Of all medical conditions affecting a man’s prostate gland, an enlarged prostate, medically known as benign prostatic hyperplasia (BPH), is the most common. Practically all men who live past the age of 50 will experience BPH in their lifetime. Percentage-wise, about half of all men between the ages of 51 and 60 will develop it and up to 90% of men over the age of 80 will have it. Since it is so ubiquitous in older men, being educated about BPH is key to knowing and understanding symptoms and treatment.
Understanding BPH and the prostate gland
If you break down the meaning of BPH starting with “B,” benign means “not cancerous” which is reassuring for men to know that BPH is not linked to prostate cancer nor does it increase a man’s risk of developing it. The “H” or hyperplasia means an enlargement of an organ or tissue caused by an increase in its cell reproduction. In regards to the prostate gland, hyperplasia indicates the walnut-shaped gland, situated in front of the rectum and below the bladder, has grown large enough to start squeezing the urethra, affecting the flow of urine often leading to urinary symptoms.
At birth, the prostate gland in baby boys is tiny. Over the course of a man’s lifetime, the prostate undergoes two growth spurts. Puberty is the first growth spurt fueled by the sex hormones made by the testicles doubling the size of the prostate. Then, the second growth spurt starts around age 25 and continues during most of a man’s life. By the time a man reaches age 40, his prostate may have gone from the size of a walnut to the size of an apricot and by the time a man reaches age 60, it might be the size of a lemon.
The prostate gland has the important function of producing a fluid that, together with sperm cells from the testicles and fluids from other glands, makes up semen. This milky prostatic fluid makes up about one-third of the volume of semen. Prostatic fluid also contains an enzyme called prostate-specific antigen (PSA), a protein produced by the cells in the prostate gland. PSA helps to “thin down” the semen so it stays liquid for the entire trip as it travels through the vagina journeying to the fallopian tubes after ejaculation during sexual intercourse.
The prostate gland is also in charge of another important function – a man’s urinary flow. That’s because the prostate surrounds the urethra, the tube that carries urine out of the body. It’s also in charge of stopping urine from leaving the bladder until a man urinates. However, when a man has BPH, this puts pressure on the urethra resulting in annoying urinary issues.
There are specific symptoms of BPH a man may have, however, not all men will have symptoms. If they do, they may include the following:
- A hesitant, interrupted, or the weak urine stream
- Urgency, leaking, or dribbling
- A sense of incomplete emptying
- More frequent urination, especially at night
- Pain or burning with urination
- The need to push or strain to urinate
- Blood in the urine
Risk factors of BPH
Risk factors increasing the likelihood of men developing BPH include:
- Family history – having a blood relative such as a father or brother with BPH
- Ethnicity – African American men have the highest risk for BPH with Asian men having the least
- Diabetes and heart disease
How to treat BPH
Because BPH is so common among older men, many assume it’s an inevitable part of aging and therefore will have to live with the symptoms. Men may also assume since BPH is not cancerous, it won’t cause any harm. However, this is not true. If BPH is left untreated, it has the potential of leading to issues of urinary tract infections, bladder or kidney stones, or serious kidney damage including obstruction or impaired functioning.
Men experiencing noticeable changes in urinary function should discuss this with their doctor. If BPH is found to be the problem, getting early treatment can head off complications later on.
That’s why it’s important for all men over the age of 50 to have their prostate checked annually even if they have no symptoms. It’s also recommended starting at age 40, for all men to have a baseline prostate specific antigen (PSA) test. A yearly physical exam along with a PSA test and digital rectal exam can help determine if a man’s prostate is enlarging.
If a man’s prostate is found to be enlarging, there are several treatments available to help reduce symptoms of BPH. However, for men with an enlarged prostate but with no or only mild symptoms, treatment may not be required. Treatment or BPH will depend on if the prostate is continuing to enlarge and what symptoms are present.
Options for treating BPH include the following:
Active surveillance or watchful waiting:
If the prostate enlargement is stable and a man has mild or few symptoms, likely there is no need for treatment. Up to one-third of men with mild BPH find that their symptoms clear up without treatment and therefore may opt to just watch and wait. During this time, lifestyle changes such as drinking fewer liquids before bedtime and becoming more physically active can help manage symptoms of an enlarged prostate.
When BPH becomes more advanced and symptoms are becoming worse, there are medications to help control the growth of the prostate and to help reduce symptoms of BPH. There are three classes of drugs for BPH:
- Alpha blockers: These relax prostate and bladder neck muscles relieving symptoms and improving urinary functioning. Commonly used alpha blockers working effectively in men with relatively small prostates include alfuzosin (Uroxatral), doxazosin (Cardura), and tamsulosin (Flomax).
- Phosphodiesterase-5 (PDE5) inhibitors: Generally used to treat erectile dysfunction, PDE5 inhibitors also relax muscles in the urinary tract increasing urine flow and relieving symptoms. Examples include sildenafil (Viagra), tadalfil (Cialis), and vardenafil (Levitra).
- 5-alpha reductase inhibitors (5-ARIs): These work best by shrinking more severely enlarged prostates by preventing hormonal changes likely contributing to prostate growth. Examples include dutasteride (Avodart) and finasteride (Proscar).
- Combination medications: The use of two or more different medications, such as an alpha blocker and a 5-alpha reductase inhibitor, may be recommended to improve BPH symptoms.
Minimally invasive procedures:
When medications are not relieving BPH symptoms, the next step is to consider a minimally invasive procedure. A procedure meeting this need is transurethral needle ablation (TUNA). This procedure involves passing a scope into the urethra placing needles into the prostate gland. Radio waves pass through the needles heating and destroying excess prostate tissue blocking urine flow.
If medication and minimally invasive procedures are unable to improve the symptoms of BPH, surgery may be recommended. Surgery may also be recommended if symptoms become severe or complications develop. Some surgical procedures can take place under local anesthetic or as an outpatient; however, some may require full anesthesia and a hospital stay. Surgical options include:
- Transurethral resection of the prostate (TURP): This surgery is considered to be the optimum treatment for BPH helping reduce symptoms quickly in 80-90% of patients. Most men will experience a stronger urine flow soon after the procedure. TURP, also known as button TURP, uses a small, button-shaped device using low-temperature plasma energy instead of heat to remove or vaporize prostate tissue. Once the extra tissue is removed under anesthesia, the area around it is sealed off to prevent bleeding. Button TURP has few complications such as bleeding after surgery and shortens the time of the use of a catheter after surgery.
- Green-light laser or Laser prostate surgery: This treatment uses high-powered laser energy to remove enlarged prostate tissue by vaporizing the tissue aiming to leave a wide channel for restoring normal urinary function. While under anesthesia, a small flexible fiber-optic is inserted into the urethra while pulses of light are sent through the fiber cutting away the prostate tissue obstructing urinary flow. The procedure takes about 60 to 90 minutes with the patient usually sent home the same day or if required, may have to spend the night. There is minimal bleeding or pain after the procedure.
- Prostate lift implant (Urolift): This is a newer procedure that compresses the prostate with sutures to make a wider opening for urine flow. This is usually done as an outpatient procedure and does not require anesthesia.