Data Extraction And Assessment
Two authors separately extracted the studies using a standardised extraction template, including study level characteristics as well population characteristics . Study authors were contacted for data clarification if necessary. The methodological quality of each study was judged using a modified version of the Newcastle-Ottawa Scale, which includes 4 criteria namely, sample representativeness and size, comparability between respondents and non-respondents, ascertainment of BPH symptoms and statistical quality. Studies were judged to be low risk of bias if they had a minimum score of 3 points of the maximum 5 points.
Personal And Family Medical History
Taking a personal and family medical history is one of the first things a health care provider may do to help diagnose benign prostatic hyperplasia. A health care provider may ask a man
- what symptoms are present
- when the symptoms began and how often they occur
- whether he has a history of recurrent UTIs
- what medications he takes, both prescription and over the counter
- how much liquid he typically drinks each day
- whether he consumes caffeine and alcohol
- about his general medical history, including any significant illnesses or surgeries
Other Less Invasive Procedures
These minimally invasive procedures carry fewer risks for incontinence or problems with sexual function than invasive procedures, but it is unclear how effective they are in the long term.
Transurethral Microwave Thermotherapy
Transurethral microwave thermotherapy delivers heat using microwave pulses to destroy prostate tissue. A microwave antenna is inserted through the urethra with ultrasound used to position it accurately. The antenna is enclosed in a cooling tube to protect the lining of the urethra. Computer-generated microwaves pulse through the antenna to heat and destroy prostate tissue. When the temperature becomes too high, the computer shuts down the heat and resumes treatment when a safe level has been reached. The procedure takes 30 minutes to 2 hours, and the patient can go home immediately afterward.
Transurethral Needle Ablation
Transurethral needle ablation is a relatively simple and safe procedure, using needles to deliver high-frequency radio waves to heat and destroy prostate tissue.
Transurethral electrovaporization uses high voltage electrical current delivered through a resectoscope to combine vaporization of prostate tissue and coagulation that seals the blood and lymph vessels around the area. Deprived of blood, the excess tissue dies and is sloughed off over time.
Water Vapor Thermal Therapy
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What Is An Enlarged Prostate
An enlarged prostate is when your prostate gland becomes larger than normal. It’s also called benign prostatic hyperplasia or BPH for short. Benign means not cancer. And hyperplasia means too much cell growth. BPH isn’t cancer and it doesn’t increase your risk of getting prostate cancer.
Usually, the prostate gland continues to grow during adult life. That’s why BPH is the most common prostate condition in people over age 50. As the prostate gets bigger, it may press against the bladder and pinch the urethra. This can slow or block the flow of urine out of your bladder.
Over time, the bladder muscle may become weak from trying to pass urine through a narrow urethra. When this happens, your bladder may not empty completely when you urinate. A narrowed urethra and weak bladder cause many of the urinary problems you may have with BPH.
What Are The Symptoms Of Benign Prostatic Hyperplasia
Lower urinary tract symptoms suggestive of benign prostatic hyperplasia may include
- urinary frequencyurination eight or more times a day
- urinary urgencythe inability to delay urination
- trouble starting a urine stream
- a weak or an interrupted urine stream
- dribbling at the end of urination
- nocturiafrequent urination during periods of sleep
- urinary incontinencethe accidental loss of urine
- urine that has an unusual color or smell
Symptoms of benign prostatic hyperplasia most often come from
- a blocked urethra
- a bladder that is overworked from trying to pass urine through the blockage
The size of the prostate does not always determine the severity of the blockage or symptoms. Some men with greatly enlarged prostates have little blockage and few symptoms, while other men who have minimally enlarged prostates have greater blockage and more symptoms. Less than half of all men with benign prostatic hyperplasia have lower urinary tract symptoms.3
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Benign Prostatic Hyperplasia And The Medication Management Of Associated Lower Urinary Tract Symptoms
Emily L. Knezevich, PharmD, BCPS, CDEAssistant Professor of Pharmacy Practice
Jon T. Knezevich, PharmD, BCPSAssistant Professor of Pharmacy Practice
Mikayla L. Spangler, PharmD, BCPSAssistant Professor of Pharmacy PracticeCreighton University School of Pharmacy and Health ProfessionsOmaha, Nebraska
Benign prostatic hyperplasia is the most common benign tumor in men.1 By age 50 years, up to 50% of men may have histologically distinguished BPH with reported prevalence increasing to 90% by age 90.2 Histology indicating the presence of BPH includes proliferation of prostatic tissue around the urethra. Despite the high prevalence of histologic diagnosis, symptoms of the disorder do not affect all men presenting with BPH. Prostatic tissue overgrowth combined with poor glandular elasticity may lead to urethral opening constriction. This may then become severe enough to negatively affect mens quality of life due to increased frequency of BPH-associated urinary symptoms. It has been reported that 50% of men diagnosed with histologic changes indicating BPH demonstrate urinary symptoms at age 80 years.3
How Might An Enlarged Prostate Affect My Life
Having an enlarged prostate affects men in different ways. Some men can manage mild symptoms and dont need treatment. Other men find they need to stay near a toilet. This can make it difficult to work, drive, be outdoors and attend social events. If you need the toilet a lot during the night, this can affect your sleep and make you feel more tired during the day.
Some men with an enlarged prostate find their symptoms improve over time without treatment. But for most, the symptoms will stay the same or slowly start to cause more problems over time unless they have treatment.
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Prevalence Rates Across The Years
The prevalence rates of BPH for the survey years of 19901999, 20002009, and 2010 till present were 26.6%, 27.8% and 22.8% respectively. The prevalence rates were not significantly change with baseline survey year . No significant interaction was detected when we tested the interactive effects with different study characteristics, suggesting that prevalence estimates were not affected by time in geographical regions or study methods.
Diagnosing Benign Prostate Enlargement
You might have several different tests to find out if you have an enlarged prostate.
A GP may do some of these tests, such as a urine test, but others might need to be done at a hospital.
Some tests may be needed to rule out other conditions that cause similar symptoms to BPE, such as prostate cancer.
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Background And Objectives For The Systematic Review
Benign Prostatic Hyperplasia is a “histologic diagnosis that refers to the proliferation of smooth muscle and epithelial cells within the prostatic transition zone.”1 Men are likely to develop BPH as they age. Half of men ages 51 60 years old and 80 percent of men over 80 years old have BPH according to autopsy data.2
About half of men with BPH develop an enlarged prostate gland, called benign prostatic enlargement , and among these, about half develop bladder outlet obstruction .3 BOO and/or changes in smooth muscle tone and resistance that can accompany BPH often result in lower urinary tract symptoms .1 LUTS are storage disturbances, such as daytime urinary urgency and nocturia, and/or voiding disturbances, such as urinary hesitancy, weak stream, straining, and prolonged voiding.2 LUTS affect an estimated three percent of men ages 4549 years old and 30 percent of men over 85 years old.2 Urinary hesitancy, weak stream, and nocturia are the most commonly reported LUTS.4 BPH/LUTS negatively impact quality of life2,3 and cost the United States over $1 billion annually.3
Monotherapy with 5-ARI agents finasteride and dutasteride is another option for LUTS/BPH and BPE.7 Systematic reviews demonstrate that 5-ARIs are safe and effective13,14 and may be better than ABs in preventing disease progression .14
What Other Problems Might An Enlarged Prostate Cause
A small number of men may find it difficult to empty their bladder properly this is called urine retention. If youve been diagnosed with an enlarged prostate, your doctor will look at your test results to see if youre at risk of urine retention. You may be more likely to get urine retention if:
- youre aged 70 or over
- your prostate is very large
- you have a raised prostate specific antigen level
- you have severe urinary symptoms and a very slow flow.
Chronic urine retention
This is where you cant empty your bladder fully, but can still urinate a little. It usually develops slowly over time. Chronic means long-lasting. The first signs often include a weak flow when you urinate, or leaking urine at night. You may feel that your abdomen is swollen, or that youre not emptying your bladder fully.
Chronic urine retention is usually painless. But the pressure of the urine can slowly stretch your bladder muscle and make it weaker. This can cause urine to be left behind in the bladder when you urinate. If you dont empty your bladder fully, you might get a urine infection, need to urinate more often, leak urine at night, or get painful bladder stones. You might also see some blood in your urine. Chronic urine retention can damage your bladder and kidneys if it isnt treated.
There are treatments for chronic urine retention, including:
- passing a thin, flexible tube called a catheter to drain urine from your bladder
- surgery to widen the urethra.
Acute urine retention
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Does Having Benign Prostatic Hyperplasia Increase The Risk Of Prostate Cancer
Research shows that having BPH doesnt increase your risk of developing prostate cancer. However, BPH and prostate cancer have similar symptoms. If you have BPH, you may have undetected prostate cancer at the same time.
To help detect prostate cancer in its early stages, every person with a prostate should get a prostate screening every year between the ages of 55 and 69. You have an increased risk of getting prostate cancer if youre Black or have a family history of prostate cancer. If you have an increased risk of prostate cancer, you should start getting prostate screenings at age 40.
Review Of Key Questions
AHRQ posted the key questions on the Effective Health Care Web site for public comment. The EPC refined and finalized the key questions after review of the public comments, and input from Key Informants and the Technical Expert Panel . This input is intended to ensure that the key questions are specific and relevant.
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Imaging And Other Investigations
Uroflowmetry is done to measure the rate of urine flow and total volume of urine voided when the subject is peeing.
Abdominal ultrasound examination of the prostate and kidneys is often performed to rule out hydronephrosis and hydroureter. Incidentally, cysts, tumours, and stones may be found on ultrasound. Post-void residual volume of more than 100 ml may indicate significant obstruction. Prostate size of 30 cc or more indicates enlargement of the prostate.
Prostatic calcification can be detected through transrectal ultrasound . Calcification is due to solidification of prostatic secretions or calcified corpora amylacea . Calcification is also found in a variety of other conditions such as prostatitis, chronic pelvic pain syndrome, and prostate cancer. For those with elevated levels of PSA, TRUS guided biopsy is performed to take a sample of the prostate for investigation. Although MRI is more accurate than TRUS in determining prostate volume, TRUS is less expensive and almost as accurate as MRI. Therefore, TRUS is still preferred to measure prostate volume.
Risk Factors Associated With Lower Urinary Tract Symptoms And Benign Prostatic Hyperplasia
On a population level, there are five broad categories of risk factors for BPH and LUTS . Aside from age, the other categories are genetics, sex steroid hormones, modifiable lifestyle factors, and inflammation.
Broad categories of epidemiologic risk factors for benign prostatic hyperplasia and lower urinary tract symptoms
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Surgery Surgery Is Used To Treat Bph When Drug Therapy Stops Workingor To Treat Those Who Can’t Urinate At All It Can Also Be Used To Relievesevere Symptoms
Transurethral resection of the prostate
Transurethral resection of the prostate removesprostate tissue through the urethra. It is the surgery most commonly used totreat BPH. While TURP relieves urinary symptoms in most men, urinary problemscan come back over time if the prostate starts to grow again. This is why youngermen may need to have this surgery more than once.
This surgery is done in an operating room. The doctor passes a resectoscope through the urethra to reach the prostate. A resectoscope is a type of endoscope . It has a thin wire that carries an electric current. The doctor uses the electric current to cut away prostate tissue around the urethra. The doctor then removes this tissue through the resectoscope.
The most common side effects of TURP include:
In rare cases, you may develop erectile dysfunction orincontinence after TURP. But this surgery has a lower risk of these sideeffects than surgery to remove the prostate .
Complementary And Alternative Medicine
The AUA does not recommend the use of complementary and alternative medicine to treat LUTS caused by BPH.3 This is related to the unavailability of clinical research demonstrating clear benefit with its use as well as the lack of standardization of available products.3
The most well-studied CAM used for treatment of BPH is saw palmetto, which has been described in some clinical trials as likely safe and possibly effective in treating LUTS associated with BPH.27 In clinical studies, saw palmetto has demonstrated mild improvements in LUTS and urinary flow measures in patients with BPH however, data from other studies are conflicting, questioning benefit in symptomatic relief with long-term use.4,27,28 Saw palmetto is well tolerated, with minimal adverse effects reported however, concern over increased risk of bleeding exists with its use, so caution should be used when combining it with other medications that may prolong bleeding time.28 Safety has been established with the use of saw palmetto for up to 1 year.27 Other CAM treatments marketed for LUTS associated with BPH are listed in TABLE 3.21,27-29
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What Are The Treatments For Bph
Not everyone needs treatment for BPH. Treatment options depend on how much your symptoms bother you, your health, age, and the size of your prostate:
Lifestyle changes may improve mild symptoms. They include:
- Drinking less before bedtime or going out
- Avoiding or cutting back on beverages with caffeine and alcohol
- Bladder training and exercising the muscles that control urine flow
- Preventing or treating constipation
Medicines can help mild to moderate symptoms by:
Sometimes combining 2 types of medicine helps more than taking just one type of medicine.
Medical procedures can help improve moderate to severe BPH symptoms when medicines don’t help enough. There are several different types of procedures. They all use an instrument inserted into the urethra to either:
Surgery may be helpful when symptoms are severe, other treatments haven’t helped, or you have another problem, such as bladder damage. Different types of surgery are used to:
Most BPH surgery is done with tools inserted into the urethra.
Your provider can explain the possible benefits and side effects of your treatment options so you can decide what’s best for you.
Figure 1 Analytical Framework For Newer Medications For Luts/bph
Figure 1: This figure depicts the key questions within the context of the PICOTS described in the previous section. In general, the figure illustrates how newer medications work in men with LUTS/BPH to improve LUTS, prostate-related quality of life, and prevent or delay BPH progression. Also, adverse events may occur at any point after the treatment is initiated.
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The Process Of Urination
The process of urination is complicated:
- It begins when waste fluids flow out of the kidneys into two long tubes called ureters.
- The ureters empty into the bladder, which rests on top of the pelvic floor, a muscular structure at the base of the pelvis, between the pubic bone and the base of the spine.
- The brain regulates muscles in the urinary tract through a pathway of nerves. As the bladder fills to its capacity of 8 to16 oz of fluid, the nerves send signals from the bladder to the brain that indicate how full the bladder is.
- As the bladder fills, the bladder wall muscles relax, and the outlet muscles contract to prevent urination.
- At the time of urination, the spinal cord initiates the voiding reflex. The detrusor muscle contracts, while the internal sphincter relaxes. These reactions are involuntary.
- When the internal urethral sphincter is open, urine flows out of the bladder into the urethra . At the same time, the external urethral sphincter also relaxes. This action is under voluntary control from the brain.
B Searching For The Evidence: Literature Search Strategies For Identification Of Relevant Studies To Answer The Key Questions
We will search Ovid Medline, Ovid PsycInfo, Ovid Embase, and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials for primary health outcomes published and indexed in bibliographic databases. We will attempt to assess long-term or rare harms with nonrandomized controlled trials and large controlled observational studies if RCTs are not available. Our search strategy includes relevant medical subject headings and natural language terms for LUTS/BPH . These concepts were combined with filters to select trials. We will supplement the bibliographic database search with forward and backward citation searching of relevant systematic reviews and other key references. We will update searches while the draft report is under public/peer review.
We will search for grey literature in ClinicalTrials.gov and to identify completed and ongoing studies. We will search for conference abstracts from the past three years to identify ongoing studies. Grey literature search results will be used to identify studies, outcomes, and analyses not reported in the published literature. Information from grey literature will also be used to assess publication and reporting bias and inform future research needs. Additional grey literature will be solicited through a notice posted in the Federal Register and Scientific Information Packets and other information solicited through the AHRQ Effective Health Care Web site.
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