Benign prostatic hyperplasia

Signs and Symptoms

Symptoms may include:

• Needing to urinate frequently
• Difficulty starting urination
• Stopping and starting while urinating
• Urinating frequently at night (nocturia)
• Dribbling after urination ends
• Being unable to empty your bladder
• Blood in the urine (BPH can cause small blood vessels to burst)
• Recurrent urinary tract infections (UTIs)

Causes

Nobody knows the basic cause of BPH. Research shows that testosterone, the male hormone, or dihydrotestosterone, a chemical produced when testosterone breaks down in a man's body, may cause the prostate to keep growing. Another theory is that changes in the ratio of testosterone and estrogen (female hormone) as men age cause the prostate to grow. Scientists are sure, however, that obesity greatly increases the risk of BPH.

Some over-the-counter medications for colds or allergies can drastically worsen BPH.

Diagnosis

Your health care provider may check the size of your prostate gland directly by putting a gloved finger in your rectum and feeling the back wall of the prostate. Your health care provider will also order blood tests, and possibly a urine sample. Other tests may include:

• Urinary flow test. Your doctor may ask you to urinate into a device that measures the flow of urine.
• Intravenous pyelography. Your doctor injects a dye into a vein to make the flow of urine visible on an x-ray.
• Transrectal ultrasound. Your doctor will insert an ultrasound probe in your rectum to get an image of your prostate gland.

In addition, you may be asked to complete a self screening form to evaluate the severity of your symptoms and the impact on your daily life. Your doctor can use this to monitor your condition over time.

Treatment Approach

Treatment will depend on your age, overall health, and the severity of your symptoms. BPH symptoms may come and go, so it is important to get regular check-ups to monitor the progression of symptoms. There are many ways to successfully treat BPH, including simple lifestyle changes, herbal remedies, and medications. If no other therapies work and the symptoms are severe enough, several types of surgery may help correct the condition.

Lifestyle

Many men with BPH have only minor symptoms. Simple lifestyle changes may be all you need to feel better:

• Urinate when you first get the urge.
• Go to the bathroom when you have the chance, even if you do not feel a need to urinate.
• Avoid alcohol and caffeine, especially after dinner. Try not to drink within 2 hours before going to bed.
• Spread out your fluid intake throughout the day. Avoid drinking large amounts of fluid at one time.
• Avoid cold and sinus medications. Decongestants and antihistamines can worsen BPH symptoms.
• Exercise regularly.
• Do Kegel exercises to strengthen your pelvic floor.
• Reduce stress.

Medications

Alpha blockers. Also known as alpha-adrenergic antagonists, these medicines cause the muscles around your bladder to relax, making it easier to urinate. These drugs were originally used to treat high blood pressure. They seem to work best in men with moderately enlarged prostates. Common side effects include decreased ejaculation and low blood pressure. These drugs should not be taken with medications for erectile dysfunction, such as Viagra or Cialis. Alpha blockers include:

• Terzosin (Hytrin)
• Doxazosin (Cardura)
• Tamsulosin (Flomax)
• Alfuzosin (Uroxatral)

Enzyme inhibitors. Also known as 5-alpha-reductase inhibitors, these medicines shrink the prostate gland by reducing the amount of testosterone the body converts into dihydrotestosterone, a hormone the prostate needs to grow. These drugs take longer to work than alpha blockers. They also lower PSA levels (a high level of PSA can indicate prostate cancer), making it harder to screen for prostate cancer. Enzyme inhibitors include:

• Finasteride (Proscar)
• Dutasteride (Avodart)
• Botulinum toxin (Botox)

Your doctor may suggest a combination therapy of taking an alpha blocker and an enzyme inhibitor at the same time.

Surgery and Other Procedures

Prostate surgery may be recommended if you have:

• Incontinence
• Recurrent blood in the urine
• Urinary retention
• Recurrent urinary tract infections

Which procedure is best for you usually depends on the severity of your symptoms and the size and shape of your prostate gland.

Minimally invasive techniques

These techniques may be better at relieving symptoms than medications, but are often not as effective as surgery. However, they are less likely to cause side effects than surgery.

Transurethtral microwave therapy. Uses heat from microwaves to shrink the prostate. This procedure works best for men with moderate symptoms and enlargement of the prostate.

Transurethral needle ablation. Uses radio waves to get rid of the part of the prostate that is blocking urine flow. It works best for men with mild-to-moderate enlargement of the prostate.

Interstitial laser therapy. Uses a laser to destroy excess tissue and shrink the prostate. It works best for men who have mild-to-moderate enlargement of the prostate and do not experience urinary retention.

Surgery

Surgery is the most effective way to reduce your symptoms, but potential side effects include a small risk of erectile dysfunction or urinary incontinence.

Transurethral resection of the prostate (TURP). TURP is the most common surgical treatment for BPH. Doctors perform TURP by inserting a scope through the penis. The primary advantage of this procedure is that it does not involve an incision, reducing the risk of infection. One potential side effect is retrograde ejaculation, where semen goes into the bladder instead of out the urethra.

Transurethral incision of the prostate (TUIP). TUIP is similar to TURP, but is usually performed in men who have a relatively small prostate. Like the TURP, a scope is inserted through the penis until the prostate is reached. Then, rather than removing prostate tissue, a small incision is made in the tissue to let the urethra expand and make urination easier. This procedure is usually performed on an outpatient basis and does not require a hospital stay.

Laser surgery. Two types of laser surgery are used to destroy excess prostate tissue. Photosensitive vaporization of the prostate (PVP) is used for men with mild-to-moderate prostate enlargement, while holmium laser enucleation of the prostate (HoLEP) is usually used for men with severely enlarged prostates. Side effects can include retrograde ejaculation.

Open prostatectomy. An open prostatectomy is usually performed using general or spinal anesthesia. An incision is made through the abdomen or perineal area (through the pelvic floor, including the region between the scrotum and the anus). This is a lengthy procedure, and usually requires a hospital stay of 5 to 10 days.

Most men who have prostate surgery see improvement in urine flow rates and symptoms. Possible complications include impotence, urinary incontinence, retrograde ejaculation, infertility, and urethral stricture (narrowing).

Nutrition and Dietary Supplements

Beta-sitosterol. Beta-sitosterol is a cholesterol-like compound found in plants. It has been studied for BPH and found to significantly improve urinary flow and decrease the amount of urine left in the bladder. It does not shrink the prostate. Beta-sitosterol is also used to lower cholesterol, making it a good option for men whose cholesterol levels are high. Plants that are high in beta-sitosterol, such as pumpkin seeds (Cucurbita pepo), are sometimes suggested for BPH. Talk to your doctor before adding any supplements to your BPH treatment regimen.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs only under the supervision of a health care provider.

• Saw palmetto (Serenoa repens). Several studies have examined whether saw palmetto can relieve BPH symptoms, and many (though not all) showed positive results. Saw palmetto appears to work like Proscar and Avodart, which prevent testosterone from being converted into dihydrotestosterone (needed for prostate growth) in the body. Some studies have shown saw palmetto to be as effective as Proscar and finasteride and with fewer side effects. A European study showed that half of German urologists preferred saw palmetto over pharmaceuticals for treatment of BPH. However, it does not shrink the overall prostate, but shrinks the inner lining of the gland. It should be noted that, unlike previous studies, a newer, high-quality study found that saw palmetto had no effect on BPH symptoms. Talk to your doctor if you want to try saw palmetto for your symptoms, and look for a fat soluble saw palmetto extract that has been standardized to contain 85 to 95% fatty acids and sterols. Saw palmetto may react with blood-thinning medications as well as hormone-related medications and conditions.
• Pygeum or African plum extract (Pygeum africanum) Pygeum has been used historically for urinary problems. In several scientific studies, pygeum relieved BPH symptoms including nocturia (increased urination at night) and improved urine flow.
• Grass pollen (Secale cereale). Two studies that compared a standardized extract of rye grass pollen to a placebo found that the grass pollen improved BPH symptoms, including reducing frequency of nighttime urination and the amount of urine left in the bladder. One study also indicated that grass pollen decreased the size of the prostate as measured by an ultrasound exam. The brand of rye grass pollen most often used in studies is Cernilton. Persons who have allergies to grass pollens should not take grass pollen supplements.

Prognosis and Complications

While the majority of men get better with treatment of BPH, men who have had long standing BPH may develop:

• Sudden inability to urinate
• Urinary tract infections
• Urinary stones
• Damage to the kidneys
• Blood in the urine

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