Prostatic Hyperplasia – Causes, Symptoms and Treatment
Prostatic hyperplasia is a benign (non-cancerous) enlargement of the prostate gland that commonly affects older men and can cause urinary symptoms.
Things worth knowing about "Prostatic Hyperplasia"
Prostatic hyperplasia is a benign (non-cancerous) enlargement of the prostate gland that commonly affects older men and can cause urinary symptoms.
What is Prostatic Hyperplasia?
Prostatic hyperplasia, most commonly referred to as benign prostatic hyperplasia (BPH), is a non-cancerous enlargement of the prostate gland. The prostate is a small gland located just below the bladder in men, surrounding the urethra. As the prostate enlarges, it can squeeze the urethra and obstruct the normal flow of urine, causing a range of urinary symptoms. BPH is one of the most common conditions in aging men and is entirely distinct from prostate cancer.
Causes
The exact cause of benign prostatic hyperplasia is not fully understood, but several key factors are known to contribute:
- Hormonal changes with age: A shift in the balance between androgens (male hormones, primarily testosterone) and estrogens promotes prostate tissue growth in older men.
- Dihydrotestostosterone (DHT): This potent androgen, converted from testosterone by the enzyme 5-alpha reductase, is considered the primary driver of prostate cell proliferation.
- Age: BPH rarely occurs before age 40, but affects more than 50% of men in their 60s and up to 90% of men in their 80s.
- Genetic predisposition: A family history of BPH increases the likelihood of developing the condition.
- Lifestyle factors: Obesity, physical inactivity, and certain dietary patterns have been associated with an increased risk.
Symptoms
Symptoms of BPH arise from both mechanical obstruction of the urethra and changes in bladder function. Common symptoms include:
- Frequent urination, especially at night (nocturia)
- Weak or interrupted urine stream
- Difficulty starting urination (hesitancy)
- Dribbling at the end of urination
- Feeling of incomplete bladder emptying (residual urine)
- Urgency: A sudden, strong urge to urinate
- In severe cases: acute urinary retention, in which urination becomes completely impossible and requires immediate medical attention
Diagnosis
The diagnosis of BPH involves a combination of clinical assessment and targeted tests:
- Medical history and symptom scoring: The International Prostate Symptom Score (IPSS) is a standardized questionnaire used to assess the severity of urinary symptoms.
- Digital rectal examination (DRE): The physician palpates the prostate through the rectum to evaluate its size and texture.
- PSA blood test: Prostate-specific antigen (PSA) levels are measured to help rule out prostate cancer.
- Ultrasound: Transrectal or abdominal ultrasound is used to measure prostate volume and assess residual urine in the bladder.
- Uroflowmetry: A test that measures urine flow rate to evaluate the degree of obstruction.
- Urinalysis: To exclude urinary tract infections or other underlying conditions.
Treatment
Watchful Waiting
For men with mild symptoms that do not significantly affect quality of life, a strategy of watchful waiting with regular monitoring may be recommended. Lifestyle changes such as reducing fluid intake before bedtime, limiting caffeine and alcohol, and performing pelvic floor exercises can also help manage symptoms.
Medication
Several drug classes are commonly used to treat BPH:
- Alpha-1 blockers (e.g., tamsulosin, alfuzosin): Relax the smooth muscle in the prostate and bladder neck, improving urine flow. These medications work relatively quickly.
- 5-alpha reductase inhibitors (e.g., finasteride, dutasteride): Block the conversion of testosterone to DHT, reducing prostate size over time. Particularly effective in men with significantly enlarged prostates.
- Phosphodiesterase-5 inhibitors (e.g., tadalafil): Also used in BPH, especially when erectile dysfunction is present simultaneously.
- Combination therapy: Using both an alpha blocker and a 5-alpha reductase inhibitor may be more effective in men with moderate to severe symptoms and a large prostate.
Surgical and Minimally Invasive Procedures
When medications are insufficient or complications occur, surgical options are available:
- Transurethral resection of the prostate (TURP): The gold standard surgical treatment; excess prostate tissue is removed through the urethra without an external incision.
- Laser procedures (e.g., HoLEP, GreenLight laser): Minimally invasive alternatives to TURP with reduced risk of bleeding, particularly suitable for patients on anticoagulants.
- Transurethral incision of the prostate (TUIP): Small incisions are made in the prostate to widen the urethra; suitable for smaller prostates.
- Open prostatectomy: Surgical removal of the enlarged prostate tissue via an abdominal incision; used when the prostate is very large.
References
- McVary KT et al.: Update on AUA Guideline on the Management of Benign Prostatic Hyperplasia. Journal of Urology, 2011;185(5):1793-1803.
- Roehrborn CG: Benign Prostatic Hyperplasia: An Overview. Reviews in Urology, 2005;7(Suppl 9):S3-S14.
- World Health Organization (WHO): Urological conditions in older men. WHO Global Health Report, Geneva, 2022.
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