Overview
Benign prostatic hyperplasia (BPH) is a condition characterized by the enlargement of the prostate gland. The prostate is located just below the bladder and in front of the rectum. It’s about the size of a walnut and surrounds a portion of the urethra; the urethra is the tube that transports urine and semen out of the body.
The prostate typically doubles in size during puberty and starts to enlarge again around the age of 25. While this enlargement is generally not problematic, abnormal growth of the prostate, known as benign prostatic hyperplasia (BPH), can compress the urethra as it passes through the center of the prostate. This can result in various lower urinary tract symptoms, including a frequent and urgent need to urinate, a weak urine stream, and a feeling that the bladder is not fully emptied.
Although BPH is not cancerous, its symptoms can sometimes resemble those of more serious conditions, such as prostate cancer (1).
Causes and risk factors
Benign prostatic hyperplasia (BPH) happens when there is an imbalance in the way prostate cells grow and die. Normally, the body keeps a balance between the creation of new cells and the death of old ones, but in BPH, more new cells are created than old ones die off. This leads to an increase in the number of cells around the urethra (the tube that carries urine), causing the prostate to enlarge. This can be seen under a microscope when examining prostate tissue.
Risk factors for developing BPH include diabetes, genetic predisposition, inflammation of the surrounding and prostate tissues, obesity, and metabolic syndrome (a group of conditions that occur together such as high blood pressure, glucose intolerance/insulin resistance, excess body fat around the waist, and abnormal cholesterol or triglyceride levels).
Dietary risk factors include excessive alcohol and/or heavy caffeine intake, and high-dose supplemental vitamin C (2).
Probability of developing BPH
According to epidemiological studies, by the age of 60, about 50% of all men will develop symptoms of benign prostatic hyperplasia (BPH). This risk increases significantly with age, reaching 90% by the age of 85. BPH typically affects a specific part of the prostate known as the transition zone, while prostate cancer is more likely to occur in another area called the peripheral region (3).
Evaluation
To study the case in depth, the physician will ask questions regarding the medical history of the patient, the urinary symptoms and the symptom score, medications and concurrent health conditions; also, will conduct a physical examination that includes a digital rectal examination.
The American Urological Association Symptom Score is a tool to identify urinary problems that need attention on patients aged 50 or older; it is used to characterize significant lower urinary tract symptoms (LUTS), determine whether they are obstructive or irritative, and evaluate their severity. Additionally, it helps quantify the intensity of symptoms, monitor symptom relief during treatment, and guide treatment decisions.
It includes questions such as: Over the past month, ...
How frequently have you had the sensation of not being able to empty your bladder completely after voiding?
How frequently have you had to urinate again less than 2 hours after finishing urination?
How frequ
ently have you found you stopped and started several times when you were voiding?
How often have you found it difficult to postpone urination?
Over the past month, how often have you had a weak stream?
How often have you had to push or strain to begin urination?
How many times did you get up to urinate from the time you go to bed until you get up in the morning?
Responses are then scored according to the following:
0 = Not at all
1 = < 1 time in 5 (once in a while)
2 = < half the time
3 = About half the time
4 = > than half the time
5 = Almost always or all the time
The symptom scores categorize patients into 3 groups based on symptoms.
The groups are mild (score 0 to 9), moderate (score 10 to 19), and severe (score 20 to 35).
For symptom score 10 or higher, BPH treatment needs to be started or adjusted. Severe symptoms might require more aggressive treatment than conservative or medical approaches alone.
An alternative to the American Urological Association symptom score is the International Prostate Symptom Score (IPSS) (2).
Tests used for the evaluation may include (2):
Urinalysis
Postvoid residual volume (PVR) to determine whether the bladder is emptying adequately
A frequency-volume chart or 24-hour voiding diary (optional)
Peak flow test (optional)
BUN and creatinine to evaluate kidney function
Fasting glucose, Hgb A1c to determine glycemic sate
PSA test, if deemed appropriate
Treatment
Current treatment options start with conservative approaches, such as lifestyle changes with or without medication, and can progress to minimally invasive surgical procedures or even open prostatectomy (removal of the whole prostate through a surgical opening in the lower abdomen).
When choosing a treatment for lower urinary tract symptoms (LUTS), patient preferences should be considered, including anatomical factors, disease severity, patient's desire to avoid general anesthesia. An additional factor to consider is that some treatment options minimize the need for future retreatment, but impact the preservation of ejaculatory function.
Medical therapy
Pharmacotherapy can effectively reduce LUTS and may help patients avoid surgery for benign prostatic hyperplasia. Alpha blockers and 5-alpha reductase inhibitors (5-ARIs) play a key role, while beta-3 agonists can be safely used for men with predominantly overactive bladder symptoms.
Surgical procedures
Enucleation, a surgical procedure used to remove the inner part of the prostate, has the lowest retreatment rates and provides the best chance of eliminating catheter dependence.
There are several new minimally invasive surgical treatments (MISTs) that show promising results for outpatient relief of LUTS, though some may have higher retreatment rates compared to procedures performed in the operating room (4).
New surgical interventions, such as ‘UroLift®’, ‘Aquablation’, ‘Rezum’, ‘prostatic artery embolization (PAE)’ and ‘temporary implantable nitinol device (iTIND)’ have re-intervention rates comparable, if not better, than transurethral resection of the prostate in the short term and remains an important factor for consideration when choosing one form of surgical intervention over another novel therapy (5).
For patients focused on preserving ejaculation, MISTs, Aquablation, and prostate artery embolization (PAE) offer the lowest risk of ejaculatory dysfunction (4).
When considering invasive treatments, the choice should be tailored to the prostate size and other patient-specific factors.
Prostate size often influences clinical success and retreatment rates, with larger prostates generally leading to higher retreatment rates for some procedures. Imaging techniques such as transrectal or abdominal ultrasound, computed tomography (CT), MRI, or cystoscopy can help determine the best treatment.
For smaller or average-sized prostates, most surgical options are effective, but once the prostate exceeds 80 grams, certain treatments become less effective and should be avoided.
Additional considerations, such as anticoagulation status, prior prostate surgery, bladder function, are also important in guiding treatment selection (4).
Lifestyle changes
Making lifestyle changes like losing weight and managing diabetes can help reduce the risk of BPH complications, including the need for surgery, and also help improve urinary symptoms. Also, drinking less caffeine and timing fluid intake carefully can help with nighttime urination. Reducing alcohol intake is another helpful measure (2).
Prognosis
Urination problems becoming more frequent and severe is the most common sign that benign prostatic hyperplasia (BPH) is getting worse. Other complications can include difficulty emptying the bladder, urinary tract infections, and blood in the urine.
Studies have shown that BPH can worsen over time if left untreated. In fact, many men with BPH need additional treatment within four years, and some even develop acute urinary retention. The risk of this complication increases with aging (2).
Specialist
The specialist that treats and performs surgical procedures related to the prostate is the urologist, some cases require a multidisciplinary team that includes general physicians, nurses, pharmacists, physical therapists, and other health professionals.
References
1. J. Gordon Betts, Kelly A. Young, James A. Wise, Eddie Johnson, Brandon Poe, Dean H. Kruse, Oksana Korol, Jody E. Johnson, Mark Womble PD. Anatomy and Physiology [Internet]. Houston, Texas: OpenStax; 2013. Available from: https://openstax.org/books/anatomy-and-physiology/pages/1-introduction
2. Ng M, Leslie SW BKBPH. Benign Prostatic Hyperplasia [Internet]. StatPearls Publishing. Treasure Island; 2024. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558920/
3. Yu XD, Yan SS, Liu RJ, Zhang YS. Apparent differences in prostate zones: susceptibility to prostate cancer, benign prostatic hyperplasia and prostatitis. Int Urol Nephrol [Internet]. 2024;56(8):2451–8. Available from: https://doi.org/10.1007/s11255-024-04012-w
4. Helman TA, Browne BM. Advances in Outpatient Therapies and Treatment of Benign Prostatic Hyperplasia: A Comprehensive Review for Men’s Health. Med Clin North Am. 2024 Sep;108(5):981–91.
5. Shin BNH, Qu L, Rhee H, Chung E. Systematic review and network meta-analysis of re-intervention rates of new surgical interventions for benign prostatic hyperplasia. BJU Int. 2024 Aug;134(2):155–65. Assessed and Endorsed by the Medreport Medical Review Board