Benign Prostatic Hyperplasia, or BPH, refers to the enlargement of the prostate and its surrounding tissue. This condition is part of a natural process where the prostate experiences two significant growth phases during a man’s life. 

The first phase occurs in early puberty, leading to a doubling of the prostate’s size. The second phase starts around the age of 25 and typically persists throughout the rest of a man’s life. 

As men age, it’s common for the prostate to increase in size. BPH specifically refers to the stage where the prostate has grown to a point where it begins to cause complications.

The enlarged prostate exerts pressure on the urethra, leading to a thickening of the bladder wall. Over time, this can result in a weakened bladder that struggles to empty completely, leaving residual urine. 

This condition is the root cause of many lower urinary tract symptoms (LUTS) associated with BPH. Understanding the way BPH triggers these symptoms can be crucial for healthcare professionals in determining the need and type of treatment.

Function of the Prostate

The prostate is an integral component of the male reproductive system, primarily responsible for producing fluid that forms part of semen. 

It’s roughly the size of a walnut, weighing about an ounce, and is located below the bladder and in front of the rectum. 

The prostate encircles the urethra, which is the tube responsible for transporting urine from the bladder out through the penis.

Symptoms of Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH) manifests a variety of symptoms, commonly including:

• Frequent or urgent need to urinate, also known as urination.
• Increased nighttime urination.
• Difficulty initiating urination.
• A weak or intermittent urine stream.
• Dribbling at the end of urination.
• Inability to completely empty the bladder.

There are also less common symptoms associated with BPH:

• Urinary tract infections.
• Complete inability to urinate.
• Presence of blood in the urine.

The progression of BPH symptoms varies; they may worsen gradually, remain stable, or occasionally improve.

Interestingly, the severity of Benign Prostatic Hyperplasia symptoms does not always correlate with the size of the prostate. Some individuals with slightly enlarged prostates may experience severe symptoms, while others with significantly enlarged prostates might have only minor issues. 

Additionally, it’s possible for someone with an enlarged prostate to exhibit no symptoms at all.

Other Potential Causes of Urinary Symptoms

It’s important to note that other health conditions can mimic the symptoms of an enlarged prostate. These conditions include:

• Urinary tract infections.
• Inflammation of the prostate.
• Urethral stricture, which is a narrowing of the urethra.
• Scarring in the bladder neck from previous surgery.
• Bladder or kidney stones.
• Nerve-related bladder control issues.
• Cancer of the prostate or bladder.

Certain medications can also induce symptoms similar to those caused by Benign Prostatic Hyperplasia. These include:

• Opioids, which are strong pain relievers.
• Medications for colds and allergies.
• Tricyclic antidepressants, which are older depression medications.

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Causes of Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH) primarily stems from the enlargement of the prostate gland, which is situated below the bladder. 

A key anatomical feature to consider is the urethra, the tube responsible for transporting urine from the bladder out through the penis. 

This tube runs directly through the center of the prostate. As the prostate enlarges, it begins to impede the flow of urine, leading to various symptoms associated with BPH.

The prostate is a gland that naturally continues to grow over the course of a man’s life. Often, this growth is significant enough to enlarge the prostate to the point where it causes noticeable symptoms or obstructs urine flow.

The exact cause of the prostate’s enlargement in Benign Prostatic Hyperplasia is not definitively understood. However, it is believed to be linked to changes in the balance of sex hormones that occur as part of the aging process. 

As men age, these hormonal changes may contribute to the prostate gland’s growth.

Risk Factors for Benign Prostatic Hyperplasia (BPH)

Certain factors increase the likelihood of developing an enlarged prostate, or Benign Prostatic Hyperplasia (BPH). These risk factors include:

1. Aging: The risk of an enlarged prostate is minimal before the age of 40. However, beyond this age, the likelihood of developing an enlarged prostate and associated symptoms progressively increases.
2. Family History: Individuals with a family history of prostate problems, particularly a blood relative who has had such issues, are at a higher risk of experiencing prostate-related problems themselves.
3. Diabetes and Heart Disease: Research indicates a correlation between diabetes and an increased risk of BPH. Similarly, heart disease is also linked to a heightened risk of developing an enlarged prostate.
4. Lifestyle Factors: Lifestyle choices play a significant role in the risk of BPH. Obesity, for instance, is known to elevate the risk of developing an enlarged prostate. Conversely, regular exercise can help mitigate this risk, offering a protective effect against the development of BPH.

Complications Arising from Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH), characterized by an enlarged prostate, can lead to several potential complications, which include:

1. Urinary Retention: This is the inability to urinate, also known as urinary retention. It might necessitate the insertion of a catheter into the bladder to facilitate urine drainage. In some cases, surgery may be required to provide relief from this condition.
2. Urinary Tract Infections (UTIs): Incomplete bladder emptying can increase the risk of urinary tract infections. Frequent UTIs may sometimes necessitate surgical intervention to remove part of the prostate.
3. Bladder Stones: These often result from the inability to completely empty the bladder. Bladder stones can lead to various issues such as illness, bladder irritation, the presence of blood in the urine, and obstruction of urine flow.
4. Bladder Damage: Over time, a bladder that doesn’t fully empty can stretch and weaken, impairing the muscular wall’s ability to contract and release urine effectively. This weakening can make it increasingly difficult to empty the bladder completely.
5. Kidney Damage: Inability to urinate can create pressure in the bladder, which may lead to kidney damage or allow bladder infections to spread to the kidneys.

Timely and appropriate treatment for Benign Prostatic Hyperplasia can significantly reduce the risk of these complications. 

However, it’s important to note that urinary retention and kidney damage can pose serious health risks.

It’s also noteworthy that having an enlarged prostate does not necessarily increase the risk of developing prostate cancer.

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Diagnosis of Benign Prostatic Hyperplasia (BPH)

Numerous tests exist for Benign Prostatic Hyperplasia (BPH). The tests listed below are commonly employed for diagnosing and monitoring BPH.

Benign Prostatic Hyperplasia Symptom Score Index

In cases of urinary symptoms or changes, your doctor might discuss the Benign Prostatic Hyperplasia Symptom Score Index with you. 

Created by the American Urological Association (AUA), this index evaluates urinary symptoms and is typically the initial step in diagnosing BPH. The index categorizes Benign Prostatic Hyperplasia from mild to severe. 

Discussions with your healthcare provider about your score and medical history are vital. This index is also known as the International Prostate Symptom Score (IPSS).

Physical Examination

Following this, a digital rectal examination (DRE) is frequently performed. In a DRE, the patient lies on their side or assumes a bent-over position. 

The physician inserts a gloved and lubricated finger into the rectum to assess the posterior surface of the prostate gland. The healthcare provider examines for signs of enlargement, tenderness, as well as any irregularities or firm areas. 

This brief examination, lasting approximately 10-15 seconds, plays a crucial role in identifying potential issues.

Urine Tests

These tests help determine how effectively urine is released, indicating if the urethra is blocked or obstructed. Types include:

• Urinalysis: Analyzes a urine sample for blood, signs of infection, sugar, protein, and other elements that can inform the diagnosis. It’s also used for bladder cancer screening.
• Post-Void Residual Volume (PVR): Measures urine left in the bladder after urination, useful both for diagnosis and pre-surgical assessment.
• Uroflowmetry: Assesses the speed of urine flow to diagnose obstruction.
• Urodynamic Pressure Flow Study: Measures bladder pressure during urination.

Scans:

These imaging tests assess the size and shape of the prostate. They include:

1. Ultrasound: Provides internal views of the prostate.
2. Cystoscopy: Involves using a scope to examine the urethra and bladder.
3. MRI and CT Scans: Offer detailed images of the prostate and surrounding areas, particularly useful if surgery is needed to restore urine flow.
4. Blood Tests:

• • If prostate cancer is a concern, blood tests may be conducted, particularly the Prostate-Specific Antigen (PSA) test.
  • The PSA test measures levels of PSA, a protein produced by the prostate gland. High or rapidly increasing PSA levels can indicate issues like prostate enlargement, inflammation, or cancer.

These diagnostic tools collectively help in accurately diagnosing Benign Prostatic Hyperplasia and determining the best course of treatment.

Treatment

There are various approaches to treating Benign Prostatic Hyperplasia. Together with the help of our trained team at Istanbul urology clinic, you will determine the most suitable option for your situation. Mild instances might not require any intervention. 

For certain cases, minimally invasive methods (surgical procedures that don’t require anesthesia) may be effective. Additionally, a mix of different treatments is often the optimal solution.

The main types of treatments for Benign Prostatic Hyperplasia are:

• Active Surveillance
• Medication Options
• Less Invasive Surgery
• More Invasive Surgery

Active Surveillance

In many cases, Benign Prostatic Hyperplasia may simply need active monitoring. This involves observing your Benign Prostatic Hyperplasia closely without immediate treatment, typically through regular check-ups with your urologist, often including an annual examination. 

Your yearly check ups  will watch for any worsening or new symptoms before considering further action. Lifestyle changes like diet and exercise are frequently advised to help prevent or control symptoms.

Active monitoring is most suitable for men experiencing mild to moderate symptoms and is also a viable choice for those who are not significantly impacted by the effects of Benign Prostatic Hyperplasia.

Medication Options

For men with Benign Prostatic Hyperplasia, prescription medication may be a viable treatment. The types of drugs include:

Alpha Blockers in Benign Prostatic Hyperplasia: 

These pills help relax the muscles in the prostate and bladder, easing Benign Prostatic Hyperplasia symptoms. They don’t reduce the size of the prostate but can improve urine flow in cases of blockage. 

Alpha blockers have immediate effects, but potential side effects include dizziness, fatigue, and issues with ejaculation. 

They are suitable for men with moderate to severe symptoms, but not recommended for those planning cataract surgery soon. Examples include alfuzosin, doxazosin, silodosin, tamsulosin, and terazosin.

5-Alpha Reductase Inhibitors: 

These drugs enhance urine flow and shrink the prostate by inhibiting DHT, a hormone that can contribute to prostate growth. They can reduce the risk of Benign Prostatic Hyperplasia complications and the need for surgery, but they may cause erectile dysfunction and decreased libido. Continuous use is necessary to maintain their effectiveness. Suitable for men with significantly enlarged prostates, these include dutasteride and finasteride.

Combined Therapy: 

This approach involves using both an alpha blocker and a 5-alpha reductase inhibitor. They may be more effective together in preventing Benign Prostatic Hyperplasia progression. 

However, combined therapy can have more side effects like dizziness, erectile dysfunction, weakness, or blood pressure drops when standing. Antimuscarinics might be added for overactive bladder symptoms. 

Candidates for this treatment are typically men with larger prostates. Combinations can be finasteride with doxazosin, dutasteride with tamsulosin (available as a single tablet), or alpha blockers with antimuscarinics.

Phytotherapies/Herbal Therapies: 

These are generally not recommended by healthcare providers due to inconsistent evidence of effectiveness. 

An example is saw palmetto, which has been shown in several studies to be ineffective. The quality and purity of these supplements can also vary greatly.

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Minimally Invasive Surgical Treatments (MIST)

Minimally invasive surgeries, or MISTs, can often be performed on an outpatient basis, eliminating the need for a hospital stay. 

These procedures generally offer a faster recovery and can alleviate symptoms including issues with urine control. 

However, some MISTs may not decrease the likelihood of requiring future surgery or medication. 

It’s important to discuss retreatment rates with your urologist when considering any MIST or more invasive procedures.

Ideal candidates for MIST include men who haven’t found relief from Benign Prostatic Hyperplasia medications or those experiencing:

• Weak urine flow
• Difficulty starting urination
• Urinary tract obstructions, bladder stones, or blood in the urine
• Incomplete bladder emptying
• Prostate bleeding

The choice of surgery depends on prostate size, overall health, and personal preference. The types of less invasive surgeries include:

Prostatic Urethral Lift (PUL): 

• This uses implants placed via a needle to lift and compress the enlarged prostate, clearing the urethra. The implants are permanent and not easily removed. 
• PUL, which can be performed under local or general anesthesia, involves no cuts or tissue removal. It’s suitable for many men with enlarged prostates and has fewer sexual side effects compared to other surgeries. 
• Discuss with your doctor how PUL may affect MRI quality for prostate cancer detection and any allergies to materials like nickel, titanium, or stainless steel. Current studies show five-year effectiveness.

Water Vapor Thermal Therapy (WVTT): 

• This procedure uses steam to destroy prostate cells, done in a doctor’s office with local anesthesia or pain medication. The body then naturally removes the dead tissue, shrinking the prostate. 
• Ideal for men who prefer not to take medication or those seeking to avoid sexual side effects. 
• Side effects might include blood in urine and temporary catheter use. Sexual dysfunction is unlikely, and symptom improvement has been observed for at least five years.

Temporary Implanted Prosthetic Devices (TIPD): 

• Inserted through a cystoscope, these devices reshape the urine channel, improving urine flow and Benign Prostatic Hyperplasia symptoms with low risk. They remain in place for about a week. 
• Side effects can include urinary infections, incontinence, and urethral scarring. Symptoms during treatment may include frequent urination and burning sensations.

Prostate Artery Embolization (PAE): 

• A radiological procedure that blocks blood flow to the prostate, potentially shrinking it to improve symptoms. It’s a newer method with limited long-term data. 
• PAE shows short-term benefits compared to observation in specific patients, but lacks extensive evidence for routine treatment over other minimally invasive therapies.

Catheterization: 

• This involves a catheter in the bladder to drain urine, useful for men with bladder control problems due to a blocked prostate. It’s a temporary solution with a risk of infection. 
• Types include clean (self or caregiver removal every 6-8 hours) and indwelling (long-term placement). Suitable for those awaiting medication effectiveness, surgery, or in end-of-life care.

More Invasive Surgical Options for BPH

In severe cases of Benign Prostatic Hyperplasia or when less invasive methods are ineffective, more invasive surgeries may be recommended. These surgeries are typically considered if you:

• Are unable to urinate
• Have kidney damage
• Experience frequent urinary tract infections
• Suffer from significant bleeding
• Have bladder stones

The type of surgery depends on your health, your doctor’s expertise, and your personal preference. The surgeries, listed from least to most invasive, include:

Transurethral Incision of the Prostate (TUIP): 

• Used for small but obstructive prostates, TUIP involves small cuts in the bladder neck and prostate to widen the urethra. Hospital stay is 1-3 days, with a catheter required for a similar duration post-surgery. Ideal for men who require surgery but don’t want a full prostatectomy.

Photoselective Vaporization (PVP): 

• This outpatient procedure uses a high-powered laser to vaporize prostate tissue. It’s suitable for most men, especially those with bleeding risks or weaker hearts, due to minimal blood loss.

Transurethral Resection of the Prostate (TURP): 

• A common Benign Prostatic Hyperplasia surgery, TURP removes prostate tissue using electric current or laser. It involves anesthesia and a resectoscope and is suitable for moderate to severe BPH symptoms.

Holmium Laser Enucleation of the Prostate (HoLEP): 

• Similar to TURP but uses a laser to destroy excess tissue. Suitable for men with larger prostates or bleeding risks. Hospital stay is usually one night with quick catheter removal.

Thulium Laser Enucleation of the Prostate (ThuLEP): 

• Similar to HoLEP but uses a different laser. Ideal for men with larger prostates who want to avoid more invasive surgery. Minimal bleeding and short hospital stay.

Transurethral Vaporization of the Prostate (TUVP): 

• Involves destroying prostate tissue with an electrical current. Suitable for men with larger prostates, with minimal bleeding and a short hospital stay.

Transurethral Water-Jet Ablation (TWJA): 

• Uses high-pressure water jets to remove excess tissue, guided by ultrasound. Requires a one-night hospital stay for bladder irrigation and a short-term catheter post-surgery.

Simple Prostatectomy: 

• Involves removing the entire prostate gland, often with laparoscopic or robotic assistance. Recommended for men with very large prostates. 
• Requires a few days’ hospital stay and limited activity for several weeks. A catheter is needed for 1-2 weeks post-surgery.

These surgeries offer varying degrees of invasiveness and recovery times and are chosen based on the specific needs and health conditions of the patient.

Post-Surgery Expectations for BPH Treatment

Following surgery for BPH, many men experience significant improvement in their symptoms. However, there are various aspects to consider regarding recovery and potential side effects:

• Sexual Function: The return of sexual function post-surgery can vary. If you were capable of achieving an erection shortly before the surgery, it is generally expected that you will be able to do so afterwards. Orgasmic function typically remains unchanged. However, some men might experience retrograde ejaculation, where semen enters the bladder instead of exiting through the penis.
• Infection, Bleeding, and Incontinence: These are possible complications following Benign Prostatic Hyperplasia treatments. The risk level may depend on the specific type of treatment undertaken.
• Scar Tissue Formation: In some instances, scar tissue may develop as a result of the surgery, potentially impacting urinary functions.
• Variability of Side Effects: The side effects can differ based on the chosen treatment method. Most side effects are temporary, but their duration and severity can vary.
• Need for Additional Treatment: Some men may require further treatment for Benign Prostatic Hyperplasia symptoms even after the initial procedure. This could be due to either the recurrence of symptoms or the development of new ones.
• Communication with Your Doctor: It’s crucial to inform your doctor about any side effects or complications you experience post-surgery. This enables timely intervention and management of any issues, improving the overall outcome of the treatment.

Remember, individual experiences can vary, and it’s important to have open and ongoing communication with your healthcare provider to manage expectations and address any concerns during the recovery process.

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Takeaway

Understanding Benign Prostatic Hyperplasia (BPH) is crucial for managing this common condition affecting the prostate gland in men.

This comprehensive article delves into the nature of Benign Prostatic Hyperplasia, its symptoms, causes, and the risk factors associated with it. 

The condition, characterized by an enlarged prostate leading to various urinary symptoms, can significantly impact a man’s quality of life. 

Knowing about the  various diagnostic methods and treatment options, ranging from active surveillance to medication and more invasive surgical approaches.

At Istanbul Urology Clinic, we are equipped to assist patients through the entire process of managing Benign Prostatic Hyperplasia, offering specialized care in men’s health issues. 

Our expertise ensures that each patient receives personalized treatment tailored to their specific needs and health status.