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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Man to Man Man to Man
 

Growing Pains: Benign Prostatic Hyperplasia


January 24, 2013

By Harvey B. Simon M.D.

Harvard Medical School

Even though the walnut-shaped prostate gland is part of the reproductive system, it causes problems with urination, not sex, when it becomes enlarged. That's because the urethra, the tube that carries urine out from the bladder, runs right through the prostate.

Like other organs, the prostate has a growth spurt during adolescence and stops growing in adulthood. Unlike other organs, however, the prostate has a second period of growth that starts slowly in midlife, and gathers speed into old age. The result is benign prostatic hyperplasia or BPH.

New surgical treatment and improved medical therapies are giving men with BPH new choices for an old problem.

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What Causes BPH?

Two things are essential for BPH to develop: age and testosterone. But doctors don't know why some men develop BPH while others don't. It seems likely that various growth factors stimulate the prostate cells in men with BPH.

Scientists have not yet discovered the cause of BPH. But they have identified some important risk factors:

  • Abdominal obesity
  • Cigarette smoking
  • Lack of exercise
  • Poor diet
  • Excessive alcohol intake

Doctors don't know if a healthy lifestyle can prevent BPH. But since these same risk factors contribute to heart disease, cancer, stroke, and diabetes, healthy living is a smart choice for everyone.

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Symptoms of BPH

Until recently, doctors thought that the symptoms of BPH were directly related to the size of the gland. But new research shows that it’s not so simple. In fact, some men with very large prostates have few symptoms, while some with relatively small glands have lots of symptoms.

Some symptoms can result from narrowing of the urethra, much as an index finger and thumb can slow the flow of fluid through a straw:

  • Having to strain and wait to start urinating
  • A weak, slow stream of urine
  • Taking a long time to void and dribbling at the end
  • Not emptying the bladder completely. In its most serious form, this means a man cannot urinate at all, an urgent problem called acute urinary retention.

Or they can be due to bladder irritation:

  • An urgent, sometimes uncontrollable, need to void and the frequent passage of small amounts of urine
  • Frequent nighttime urination

You can rate your symptoms using the American Urological Association's (AUA) Symptoms Index in its Patient's Guide.

Serious complications of BPH are rare, but include:

  • A complete blockage in urine flow that requires emergency treatment
  • Urine backing up towards the kidney, reducing kidney function
  • Bladder stones, bleeding or urinary tract infections

BPH does not increase a man's risk of prostate cancer. However, it can complicate the diagnosis of prostate cancer, since BPH often raises the blood prostate specific antigen (PSA) results to levels considered suspicious for cancer.

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Diagnosing BPH

Elaborate medical tests are not necessary to diagnose BPH. The AUA Symptoms Index is the most important part of an evaluation. But your doctor should also:

  • Check for other conditions that can produce urinary symptoms, such as diabetes and neurological disorders
  • Perform a digital rectal examination to evaluate the size of the prostate and to check for abnormalities that could indicate cancer or infection
  • Check kidney function with a urinalysis and blood tests

A PSA blood test can also screen for prostate cancer. Additional tests are available for men with complications. Men should also report medications that can slow urine flow, such as decongestants and antihistamines.

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Treatment Options

BPH is severe enough in some men to require immediate treatment. But in most men, BPH progresses slowly. They can decide for themselves when and if they should be treated. Here are the options.

Watchful waiting is a safe choice as well as the only choice for men with low Symptom Index scores. It's also a reasonable choice for many others who find that simple adjustments in lifestyle reduce the daily nuisance-factor of BPH. Here are a few lifestyle changes to try:

  • Reduce your intake of fluids, particularly after dinner.
     
  • Limit your intake of alcohol and caffeine, and avoid them after mid-afternoon; both are diuretics that increase urine flow.
     
  • Avoid medications that stimulate muscles in the bladder neck and prostate, such as pseudophedrine and other decongestants.
     
  • Avoid medications with anticholinergic properties that weaken bladder contractions. Antihistamines such as diphenhydramine are the most common offenders. Various antidepressants and antispasmodics have similar properties.
     
  • If you are taking diuretics for high blood pressure or heart problems, ask your doctor to try to reduce the dose or substitute another medication that will work as well without increasing urine flow.
  • Never pass up a chance to use the bathroom, even if your bladder does not feel full. Take your time, so you empty your bladder as much as possible. Plan to stop at regular intervals during auto trips. Request an aisle seat for air travel or at theatrical and sports events.
  • When you are in new surroundings, learn the location of the bathroom before you really need it.
  • Make your night-time trips to the bathroom easy and safe. Be sure there is enough light to see where you're going. Avoid bright light that jolts you awake, making it hard for you to get back to sleep. Be sure there are no electrical cords, telephone wires, loose rugs or stray objects that might trip you up.

If you can live comfortably with BPH, do it. But if your symptoms are bothersome, you'll have several new and improved options to consider.

Prescription drugs can reduce the bothersome symptoms of BPH.

  • Alpha-blockers relax smooth muscle cells in the prostate and bladder. The older drugs, terazosin and doxazosin can cause dizziness by lowering the blood pressure too much in some men with BPH. The newer drugs, tamsulosin and alfuzosin have much less effect on blood pressure. All these medications act within weeks, and about 70% of men with BPH improve. Side effects may include nasal stuffiness, headache, dry mouth, and decreased ejaculation (less likely with alfuzosin).
     
  • Hormone blockers, finasteride and dutasteride, actually shrink the size of the gland. These drugs work slowly — over 6 months or longer — and they are only helpful for men with rather large prostates. Side effects may include decreased sexual function.
     
  • Combination therapy with an alpha-blocker and a hormone blocker may reduce the risk of complications for men with moderate or severe BPH.

Surgery used to be the only effective treatment for BPH before modern medications. Although drugs are effective for many men with BPH, some still need surgery. Several approaches are available:

  • Transurethral resection of the prostate (TURP) has been the "gold standard" of BPH therapy. In recent years though, its luster has tarnished — not because of problems with the operation itself (it's actually gotten better), but because of new medical and surgical rivals. TURP does not require an incision through the skin, but the 90-minute operation does require hospitalization and spinal or general anesthesia. The surgeon passes a resectoscope through the patient's urethra, then uses an electrical loop to cut away prostate tissue that is slowing the flow of urine. A Foley catheter is left in place to empty the bladder for a day or two, after which the patient can void on his own. If all goes well, he's home in two or three days. Although results vary, TURP reduces BPH symptoms in 80% to 90% of patients. But there can be early complications, such as infection or bleeding. Later 50% to 75% of patients experience dry ejaculation, 5% to 10% have erectile dysfunction, and 1% to 3% experience incontinence. And since the prostate can grow back, up to 20% of TURP patients require more treatment within 10 years.
     
  • Newer, Less Invasive Therapies sound like alphabet soup: TUMT, TUNA, TUIP, HIFU, CLAP, TUBD, for example. Some treatments use the energy from lasers, microwaves, ultrasound or electricity to destroy unwanted prostate tissue, while others rely on tiny incisions in the gland. Because these therapies are new, they are not available in all hospitals. Long-term results are not known, but most appear more effective than medication, but less successful than TURP. Still, if they are available in your medical center, they may be worth considering because they generally have a lower risk of complications than TURPs and a quicker return to normal activities.

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Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.

 

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