BPH OVERVIEW

Benign prostatic hyperplasia is a condition that occurs when the prostate enlarges, potentially slowing or blocking the urine stream. Other names for benign prostatic hyperplasia include benign prostatic hypertrophy, an enlarged prostate, and BPH. BPH occurs only in men; approximately 8 percent of men aged 31 to 40 have BPH. In men over age 80, more than 80 percent have BPH.

Many men with BPH have no symptoms. In men with symptoms, the most common include needing to urinate frequently (during the day and night), a weak urine stream, and leaking or dribbling of urine. These symptoms are called lower urinary tract symptoms (LUTS). For men with bothersome symptoms, treatment with one or more medicines or surgery is available.

More detailed information about BPH is available by subscription. (See "Medical treatment of benign prostatic hyperplasia" and "Surgical and other invasive therapies of benign prostatic hyperplasia".)

THE PROSTATE GLAND

The prostate is a small gland that is part of the male reproductive system. It sits just below the bladder and in front of the rectum (figure 1). The prostate is normally about the size of a walnut.

The prostate is composed of two lobes, covered by an outer layer of tissue. The prostate surrounds the urethra, the tube that carries urine from the bladder through the penis and outside the body.

BENIGN PROSTATIC HYPERPLASIA CAUSES

It is not clear why some men develop symptoms of BPH or lower urinary tract symptoms (LUTS) and others do not. The prostate normally enlarges to some degree in all men with advancing age, although not all men require treatment. Several hormones are required for BPH to develop, but these hormones alone do not cause the condition.

Some experts believe that a family history of the condition increases a man's risk of developing BPH. Frequency of sex and having a vasectomy do not increase a man's chances of developing BPH.

BENIGN PROSTATIC HYPERPLASIA SYMPTOMS

The symptoms of BPH usually begin after age 50. The most common symptoms of BPH include:

• Frequent urination, especially at night
• A hesitant, interrupted, or weak stream of urine
• The need to urinate frequently
• Leaking or dribbling of urine

These symptoms tend to appear over time and may gradually worsen over the years. However, some men have an enlarged prostate that causes few or no symptoms, while other men have symptoms of BPH that later improve or stay the same. Some men are not bothered by their symptoms, while others are bothered a great deal.

In a small percentage of men, untreated BPH can cause urinary retention, meaning that the man is unable to empty the bladder. The risk of urinary retention increases with age and as symptoms worsen.

Symptoms of BPH can also be caused by other conditions, including prostate or bladder cancer, kidney stones, and overactive bladder. Overactive bladder causes a strong, frequent, uncomfortable need to urinate immediately.

BENIGN PROSTATIC HYPERPLASIA DIAGNOSIS

To know if BPH or another problem is causing your symptoms, a doctor or nurse will ask you questions, perform an exam, and do blood and urine tests. (See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia".)

• Rectal exam — Your doctor or nurse will need to perform a rectal examination to feel the size and shape of the prostate gland. A rectal exam can help to determine if there are signs of prostate cancer (figure 2).
• Urinalysis — You might be asked for a urine sample to see if you have a bladder infection. (See "Patient information: Urinary tract infections in adolescents and adults (Beyond the Basics)".)
• Blood tests — A blood test to check the prostate-specific antigen (PSA) level is recommended. PSA is a protein produced by prostate cells; the PSA level may be increased in men with BPH. Men who have prostate cancer often have a highly disproportionately-elevated PSA level, although prostate cancer is also found in men who do not have an elevated PSA.

Having BPH does not increase your risk for prostate cancer. However, it is possible to have both BPH and prostate cancer at the same time. If your PSA test is higher than normal, you will need further testing to be sure that you do not have prostate cancer. (See "Patient information: Prostate cancer screening (Beyond the Basics)".)

Urodynamic study — A bladder test, known as a urodynamic study, might be recommended for some men who have signs or symptoms of BPH. This test can give information about how well the bladder and urethra are working.

BENIGN PROSTATIC HYPERPLASIA TREATMENT

Treatments for BPH can help to reduce urinary symptoms. Treatment options include medicines and surgery.

Men with mild BPH might not need treatment. In this case, most experts recommend a "wait and watch" approach. This means that you will watch your symptoms over time. In some cases, BPH symptoms improve without treatment. However, men with moderate to severe symptoms usually require treatment.

Medicines — There are two types of medicine used to treat BPH: alpha blockers and alpha-reductase inhibitors. Most men with BPH who start taking a medicine will need to take it forever. (See "Medical treatment of benign prostatic hyperplasia".)

Alpha blockers — These medications relax the muscle of the prostate and bladder neck, which allows urine to flow more easily. There are at least four medications in this category: terazosin (Hytrin®), doxazosin (Cardura®), tamsulosin (Flomax®), alfuzosin (Uroxatral®), and silodosin (Rapaflo®). Terazosin and doxazosin were initially developed to treat high blood pressure, but were later found to be useful for men with BPH.

Alpha blockers begin to work quickly and are usually recommended as a first-line treatment for men with mild to moderate symptoms.

• Side effects — The most important side effects of alpha blockers are dizziness and low blood pressure after sitting or standing up. Terazosin and doxazosin are usually taken at bedtime (to reduce lightheadedness). The dose can be increased over time if needed.

You should not take terazosin and doxazosin if you take a medicine for erectile dysfunction (ED), such as sildenafil (Viagra®), vardenafil (Levitra®), and tadalafil (Cialis®). Tamsulosin and alfuzosin usually do not interact with ED medications.

Alpha-reductase inhibitors — Alpha-reductase inhibitors are medicines that can stop the prostate from growing further or even cause it to shrink. Finasteride (Proscar®) and dutasteride (Avodart®) are alpha-reductase inhibitors.

This type of medicine works better in men with a larger prostate. It can reduce the risk of urinary retention (not being able to empty the bladder) and the need for surgery. Most men see an improvement within six months of starting treatment.

• Side effects — A small percentage of men who take alpha-reductase inhibitors have decreased sex drive or difficulty with erection or ejaculation. Rarely, this problem causes men to stop BPH treatment. This side effect is reversed when the drug is stopped.

PSA levels decrease by about 50 percent in men who take finasteride or dutasteride. This is important to remember if you have PSA testing to screen for prostate cancer. (See "Patient information: Prostate cancer screening (Beyond the Basics)".)

Combination treatment — A combination of an alpha blocker and an alpha-reductase inhibitor might be recommended for certain men. This may benefit men:

• With severe symptoms
• With a large prostate
• Who do not improve with the highest dose of an alpha blocker

Herbal medicines — Herbal therapies for BPH, such as saw palmetto, are commonly used in Europe for treatment of BPH. However, the best studies of saw palmetto have shown no benefit in reducing the symptoms of BPH. For this reason, we do not recommend the use of saw palmetto or other herbal medicines to treat BPH. (See "Clinical use of saw palmetto".)

Lifestyle changes — All men with BPH should avoid medicines that can worsen symptoms or cause urinary retention. These include certain antihistamines (such as diphenhydramine [Benadryl®]) and decongestants (eg, pseudoephedrine [found in some cold medicines]).

Lifestyle changes are also recommended if you are bothered by having to go to the bathroom frequently. This includes:

• Stop drinking fluids a few hours before bedtime or going out
• Avoid or drink less fluids that can make you go more often, like caffeine and alcohol
• Double void. This means that after you empty your bladder, you wait a moment and try to go again. Do not strain or push to empty.

Surgical treatments — If medicines do not relieve your symptoms of BPH, a surgical treatment may be recommended. Surgery is used to reduce to reduce the amount of prostate tissue around the urethra (figure 1). This may be done by:

• Removing some prostate tissue
• Shrinking the prostate with heat

Each treatment has advantages and disadvantages, and the best treatment depends on the size and location of the excess prostate tissue and your preferences. (See "Surgical and other invasive therapies of benign prostatic hyperplasia".)

Transurethral resection of the prostate (TURP) — Transurethral resection of the prostate (TURP) is the most common surgical treatment for BPH. The surgeon inserts a device through the urethra to remove strips of the enlarged prostate. The procedure is done while you are asleep and takes 60 to 90 minutes. Most men stay in the hospital overnight after TURP.

Serious complications are rare with TURP. The most common complications include:

• Needing to wear a catheter to empty the bladder temporarily
• Bleeding for up to several weeks after surgery
• Injury of the prostate

After surgery, most men have less semen with ejaculation because much of the semen is directed into the bladder. However, difficulties with erection and pain with ejaculation often improve after surgery.

Transurethral needle ablation (TUNA) — In this procedure, specific areas of the enlarged prostate are burned away. TUNA can usually be performed using only local anesthesia (usually lidocaine gel, which is inserted into the urethra), and the man is usually able to go home after the procedure. This procedure improves the flow of urine and reduces BPH symptoms.

TUNA is often preferred for men with medical problems, particularly men who must take blood-thinning medications like warfarin (Coumadin®). TUNA is also an alternative for men who prefer a procedure that has a lower risk of urine leakage and sexual side effects. However, men treated with TUNA are more likely to need another BPH procedure over time compared with men who have TURP.

Other procedures — A number of other surgical procedures are available for men with BPH.

• Microwave thermotherapy — This procedure uses heat to destroy excess prostate tissue. It is performed as a day surgery, and most men are able to go home after the procedure.
  
  Thermotherapy does not cure BPH or problems emptying the bladder (retention). However, it does improve symptoms of needing to rush to the bathroom frequently, the need to strain, and slow urine flow.

• Transurethral incision of the prostate (TIP) — In this procedure, a surgeon widens the urethra (figure 1). Prostate tissue is not removed. Transurethral incision of the prostate (TIP) is performed with anesthesia and generally requires a 24-hour stay in the hospital.
  
  TIP might be recommended for men who cannot empty their bladder and do not have a large prostate, especially if the man has other medical problems. Another surgical treatment for BPH is sometimes needed a few years after TIP.

• Removal of the prostate — Surgery to remove the prostate (prostatectomy) might be recommended for men who are healthy and have a very enlarged prostate.
• Laser surgery — With laser surgery, a surgeon uses laser to destroy prostate tissue and shrink the prostate. Laser surgery is similar to a TURP but causes less bleeding.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Benign prostatic hyperplasia (enlarged prostate) (The Basics)
Patient information: Prostate cancer screening (PSA tests) (The Basics)
Patient information: Prostatitis (The Basics)
Patient information: Urinary incontinence in men (The Basics)
Patient information: Hydronephrosis in adults (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Urinary tract infections in adolescents and adults (Beyond the Basics)
Patient information: Prostate cancer screening (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia
Clinical use of saw palmetto
Epidemiology and pathogenesis of benign prostatic hyperplasia
Medical treatment of benign prostatic hyperplasia
Surgical and other invasive therapies of benign prostatic hyperplasia

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/prostatediseases.html)

• American Urological Association

     (www.auanet.org)

• National Institute of Diabetes and Digestive and Kidney Diseases

     (http://kidney.niddk.nih.gov/kudiseases/pubs/prostateenlargement/index.htm)

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