Diagnosis And Management Of Benign Prostatic Hyperplasia
JONATHAN L. EDWARDS, MD, Barberton Citizens’ Hospital, Barberton, Ohio
Am Fam Physician. 2008 May 15 77:1403-1410.
Patient information: See related handout on benign prostatic hyperplasia, written by the author of this article.
Benign prostatic hyperplasia is a common condition in older men. Histologically, it is characterized by the presence of discrete nodules in the periurethral zone of the prostate gland.1 Clinical manifestations of BPH are caused by extrinsic compression of the prostatic urethra leading to impaired voiding. Chronic inability to completely empty the bladder may cause bladder distension with hypertrophy and instability of the detrusor muscle. Some patients with BPH present with hematuria. Because the severity of symptoms does not correlate with the degree of hyperplasia, and other conditions can cause similar symptoms, the clinical syndrome that often accompanies BPH has been described as lower urinary tract symptoms.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Men with suspected BPH can be evaluated with a validated questionnaire to quantify symptom severity.
BPH = benign prostatic hyperplasia.
A = consistent, good-quality patient-oriented evidence B = inconsistent or limited-quality patient-oriented evidence C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1360 or .
SORT: KEY RECOMMENDATIONS FOR PRACTICE
What Are The Symptoms
BPH causes urinary problems such as trouble starting and stopping the flow of urine, needing to urinate often, or feeling like your bladder isn’t completely empty after you urinate. BPH does not cause prostate cancer and does not affect a man’s ability to father children. It does not cause erection problems.
Turp / Greenlight Pvp Laser / Thermotherapy
Transurethral resection of the prostate has long been the mainstay of enlarged prostate surgery, but less invasive alternatives are now available, with the potential for equal results. With TURP, the obstructing portion of the enlarged prostate tissue is removed. Although effective, TURP requires hospitalization and catheterization for 48 hours or more and comes with risks associated with anesthesia bleeding during and after the operation and, in rare cases, fluid absorption that can be life-threatening.
Prostate LaserOne alternative that has emerged is laser enlarged prostate surgery. Like TURP, the so-called GreenLight PVP Laser Therapy aims to create a channel in the urethra through which men can urinate more freely but the surgery is considerably less invasive. Instead of cutting tissue out, the newer technique creates the channel by vaporizing the tissue using laser energy. Thus far, almost every study has shown that when done by experienced urologists, the laser enlarged prostate surgery produces results that are equal to those with TURP, but without the severe side effects and risks. It is an outpatient procedure with minimal to no bleeding, no risk of fluid absorption, and catheterization only overnight, if at all.
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Which Progression Events Are Of Most Concern To Our Patients
The above data provide convincing evidence that BPH is a progressive disease in many men and that progression can take a variety of forms in individual patients. The most common complaint associated with BPH is bothersome LUTS. However, some patient surveys have reported that the risk of surgery is a greater concern for patients than other factors such as symptoms or even quality of life . In a survey of men treated with finasteride, 93% of respondents ranked reducing the need for surgery as very or extremely important and 88% said that reducing the risk of major urological complications was very or extremely important, while symptoms and quality of life were considered less important . Similarly, a survey of men with BPH in five European countries found that 58% and 56% of patients were fairly or very concerned about the risk of developing AUR and requiring prostate-related surgery, respectively. Halving the risk of requiring surgery was ranked as a more important drug treatment outcome than rapid symptom relief by more than three-quarters of men in this study. This highlights the need for effective communication with patients so that treatment decisions are driven by an understanding of what concerns them most.
F Grading The Strength Of Evidence For Major Comparisons And Outcomes
The overall strength of evidence for primary outcomes of KQ1 within each comparison will be evaluated based on five required domains: study limitations directness consistency precision and reporting bias.23 Based on study design and risk of bias, study limitations will be rated as low, medium, or high. Consistency among studies will be rated as consistent, inconsistent, or unknown/not applicable based on the whether intervention effects are similar in direction and magnitude, and statistical significance of all studies. Directness will be rated as either direct or indirect based on the need for indirect comparisons when inference requires observations across studies. That is, more than one step is needed to reach the conclusion. Precision will be rated as precise or imprecise based on the degree of certainty surrounding each effect estimate or qualitative finding. An imprecise estimate is one for which the confidence interval is wide enough to include clinically distinct conclusions based upon established noticeable differences when available. Other factors that may be considered in assessing strength of evidence include dose-response relationship, the presence of confounders, and strength of association.
Based on these elements, we will assess the overall strength of evidence for each comparison and outcome as:23
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Benign Prostatic Hyperplasia Prevalence And Risk Factors
The risk of BPH increases year by year after a man turns 40, but estimates on the prevalence of BPH among age groups vary.
Twenty percent of men in their fifties have BPH, while 60 percent of men in their sixties have it, and 70 percent of men in the their seventies do, according to the Prostate Cancer Foundation.
In its Andrology Handbook, however, the American Society of Andrology states that about 50 percent of men have BPH at age 50 and 90 percent at age 90. A report published in July 2017 in the Asian Journal of Urology, on the other hand, notes that 8 to 60 percent of men have BPH at age 90.
Aside from increased age, risk factors for BPH include:
- Family history of BPH
Doctors advise men to seek medical care if they experience the above complications.
What To Think About
Unless surgery is required because of a complication, choosing a treatment is largely up to you and your doctor. If complications arise, surgery may be needed.
The extent to which treatment improves your symptoms depends partly on how bad your symptoms are and how much you are bothered by them. If you are not bothered by your symptoms before treatment, you are less likely to notice much improvement after treatment.
Surgery offers the best chance for improving the symptoms but also has the risk of causing other problems.
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Diagnosing Benign Prostate Enlargement
To find out whether your prostate gland is enlarged, you’ll need to have a few tests.
Some tests will be carried out by your GP and others will be carried out by a urologist .
First, your GP will ask about your symptoms. If it seems that you have symptoms of benign prostate enlargement, the next stage is to calculate your International Prostate Symptom Score .
How Is It Treated
As a rule, you donât need treatment for BPH unless the symptoms bother you or you have other problems such as backed-up urine, bladder infections, or bladder stones.
Although home treatment cannot stop your prostate from getting larger, it can help reduce or control your symptoms. Here are some things you can do that may help reduce your symptoms:
- Practice âdouble voiding.â Urinate as much as you can, relax for a few moments, and then urinate again.
- Avoid caffeine and alcohol. They make your body try to get rid of water and can make you urinate more often.
- If possible, avoid medicines that can make urination difficult, such as over-the-counter antihistamines, decongestants , and allergy pills. Check with your doctor or pharmacist about the medicines you take.
If home treatment does not help, BPH can be treated with medicine. Medicine can reduce the symptoms, but it rarely gets rid of them. If you stop taking medicine, symptoms return.
If your symptoms are severe, your doctor may suggest surgery to remove part of your prostate. But few men have symptoms or other problems severe enough to need surgery.
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Can Prostate Problems Be Prevented
The best protection against prostate problems is to have regular medical checkups that include a careful prostate exam. See a doctor promptly if symptoms occur such as:
- a frequent urge to urinate,
- difficulty in urinating, or
- dribbling of urine
Regular checkups are important even for men who have had surgery for BPH. BPH surgery does not protect against prostate cancer because only part of the prostate is removed. In all cases, the sooner a doctor finds a problem, the better the chances that treatment will work.
Efficacy And Side Effects Of Drugs Commonly Used For The Treatment Of Lower Urinary Tract Symptoms Associated With Benign Prostatic Hyperplasia
- 1Department of Urology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- 2Medical Department of Graduate School, Nanchang University, Nanchang, China
- 3Department of Clinical Medicine, Xi’an Jiao Tong University Health Science Center, Xi’an, China
- 4Department of Pathology, Jiangxi Provincial People’s Hospital Affiliated to Nanchang University, Nanchang, China
- 5Institute of Clinical Medicine, Jiangxi Provincial People’s Hospital Affiliated to Nanchang University, Nanchang, China
- 6Department of Ultrasound, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Sidebar 1 Bph Case Report
Chief Complaint: LF is a 64-year-old white male presenting with fatigue and sleep pattern changes that have lasted over the past several years. He believes his poor sleep habits are due to frequent nighttime urination, occurring three to four times per night. He denies drinking any fluids in the evening. LF also complains of difficulty starting a stream, especially in public restrooms, and notes that this stream has become weaker over time. He also feels that it takes him longer to completely empty his bladder. He admits to âgoing a little in his shortsâ after urinating and confirmed postvoid dribbling. He experiences some mild urgency but denies dysuria. He also confirms knowledge of all of the bathroom locations in his office building.
Past Medical History: LF denies blood in his urine, a past history of STDs, or other UTIs. He reluctantly reports difficulty keeping firm erections during sexual intercourse compared to when he was younger. However, he maintains that this issue is not one of his major concerns.
Family History: Negative family history of prostate cancer
Social History: Nonsmoker, no illicit drugs, mild alcohol consumption
Physical Examination: Male pattern baldness
Vital Signs: WNL
â¢ Niacin 1,000 mg 1 daily
â¢ Cinnamon tablet 1 daily
Inability To Empty The Bladder Completely
As the prostate continues to enlarge, the bladder muscle gets thicker, stronger, and more sensitive. This is likely due, in part, to the greater force the bladder must exert to push urine through the pinched urethra. As the enlargement advances, the bladder muscle becomes unable to overcome the narrowing of the urethra. As the walls of the bladder thicken and get stronger, the bladder is no longer able to pull itself together to squeeze out urine. This leads to an inability to empty the bladder completely. A small amount of urine will remain in the bladder after urinating. Benign prostatic hyperplasia may leave you with the feeling your bladder has not been fully emptied, and you may notice a weak urine flow.
Continue reading to uncover another common symptom of BPH.
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Lifestyle Changes For Benign Prostatic Hyperplasia
If you have only very mild symptoms from BPH, your doctor may recommend certain lifestyle changes to manage your BPH. These include:
- Reducing your liquid intake, especially before leaving the house or sleeping
- Avoiding caffeine, alcohol, and certain medication that may make you urinate more
- Training the bladder to keep urine flowing longer
- Exercising your pelvic floor muscles
Men who are older than 50 have a higher risk for benign prostatic hyperplasia .
The hormone testosterone, which is produced mainly by the testicles, is needed in order for BPH to develop. Men who have their testicles removed before puberty never develop BPH. Men who have their testicles removed after puberty rarely develop BPH.
A vasectomy does not increase your risk of BPH.
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What Is The Prostate Gland
The prostate is a small organ about the size of a walnut. It lies below the bladder and surrounds the urethra . The prostate makes a fluid that helps to nourish sperm as part of the semen .
Prostate problems are common in men 50 and older. Most can be treated successfully without harming sexual function.
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How Is Bph Treated
In some cases, in particular where symptoms are mild, BPH requires no treatment. At the opposite extreme, some men require immediate intervention if they cannot urinate at all or if kidney/bladder damage has occurred. When treatment is necessary, many men will simply require daily medication. If this fails to completely treat the symptoms, or if there are signs of damage from BPH, the doctor may recommend minimally invasive endoscopic surgery . Or, in some cases, traditional surgery may be recommended.
- Drug treatment: The FDA has approved several drugs to relieve common symptoms associated with an enlarged prostate, including drugs that inhibit the production of the hormone DHT and drugs that relax the smooth muscle of the prostate and bladder neck to improve urine flow.
For surgery, there are many procedures to choose from, and the choice depends largely on your specific prostate anatomy, and surgeon preference and training. These procedures all have a common goal of widening the urethral channel as it passes through the prostate. Procedures include the following:
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Tests That Are Often Done
- A digital rectal examination checks the size and firmness of the prostate. But the size of the prostate does not always determine the severity of the symptoms.
- A urinalysis and urine culture check for a urinary tract infection that might be the cause of the symptoms.
- A prostate-specific antigen test helps check for prostate cancer, which can cause the same symptoms as BPH.
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Minimally Invasive Therapy And Surgery
The AUA Guidelines recommend a host of minimally invasive therapies for the treatment of bothersome LUTS with BPH. Among the recommended treatments are TUMT, TUNA, and in select patients, the placement of a urethral stent. The AUA Guidelines Committee designates ILC and water-induced thermotherapy as emerging technologies and both ethanol injection and high-intensity focused ultrasound as investigational.
Minimally invasive therapies are chosen by patients and health care providers because they fill a critical need between medications and surgical procedures. Patients may have adverse effects from drugs or may not experience the hoped for improvement in symptoms, or they may find the need for daily medication both bothersome and costly. On the other hand, these interventions done in the office are well suited for those patients not willing or medically not fit to have a surgical procedure done under general anesthesia.
Both in the intermediate and long term, minimally invasive treatment options are superior to medical therapy in terms of symptom and flow rate improvement, whereas the tissue ablative surgical treatment options are superior to both minimally invasive and medical therapy options .
Comparisons of symptom score and flow rate improvement by treatment modality and follow-up. Data from the American Urological Association Practice Guidelines Committee.
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Constant Urination During The Night
Waking up constantly in the middle of the night to urinate is a medical condition known as nocturia. While most adults are able to sleep at least six to eight hours throughout the night uninterrupted, an individual dealing with BPH might find themselves waking up several times or more during the night to relieve themselves. Unfortunately, nocturia has many side effects as well. Besides feeling like they were up all night long, the patient may also feel extremely tired and fatigued, as nocturia can negatively affect their quality of life such as putting them at an increased risk of nighttime falls, depression, and decreasing their work efficiency, among other problems. Nocturia is also prevalent in men over the age of sixty, and an enlarged prostate and benign prostatic hyperplasia are the common causes of this condition as well. What happens is the enlarged prostate can close off the urethra, causing the bladder to contract harder to push out urine, eventually weakening the bladder and resulting in frequent urination throughout the night.
Discover the various complications BPH can cause now.