Benign prostatic hyperplasia (BPH)

Benign prostatic hyperplasia (BPH) is an enlargement of the prostate caused by an overgrowth of cells (called hyperplasia) in the prostate.

BPH is a non-cancerous (benign) condition of the prostate. Non-cancerous conditions don't spread (metastasize) to other parts of the body and are not usually life-threatening. BPH doesn't increase the risk of prostate cancer and it isn't considered a health problem unless it causes symptoms.

By age 70, almost all men will have some prostate enlargement.

The following increase your chance of developing BPH:

• getting older
• having extra fat on your abdomen (called abdominal obesity)
• not getting enough physical activity

Men with BPH may not have any signs or symptoms. If signs and symptoms develop, they most often happen in those older than 50.

Signs and symptoms of BPH start when the enlarged prostate puts pressure on the urethra and bladder. This can narrow (constrict) or block the urethra, which can cause changes in bladder habits and problems urinating (peeing).

BPH can cause the following, which are sometimes called lower urinary tract symptoms (LUTS):

• difficulty passing urine
• more frequent urination (called urinary frequency), especially at night
• a strong or sudden urge to urinate (called urinary urgency)
• weak or slow urine stream
• being unable to empty the bladder completely, which can lead to urinary tract infections and bladder stones
• difficulty starting the urine stream (called straining)
• difficulty controlling the bladder (called incontinence), which can cause urine to leak and dribble
• blood in the urine

If you have symptoms of BPH, your doctor will ask you how bad they are. You may also be asked to complete a questionnaire about your urinary symptoms and bladder habits.

If your doctor thinks you might have BPH, you will be sent for tests to diagnose or rule out BPH as well as other problems, such as a urinary tract infection or prostate cancer. These tests include:

• a physical exam
• a digital rectal exam (DRE)
• urine tests, including urinalysis
• blood tests, including the prostate-specific antigen (PSA) test

If your test results are abnormal or your doctor can't make a diagnosis, you may have the following:

• a cystoscopy
• a test to check the flow rate of the urine followed by an ultrasound to see how much urine is left behind in the bladder (called flow rate and residual ultrasound)
• imaging tests, such as an x-ray or ultrasound, to check the kidneys, bladder and prostate
• a special test called a urodynamic assessment to see how well the bladder and urethra can hold and release urine
• a biopsy of the prostate done through the rectum using an ultrasound to guide the needle (called a transrectal ultrasound-guided biopsy)

You and your doctor will discuss which treatment is right for you. This decision is usually based on your symptoms, how bad your symptoms are (called severity), how much they bother you, your test results and your preferences. Treatment options for BPH include the following.

Watchful waiting means using tests and exams to watch BPH to see if signs or symptoms are getting worse. It is often used for men who have mild symptoms that don't bother them. Other treatments will be started if BPH causes problems.

If you have mild symptoms, you may want to make some lifestyle changes to help manage them.

Try to limit the fluids you drink, especially before bedtime. Also try to avoid fluids with caffeine (such as coffee and soda) and spicy foods.

Some medicines can make the symptoms of BPH worse. Talk to your doctor if you are taking the following medicines:

• drugs that increase the amount of urine that the body makes (called diuretics)
• decongestants
• antihistamines
• antidepressants

You may want to try retraining your bladder. Instead of urinating every time you have the urge, try urinating only at certain times of the day or after a certain amount of time (such as every 3 hours).

Talk to your healthcare team about learning pelvic floor exercises. They can strengthen the muscles in the pelvic floor to help control urination.

Constipation can put pressure on the bladder. If you are constipated, talk to your healthcare team about ways you can manage it. They may recommend lifestyle changes, such as getting more fibre and drinking more fluids, or taking medicines to help relieve constipation.

Most doctors begin treating BPH with medicines before using other treatments such as surgery. The following drugs can be used to relieve symptoms. Talk to your doctor about these medicines and their side effects.

Alpha-blockers are drugs that relax the muscles near the prostate, which relieves pressure on the urethra and allows urine to flow more easily. Alpha-blockers don't shrink the prostate. They usually start working within a week. The most common alpha-blockers used for BPH are:

• terazosin
• doxazosin
• tamsulosin (Flomax)
• silodosin (Rapaflo)
• alfuzosin (Xatral)

5-alpha-reductase inhibitors help shrink the prostate to relieve symptoms. These drugs prevent the enzyme 5-alpha-reductase from changing testosterone into dihydrotestosterone, which makes the prostate grow. They work best in those with large prostates. Finasteride (Proscar) and dutasteride (Avodart) are 5-alpha-reductase inhibitors used to treat BPH. It may take 6 months to a year before symptoms get better.

Combination therapy may be an option if you have a large prostate and symptoms that bother you. It includes the alpha-blocker tamsulosin and the 5-alpha-reductase inhibitor dutasteride. These drugs are given together in one pill under the brand name Jalyn.

Phosphodiesterase-5 (PDE5) inhibitors relax muscles in the bladder, urethra and prostate. Tadalafil (Cialis) is a PDE5 inhibitor that is used to relieve symptoms of BPH. It is also used to treat erectile dysfunction.

Muscle relaxants can be used to help lessen bladder contractions, reduce leakage and reduce the urge to urinate. Doctors may give the muscle relaxant solifenacin (Vesicare) or mirabegron (Myrbetriq) with an alpha-blocker.

Surgery is used to treat BPH when drug therapy stops working or to treat those who can't urinate at all. It can also be used to relieve severe symptoms.

Transurethral resection of the prostate (TURP) removes prostate tissue through the urethra. It is the surgery most commonly used to treat BPH. While TURP relieves urinary symptoms in most men, urinary problems can come back over time if the prostate starts to grow again. This is why younger men 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:

• bleeding
• infection
• semen flowing into the bladder instead of out the end of the penis (called retrograde ejaculation)

In rare cases, you may develop erectile dysfunction or incontinence after TURP. But this surgery has a lower risk of these side effects than surgery to remove the prostate (called prostatectomy).

The following may also be used to relieve urinary symptoms caused by BPH.

Laser prostatectomy uses a laser to destroy prostate tissue. Doctors do this procedure with a laser that is passed through a cystoscope (a lighted magnifying instrument that is used to look at and treat areas inside the urethra and bladder). A laser prostatectomy can be done by holmium laser enucleation or photoselective vaporization (PVP).

Transurethral incision of the prostate (TUIP) uses a special tool on a cystoscope to make small incisions (surgical cuts) in the prostate. TUIP helps relieve pressure on the urethra but it doesn't remove any tissue. TUIP is mostly used in those with smaller prostates.

Transurethral electrovaporization (TUEVP) uses an electrode attached to a resectoscope. The electrode delivers electricity to heat prostate tissue until it is destroyed.

Prostatic urethral lifts are implants that the doctor places in the prostate to help pull it away from the urethra.

Prostatectomy is surgery to remove the prostate. A prostatectomy is only used in rare cases when other procedures or surgeries can't be done. It may also be used if the urethra is completely blocked or if the prostate is very large.