Benign Prostatic Hyperplasia – BPH
BPH – Benign Prostatic Hyperplasia (Enlarged Prostate)
Most men – if they live long enough – suffer from BPH (Benign Prostatic Hyperplasia). BPH is the swelling or enlargement of the prostate which occurs naturally in men as they age.
How does BPH occur?
The innermost layer of the prostate – the transitional zone – gradually begins to swell in middle aged men and is a normal part of the ageing process. An enlarged prostate begins to cause problems when it interferes with daily activities.
Why is BPH a problem?
The prostate gland is situated between the bladder and the penis. The urethra – which transmits urine from the bladder and semen when we ejaculate – runs through the centre. An enlarged prostate can cause the following issues because of its location in the body:
- Difficulty urinating -BPH gradually compresses and narrows the urethra making urination slower and more difficult.
- Increased night time urination – when the prostate enlarges upwards it alters the shape of a valve at the bottom of our bladder. This valve is more affected when we are lying down making night time urination more frequent.
What Are The Symptoms of BPH?
- Slowness of urinary flow
- Frequent urination
- Difficulty urinating
- Night time urination
- Dribbling after urinating
What are uncommon symptoms of BPH?
If you are experiencing any of the below symptoms it is recommended that you visit your GP.
- Blood in the urine – should be checked with your GP but it can sometimes be caused by BPH.
- Pain on urination – likely to be due to infection or inflammation and needs to be investigated.
- Pain on ejaculation
- Frequent urination – This may be diabetes if associated with thirst and drinking a lot of fluids.
- Lower abdominal pains
If you think you may have BPH, the first thing to do is complete the International Prostate Symptom Score, or IPSS which is available here. Ideally print off your copy and bring it with you to your prostate check-up.
The total scored is divided into three categories.
Mild Prostatic Symptoms
If you are experiencing mild prostatic symptoms, you can adopt some simple measures and repeat the score in one year:
- Reduce the amount that you drink before a particular activity where frequent urination would be a problem. Also, don’t drink within 2 hours of bedtime.
- After passing urine, go back to the toilet again after a few minutes to try to pass some more to ensure the bladder is emptied completely.
- Consider reducing or stopping caffeine (commonly found in tea, coffee and cola). Coffee is the worst.
- If urgency is a problem try some distraction techniques such as breathing exercises and mental tricks (for example, counting) to take your mind off the bladder.
- If frequency is a problem try retraining the bladder by holding on for as long as you can each time before passing urine. The bladder muscle can be trained to expand more in this way. Eventually, the bladder may be trained to hold on for longer each time before you need to go to the toilet.
- If you are a smoker then stopping smoking may significantly improve your symptoms, as nicotine directly irritates the bladder. This is not a myth.
Moderate to severe symptoms.
If you are experiencing moderate to severe symptoms – and score more 8 or more on the IPSS – you should get your prostate checked.
While symptoms of BPH are most of the time caused by an enlarged prostate, there can be other reasons which need to be checked. A prostate check-up ideally involves the following:
- A prostate symptom questionnaire
- Physical examination by a doctor
- Urine and blood tests
- An ultrasound examination of your bladder
Find out more detail about what is involved here.
What happens next?
Your results will depend on what happens next which will be one of the following:
- Do nothing specific except the general measures advised for mild prostate symptoms.
- Your doctor may suggest medical treatment with tablets.
- You may be referred to a specialist called a urologist. This is usually because of more severe symptoms, a concern about prostate cancer, a bladder abnormality or just to get another opinion.
There are two types of medicines used for treating BPH. These are called:
- Alpha Blockers
- 5-alpha reductase inhibitors (5ARIs)
With BPH the slowing of urine flow is caused by a combination of two problems:
- The physical swelling of the innermost layer of the prostate
- The action of a type of muscle called smooth muscle within the gland, at the bottom of our bladders. When these smooth muscles over-tighten they can squeeze the urethra – the tube that we urinate through – and slow down the flow of urine.
Smooth muscle cannot be consciously told what to do by our brains, unlike our other muscles which do what they are told, such as move my thumb.
Alpha Blockers are medicines that relax smooth muscles and can be used to treat the symptoms of BPH.
Selective Alpha1 Blockers work specifically on prostate and bladder muscles. They mainly block the so called Alpha 1A receptors – found in the bladder and prostate – rather than the Alpha1B receptors found in the arteries therefore they don’t have they same, negative side effects as older Alpha blockers.
Alpha 1 blockers are taken once a day, and generally improve things within a week. They can be taken indefinitely and side effects are uncommon.
Side Effects of Alpha 1 Blockers
All these will go away if the drug is stopped, but most men are happy to continue with these drugs. Side effects can include:
- Runny nose
- Difficulty ejaculating
- Retrograde ejaculation – this can happen where a man experiences orgasm but no semen comes out.
There is a possible link with a disorder known as ‘floppy iris syndrome’, and it is advised that anyone taking an Alpha 1 blocker and needing eye surgery inform their surgeon they are taking the medicine.
The most commonly used alpha blockers are:
- Silodosin – arguably the most refined Alpha1 blocker. This Alpha1 blocker has been proven least likely to cause dizziness and unsteadiness often due to a sudden drop in blood pressure.
The improvement noticed with an Alpha Blocker may eventually wear off, but most men will get many years of relief and improvement.
5-Alpha Reductase Inhibitors (5-ARI)
These drugs work by shrinking the prostate and letting urine flow easier by blocking the conversion of an inactive hormone called testosterone to its active form. This happens only inside the prostate, and doesn’t affect our hormones elsewhere. It is like shutting off its food supply, and the prostate slowly reduces in size. This is very gradual, and takes up to 6 months before the effect is noticed.
They are really only suitable for men with moderately enlarged prostates. They also lower the blood levels of an important enzyme called PSA, which is produced by the prostate, and measuring the blood level of this is one of the ways that risk of prostate cancer is assessed.
There are two main 5-ARIs:
They are taken once a day, and can be used indefinitely.
Side Effects of 5-Alpha Reductase Inhibitors (5-ARI)
Similar to the Alpha1 blockers, all side-effects should go away if the drug is stopped. If you have severe liver disease you should not take a 5-ARI.
- Loss of interest in sex
- Erectile difficulty
- Problem with ejaculation
- Swollen feet (rare)
There are concerns that 5-ARIs could be of harm to a pregnant woman, it is advisable not to donate blood if taking one, in case the blood is given to a pregnant woman.
Combination drug treatment for BPH
In theory, taking a combination of an Alpha Blocker and a 5-ARI drug should give us the best of both worlds – a fairly quick improvement of symptoms and a longer term reduction in the size of the prostate. However, this combination is best suited for men with moderately enlarged prostates. This makes sense, as small prostates will not benefit from size reduction. Very large prostates may be beyond medical treatment and usually need surgery.
A tablet that combines the alpha blocker Tamsulosin with the 5-ARI Dutasteride has been available for some years. Side effects are the same as those for the individual drugs.
Surgical treatment for BPH
Surgical treatment for BPH has been performed for over a century, with newer techniques and instruments being developed. Most surgical techniques involve removing the inner part of the gland only, and leaving the outer sections. This is enough to allow us urinate freely.
There are many reasons why we may consider surgery for BPH. They include:
- Failed medical management. This could be because of unacceptable side effects, not enough improvement, or gradual loss of effectiveness of the treatment taken.
- More severe BPH, usually with higher IPSS score.
- Men with very large prostates.
- Acute urinary retention, especially if it recurs. When this happens we suddenly find it impossible to pass water, and it is a medical emergency. We will need to have a tube called a catheter passed up the penis into the bladder.
- Inability to empty the bladder. Here the bladder cannot fully empty itself, and gradually gets bigger and bigger. Eventually it can lose the ability to push the urine out.
- When there is evidence that BPH is causing kidney problems.
- Some of us may prefer to have surgery, and get it over with, as opposed to ongoing medication.
TURP can be described as getting a re-bore of the prostate, rather like the old fashioned apple corer, where only the centre part is removed and the rest left alone. Since it is the innermost layer of our prostate – called the transitional zone – that swells up and blocks the flow of urine, it makes sense just to remove this part.
How it is done?
TURP is only done in a hospital, with either a full general or a spinal anaesthesia. Your urologist will insert a resectoscope, a thin metal wire with a light, a camera and a loop at the end in through the penis. It goes up the urethra – the tube we pee through. He will view it on a monitor. An electrical current heats the loop, which cuts away the centre of the prostate.
Towards the end of the procedure a catheter, a thin flexible tube, is used to irrigate fluid into the bladder and remove all the cut sections of tissue. The operation takes about one hour. The catheter is left in temporarily. Normally, 24-48 hours after the op the catheter is removed, and you can go home. Most physical activities can be gradually resumed within 4 weeks, and there should be little pain.
What happens after?
Most urologists advise us to rest for one week, but walking around the house and garden is usually OK. You should find urinating much easier than before, but there will be some blood in the urine for a couple of weeks. It is also normal to have slight irritation and some urinary frequency because your bladder and urethra have been irritated during the op.
You will need to discuss with your urologist when it is safe to return to work.
Advantages of TUR
- 85% experience a significant improvement in symptoms
- Only 10% will need a second op – about 2% per year.
- Improvement is nearly immediate.
Problems of TUR
- The majority of men who have TUR are not able to ejaculate normally having sex, and suffer from ‘retrograde ejaculation’, where semen in ejaculated upwards into the bladder. However, the sensation of orgasm is not affected.
- Urinary incontinence happens to 2%. Mostly it is better in one month, but in some men it persists.
- The urethra – the tube we pee through – can be damaged, and symptoms similar to BPH can recur. This thankfully is fairly easy to treat, but with a minor op.
- Erectile dysfunction affects 5-10%, but can usually be successfully treated with medicine.