Benign prostatic hyperplasia (BPH) is not simply a case of too
many prostate cells. Prostate growth involves hormones, occurs
in different types of tissue (e.g., muscular, glandular), and
affects men differently. As a result of these differences,
treatment varies in each case. There is no cure for BPH and
once prostate growth starts, it often continues, unless
medical therapy is started.
The prostate grows in two different ways. In one type of
growth, cells multiply around the urethra and squeeze it, much
like you can squeeze a straw. The second type of growth is
middle-lobe prostate growth in which cells grow into the
urethra and the bladder outlet area. This type of growth
typically requires surgery.
Anatomy
The prostate is a walnut-sized gland located beneath the
bladder and in front of the rectum. It is surrounded by a
capsule of fibrous tissue called the prostate capsule. The
urethra (tube that transports urine and sperm out of the body)
passes through the prostate to the bladder neck. Prostate
tissue produces prostate specific antigen and prostatic acid
phosphatase, an enzyme found in seminal fluid (the milky
substance that combines with sperm to form semen).
Incidence and Prevalence
It is difficult to establish incidence and prevalence of BPH
because research groups often use different criteria to define
the condition. According to the National Institutes of Health
(NIH), BPH affects more than 50% of men over age 60 and as
many as 90% of men over the age of 70.
Risk Factor
BPH is a condition of aging. Nearly all men over the age of 50
have an enlarged prostate.
Causes
The cause of benign prostatic hyperplasia is unknown. It is
possible that the condition is associated with hormonal
changes that occur as men age. The testes produce the hormone
testosterone, which is converted to dihydrotestosterone (DHT)
and estradiol (estrogen) in certain tissues. High levels of
dihydrotestosterone, a testosterone derivative involved in
prostate growth, may accumulate and cause hyperplasia. How and
why levels of DHT increase remains a subject of research.
Signs and Symptoms
Common symptoms of benign prostatic hyperplasia include the
following:
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Blood in the
urine (i.e., hematuria), caused by straining to void
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Dribbling
after voiding |
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Feeling that
the bladder has not emptied completely after urination
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Frequent
urination, particularly at night (i.e., nocturia)
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Hesitant,
interrupted, or weak urine stream caused by decreased
force |
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Leakage of
urine (i.e., overflow incontinence)
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Pushing or
straining to begin urination |
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Recurrent,
sudden, urgent need to urinate |
In severe cases of BPH, another symptom,
acute urinary retention (the inability to urinate), can result
from holding urine for a long time, alcohol consumption, long
period of inactivity, cold temperatures, allergy or cold
medications containing decongestants or antihistamines, and
some prescription drugs (e.g., ipratropium bromide, albuterol,
epinephrine). Any of these factors can prevent the urinary
sphincter from relaxing and allowing urine to flow out of the
bladder. Acute urinary retention causes severe pain and
discomfort. Catheterization may be necessary to drain urine
from the bladder and obtain relief.
Diagnosis
A physical examination, patient history, and evaluation of
symptoms provide the basis for a diagnosis of benign prostatic
hyperplasia. The physical examination includes a digital
rectal examination (DRE), and symptom evaluation is obtained
from the results of the AUA Symptom Index.
Digital rectal examination (DRE)
DRE typically takes less than a minute to perform. The doctor
inserts a lubricated, gloved finger into the patient’s rectum
to feel the surface of the prostate gland through the rectal
wall to assess its size, shape, and consistency. Healthy
prostate tissue is soft, like the fleshy tissue of the hand
where the thumb joins the palm. Malignant tissue is firm,
hard, and often asymmetrical or stony, like the bridge of the
nose. If the examination reveals the presence of unhealthy
tissue, additional tests are performed to determine the nature
of the abnormality.
AUA Symptom Index
The AUA (American Urological Association) Symptom Index is
a questionnaire designed to determine the seriousness of a
man's urinary problems and to help diagnose BPH. The patient
answers seven questions related to common symptoms of benign
prostatic hyperplasia. How frequently the patient experiences
each symptom is rated on a scale of 1 to 5. These numbers
added together provide a score that is used to evaluate the
condition. An AUA score of 0 to 7 means the condition is mild;
8 to 19, moderate; and 20 to 35, severe.
PSA and PAP Tests
Blood tests taken to check the levels of prostate specific
antigen (PSA) and prostatic acid phosphatase (PAP) in a
patient who may have benign prostatic hyperplasia helps the
physician eliminate a diagnosis of prostate cancer.
Prostate-specific antigen (PSA) is a specific antigen produced
by the cells of the prostate capsule (membrane covering the
prostate) and periurethral glands. Patients with benign
prostatic hyperplasia (BPH) or prostatitis produce larger
amounts of PSA. The PSA level also is determined in part by
the size and weight of the prostate.
The test measures the amount of PSA in the blood in nanograms
per milliliter (ng/mL). A PSA of 4 ng/mL or lower is normal; 4
– 10 ng/mL is slightly elevated; 10 – 20 is moderately
elevated; and 20 – 35 is highly elevated. Most men with
slightly elevated PSA levels do not have prostate cancer, and
many men with prostate cancer have normal PSA levels. A highly
elevated level may indicate the presence of cancer.
The PSA test can produce false results. A false positive
result occurs when the PSA level is elevated and there is no
cancer. A false negative result occurs when the PSA level is
normal and there is cancer. Because of this, a biopsy is
usually performed to confirm or rule out cancer when the PSA
level is high.
Free and total PSA (also known as PSA II) PSA in the blood may
be bound molecularly to one of several proteins or may exist
in a free, or unbound, state. Total PSA is the sum of the
levels of both forms; free PSA measures the level of unbound
PSA only. Studies suggest that malignant prostate cells
produce more bound PSA; therefore, a low level of free PSA in
relation to total PSA might indicate a cancerous prostate, and
a high level of free PSA compared to total PSA might indicate
a normal prostate, BPH, or prostatitis.
Age-specific PSA Evidence suggests that the PSA level
increases with age. A PSA of up to 2.5 ng/mL for men age 40–49
is considered normal, as is 3.5 ng/mL for men age 50–59, 4.5
ng/mL for men age 60–69, and 6.5 ng/mL for men 70 and older.
The use of age-specific PSA levels is not endorsed by all
medical professionals.
Use the PSA Age/Race Quiz or the PSA Velocity Quiz to
deterimine your risk of prostate cancer.
Urodynamic Testing
Urodynamic tests, usually performed in a physician’s office,
are used to measure the volume and pressure of urine in the
bladder and to evaluate the flow of urine. They are
particularly useful for the diagnosis of Intrinsic sphincter
deficiency and uncertain cases of mixed, overflow, urgency, or
total incontinence. Additional tests may be conducted if
symptoms indicate that blockage is caused by a condition other
than BPH.
Uroflowmetry is a simple test performed to record urine
flow, to determine how quickly and completely the bladder can
be emptied, and to evaluate obstruction. With a full bladder,
the patient urinates into a device that measures the amount of
urine, the time it takes for urination, and the rate of urine
flow. Patients with stress or urge incontinence usually have a
normal or increased urinary flow rate, unless there is an
obstruction in the urinary tract. A reduced flow rate may
indicate BPH.
A pressure flow study measures pressure in the bladder during
urination and is designed to detect a blockage of flow. It is
the most accurate way to evaluate urinary blockage. This test
requires the insertion of a catheter through the urethra in
the penis and into the bladder. The procedure is uncomfortable
and rarely may cause urinary tract infection (UTI).
Post-void residual (PVR) test measures the amount of
urine that remains in the bladder after urination. The patient
is asked to urinate immediately prior to the test and the
residual urine is determined by ultrasound or catheterization.
PRV less than 50 mL generally indicates adequate bladder
emptying and measurements of 100 to 200 mL or higher often
indicate blockage. Nervousness and other types of stress may
affect the result; therefore, the test is often repeated.
Minimally Invasive Treatment
Minimally invasive BPH treatments use state-of-the-art tools
and techniques to reduce or eliminate symptoms. Men are
treated on an outpatient basis in a urologist's office or the
hospital. Other advantages of minimally invasive treatments
are less pain, faster recovery, lower costs, and local
anesthesia and mild sedative.
Usually, heat is used to destroy excess
prostate tissue. Techniques differ in heat source, heat
delivery method, side effects, and number of treatments.
Delivery methods include:
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Laser
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Indigo
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PVP
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Microwave
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CoreTherm®
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Cooled
ThermoTherapy™/TUMT™ |
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TherMatrx®
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Prolieve™
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Other
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AquaTherm™
System |
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TUNA
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TUVP
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HIFU
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Patients who want to stop taking medication
or whose medication no longer improves symptoms may elect to
have one of these procedures. However, patients with severely
enlarged prostates and whose bladders do not work properly may
not be good candidates.
Prior to diagnosis and treatment of BPH, a prostate-specific
antigen (PSA) test and digital rectal examination (DRE) are
performed to rule out prostate cancer. A transrectal
ultrasound and cystoscopy also may be performed to determine
if prostatectomy or TURP is indicated.
Medical Treatment
There are several treatment options for men with benign
prostate hyperplasia, depending on the severity of symptoms.
If symptoms do not threaten the man’s health, he may choose
not to be treated. If symptoms are severe enough to cause
discomfort, interfere with daily activities, or threaten
health, treatment is usually recommended.
Watchful waiting
Men with mild symptoms may choose to return for annual
examinations. The physician will perform an examination that
includes a DRE, PSA tests, and a urinary flow rate. The
patient will be asked to describe symptoms in order to
determine if the condition is worsening.
Medication
5-Alpha reductase inhibitors such as finasteride (Proscar®)
and dutasteride (Avodart™) prevent the conversion of
testosterone to the hormone dihydrotestosterone (DHT). In many
cases, a treatment period of 6-month is necessary to see if
the therapy is going to work. These drugs are taken orally,
once a day. Finasteride is available in tablet form and
dutasteride is available as soft gelatin capsules. Patients
should see their physician regularly to monitor side effects
and adjust the dosage, if necessary.
Side effects include reduced libido, impotence, breast
tenderness and enlargement, and reduced sperm count. Long-term
risks and benefits have not been studied.
Women who may be pregnant must avoid handling dutasteride
capsules and broken or crushed finasteride tablets because
exposure to the drugs may cause serious side effects to the
fetus. Intact tablets are coated to prevent absorption through
the skin during normal handling. Patients should wait at least
6 months after dutasteride treatment to donate blood to
prevent pregnant women from being exposed to the drug through
blood transfusion.
Alpha blockers relax smooth muscle tissue in the bladder neck
and prostate, which increases urinary flow. They typically are
taken orally, once or twice a day.
Commonly prescribed alpha blockers include the following:
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alfuzosin (UroXatral™),
extended-release tablet taken once daily
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doxazosin (Cardura®),
tablet taken once daily |
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prazosin (Minipress®),
capsule taken 2 or 3 times daily |
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tamsulosin
hydrochloride (Flowmax®), capsule taken once daily
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terazosin (Hytrin®),
capsule taken once daily |
Patients taking an alpha blocker require
follow-up during the first 3 or 4 weeks to evaluate the effect
on symptoms and adjust the dosage, if necessary. Side effects
include headache, dizziness, low blood pressure, fatigue,
weakness, and difficulty breathing. Long-term risks and
benefits have not been studied.
Prostatic stents
Although a prostatic stent is not a medical treatment, neither
does it fall under the classification of a surgical procedure.
Prostatic stents are used most often for patients with
significant medical problems that prohibit medication or
surgery. It is a tiny, springlike device inserted into the
urethra. When expanded, it pushes back the surrounding tissue
and widens the urethra. Prostatic stents have several
advantages:
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They can be
placed in less than 15 minutes under regional anesthesia.
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Bleeding
during and after surgery is minimal.
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The patient
can be discharged the same day or the next morning.
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There are
also several disadvantages: |
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Prepositioning can be difficult. |
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They may
cause irritation and frequent urination.
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They may
cause pain or incontinence. |
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Removing them
(necessary in one-third of cases) can be difficult.
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Surgical Treatment
Surgery involves removing the enlarged part of the prostate
that constricts the urethra. It is recommended for patients
who experience serious complications, such as the following:
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Bleeding
through the urethra as a result of BPH
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Damage to the
kidneys caused by urine backing up
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Frequent
urinary tract infections |
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Inability to
urinate |
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Stones in the
bladder |
TURP
Transurethral resection of the prostate (TURP) is the gold
standard to which other surgeries for BPH are compared. This
procedure is performed under general or regional anesthesia
and takes less than 90 minutes.
The surgeon inserts an instrument called a resectoscope into
the penis through the urethra. The resectoscope is about 12
inches long and one-half an inch in diameter. It contains a
light, valves for controlling irrigating fluid, and an
electrical loop to remove the obstructing tissue and seal
blood vessels. The surgeon removes the obstructing tissue and
the irrigating fluids carry the tissue to the bladder. This
debris is removed by irrigation and any remaining debris is
eliminated in the urine over time.
Patients usually stay in the hospital for about 3 days, during
which time a catheter is used to drain urine. Most men are
able to return to work within a month. During the recovery
period, patients are advised to
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avoid heavy
lifting, driving, or operating machinery;
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drink plenty
of water to flush the bladder; |
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eat a
balanced diet; |
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use a
laxative if necessary to prevent constipation and
straining during bowel movements.
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Complications
Blood in the urine (hematuria) is common after TURP surgery
and usually
resolves by the time the patient is discharged. Bleeding also
may result from straining or activity. Postsurgical bleeding
should be reported to the urologist immediately.
Some patients have initial discomfort, a
sense of urgency to urinate, or short-term difficulty
controlling urination. These conditions slowly improve as
recovery progresses, but it is important to remember that the
longer the urinary problems existed before surgery, the longer
it takes to regain full and normal bladder function after
surgery.
Up to 30% of men who undergo TURP experience problems with
sexual function. Complete recovery of sexual function may take
up to 1 year. The most common, long-term side effect of
prostate surgery is retrograde ejaculation (dry climax), which
results when the muscle that closes the bladder neck during
ejaculation is removed along with the obstructing prostate
tissue. Semen enters the wider opening to the bladder instead
of being expelled through the penis, causing sterility but not
affecting the man’s ability to experience sexual pleasure.
This complication is not an issue for most men requiring
prostate surgery.
Prostatectomy
If the prostate is greatly enlarged, if the bladder has been
damaged, or if the patient has complications prohibiting
transurethral surgery, prostatectomy (removal of the
obstructing prostate) may be necessary. This procedure is
sometimes the best and safest approach.
Prostatectomy is performed under general or regional
anesthesia. The surgeon makes an external incision in the
lower abdomen or in the perineum (area between the rectum and
the scrotum). If the surgeon accesses the prostate from the
abdomen, the procedure is called suprapubic or retropubic
prostatectomy; surgery through the perineum is called perineal
prostatectomy. Once access is gained, the prostate is removed.
After prostate surgery, a urinary catheter is inserted to
ensure bladder emptying. Urine output and color and continuous
bladder irrigation (CBI), if present, are monitored. Blood in
the urine is an expected side effect of prostate surgery. CBI
is used to maintain the effectiveness of the urinary catheter,
remove blood clots, and cleanse the surgical area. If bladder
spasms occur, the surgeon should be notified.
Once they have been discharged from the hospital, patients
should abstain from sexual intercourse for 6 weeks after
surgery. Strenuous activity and lifting is to be avoided
throughout the recovery period, which can take up to 8 weeks.
Potential complications include incontinence and impotence.
Depending on the procedure, stress urinary incontinence may
result when pressure is put on abdominal muscles. Urge
incontinence and involuntary passing of urine while asleep
also may occur. Patients are encouraged to use Kegel exercies
to strengthen pelvic floor muscles and to increase their water
intake. Ejaculatory and erectile dysfunction (impotence) may
occur, depending on the procedure.
TUIP
Transurethral incision of the prostate (TUIP) may be
recommended to treat a prostate that is not greatly enlarged.
The surgeon makes one or more cuts in the bladder neck where
the urethra joins the bladder, extending into the prostate.
This reduces the prostate's pressure on the urethra and makes
urination easier. TUIP may provide relief with a lower
incidence of retrograde ejaculation than TURP. However, its
long-term benefits and risks compared to TURP have not been
established.
TULIP
Transurethral ultrasound-guided laser incision of the prostate
(TULIP) is a new procedure that is similar to TUIP, except
that the cuts are made with a laser.
HoLEP
Holmium laser enucleation of the prostate (HoLEP) produces
results that are similar to TURP with fewer complications
(e.g., less intraoperative bleeding). In this procedure, a
holmium laser is used to remove obstructive prostatic tissue
and seal blood vessels. HoLEP is usually performed as a day
procedure in the hospital. Benefits of HoLEP over traditional
surgery include the following:
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Shorter
hospital stay |
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Shorter
catheterization time |
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Shorter
recovery time |
Approximately 10–15% of patients with large
prostates (>100 gm) experience stress incontinence after
undergoing HoLEP. In most cases, incontinence resolves within
6 weeks.
Naturopathic
Treatment
The goal of benign prostatic hyperplasia (BPH) treatment is to
reduce excessive cell growth by inhibiting the conversion of
testosterone into the more potent hormone dihydrotestosterone
(DHT) and by preventing estrogen from attaching to receptors
in prostate tissue. From a naturopathic viewpoint, this is
accomplished through nutrition and the use of supplements and
herbs.
Nutrition
Eat whole, fresh, unrefined, and unprocessed foods. Include
fruits, vegetables, whole grains, soy, beans, seeds, nuts,
olive oil, and cold-water fish (salmon, tuna, sardines,
halibut, and mackerel). Eating organic food helps reduce
exposure to hormones, pesticides, and herbicides.
Avoid refined sugar and flour, dairy products, refined foods,
fried foods, junk foods, hydrogenated oils, alcohol
(particularly beer), and caffeine.
Eliminate food sensitivities. Use an elimination and challenge
diet to determine food sensitivities.
Drink ½ of your body weight in ounces of water daily (e.g., if
you weigh 150 lbs, drink 75 oz of water daily).
Herbal Medicine
Herbal medicines usually do not have side effects when used
appropriately and at suggested doses. Occasionally, an herb at
the prescribed dose causes stomach upset or headache. This may
reflect the purity of the preparation or added ingredients,
such as synthetic binders or fillers. For this reason, it is
recommended that only high-quality products be used. As with
all medications, more is not better and overdosing can lead to
serious illness and death.
These herbs may be used to treat BPH:
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Saw palmetto
(Serenoa repens)— Inhibits the conversion of testosterone
to DHT in the prostate, has an antiestrogenic effect, and
helps improve all symptoms of BPH. Recommended dosage is
320 mg of extract (standardized to contain approximately
85% fatty acids and sterols) daily.
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Pygeum (Pygeum
africanum)— Reduces BPH symptoms. Recommended dosage is
100-200 mg of extract (standardized to 14% triterpenes) 2
times daily. |
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Stinging
nettles (Urtica dioica)— The concentrated extract reduces
symptoms.Recommended dosage is 120 mg daily.
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Hydrotherapy
Cold sitz bath
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