Benign Prostatic Hyperplasia: Made Simple

Disease and Therapy , Knowledge Base / October 3, 2016

Prostate gland enlargement, also known as benign prostatic hyperplasia (BPH) or prostatic hypertrophy, is a common condition men suffer from as they grow older, which can cause bothersome urinary symptoms. Left untreated, it can result in blockage of the flow of urine out of the bladder, and can cause bladder, urinary tract or kidney problems.

1. Introduction:

The prostate gland lies beneath the bladder and it is the male organ responsible for producing most of the fluid in the semen, the milky-colored fluid that nourishes and transports sperm out of the penis during ejaculation. The tube which transports urine from the bladder out of the penis, the urethra, passes through the center of the prostate; hence, when the prostate enlarges, it begins to obstruct urine flow.

Most men have continued prostate growth throughout life, and in many men this continued growth enlarges the prostate enough to cause urinary symptoms or to significantly block urine flow.

While there are several effective treatments for BPH, the physician will consider particular symptoms, prostate size, and other patient-specific conditions before deciding on the best treatment option for the individual patient. Treatment options include medications, lifestyle changes and surgery.

2. Symptoms:

BPH varies in severity among men with a tendency to gradually worsen over time. Symptoms of BPH commonly include:

  • Weak urine stream
  • Difficulty starting urination
  • Stopping and starting while urinating
  • Dribbling at the end of urination
  • Frequent or urgent need to urinate
  • Increased frequency of night-time urination (nocturia)
  • Straining while urinating
  • Not being able to completely empty the bladder
  • Urinary tract infection
  • Formation of stones in the bladder
  • Reduced kidney function

The size of the prostate does not necessarily mean that symptoms will be worse. Some men with only slightly enlarged prostates experience significant symptoms; while others with much enlarged prostates suffer minor urinary symptoms. Only about half the men with prostate enlargement have symptoms that become bothersome enough for them to seek medical attention. In some men, these symptoms eventually stabilize and may even improve over time.

3. Causes:

Doctors aren’t sure exactly what causes the prostate to enlarge; one theory is that it may be due to changes in the balance of sex hormones as men grow older.

4. Risk Factors:

The main risk factors for prostate gland enlargement include:

  • Ageing: Prostate gland enlargement rarely causes signs and symptoms in men younger than 40. By 55, about 1 in 4 men have some signs and symptoms. By 75, about half of men report some symptoms.
  • Family history: Having a blood relative with prostate problems, means a person is more likely to experience similar problems as well.
  • Location: Prostate enlargement is more common among American and Australian men. It is less common in Chinese, Indian and Japanese men.

5. Complications

Prostate gland enlargement becomes a serious problem when it severely interferes with a person’s ability to empty their bladder. In this case, surgery will most likely be needed. Complications of an enlarged prostate include:

  • Acute urinary retention: A sudden, painful inability to urinate. It may occur after taking an over-the-counter decongestant medication for allergies or cold. The doctor may place a tube (catheter) through the urethra and into the bladder, or a suprapubic tube (a catheter that drains the bladder through the lower abdomen). Some men with an enlarged prostate require surgery to relieve urinary retention.
  • Urinary tract infections
  • Bladder stones: They are mineral deposits that can cause infection, bladder irritation, blood in the urine, and obstruction of urine flow. These are generally caused by inability to completely empty the bladder.
  • Bladder damage: This occurs when the bladder hasn’t completely emptied over a long period of time. This results in stretching and weakening of the muscle wall which can no longer contract properly. Symptoms of bladder damage often improve after prostate surgery or treatment, though not always.
  • Kidney damage: This is caused by high pressure in the bladder due to urinary retention. This high pressure can directly damage the kidneys or allow bladder infections to reach the kidneys. When an enlarged prostate causes obstruction of the kidneys, a condition called hydronephrosis (swelling of the urine-collecting structures in one or both kidneys) may result.

Even though most men with an enlarged prostate don’t develop these complications, acute urinary retention and kidney damage in particular can be serious health threats when they develop.

6. Tests and Diagnosis

An initial evaluation for enlarged prostate will likely include:

  • Symptom questionnaire
  • Digital rectal exam
  • Neurological exam
  • Urine test (urinalysis)

Additional tests may be conducted to rule out other problems and help confirm that an enlarged prostate is the cause of the urinary symptoms. These tests can include:

  • Prostate –specific antigen (PSA) blood test: PSA is normally produced by the prostate gland, which helps liquefy semen. PSA levels are increased in case of enlarged prostate, prostate cancer, recent tests, surgery or prostatitis.
  • Urinary flow test: This test measures the strength and amount of urine flow. The results, over time, help determine if a patient’s condition is getting better or worse.
  • Postvoid residual volume test: This test measures a person’s ability to empty their bladder completely.
  • Transrectal ultrasound
  • Prostate biopsy
  • Urodynamic and Pressure flow studies: Allow measurement of bladder pressures and determination of how well bladder muscles are working.
  • Cytoscopy (Urethroscopy): After administratin of a local anesthetic, a lighted flexible telescope (cytoscope) is inserted into the urethera.
  • Intravenous pyelogram or CT program: Test helps detect urinary stones, tumors or blockages above the bladder. The dye injected into a vein helps outline the drainage system of the kidneys as it is visualized by x-rays or CT scans.

Various other causes of urinary symptoms may exist. Problems that can cause urinary symptoms similar to those of enlarged prostate include:

  • Bladder stones
  • Bladder and urinary tract infections
  • Diabetes
  • Neurological problems
  • Prostatitis
  • Prostate cancer
  • Stroke
  • Muscle and nerve disorders
  • Scarring or narrowing of the urethra

Prostate cancer is very different from prostate gland enlargement, even if they can share similar symptoms and be detected by the same tests. Having an enlarged prostate doesn’t reduce or increase the risk of prostate cancer, and even if you’re being treated for prostate gland enlargement, you still need to continue regular prostate exams to screen for cancer.

7. Treatment and Drugs

A wide range of treatment options are available for enlarged prostate, including medications, surgery and minimally invasive surgery. The optimal treatment choice depends on several factors, including how bothersome the symptoms are, prostate size, concomitant health conditions, age and preference. Sometimes the symptoms aren’t too bothersome, and the patient will decide to live with them until the need for treatment arises.

7.1 Medications:

Medications are the most common treatment option for moderate symptoms of prostate enlargement. Medications used to relieve symptoms of enlarged prostate include:

7.1.1 Alpha Blockers:     

Alpha blockers relax bladder neck muscles and muscle fibers in the prostate itself, making it easier to urinate. These medications work quickly, within a day or two, to increase urinary flow and reduce the need to urinate.

Alpha blockers can start to work within two to three days, and may show an effect of relieving urinary symptoms within two to three weeks. They, however, do not stop the prostate from continuing to grow.

Alpha blockers may result in a harmless condition called retrograde ejaculation, where semen tends to go back into the bladder rather than out the tip of the penis. They cannot be taken with medications used to treat erectile dysfunction, such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). Concomitant administration of these two medication classes can result in an unhealthy lowering of blood pressure.

Alpha blockers include doxazosin (Cardura), tamsulosin (Flomax, Block-Alpha, Cure-Pro, Omnic, Omnic Ocas, Tamsul, Tamsulin), alfuzosin (Uroxatral, Prostetrol, Xatral-SR, Xatral-XL), terazosin (Hytrin), and silodosin (Rapaflo),

7.1.2 5-Alpha Reductase Inhibitors:

These medications shrink the prostate by inhibiting the effect of male hormones (androgens) on the prostate, which may slow growth and even cause the prostate to shrink. They generally work best for much enlarged prostates, and it may take several weeks or months for signs of improvement to show.

Several sexual side effects may be noticed with 5-alpha reductase inhibitors, including impotence (erectile dysfunction), decreased libido, or retrograde ejaculation. In addition, these medications tend to lower prostate-specific antigen (PSA) levels in the blood, which is a marker used for detection of early-stage prostate cancer.

5-alpha reductase inhibitors can be taken safely with medications used for erectile dysfunction.

These medications include finasteride (Proscar, Prostec, Prostride) and dutasteride (Avodart).

7.1.3 Combination Drug Therapy:

Concomitant administration of an alpha blocker with a 5-alpha reductase inhibitor is generally more effective than taking either alone.

7.1.4 Tadalafil (Cialis):

This medication, belonging to the phosphodiesterase inhibitors class of drugs, is often used to treat impotence (erectile dysfunction). It can, however, also be used to treat prostate enlargement.

Tadalafil can’t be used in combination with alpha blockers, and it also can’t be used with nitrates or nitrate-containing medications, such as nitroglycerin.

7.2   Dietary Supplements:

7.2.1. Saw Palmetto Extract:

It is a fat-soluble extract of the saw palmetto berry which has become one of the leading natural treatments for BPH. While it may not reduce the size of the prostate, numerous human trials showed that saw palmetto improves the symptoms of BPH.

Saw palmetto appears to possess 5-alpha reductase inhibitor activity, preventing the conversion of testosterone to dihydrotestosterone (DHT), thus helping to maintain normal prostate function. It also prevents DHT from binding in the prostate.

A three-year preliminary study in Germany found that 160 mg of saw palmetto taken twice daily reduced night-time urination in 73% of patients and significantly improved urinary flow rates. A review of all available double-blind trials has concluded that saw palmetto is effective for treatment of men with BPH, and is just as effective as, with fewer side effects, than the drug finasteride.

7.2.2 Pumpkin Seed:

Approved for this use in 1985, pumpkin seed has become a popular treatment today for BPH.

One of the factors that contribute to BPH is overstimulation of the prostate cells by testosterone and its conversion product, DHT. Components in pumpkin seed oil are able to interrupt this triggering of prostate cell multiplication by testosterone and DHT, although the exact mechanism for this effect is still a matter of discussion. The carotenoids and omega-3 fats found in pumpkin seeds are also being studied for their potential prostate benefits. Men with higher amounts of carotenoids in their diet possess a lower risk for BPH

Pumpkin seed is considered to be one of the best natural sources of essential fatty acids (EFA’s), which promote free urinary flow. As the body does not manufacture EFA’s, they need to be replenished through a healthy diet or supplements.

Pumpkin seed oil has been used in combination with saw palmetto in two double blind human studies to effectively reduce symptoms of BPH. Researchers have suggested that the zinc, free fatty acid, or plant sterol content of pumpkin seeds might account for their benefit in men with BPH. Studies have shown that pumpkin seed extracts can improve the function of the bladder and urethra, this might partially account for BPH symptom relief.

7.2.3 Zinc:

Zinc is possibly the single most important nutrient for a healthy prostate. The normal prostate gland contains more zinc than any other organ. Zinc supplementation has been shown to diminish the symptoms of BPH and actually reduce the size of the prostate. Furthermore, adequate zinc levels also prevent the formation of DHT.

7.2.4 Vitamin E:

Numerous studies indicate that Vitamin E substantially reduces the risk of prostate cancer. A study conducted in Finland followed 29,132 men from 1985 to 1991. The men who took Vitamin E (50 IU’s per day) experienced 41 percent fewer deaths from prostate cancer than those not receiving Vitamin E.

7.2.5 Vitamin B6 (Pyridoxine):

Vitamin B6, the universal catalyst or carrier, helps all other nutrients to perform better. Additionally, Vitamin B-6 has a direct effect upon prolactin levels, reducing them safely and naturally. A reduction of prolactin prevents the conversion of testosterone to DHT.

7.2.6 Pygenum Africanum:

Pygenum Africanum is an extract from the bark of an African plum tree, and has been used historically to treat urinary tract infections. Pygeum Africanum has been used to treat BPH in Europe since the 1980s. It is believed that it also inhibits the conversion of testosterone to DHT, thus helping to maintain normal prostate function.

In an analysis of 18 trials, the herb provided a moderate improvement in the symptoms associated with BPH compared to placebo, with mild side effects.

7.2.7 Lycopene:

Lycopene is an antioxidant that may lower the risk of prostate cancer especially when combined with Vitamin E. A Harvard Medical School study showed a considerable relationship between lycopene and the reduction of prostate cancer.

Other natural ingredients that have been shown to support overall prostate health include Magnesium, Selenium, Folic Acid, and Vitamin B12 (cyanocobalamin).

7.3 Surgery:

Surgery may be recommended in cases where medications haven’t proved effective or if symptoms are too severe. Several types of surgery exist for an enlarged prostate and they all aim at reducing the size of the prostate gland and opening the urethra by treating the enlarged prostate tissue that blocks urine flow.

Deciding which type of surgery may be an option is based on a number of factors, including size of the prostate, severity of symptoms, and available treatment options. Any type of surgery can cause side effects, such as retrograde ejaculation, urinary incontinence, and impotence.

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