Benign prostatic hyperplasia (benign prostate enlargement)
Beginning at puberty, the prostate experiences a progressive increase in size due to the action of the sexual hormones until it reaches 15-20 grams. From the age of 35, benign growth begins in the zone of the prostate closest to the urethra or the emptying point of the bladder; this process is known as benign prostatic hyperplasia, or BPH. Prostate enlargement can obstruct normal urine flow, narrowing the passage of urine through the neck of the bladder and/or the prostatic urethra. In addition, another factor also contributes to obstruction: an increase in the tension of the muscle fibers that surround the neck of the bladder and the first section of the prostatic urethra like a ring. BPH affects approximately 50% of males between 51 and 60 years of age, increasing to 90% in males 80 years of age, but only results in significant symptoms in 30% of them.
What are the causes of benign prostate hyperplasia?
- Androgens: Androgens and male sexual hormones (testosterone and dihydrotestosterone) are necessary for the development of BPH.Patients that have been castrated before puberty or those with genetic disorders in whom androgens either cannot be produced or function improperly do not develop BPH.
- Familiar and genetic factors: It is known that BPH has a hereditary component (autosomal dominant) in 50% of men treated surgically for BPH before the age of 60.In contrast, only 9% of those treated after age 60 have a hereditary factor.
Are there risk factors for developing BPH?
Obesity, excessive consumption of saturated fats and animal proteins, lack of physical exercise and excessive consumption of alcohol are the greatest relative risk factors for disease development.Accordingly, an increase in the consumption of fruits and vegetables (a heart-healthy diet), maintenance of an appropriate weight, physical exercise, cessation of smoking, and consumption of only a moderate amount of alcohol are all recommended.
Does BPH progress to prostate cancer?
No, BPH is a benign process and is not a cause of prostate cancer, although these processes sometimes coexist.This is why we recommend getting a blood test to evaluate PSA levels and advise getting a digital rectal exam.
What are the symptoms of BPH urinary obstruction?
Usually, the patient experiences changes in their urination habits over the years, which are due to benign enlargement of the prostate and changes that the bladder undergoes during aging. On occasion, these processes severely alter urination (obstruction/irritation) and the patient’s quality of life. The most common symptoms are:
- Difficulty starting or needing to use force to urinate.
- Feeling that the bladder has not completely emptied after urination.
- Difficulty resisting the urge to urinate.
- Weak or interrupted urine stream, and prolonged urination.
- The need to urinate again shortly after the last urination.
- Getting up several times during the night with the urge to urinate.
In the initial stages of disease, the bladder is able to compensate for the difficulty of the passage of urine by increasing the force of contraction, but with time the walls become thicker, and a time may come in which it will not be able to expel the urine.
Diagnosis of BPH obstruction
- Clinical history: A specialist will ask a series of questions regarding the urinary symptoms that the patient is experiencing and any medications that he is taking that may affect urination.Also, they will pose a series of questions through the I-PSS (International Prostate Symptom Score) questionnaire, where they score problems with urination (0-35 points) and the impact that the symptoms have on the patient’s quality of life (0-6 points).
- Analysis: Beginning at 40 years of age, it is recommended to periodically assess blood PSA levels (total and free) for the early diagnosis of prostate cancer. PSA levels may increase due to age, benign enlargement of the prostate, or infections of the prostate, which the specialist should consider in each case. A urine analysis is also carried out to evaluate the presence of blood or infection.
- Digital rectal exam: This is done to evaluate the consistency and size of the prostate, and check for any suspicious areas. When PSA levels are low, a rectal exam is not considered necessary for diagnosis.
- Urodynamic testing: The patient urinates into an apparatus that measures the urination flow with respect to a series of parameters (maximal flow, average flow, rate of flow, etc.) that allows us to determine the degree of obstruction.
- Urologic ultrasound: The specialist performs a full ultrasound study of the kidneys, the bladder and the prostate. This can show if the bladder has changes in its thickness due to obstruction and can evaluate for the presence of residual liquid after urination. It also shows greater detail of the prostate, evaluating its size and shape of growth. In some cases, a rectal prostate ultrasound is also carried out, which allows for more precise study of the prostate gland.
Is it always necessary to treat cases of BPH obstruction?
No, we only recommend treatment in patients that have a pronounced symptom that alters their quality of life (factors that are evaluated by the I-PSS questionnaire), complications from urine retention, bladder stones, recurring urinary tract infections, blood in the urine, or, less frequently, impaired renal function. A large prostate does not necessarily mean that treatment should be started.
Selection of appropriate treatment, whether it be pharmacological or surgical, will depend on the severity of the patient’s symptoms. Accordingly, early diagnosis allows for conservative treatment, while a late diagnosis exhibiting severe symptoms usually requires more aggressive treatment.
Are there medications that can worsen symptoms?
Yes, there are medications that can exacerbate symptoms:
- Antihistamines and tricyclic antidepressants: diminish the force of bladder muscle contraction.
- Decongestants (cold remedies): increase the contraction of the muscles that surround the neck of the bladder.
- Diuretics: increase urine production.
- Opiates: interfere with neuro-muscular mechanisms of urination.
Treatment for BPH obstruction
Treatment strategies depend on the severity of symptoms of the patient, and these can be divided into three groups:
- Regular monitoring (watchful waiting): is recommended for those patients with mild symptoms that do not affect their quality of life. The specialist will advise a regular check-up to make sure that there are no additional complications due to BPH.
- Medication: There are two main pharmacological groups, the alpha-blockers and inhibitors of the enzyme 5-alpha-reductase.
- Alpha-blockers: These drugs were initially used to treat arterial hypertension because they relax the muscle surrounding the arteries. This same action occurs around the muscles that surround the neck of the bladder and the prostatic urethra, improving urine flow. Alpha-blockers do not reduce the size of the prostate or affect PSA levels. The most frequently used drugs are tamsulosin and alfuzosin, which are also the most uro-selective. These drugs are given orally once per day and maintain their effect for 24 hours. Also, less frequently, terazosin and doxazosin are used. Patients begin to notice improvement of symptoms by 2-4 weeks after treatment has begun, and maximal effect is reached after 3 months. Side effects may include nasal congestion, orthostatic or postural hypotension, fatigue, and retrograde ejaculation (semen goes to the bladder during ejaculation due to relaxation of the muscles of the bladder neck).
- 5-alpha-reductaseinhibitors are drugs that inhibit the conversion of testosterone to dihydrotestosterone, thereby suppressing the growth of the prostate and diminishing its size by 25-30%. These are the most beneficial in prostates of greater than 40 grams, and symptoms begin to improve after the sixth month of treatment. These drugs reduce the risk of urine retention and the necessity of undergoing future surgery. There are two drugs on the market (finasteride and dutasteride) that are given orally once per day. The most common side effects are reduced sexual desire (4%), erectile dysfunction (7%), diminished volume of semen (2%) and reduction in breast size (2%). Since these drugs can lower PSA levels, a correction factor should be applied to determine an accurate level.
- Combined treatment of both alpha-blockers and 5-alpha-reductase inhibitors can be used if symptoms are severe; a greater effect has been seen in improving urinary function when two drugs are used.
Are herbal remedies effective for the treatment of BPH?
No, they are not. In the past century, when effective drugs such as those that we have already mentioned were not yet available, specialists would frequently prescribe “natural remedies” such as extracts from Pygeum africanum, Serenoa repens, Hypoxis rooperi, Urtica dioca pumpkin seeds, etc. In some cases they improved symptoms, but it is considered to be a “placebo effect” and not a real pharmacological activity.
Currently up to 34% of patients with BPH use them, believing that these products are “natural” and “safe,” and that by using them they can avoid surgical procedures, and falsely hope they can prevent prostate cancer. The reality is that the latest scientific efforts have not demonstrated any efficacy of Serenoa repens or Pygeumn africanum compared to placebo. In 2006, a study published in the prestigious journal New England Journal of Medicine showed that Serenoa repens does not improve the symptoms of obstructive BPH. At present, the American Urological Association (AUA) does not recommend the use of herbal remedies and we do not consider it to be appropriate to use placebos when drugs exist that have been proven to be effective.
When is surgical treatment recommended?
Surgical treatment is recommended in patients that have:
- Moderate to severe symptoms (IPSS > 25) and a poor quality of life that cannot be controlled with pharmacological treatment.
- Episodes of acute urinary retention despite drug treatment.
- Multiple episodes of urinary infections associated with severe symptoms.
- Blood in the urine despite treatment with 5-alpha-reductase inhibitors.
- The presence of stones in the bladder.
- Renal impairment due to urinary obstruction.
Surgical techniques are based on extraction, destruction or decreasing the size (atrophy) of BPH tissue to make a broad canal at the exit of the bladder, thus allowing urination without problems. These techniques do not eliminate all of the prostate gland, as its removal is only indicated in patients with prostate cancer.
This was the first procedure to be used (practiced since the end of the 19th Century) and it is currently recommended for very large prostates (> 90 grams) with or without the presence of large stones, bladder diverticula, urethral stenosis (tightening of the urethra) or concomitant inguinal hernia.
The procedure is carried out under general or regional (spinal) anesthesia. The surgeon makes a small incision between the belly button and the pubic bone. The prostate is reached through the bladder or the bladder neck, and all of the BPH tissue is removed. A urethral catheter is placed that is removed five days after the procedure. The hospital stay ranges from 5 to 7 days. In most cases the outcome is excellent and the patient has increased urinary flow compared to other less invasive procedures (TUR or laser), and there is minimal incidence of repeat intervention or urethral stenosis (tightening). With current surgical techniques, blood transfusion is only necessary for 7% of patients.
Transurethral resection (TUR) of the prostate
This technique was first described in the 1920’s and its use spread extensively in 1970. Since then, the gradual implementation of new technologies has introduced improvements in this technique. Currently TUR of the prostate is considered to be the most effective surgery for treatment of BPH. It is estimated that 95% of surgeries for prostates between 30 and 90 grams utilize this technique. To demonstrate the efficacy of the most innovative procedures, such as laser techniques, they are compared against TUR.
The operation is carried out under general or regional (spinal) anesthesia with a resectoscope, an instrument inserted into the urethra that uses an electrical current to cut the BPH tissue into fine slivers and clot any points of bleeding. Due to the use of irrigation liquids, the surgery should not last more than 2 hours due to the risk of changes in the ion concentration of the blood (hyponatremia). The hospital stay ranges between 2 and 3 days.
Plasmakinetic TUR and prostate vaporization
This is the most advanced TUR technique in which electrical energy converts the saline solution into a plasma cloud with a field of ionized particles that permit a precise “cut and seal,” cutting the length of the procedure in half compared to classical TUR. Other advantages of bipolar TUR (plasmakinetic system) include the possibility of treating prostates of greater size with minimal blood loss and with a much shorter post-operative period with fewer problems. This technique also allows for a vaporization system that effectively destroys the prostate tissue. The hospital stay is 1 or 2 days.