protects sperm. Prostate normal size roughly matches the size of a walnut. It typically weighs about 15-25 grams and measures around 4 cm in width, 3 cm in height, and 2 cm in thickness.

In BPH, the prostate gland becomes enlarged, squeezing the urethra and potentially obstructing the flow of urine. This can lead to a variety of urinary symptoms.

BPH is incredibly common, especially in older men. Here's a general idea of how prevalent it is:

• Increases with age: BPH rarely causes symptoms before age 40, but the likelihood increases significantly with each decade after that.
• Majority affected: More than half of men in their 60s and up to 90% of men in their 80s have BPH.

While the exact cause of BPH or an enlarged prostate is not fully understood, several factors contribute to the development of this condition:

Hormonal Changes

As men age, the balance of hormones, particularly testosterone and dihydrotestosterone (DHT), changes. DHT is thought to play a key role in prostate growth, and an increase in DHT levels or increased sensitivity to DHT may stimulate prostate cells to multiply and enlarge.

Ageing

The prostate continues to grow throughout a man's life. While this growth is benign, it can lead to BPH in many men as they get older. Ageing also brings cellular and molecular changes within the prostate that might contribute to BPH development.

Family History

Having a father or brother with BPH increases your risk. This suggests a genetic component may be involved in the development of the condition.

Lifestyle Factors

• Obesity: Being overweight or obese increases the risk of BPH. Fat cells produce hormones and growth factors that may stimulate prostate growth.
• Lack of Physical Activity: A sedentary lifestyle is associated with an increased risk of BPH. Regular exercise may help regulate hormone levels and reduce inflammation, potentially protecting against prostate enlargement.

Medical Conditions

• Diabetes and Heart Disease: Some studies suggest a link between these conditions and BPH. This may be due to shared risk factors like obesity and inflammation.

BPH or an enlarged prostate can cause a variety of urinary symptoms, including:

• Frequent urination: Needing to urinate more often, especially at night (nocturia). This can disrupt sleep and lead to fatigue.
• Urgency: A sudden, strong urge to urinate, which can be difficult to control and may lead to incontinence (urine leakage).
• Difficulty starting urination: Hesitancy or straining to begin urinating. This can be frustrating and time-consuming.
• Weak urine stream: A slow or dribbling flow of urine, making it take longer to empty the bladder.
• Feeling of incomplete bladder emptying: Sensation that the bladder is not fully empty after urinating, which can lead to discomfort and increased frequency.
• Intermittency: Stopping and starting several times during urination, indicating a blockage in the urine flow.
• Dribbling after urination: Urine leakage after finishing urination, which can be embarrassing and inconvenient.

To diagnose BPH and rule out other conditions, a doctor will typically perform a combination of the following:

Medical history

A detailed discussion about your symptoms, their severity, and how they are affecting your daily life. Your doctor will also ask about your overall health, medical history, and family history of prostate problems.

Physical examination

This will include a digital rectal exam (DRE) to assess the size, shape, and consistency of the prostate. The DRE allows the doctor to feel for any abnormalities in the prostate.

Urine tests

A urinalysis to check for infection, blood in the urine, or other abnormalities that may indicate a different condition.

Blood tests

• Prostate-specific antigen (PSA) test: PSA is a protein produced by the prostate. Elevated PSA levels can indicate prostate cancer, so this test helps rule out cancer as a cause of your symptoms.
• Creatinine test: This test measures kidney function. BPH can sometimes affect kidney function if it causes significant blockage of urine flow.

Urodynamic tests

These tests measure how well the bladder and urethra are functioning. They can assess the bladder's ability to store and empty urine, the strength of the urine stream, and any blockages in the urinary tract.

Imaging tests

• Transrectal ultrasound: A probe is inserted into the rectum to create images of the prostate. This helps determine the size and shape of the prostate and identify any abnormalities.
• MRI: May be used in some cases to provide more detailed images of the prostate and surrounding tissues.

Treatment for BPH depends on the severity of your symptoms, how much they're affecting your quality of life, and your overall health. Options include:

Lifestyle changes

Weight loss

Losing weight if you are overweight or obese can help improve BPH symptoms. Excess weight can increase pressure on the bladder and prostate, contributing to urinary problems. Even a small amount of weight loss can make a difference. 

Exercise

Regular physical activity can help improve urinary function and reduce BPH symptoms. Aim for at least 30 minutes of moderate-intensity exercise most days of the week. Activities like brisk walking, swimming, and cycling are good options.   

Dietary changes

Limiting caffeine and alcohol intake can reduce bladder irritation. These substances can increase urine production and worsen urgency and frequency. Avoiding drinking large amounts of fluids before bedtime can help reduce nighttime urination. 

Bladder training

Techniques like timed voiding (urinating on a schedule) and pelvic floor exercises (Kegel exercises) can help improve bladder control. These exercises strengthen the muscles that control urination.

Medications

Alpha-blockers 

These medications (e.g., tamsulosin, alfuzosin) relax the muscles in the prostate and bladder neck, making it easier to urinate. They work quickly to improve urine flow and reduce symptoms like hesitancy and straining. (Brands Available: Urimax, Veltam, Alfoo)

5-alpha reductase inhibitors 

These medications (e.g., finasteride, dutasteride) shrink the prostate by blocking the production of dihydrotestosterone (DHT), a hormone that contributes to prostate growth. They may take several months to show their full effect. (Brand Available: Dutas)

Combination therapy

Using both alpha-blockers and 5-alpha reductase inhibitors can be more effective than using either medication alone in some cases. (Brands Available: Urimax D, Veltam Plus, Flodart Plus, Rapilif D)

Phosphodiesterase-5 inhibitors 

Medications like tadalafil, commonly used for erectile dysfunction, may also help improve BPH symptoms.

Minimally invasive procedures

Transurethral microwave therapy (TUMT)

This procedure uses microwave energy to destroy excess prostate tissue. It is typically performed under local anaesthesia.

Transurethral needle ablation (TUNA)

This procedure uses radiofrequency energy to shrink prostate tissue. It is also usually performed under local anaesthesia.

Prostatic urethral lift (PUL)

This procedure involves placing small implants to lift and hold the prostate tissue away from the urethra, improving urine flow. It is less invasive than traditional surgery and has a shorter recovery time.

Water vapor thermal therapy 

This procedure uses steam to destroy excess prostate tissue. It is generally well-tolerated and has a low risk of complications.

Surgery

Transurethral resection of the prostate (TURP)

This is the most common surgical procedure for BPH. It involves inserting a scope through the urethra to remove excess prostate tissue. TURP is very effective in relieving symptoms but may have side effects like retrograde ejaculation (semen flowing backward into the bladder).

Open prostatectomy

This is a more invasive surgery to remove the prostate. It is usually reserved for very large prostates or when other treatments are not suitable. Open prostatectomy requires a longer hospital stay and recovery time.

Laser surgery

Various laser techniques can be used to remove or destroy prostate tissue. Laser surgery is generally less invasive than TURP and may have fewer side effects.

While there's limited scientific evidence to support their effectiveness, some men find relief from BPH symptoms with alternative therapies such as:

• Saw palmetto: An herbal extract from the berries of the saw palmetto plant. It may help reduce prostate inflammation and improve urinary symptoms. 
• Beta-sitosterol: A plant sterol found in various plants. It may improve urinary flow and reduce symptoms like nocturia and urgency. 
• Pygeum: An extract from the bark of the African cherry tree. It may have anti-inflammatory effects on the prostate and improve urinary symptoms.
• Rye grass pollen extract: This extract may help reduce inflammation and improve urinary flow.
• Pumpkin seed oil: May help improve urinary function and reduce BPH symptoms.

Several factors can increase your risk of developing BPH, including:

• Age: The risk of BPH increases significantly with age.
• Family history: Having a close relative with BPH.
• Ethnicity: BPH is more common in African American and Hispanic men.
• Obesity: Being overweight or obese.
• Lack of physical activity: A sedentary lifestyle.
• Diabetes and heart disease: These conditions may increase your risk.

While BPH is usually not a serious condition, it can sometimes lead to complications such as:

• Urinary tract infections (UTIs): Difficulty emptying the bladder completely can increase the risk of UTIs.
• Bladder stones: Urine that remains in the bladder can crystallize and form stones.
• Bladder damage: The bladder can become stretched and weakened if it's not able to empty properly.
• Kidney damage: In rare cases, BPH can cause urine to back up into the kidneys, leading to damage.

If you have BPH, these tips can help you manage your symptoms and improve your quality of life:

1. Go to the toilet when you first feel the urge. Don't delay urination.

2. Urinate twice. Wait a few minutes after urinating and try to go again to empty your bladder more completely.

3. Drink plenty of fluids, but limit them before bedtime. Staying hydrated is important, but avoid drinking too much in the evening to reduce nighttime urination.

4. Avoid alcohol and caffeine as these can irritate the bladder and worsen symptoms.

5. Manage stress because stress can worsen urinary symptoms.

6. Do pelvic floor exercises to strengthen the muscles that help control urination.

BPH is prostate cancer.

BPH is a benign (non-cancerous) condition and is not related to prostate cancer.

BPH always requires surgery.

Many men with BPH can manage their symptoms with lifestyle changes or medication.

BPH only affects older men.

While more common in older men, BPH can affect men of any age.

See a doctor if you experience any urinary symptoms, such as:

• Frequent urination
• Urgency
• Difficulty starting urination
• Weak urine stream
• Feeling of incomplete bladder emptying
• Blood in your urine

• What is the cause of my symptoms?
• What are my treatment options?
• What are the risks and benefits of each treatment?
• What lifestyle changes can I make to improve my symptoms?
• What are the potential complications of BPH?

If someone you know has BPH, you can offer support by:

• Being understanding and patient as BPH can be a frustrating condition.
• Encouraging them to seek medical help because early diagnosis and treatment can help prevent complications.
• Helping them make lifestyle changes. Offer support with healthy eating and exercise.
• Being a good listener. Let them talk about their concerns and frustrations.

Benign prostatic hyperplasia (BPH) is a common condition that can affect men as they age. While an enlarged male prostate can cause bothersome urinary symptoms, there are effective treatments available to manage the condition and improve quality of life. Early diagnosis and treatment are essential to prevent complications. If you have any concerns about BPH, talk to your doctor.