Benign Prostatic Hypertrophy (BPH)
Benign prostatic hypertrophy (sometimes called benign prostatic hyperplasia or simply BPH) is perhaps the most common ailment in men. The name itself “Benign” (non-cancerous growth), “prostatic” (of the prostate), “hypertrophy” (oversized) or “hyperplasia” (overgrowth) explains perfectly the disease (a non-cancerous enlargement of the prostate). BPH is often called an “enlarged prostate”. Some men may start getting symptoms of BPH as early as their 30’s. By the time men are in their 50’s, nearly half of them will have BPH. The chances of having BPH increases with age - in fact, nearly all men will get BPH if they live long enough. This occurs because the prostate tissue continues to grow when stimulated by DHT. And since men produce DHT their entire lives, this prostate tissue will continue to grow throughout their life.
Most of the prostate growth in BPH occurs in the transitional zone near the urethra. Thus, the swelling in BPH tends to move inwards more than outwards, thus making the urethra within the prostate narrower and narrower over time. This narrowing of the urethra effects how well urine can flow through the urethra from the bladder. In fact, nearly all of the symptoms of BPH are symptoms that involve urination not sexual congestion. The main symptoms of BPH are urinary frequency, urgency, and hesitancy. Image below copyrighted by DNA Illustrations and used by permission.
Most of the symptoms of BPH involve urinary symptoms rather than sexual symptoms. This is because the peripheral zone is responsible for prostate fluid production while the transition zone is less involved. Urinary symptoms often include the following:
Frequency (having to go to the bathroom a lot – including at night)
Urgency (having to suddenly go to the bathroom)
Hesitancy (having difficulties starting a stream of urine)
Dribbling after urination
Weak urine stream
Urinary frequency occurs because it can be very difficult for men to empty their bladder all the way. When the prostate is enlarged, it takes a great amount of pressure to push urine past the tight urethra in the prostate. Sometimes this requires that the bladder be full to provide that pressure. As the amount of urine drops in the bladder, so does the pressure. This leads to the bladder not emptying all the way, causing a man to have to go to the bathroom frequently to get rid of sometimes only 10% of the urine in the bladder. This frequency is particularly problematic during the night. Rather than being able to hold urine until the morning, men often find that in their 30’s (or even before) that they need to get up in the night to urinate. As men age and as the prostate swells larger and larger, this may end up resulting in men having to get up multiple times a night to go to the restroom. This can lead to sleep deprivation and difficulties with drowsiness and mental function during the day.
Urgency occurs due to many of the same factors as frequency. Since men with BPH can’t completely empty their bladders, they’re often running on more than a “full tank” of urine. So it isn’t uncommon for the bladder to become completely full, even if the guy went to the restroom an hour before. This complete fullness can lead to urgency which may result in a man having only a minute or two of “warning” which can lead to him wetting his pants before he can reach a restroom. Since he often feels like his bladder is “full”, the urgency to urinate can become difficult to control once the bladder has filled to capacity.
Urinary hesitancy is also caused by the enlarged prostate. Hesitancy is the inability to start the flow of urine as quickly as a man would like. Now every guy can get stage fright in the public bathroom and not be able to start urinating immediately. This “stage fright” is part of the fight or flight response in the body that causes the neck of the bladder to contract (in the animal world, this would prevent an animal from urinating as they ran away from a bear thus leaving a scent trail behind). Rather than “stage fright”, urinary hesitancy is the inability to start a urine stream easily because the prostate is blocking that urine stream from beginning.
Oftentimes, it can take men a minute or two to get a urine stream going.
On the flip side, stopping the urine flow can also be difficult. Rather than “shutting off” urine flow, the flow slows and in some cases urine can become “stuck” in the urethra dribbling out seconds or even minutes after a man has finished going to the bathroom. This urine typically doesn’t come from the bladder, but from “stuck urine” in the urethra. This can be problematic for men as oftentimes they may have to take a few minutes to start urinating and a few minutes afterwards to ensure urination is complete. Sometimes sitting to urinate helps reduce stress (especially in a public restroom) and staying seated for a couple of minutes after urination to ensure that all dribbled urine makes it into the toilet rather than into the underwear.
The stream of urine is often quite weak since the urethra is constricted and not a lot of volume can come out at once. A “healthy” stream of urine would allow a man to “aim” in the toilet bowl or “write his name in the snow”. Weak urine streams can create difficulties aiming appropriately thus making sitting to use the bathroom an option that many men choose. As BPH worsens, urination may be more drips than stream and in severe cases the urine stream can stop altogether and men have to be catheterized in order to open the urethra for urination. Catheters are small, hollow tubes that are inserted into the penis, through the prostate, and into the bladder that allow urine to flow out.
Diagnosis can be made by a healthcare provider. This often is based on the symptoms mentioned above. During a physical exam, your provider may perform a digital rectal exam to determine how large your prostate is. This is done by them inserting a lubricated, gloved finger into the anus to feel the prostate through the lower colon. This can be uncomfortable but it is not painful. In men with BPH, the provider will be able to feel the enlarged size of the prostate (see pages 438-439). They can often notice on examination that the prostate feels firm and enlarged rather than boggy (a boggy feeling is often found in prostatitis and prostatic congestion).
The first treatment is non-drug. It involves limiting liquids before bedtime to reduce how many times a man needs to wake up to go to the restroom as well as sitting to urinate to aid in hesitancy and dribbling. This may be a valid treatment in the early stages of BPH but it does not change the course of the disease or lead to long-term relief of symptoms. As BPH progresses these non-drug therapies tend to not work as well as one would hope. Hydration is important so limiting fluids too much can be a problem. If fluid restriction results in darker yellow urine, then more fluids should be consumed so medication therapy is usually necessary. There are three main drugs types that can be used to treat BPH in these cases – alpha blockers, 5 alpha-reductase inhibitors, and PDE-5 inhibitors:
Alpha Blockers work by relaxing the muscles in the prostate thus relaxing the area around the urethra to make urination easier. Older alpha blockers (like terazosin, doxazosin, and prazosin) relaxed smooth muscles all over the body (including the blood vessels) which lowered blood pressure. This drop in blood pressure cause dizziness in some men when they stand up (the blood can rush out of their heads because of the relaxed blood vessels). Newer alpha blockers (like tamsulosin, alfuzosin, and silodosin) have been designed to work primarily in the prostate. Even though some men may experience some lightheadedness, these medications focus the relaxation on the prostate. One side effect that sexually active men may notice is a condition called retrograde ejaculation. This occurs when the urethra doesn’t close well during ejaculation, causing semen to take the “shorter route” to the bladder, rather than the “longer route” out of the penis.
5-Alpha Reductase Inhibitors (5ARI’s) work in an entirely different way than alpha blockers. These medications work by blocking the conversion of testosterone into DHT. If there is no DHT, then the prostate stops growing. In fact, in the absence of DHT, the prostate can begin to shrink. There are two medications available in the U.S. – finasteride and dutasteride. These medications work slowly by reversing the cause of BPH, so it can take longer for men to tell that they’re having an effect.
Phosphodiesterase Type 5 Inhibitors (PDE-5 Inhibitors) are used primarily for erectile dysfunction. However, they have been shown to improve the symptoms of BPH. There are multiple theories as to how they work, one being that they cause relaxation of smooth muscle. However, unlike alpha blockers, PDE-5 inhibitors work in less than half of men who use them – in fact, they usually only work in less than 1 in 5 men. Another theory is that PDE-5 inhibitors allow an older man to reduce the size of the prostate by eliminating excess prostate fluid through ejaculation. Since BPH affects primarily older men, it is also more likely to occur in men who have erectile dysfunction. Since the main purpose of the prostate is to create prostatic fluid as a major portion of semen, it stands to reason that less frequent ejaculation can cause some of this fluid to build up in the prostate thus increasing pressure in the gland and on the urethra. In addition, since wet dreams are often caused by higher testosterone levels, men with lower testosterone levels are less apt to have a wet dream to eliminate excess prostate fluid. This final theory works on the assumption that a prostate that doesn’t have as much prostatic fluid in it, is less swollen, and thus likely to improve BPH symptoms.
Supplements are also widely available on the market for treatment of BPH. Most include a natural product called Saw Palmetto. Saw Palmetto has little to no evidence that it helps with BPH. Other supplements include lycopene, pumpkin seed oil, and selenium. Some trials with supplements have shown some improvements in symptoms while others have not. Before starting any supplement, check with your medical provider to ensure that it won’t worsen symptoms or place you at risk with certain side effects.
In the final stages when medication options don’t work any longer, inserting a catheter in the urethra to create an opening for urine to flow through is often seen as the next step. Surgical procedures called a TURP (short for transurethral resection of the prostate) can also be performed to remove part of the prostate tissue around the urethra that blocks the flow of urine (see image below). One side effect of a TURP can involve some dribbling or incontinence due to the opening up of the urethra for a period of time until full healing. However, a TURP can remove the need for catheters for some. Other surgical options to open the prostatic urethra are also available on the market.
Because other symptoms can mimic BPH, it is important to see a healthcare provider. Enlarged prostates can also occur due to prostatitis and prostate cancer. It’s important to have a healthcare provider rule out these more serious causes of symptoms.
Images on this page from top to bottom include:
copyrighted by DNA Illustrations and used by permission.