Introduction:

Benign prostatic hyperplasia (BPH), a noncancerous enlargement of the prostate gland, makes urination difficult and uncomfortable. Your prostate gland is located underneath your bladder and surrounds your urethra, which empties urine from the bladder. As the prostate gland expands, it squeezes the urethra or causes the muscles around the urethra to contract, making it difficult to urinate.

Prostate enlargement is very common as men age -- symptoms usually develop around age 50 and by age 60, most men have some degree of BPH. At age 85, men have an 90% chance of having urination problems caused by BPH. It’s important to note that BPH is not cancer and it does not put you at increased risk for developing prostate cancer.

Signs and Symptoms:

Symptoms may include:

• Needing to urinate frequently
• Difficulty starting urination
• Stopping and starting while urinating
• Urinating frequently at night (nocturia)
• Dribbling after urination ends
• Being unable to empty your bladder
• Blood in the urine (BPH can cause small blood vessels to burst)
• Recurrent urinary tract infections

Causes:

Nobody knows the basic cause of BPH. Research shows that testosterone, the male hormone, or dihydrotestosterone, a chemical produced when testosterone breaks down in a man's body, may cause the prostate to keep growing. Another theory is that changes in the ratio of testosterone and estrogen (female hormone) as men age cause the prostate to grow.

Some over the counter medications for colds or allergies can drastically worsen BPH.

Diagnosis:

Your health care provider may check the size of your prostate gland directly by putting a gloved finger in your rectum and feeling the back wall of the prostate. Your health care provider will also order blood tests and possibly a urine sample. Other tests may include:

• Urinary flow test -- Your doctor may ask you to urinate into a device that measures the flow of urine.
• Intravenous pyelography -- Your doctor injects a dye into a vein to make the flow of urine visible on an X ray.
• Transrectal ultrasound -- Your doctor will insert an ultrasound probe in your rectum to get an image of your prostate gland.

In addition, you may be asked to complete a self screening form to evaluate the severity of your symptoms and the impact on your daily life. Your doctor can use this to monitor your condition over time.

Treatment Approach:

Treatment will depend on your age, overall health, and the severity of your symptoms. BPH symptoms may come and go, so it’s important to receive regular check-ups to monitor the progression of symptoms. There are many ways to successfully treat BPH, including some simple lifestyle changes if your symptoms are mild and several herbal remedies and medications that can be effective. If no other therapies work and the symptoms are severe enough, there are also several types of surgery to correct the condition.

Lifestyle

Many men with BPH have only minor symptoms. Some simple lifestyle changes may be all you need to feel better:

• Urinate when you first get the urge.
• Go to the bathroom when you have the chance, even if you don't feel a need to urinate.
• Avoid alcohol and caffeine, especially after dinner. Try not to drink within 2 hours before going to bed.
• Spread out your fluid intake throughout the day -- avoid drinking large amounts of fluid at one time.
• Avoid cold and sinus medications. Decongestants and antihistamines can worsen BPH symptoms.
• Exercise regularly.
• Do Kegel exercises to strengthen your pelvic floor.
• Reduce stress.

Medications

Alpha blockers -- cause the muscles around your bladder to relax, making it easier to urinate. These drugs were originally used to treat high blood pressure, and seem to work best in men with moderately enlarged prostates. Common side effects include decreased ejaculation and low blood pressure. These drugs should not be taken with medications for erectile dysfunction, such as Viagra or Cialis. Alpha blockers include:

• Terzosin (Hytrin)
• Doxazosin (Cardura)
• Tamsulosin (Flomax)
• Alfuzosin (Uroxatral)

5-alpha-reductase inhibitors -- shrink the prostate gland by lowering the amount of testosterone that the body converts into dihydrotestosterone, a hormone the prostate needs to grow. These drugs take longer to work than alpha blockers, and they lower PSA levels (a high level of PSA can indicate prostate cancer), making it harder to screen for prostate cancer. Enzyme inhibitors include:

• Finasteride (Proscar)
• Dutasteride (Avodart)
• Botulinum Toxin - Recent studies suggest that most patients with BPH experience symptomatic improvement from injections of botulinum toxin into the prostate.

Your doctor may suggest combination therapy -- taking an alpha blocker and an enzyme inhibitor at the same time.

Surgery and Other Procedures

Prostate surgery may be recommended if you have:

• Incontinence
• Recurrent blood in the urine
• Urinary retention
• Recurrent urinary tract infections

Which procedure is best for you usually depends on the severity of your symptoms and the size and shape of your prostate gland.

Minimally invasive techniques

These techniques may be better at relieving symptoms than medications, but are often not as effective as surgery. However, they are less likely to cause side effects than surgery.

Transurethtral microwave therapy -- uses heat from microwaves to shrink the prostate. This procedure works best for men with moderate symptoms and enlargement of the prostate.

Transurethral needle ablation -- uses radio waves to get rid of the part of the prostate that is blocking urine flow. It works best for men with mild to moderate enlargement of the prostate.

Interstitial laser therapy -- uses a laser to destroy excess tissue and shrink the prostate. It works best for men who have mild to moderate enlargement of the prostate and don’t experience urinary retention.

Surgery

Surgery is the most effective way to reduce your symptoms, but potential side effects include a small risk of erectile dysfunction or urinary incontinence.

Transurethral resection of the prostate (TURP) -- is the most common surgical treatment for BPH. It is performed by inserting a scope through the penis and removing the interior of the prostate piece by piece. It reduces symptoms quickly and is often used to treat men with moderately or severely enlarged prostates. One potential side effect is retrograde ejaculation, where semen goes into the bladder instead of out the urethra.

Transurethral incision of the prostate (TUIP) -- similar to TURP, but is usually performed in men who have a relatively small prostate. Like the TURP, a scope is inserted through the penis until the prostate is reached. Then, rather than removing prostate tissue, a small incision is made in the tissue to let the urethra expand and make urination easier.

Laser surgery -- Two types of laser surgery are used to destroy excess prostate tissue. Photosensitive vaporization of the prostate (PVP) is used for men with mild to moderate prostate enlargement, while holmium laser enucleation of the prostate (HoLEP) is usually used for men with severely enlarged prostates. Side effects can include retrograde ejaculation.

Open prostatectomy -- usually performed using general or spinal anesthesia. A surgeon makes an incision in your lower abdomen to reach the prostate and removes the inner part of the gland. This is a lengthy procedure, and usually requires a hospital stay of 5 - 10 days.

Most men who have prostate surgery see improvement in urine flow rates and symptoms. Possible complications include impotence, urinary incontinence, retrograde ejaculation, infertility, and urethral stricture (narrowing).

Nutrition and Dietary Supplements

Beta-sitosterol (60 - 130 mg per day) -- Beta-sitosterol is a cholesterol like compound found in plants. It has been studied for BPH and found to significantly improve urinary flow and decrease the amount of urine left in the bladder. It does not shrink the prostate, however. Beta-sitosterol is also used to lower cholesterol, making it a good option for men whose cholesterol levels are high. Plants that are high in beta-sitosterol, such as pumpkin seeds (Cucurbita pepo), are sometimes suggested for BPH. Talk to your doctor before adding any supplements to your BPH treatment regimen.

Herbs

The use of herbs is a time honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care practitioner.

• Saw palmetto (Serenoa repens, 320 mg per day) -- A number of studies have examined whether saw palmetto can relieve BPH symptoms, and many (though not all) showed positive results. Saw palmetto appears to work like Proscar and Avodart, which prevent testosterone from being converted into dihydrotestosterone (needed for prostate growth) in the body. Some studies have shown saw palmetto to be as effective as Proscar and finasteride and with fewer side effects. A European study showed that half of German urologists preferred saw palmetto over pharma agents for treatment of BPH. However, it does not shrink the overall prostate, but shrinks the inner lining of the gland. It should be noted that, unlike previous studies, a newer, high quality study found that saw palmetto had no effect on BPH symptoms. Talk to your doctor if you want to try saw palmetto for your symptoms, and look for a fat soluble saw palmetto extract that has been standardized to contain 85% - 95% fatty acids and sterols.
• Pygeum or African plum extract (Pygeum africanum, 75 - 200 mg per day) -- Pygeum has been used historically for urinary problems. In several scientific studies, pygeum relieved BPH symptoms including nocturia (increased urination at night) and improved urine flow.
• Grass pollen (Secale cereale) -- Two studies that compared a standardized extract of rye grass pollen to placebo found that the grass pollen improved BPH symptoms, including reducing frequency of nighttime urination and the amount of urine left in the bladder. One study also indicated that grass pollen decreased the size of the prostate as measured by ultrasound. The brand of rye grass pollen most often used in studies is Cernilton. People who have allergies to grass pollens should not take grass pollen supplements.

Prognosis and Complications

While the majority of men get better with treatment of BPH, men who have had long standing BPH may develop:

• Sudden inability to urinate
• Urinary tract infections
• Urinary stones
• Damage to the kidneys
• Blood in the urine

Alternative Names:

BPH; Prostate enlargement