Benign Prostatic Hyperplasia (BPH)

Topic Highlights

●   The prostate gland is an exocrine gland of the male reproductive system.  

●   The main function of the gland is to protect and nourish sperm cells.  

●   Benign Prostatic Hyperplasia or BPH is a non-malignant enlargement of the prostate gland.  

●   This enlargement affects the flow of urine and leads to prostatism.  

●   This animation helps to understand the condition, elucidates possible complications of BPH, and explains treatment options for BPH.  

Transcript

The prostate is a walnut-sized gland that forms part of the male reproductive system. Situated between the bladder and the urethra, it plays a role in both sex and urination. It is common for the prostate gland to become enlarged as a man ages. This condition is called benign prostatic hyperplasia or BPH. As the prostate enlarges, it triggers physiological changes that lead to urination problems.

Symptoms of BPH start gradually and are rarely seen before age 40, but most men in their sixties and above have some symptoms of BPH. These signs may also be indicative of more serious diseases, such as a bladder infection or bladder cancer, and demand medical attention.

BPH is a common accompaniment to aging in men. Millions of men suffer from BPH. While BPH is a benign disease, its symptoms can significantly impact the quality of life of the patient and his spouse. Sleep deprivation, interference with outdoor activities like sports or travel and lack of satisfaction from sexual relationships impact the mental and emotional health of the patient. Further, the reduction in the quality of life impacts the patient's productivity at work and results in an economic burden as well.

As the life expectancy rises in developed countries, the incidence of BPH has increased. BPH affects nearly 20% of men in the age group of 41 to 50, about 50% of men in the age group of 51 to 60, and nearly 90% of men >70 years of age. BPH is a non-cancerous enlargement of the prostate gland. It is normal for the prostate gland to keep growing throughout a man's life. It grows from the size of a pea, around puberty, to the size of a walnut or larger later in life. However, this enlargement may cause symptoms only later in life, usually after age 40. Nearly 30% of men may only suffer mild symptoms that will spontaneously stop after some time. However, for others the symptoms of BPH may severely affect their quality of life.

The prostate gland is found in the male body. It helps in the process of reproduction. It is located beneath the urinary bladder, where urine is stored, and in front of the rectum, the end of the digestive tract. The urethra is a tube that emerges from the bladder, passes through the prostate gland and carries the urine and sperm outside the male body. The main function of the prostate gland is to secrete a fluid, which helps provide transport medium and nutrition to sperms as they move through the urethra during sexual climax.

The symptoms of BPH occur due to an abnormal enlargement of the prostate gland. The urinary bladder usually contracts when it is filled to its maximum capacity with urine and propels the urine through the urethra to the outside. In a person with BPH, as the prostate gland expands, it compresses the urethra that passes through it. This obstructs the outlet to the bladder, making it more difficult to pass urine being retained in the bladder and can be associated with an increased irritability of the bladder walls. With time, the irritated bladder starts contracting even when small volumes of urine are present in it. Thus, the person experiences an increased frequency to urinate.

The main symptoms of BPH are increased frequency to urinate, increased urgency to urinate, leaking/dribbling of urine and weak or hesitant or interrupted stream while urinating.

Symptoms of BPH may be noticed by the patient himself. After discussion with the doctor, the patient may be referred to a urologist. The urologist will perform tests to confirm BPH. In the Digital Rectal Exam, the doctor will insert a gloved finger into the rectum and try to feel the prostate gland lying in front of it. This test will give a general idea about the size of the prostate gland. He may elect to carry out a blood test called prostate specific antigen test (PSA).

If the urologist detects any abnormality, he may need to perform a transrectal ultrasound scan. The doctor will insert a probe or a tube into the rectum. This probe will emit sound waves that hit against the prostate, the resulting echo draws an image of the prostate gland that is displayed on a television screen. This visualization of the prostate will help the doctor determine the size of the prostate and is often combined with a tissue sample from the prostate.

In the urine flow test, the doctor will ask the patient to urinate into a device that will measure the rate at which the urine is flowing into it. Obstruction to the bladder outlet possibly due to BPH is suspected if the rate is slow.

If BPH symptoms are mild, the doctor may suggest waiting and watching instead of immediate treatment. This is because in as many as one third of the cases with mild BPH, the symptoms may stay stable or resolve spontaneously after some time. The doctor will recommend treatment only if the symptoms steadily worsen and cause inconvenience to the patient.

Persons with severe BPH can develop serious complications. Retention of urine in the bladder over time can lead to urinary tract infections (UTIs), bladder stones and permanent damage to bladder or kidneys. In rare cases BPH may lead to retention, when urination stops completely. This is a serious condition and requires immediate medical attention.

The drugs that the doctor prescribes to treat BPH will all aim at relaxing the muscle in the prostate or shrinking the size of the prostate gland thereby improving the flow of urine, thus relieving the patient of his symptoms.

Drugs like 5-alpha reductase enzyme inhibitors and alpha adrenergic receptor blockers are prescribed to treat BPH. Testosterone inside the prostate cells is converted to Dihydrotestosterone (DHT) using the enzyme 5-alpha reductase. The DHT stimulates the growth of cells in the prostate and hence leads to prostate enlargement.

Drugs like Finasteride and Dutasteride inhibit the enzyme alpha reductase and prevent the conversion of testosterone to dihydrotestosterone, thus limiting the growth of the prostate cells. Hence the cells of the prostate get a reduced stimulus to grow and the prostate gland shrinks in size, relieving the lower urinary tract symptoms associated with BPH.

Alpha adrenergic receptors are found on the surface of smooth muscle walls of the bladder and urethra. When Alpha receptor sites are occupied by adrenaline, they result in the contraction of smooth muscle walls. Alpha receptor site blockers like tamsulosin and alfuzosin block the receptor sites on the surface of the smooth muscle walls of the bladder and the urethra, thus preventing adrenaline from occupying these receptor sites. This results in the relaxation of the bladder and the urethra and eases the passage of urine.

If drug treatment is not effective or if there are significant complications like blood in the urine, recurrent UTIs, swelling of the kidneys or kidney failure, the doctor may recommend further tests or even surgical removal of the enlarged portion of the prostate. There are several types of surgical procedures, however, most of them remove the portion of the prostate that is pressing down on the urethra and leave the rest of the gland intact. Thus, the obstruction is removed and the urine can flow more freely, relieving the symptoms of BPH.

The types of surgical treatments used are transurethral surgery, open surgery and laser surgery. In the transurethral surgery, no incision is made. After administering a local anesthetic, the doctor inserts a tube or probe (resectoscope) through the urethra and cuts out portions of the prostate gland.

In open surgery the patient will be under general anesthesia and an incision will be made in the abdomen. Enlarged portions of the prostate gland that obstruct the urethra will be cut out. In laser surgery, after administering a local anesthetic, a tube carrying laser fibers is inserted into the urethra and laser energy is used to burn or cut away the occluding portions of prostatic tissue.

Minimally invasive procedures can be performed on an out-patient basis with just a local anesthetic and the patient can be sent home the same day. Microwaves and radio waves are used to heat and burn away a predetermined portion of the prostate. Thus, the extra prostate tissue is burned away, resulting in less obstruction and easier flow of urine through the urethra.

It may take 6 to 8 weeks after surgery to recover completely. Some blood in the urine may be noticed for the first few weeks after surgery. While recovering at home for the first few weeks, the patient should not lift heavy weights, drive or operate heavy machinery. Drink plenty of water to flush the bladder continuously. The doctor may recommend a laxative to prevent constipation and straining during bowel movements to prevent tearing the urethra.

Two main groups of complications can occur after surgery for BPH ' incontinence and impotence. Incontinence or involuntary passing of urine may remain a problem after surgery. Ejaculatory dysfunction results from the surgeon cutting away a portion of the neck of the bladder and during climax the semen flows in the opposite direction, into the bladder. Impotence results with interference of the erectile mechanisms.