WHEN THE PROSTATE SEQUESTERS THE URETHRA,
A REVIEW OF BENIGN PROSTATIC HYPERPLASIA
Benign prostatic hyperplasia, a noncancerous enlargement of the prostate gland, is the most common benign tumor found in men. As is true for prostate cancer, BPH occurs more often in the West than in Eastern countries, such as Japan and China, and it may be more common among black people. Not long ago, a study found a possible genetic link for BPH in men younger than age 65 that have a very enlarged prostate: Their male relatives were four times more likely than other men to need BPH surgery at some point in their lives, and their brothers had a six fold increase in risk. BPH produces symptoms by obstructing the flow of urine through the urethra. Symptoms related to BPH are present in about one in four men by age 55, and in half of 75-year-old men. However, treatment is only necessary if symptoms become bothersome. By age 80, some 20% to 30% of men experience BPH symptoms severe enough to require treatment. Surgery was the only option until the recent approval of minimally invasive procedures that open the prostatic urethra, and drugs that can relieve symptoms either by shrinking the prostate or by relaxing the prostate muscle tissue that constricts the urethra.
Symptoms of Benign Prostatic Hyperplasia
The severity of symptoms in people who have prostate gland enlargement varies, but symptoms tend to gradually worsen over time. Common signs and symptoms of BPH include:
- Frequent or urgent need to urinate
- Increased frequency of urination at night (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
Less common signs and symptoms include:
- Urinary tract infection
- Inability to urinate
- Blood in the urine
The size of your prostate doesn’t necessarily determine the severity of your symptoms. Some men with only slightly enlarged prostates can have significant symptoms, while other men with very enlarged prostates can have only minor urinary symptoms. In some men, symptoms eventually stabilize and might even improve over time.
Other possible causes of urinary symptoms
Conditions that can lead to symptoms similar to those caused by enlarged prostate include:
- Urinary tract infection
- Inflammation of the prostate (prostatitis)
- Narrowing of the urethra (urethral stricture)
- Scarring in the bladder neck as a result of previous surgery
- Bladder or kidney stones
- Problems with nerves that control the bladder
- Cancer of the prostate or bladder
Causes of Benign Prostatic Hyperplasia
The prostate gland is located beneath your bladder. The tube that transports urine from the bladder out of your penis (urethra) passes through the center of the prostate. When the prostate enlarges, it begins to block urine flow. Most men have continued prostate growth throughout life. In many men, this continued growth enlarges the prostate enough to cause urinary symptoms or to significantly block urine flow.
It isn’t entirely clear what causes the prostate to enlarge. However, it might be due to changes in the balance of sex hormones as men grow older.
Risk factors for BPH
Risk factors for prostate gland enlargement include:
- Aging. Prostate gland enlargement rarely causes signs and symptoms in men younger than age 40. About one-third of men experience moderate to severe symptoms by age 60 and about half do so by age 80.
- Family history. Having a blood relative, such as a father or a brother, with prostate problems means you’re more likely to have problems.
- Diabetes and heart disease. Studies show that diabetes, as well as heart disease and use of beta blockers, might increase the risk of BPH.
- Lifestyle. Obesity increases the risk of BPH, while exercise can lower your risk.
When is Benign Prostatic Hyperplasia Treatment Necessary?
The course of BPH in any individual is not predictable. Symptoms, as well as objective measurements of urethral obstruction, can remain stable for many years and may even improve over time for as many as one-third of men, according to some studies. Decisions regarding treatment are based on the severity of symptoms (as assessed by the AUA Symptom Index), the extent of urinary tract damage and the man’s overall health. In general, no treatment is indicated in those who have only a few symptoms and are not bothered by them. Intervention — usually surgical — is required in the following situations:
- Inadequate bladder emptying resulting in damage to the kidneys
- Complete inability to urinate after acute urinary retention
- Incontinence due to overfilling or increased sensitivity of the bladder
- Bladder stones
- Infected residual urine
- Recurrent severe hematuria (presence of blood in a person’s urine)
- Symptoms that trouble the patient enough to diminish his quality of life
Diagnosis of Benign Prostatic Hyperplasia
Your doctor will start by asking detailed questions about your symptoms and doing a physical exam. This initial exam is likely to include:
- Digital rectal exam. The doctor inserts a finger into the rectum to check your prostate for enlargement.
- Urine test. Analyzing a sample of your urine can help rule out an infection or other conditions that can cause similar symptoms.
- Blood test. The results can indicate kidney problems.
- Prostate-specific antigen (PSA) blood test. PSA is a substance produced in your prostate. PSA levels increase when you have an enlarged prostate. However, elevated PSA levels can also be due to recent procedures, infection, surgery or prostate cancer.
What are the Treatment Options for Benign Prostatic Hyperplasia?
Currently, the main options to address BPH are:
- Watchful waiting-Because the progress and complications of BPH are unpredictable, a strategy of watchful waiting — no immediate treatment is attempted — is best for those with minimal symptoms that are not especially bothersome. Physician visits are needed about once per year to review the progress of symptoms, perform an examination and do a few simple laboratory tests. During watchful waiting, the man should avoid tranquilizers and over-the-counter cold and sinus remedies that contain decongestants. These drugs can worsen obstructive symptoms. Avoiding fluids at night may lessen nocturia.
- Medication-Data is still being gathered on the benefits and possible adverse effects of long-term medical therapy. Currently, two types of drugs — 5-alpha-reductase inhibitors and alpha-adrenergic blockers — are used to treat BPH. Preliminary research suggests that these drugs improve symptoms in 30% to 60% of men, but it is not yet possible to predict who will respond to medical therapy or which drug will be better for an individual patient
- Surgery (prostatic urethral lift, transurethral resection of the prostate, photovaporization of the prostate, open prostatectomy) – Surgical treatment of the prostate involves displacement or removal of the obstructing adenoma of the prostate. Surgical therapies have historically been reserved for men who failed medical therapy and those who developed urinary retention secondary to BPH, recurrent urinary tract infections, bladder stones or bleeding from the prostate. However, a large number of men are poorly compliant with medical therapy due to side effects. Surgical therapy can be considered for these men to prevent long-term deterioration of bladder function.
To help control the symptoms of an enlarged prostate, try to:
- Limit beverages in the evening. Don’t drink anything for an hour or two before bedtime to avoid middle-of-the-night trips to the toilet.
- Limit caffeine and alcohol. They can increase urine production, irritate the bladder and worsen symptoms.
- Limit decongestants or antihistamines. These drugs tighten the band of muscles around the urethra that control urine flow, making it harder to urinate.
- Go when you first feel the urge. Waiting too long might overstretch the bladder muscle and cause damage.
- Schedule bathroom visits. Try to urinate at regular times — such as every four to six hours during the day — to “retrain” the bladder. This can be especially useful if you have severe frequency and urgency.
- Follow a healthy diet. Obesity is associated with enlarged prostate.
- Stay active. Inactivity contributes to urine retention. Even a small amount of exercise can help reduce urinary problems caused by an enlarged prostate.
- Urinate — and then urinate again a few moments later. This practice is known as double voiding.
- Keep warm. Colder temperatures can cause urine retention and increase the urgency to urinate