Mesothelioma Info

An enlargement of the prostate gland that is not cancerous (malignant) is called benign prostatic hyperplasia (BPH). Recently, the term LUTS, an acronym for "lower urinary tract symptoms," has been introduced as an alternative term for BPH, since many patients with typical symptoms of BPH have small prostates. The prostate gland, found in men only, surrounds the tube through which urine leaves the bladder (the urethra). BPH is usually progressive because the prostate tends to enlarge as a man ages. Such enlargement may lead to obstruction of the urethra and interfere with urine flow. In patients with small prostates, increased tone of the smooth muscle in the bladder neck, rather than enlargement of the prostate, causes symptoms. Symptoms, whether from a large or a small prostate, are divided into three stages: mild, moderate, or severe.
BPH is not life-threatening, but it is important that it be diagnosed early. Severe BPH causes significant amounts of urine to be retained in the bladder after voiding. Severe BPH may also reflect a major obstruction that could lead to repeated urinary tract infections along with bladder and/or kidney damage. Early detection along with treatment greatly reduces the risk for these complications.
BPH is common in men after age 50; in fact, it affects two-thirds of men over 55 years of age. A specialist is not usually required to treat BPH. A general physician can treat an uncomplicated case. Many patients with BPH live with their symptoms and do not seek medical help, although this is not recommended.
Figure 1. The prostate gland
The prostate is a gland in men about the size and shape of walnut that surrounds the urethra at the point where the urethra connects to the bladder.
Causes

Increasing age and the presence of normal male hormones (testosterone and dihydrotestosterone [DHT]) are the best-known factors that contribute to BPH. A hormone known as 5α-reductase converts testosterone into DHT in the prostate gland, which results in prostate enlargement. DHT concentrations in BPH tissue have been shown to be increased when compared with normal prostate tissue. Of great interest is the fact that BPH does not occur in males who are castrated before age 40, indicating the great importance of the male hormone in this disorder.
BPH occurs with nearly equal frequency in all races and cultures with the exception of Asians, in whom it occurs much less often. The cause for this is suspected to be environmental, since Asians who migrated to the U.S. developed an equal frequency of BPH. The average age for detection is somewhat earlier in African-Americans (60 years) than in whites (65 years).
Symptoms

The symptoms of BPH can be classified as obstructive and irritative. Obstructive symptoms include straining to initiate urination, hesitancy in starting the stream, intermittency of urination, dribbling after urination, a weak urine stream, and a sensation of incomplete bladder emptying. Irritative symptoms include frequent urination during the daytime and nighttime, and a strong sense of urgency to urinate.
Table 1. Symptoms of BPH

Obstructive symptomsIrritative symptomsHesitancyFrequency of urination during the dayStraining to start the streamFrequency of urination at nightWeak urine streamUrgency to urinate at all timesTerminal dribbling after urinatingIntermittency of urinationSome BPH symptoms are also symptoms of bladder or prostate cancer and bladder infection. Patients with symptoms of BPH must have these other possible disorders ruled out by a series of simple diagnostic tests, including a urine test for red cells and white cells, a serum prostate-specific antigen (PSA) test, and, of course, a digital rectal exam. Another disorder the doctor will check for, although it is somewhat less common than the aforementioned disorders, is prostatitis. Prostatitis may raise the serum PSA in the absence of prostate cancer. Therefore, to rule this disorder out, a patient should have a prostatic massage followed by collection of either a seminal fluid specimen to be examined for white blood cells, or a first-voided urine sample to be examined for white blood cells and possibly for organisms.
Your doctor may give you the international prostate symptom scale (ISPS) test. Your score on the International Prostate Symptom Scale (ISPS) test can be helpful in gauging the severity of the condition. This scale was recently published by the American Urological Association (AUA). Scores of 8 or less indicate mild disease, 9 to 19 indicate moderate disease, and 20 and above indicate severe disease. The symptom score is a good guide for initiation of therapy, since patients with mild disease are usually just monitored carefully and not treated, whereas patients with moderate disease usually begin treatment. Patients with severe disease are almost always treated.
Table 2. International Prostate Symptom Score

Not at allLess than 1 time in 5Less than half the timeAbout half the timeMore than half the timeAlmost alwaysOver the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?012345Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?012345Over the past month, how often have you found you stopped and started again several times when you urinated?012345Over the past month, how often have you found it difficult to postpone urination?012345Over the past month, how often have you had a weak urinary stream?012345Over the past month, how often have you had to push or strain to begin urination?012345Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?012345Total international prostate symptom score Quality of life resulting from urinary symptomsDelightedPleasedMostly satisfiedMixed—about equally satisfied and dissatisfiedMostly dissatisfiedUnhappyIf you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?012345Adapted from Berry SJ, Coffey DS, Walsh PC: The development of human benign prostatic hyperplasia with age. J Urol 1984, 132: 474-479.
Risk Factors

Risk factors for this condition are unclear. BPH is equally prevalent in all races except for Asians, in whom it is less common. Asians, including Indians, Chinese, and Japanese, may be protected from the factors resulting in BPH by their dietary habits, which are largely vegetarian with much lower fat intake. The Asians also consume a large quantity of soy products, which have been thought to have factors such as isoflavones, which may inhibit growth of the prostate. No study has found a clear connection between BPH and smoking, obesity, alcohol consumption, liver dysfunction, or vasectomy. Evidence is beginning to suggest that BPH has a genetic component.
Diagnosis

Your doctor will take a medical history and conduct a physical examination and urinalysis to learn about your condition. The history will focus on the urinary tract and general health issues, such as high blood pressure and diabetes. The physical examination will include a digital rectal examination and an examination of your genitals. If hard areas, nodules, or asymmetry are present, the doctor may suspect cancer and do further testing. Dipstick urinalysis and microscopic examination of urinary sediment should be done to rule out blood in the urine and urinary tract infection.
Testing urinary flow rates is also helpful. Maximal flow rates of less than 10 mL/sec indicate severe disease; rates above 10 mL/sec indicate moderate to mild disease. Your doctor can also estimate the amount of residual urine with straight catheterization or bladder ultrasonography. Values over 200 mL indicate significant long-standing outlet obstruction and early bladder failure, and point to advanced disease.
Your doctor may give you a prostate-specific antigen (PSA) test. Once you reach age 50, your doctor should give you a PSA test after discussing the risks and benefits of early detection of prostate cancer. If you have a family history of prostate cancer or are African-American, your doctor will begin PSA testing at age 40 to 45. Patients with PSA levels above normal (4 µg/L) should be referred to a urologist for further testing. African-American males with a PSA level above 2.5 µg/L, and all men whose PSA level has increased substantially in 12 months should also be referred to a specialist. PSA testing can also help your doctor estimate the size of your prostate, which helps determine a course of treatment for BPH.
Prevention and Screening

There is no proven way to prevent BPH. However, according to the National Cancer Institute and the American Cancer Society, all men over 50 should have a digital rectal examination once a year to screen for prostate cancer. Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to urinate at all. This condition, called acute urinary retention, may be triggered by taking over-the-counter cold or allergy medicines. Such medicines contain a decongestant drug known as a sympathomimetic. A potential side effect of this drug may be to prevent the bladder opening from relaxing and allowing urine to empty. When partial obstruction is present, urinary retention also can be brought on by alcohol, cold temperatures, or a long period of immobility.
Treatment

Urgent Care

BPH can result in complete blockage of the urethra. Complete blockage results in a condition known as acute urinary retention. Acute urinary retention may result from taking over-the-counter decongestants, which contain an ingredient that can prevent the bladder neck sphincter from opening and allowing urine to empty. Nonacute urinary retention can be caused by cold temperature, extended periods of immobility, and alcohol consumption. Patients who are unable to urinate must go immediately to an emergency room and be catheterized, which means having a tube placed in the penis to drain urine. Being unable to urinate increases the risk of acute kidney failure, a serious disease.
Self Care

Lifestyle changes may make you more comfortable. If your prostate is enlarged, you should avoid such bladder irritants as caffeine, alcohol, and spicy food. Limit fluids in the evening to decrease the need to urinate during the night.
Drug Therapy

Your doctor is the best source of information on the drug treatment choices available to you.
Other Therapies

Watchful waiting is an option for mild cases. If you have mild symptoms of BPH (ISPS test score 8 or less), your doctor will probably recommend a course of watchful waiting, or deferred therapy. Your doctor will tell you about lifestyle changes that can reduce symptoms, such as cutting down on caffeine, spicy foods, and alcohol, all of which can be bladder irritants. Decreasing fluid intake in the evening can reduce the need to urinate during the night. Your doctor will continue to monitor your symptoms and status, probably annually.
Surgery

Minimally invasive techniques are available for moderate cases. Drug treatment is not always effective in moderate cases of BPH. In such cases, some minimally invasive therapies, which shrink the gland and relieve BPH symptoms, are available. These therapies include transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA). In TUMT, microwaves heat and destroy excess prostate tissue. The TUNA system delivers low-level radiofrequency energy to burn away a defined portion of the prostate.
Surgical options are available. In advanced BPH, symptoms are usually sufficiently severe to affect quality of life and mandate aggressive therapy. When recurrent urine retention, urinary tract infection, blood in the urine, bladder stones, or renal failure is present, surgery is indicated.
The most common surgery for BPH is transurethral resection of the prostate (TURP), in which a surgeon threads an instrument up the urethra and cuts away part of the prostate to make the opening bigger for the urethra. Other surgical options are transurethral incision of the prostate (TUIP), in which the surgeon makes a cut in the neck of the bladder; transurethral electrovaporization of the prostate (TVP), in which excess tissue is vaporized; laser prostatectomy (removal of the prostate); and balloon dilation of the prostate. Possible complications of surgery include bleeding, urinary tract infection, retrograde ejaculation, sexual dysfunction, urinary incontinence, and, in rare cases, death. As previously mentioned, recurrence of BPH occurs in about 12% of patients during an eight-year follow-up. Therefore, patients who do have TURPs should be followed very closely and certainly put on medical therapy if there is any indication of regrowth of the prostate.
Figure 2. Transurethral resection of the prostate (TURP) (animation and audio)
Alternative Medicine

Certain herbs and minerals have shown good results with BPH. Saw palmetto is the most popular herb being taken for BPH. Its effects include increased urine flow, decreased residual urine, and less frequent urination. Licorice has also been recommended, as it contains a compound that prevents the conversion of testosterone to DHT. Large doses of zinc may also help to shrink the prostate. Talk to your doctor if you are interested in trying these alternatives. Although herbs are used widely in Europe and to some extent in the U.S. for the treatment of BPH, the medications used are questionable since it is not yet known how they work. For instance, there is no demonstrated effect of saw palmetto on either prostate size or alpha-adrenergic tone. It remains for future studies to establish whether or not these alternative herbs are of any real value or not.
Prognosis

BPH is very rarely a life-threatening disease. It can, however, have a profound effect on quality of life. Urine retention and strain on the bladder can lead to uncomfortable urinary tract infections in addition to bladder and kidney damage. Inability to completely empty the bladder and inability to urinate despite having the urge can also be very uncomfortable. Incontinence can lead to reduction in social activities, and frequent sleep interruption can result from the need to urinate throughout the night.
Follow-up

More tests will follow to chart your progress. Digital rectal examination and plasma PSA measurements should be done every six months for the first year after the diagnosis. (Blood for the test should be drawn before the digital rectal examination.) Your doctor may continue to monitor you after that period.