Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy or enlarged prostate, is the noncancerous growth of the prostate gland. BPH is very common in the US, in fact most men over the age of 60 have the disorder. The enlarged prostate can start to squeeze the urethra and make urination difficult. Typically, one-third of all men experience BPH-related symptoms by age 50, and 70 percent of men experience BPH-related symptoms by age 70. Generally, no treatment is needed if BPH symptoms are mild, while moderate symptoms should be addressed with some form of treatment.
Experts do not know for certain what causes BPH. One theory is that the prostate glands of older men respond better to the male hormone testosterone and its directive to “grow.” Another theory is that a fluctuation in the ratio of testosterone to estrogen may trigger the growth (men produce small amounts of the typically female hormone estrogen; or more specifically, a type of estrogen called estradiol). Other factors include:
- Age: The half-century mark seems to be the tipping point when it comes to greater risk of developing BPH. While slightly more than 20 percent of American men ages 40 to 49 have symptoms of BPH, this figure rises to 35 percent among men 50 to 59, 58 percent in the 60 to 69 age group, and 84 percent in men age 70 and older. Factors that may contribute to the age-related risk of developing BPH include changes in hormone levels and damage to the blood vessels that supply the prostate and surrounding structures. When the prostate cells are deprived of enough blood, some experts speculate that this triggers the unwanted growth.
- Family history: Men who have a close male relative (father, grandfather, brother, son) who have BPH have an increased risk of getting the disease, especially if their relatives had symptoms severe enough to require treatment before the age of 60
- Excessive DHT: DHT is the acronym for dihydrotestosterone, a substance that is the result of a conversion of testosterone by an enzyme called 5-alpha reductase. BPH is an “androgen-dependent disease,” which means it is influenced by the male hormone (androgen) testosterone. The prostate will not grow unless it is “directed” to do so by testosterone, which is made mainly by the testes. Boys who have their testicles removed before they reach puberty will never develop BPH, and removing them after puberty but before BPH develops dramatically reduces the chance of suffering from the disease. But testosterone alone is not the bad guy: it must be converted by 5-alpha-reductase into DHT, and the DHT is what promotes the prostate cells to grow. Experts believe DHT levels rise in many men as they age, even if testosterone levels decline, and that the buildup of DHT may be a factor in BPH.
- Elevated Estradiol: It’s natural for men to have some of the female hormone estrogen (in the form of estradiol). Estradiol is produced as a byproduct of conversion of testosterone, among other means. The proper balance of estrogen-to-testosterone in men is important for a healthy sex drive, to enhance brain function, protect the heart, and strengthen the bones. When estradiol levels are too high, however, and the ratio is out of balance, men can experience fatigue, increased body fat, loss of libido and an enlarged prostate. An imbalance between estrogen and testosterone increases DHT activity, and thus encourages prostate cells to grow.
- Overweight/Obesity: Being overweight, especially around the midsection, raises the risk of excessive prostate growth. (Zucchetto 2005; Enlarged Prostate, AUA) A review study published in July 2009 also noted a strong relationship between obesity and the development of BPH and lower urinary tract infections. The link between obesity and BPH may be related to the reduced testosterone levels seen in the obese. Also, a drop in testosterone means there’s an accompanying rise in estrogen levels, which can increase the activity of DHT and thus prostate growth. Obesity also affects insulin levels in the blood, which is another risk factor for BPH (see below).
- Diabetes: Having diabetes increases the risk of developing BPH, perhaps significantly. (Sarma 2009) Research indicates it may be due to elevated insulin levels, which not only “corral” the blood sugar and usher it into the cells, but also stimulate growth. (Nandeesha 2006) The diabetes-BPH link may also be related to the damage that diabetes does to blood vessels. If the vessels that service the prostate are damaged, an enlarged prostate may be the result. (Berger 2005a)
- High blood pressure: Although no one is exactly sure how high blood pressure may trigger or worsen BPH, researchers have found a link between hypertension and BPH.
- High “Bad” Cholesterol: In 2008, researchers at the UCSD School of Medicine reported that among men with diabetes, those who had higher levels of the notorious “bad” cholesterol, low-density lipoprotein (LDL), were more likely to develop BPH than men who had normal LDL levels. (Parsons 2008) When the researchers divided the men into three groups (high, medium, low), those with “high” LDL levels were four times more likely to have BPH than those in the “low” group.
- Metabolic syndrome: Also referred to as “Syndrome X,” metabolic syndrome is a cluster of disorders that increase the risk of developing cardiovascular disease. These disorders include obesity, elevated blood pressure, glucose intolerance or insulin resistance (the inability of normal amounts of insulin to transport blood sugar into cells on command), a pro-inflammatory state (elevated C-reactive protein in the blood), and a prothrombotic state (high fibrinogen or plasminogen activator inhibitor-1 in the blood). Researchers discovered that these factors also increased the risk of developing BPH. A group of Swedish scientists have suggested that BPH and metabolic syndrome may be linked by problems with insulin and blood sugar regulation, which results in elevated levels of insulin. (Hammersten 1998)
- Atherosclerosis: If you have atherosclerosis–the hardening and thickening of artery walls caused by the accumulation of plaque—you may be at increased risk for BPH, according to at least one study. (Berger 2006)
- Ethnicity: Results of a large-scale study published in 2007 found that black and Hispanic men are more likely to develop BPH than white and Asian men. However, other studies have not found much difference between ethnic groups.
- Sedentary Lifestyle: A lack of exercise may increase your chances of developing BPH, possibly because exercise helps fight obesity, type 2 diabetes, insulin resistance, and other risk factors associated with BPH.
- Poor Diet: According to a 2008 study published in the American Journal of Epidemiology, consuming greater amounts of vegetables and lesser amounts of fat and red meat may reduce the risk of developing BPH. (Kristal 2008) For example, the study showed that eating a high-fat diet raised the odds of developing BPH by 31 percent, while eating red meat daily increased the chances by 38 percent. However, if you consume at least four servings of vegetables daily, you can reduce your risk by 32 percent. The exact role that fat plays in causing the prostate to grow is not understood, although researchers have some ideas. Fat has the ability to increase the levels of testosterone, estrogen, and other hormones, which have been linked with BPH.
- Alcohol consumption: A study in the American Journal of Epidemiology found that two drinks per day have a protective effect against BPH. (Kristal 2008) One possible explanation is that alcohol lowers the levels of certain hormones and encourages muscles in the prostate to “relax.”
- Weak immune system: Exercise, poor diet, stress and poor lifestyle can all compromise and weaken the immune system leading to disease and inflammation and an increased risk of prostate disease. A strong immune system is promoted by leading a prostate friendly lifestyle based on the 6 Pillars of Prostate Health.
Symptoms and Severity
Symptoms of BPH are unpredictable. Some men who have an enlarged prostate experience mild symptoms while some who have minor overgrowth suffer greatly. Symptoms progress very slowly in some men and worsen rapidly in others. Here are a range of symptoms:
- Hesitation: Having to wait, for what can seem like forever, for the urinary stream to begin. Hesitation occurs because the enlarged prostate prevents the urethra from opening wide right away.
- Starting and stopping: This is like driving in city traffic—all stops and starts. When it’s a struggle to keep the urine flowing, the bladder muscles eventually become overgrown, damaged, and weakened. Instead of being able to push all of the fluid out of the bladder with a single, strong and prolonged contraction, the muscles may react with a series of weak pushes that cause the urinary flow to stop and start. Just like driving in traffic, it’s very annoying.
- Weak stream: Boys and young men typically fill the toilet bowl with bubbles when the urinary stream collides with the water. Not so if you have BPH. What happens is that the bladder muscles have been weakened by repeatedly trying to push the fluid through the narrowed prostate.
- Dribbling: When the bladder muscles are strong and there is no resistance to the flow of urine, the bladder empties quickly and almost completely. The few drops that remain can be easily squeezed out. But when the urinary system has been weakened by BPH, more than a few drops remain in the bladder or urethra waiting for your final push. You think you’re done, but you’re not, thus the dribble.
- Incomplete urination: Eventually, a weakened bladder can become unable to empty itself completely, leaving some urine behind. Because the bladder never empties, it refills faster, which then triggers the urge to urinate sooner than you would expect. In advanced cases of BPH, the urge to go may happen every 45 to 60 minutes, or even more often.
- Frequent nighttime urination (nocturia): Men with BPH may need to get up and go to the bathroom two, three, or more times a night.
- Urgency: An overworked and damaged bladder becomes overly sensitive and sends emergency signals to brain that you need to go immediately.
- Urinary tract infections: Urine that is left behind in the bladder can become a breeding ground for bacteria, resulting in urinary tract infections.
- Incontinence: Also known as leakage, men with BPH may experience this problem if damage to the bladder is extensive, making it impossible to control the flow of urine.
- Inability to urinate: If the prostate overgrowth becomes too severe, the flow of urine may be blocked completely, causing acute urinary retention, which is an emergency.
- Frequent urination: Having to run to the bathroom a lot, even if very little comes out, is a common problem for men who have BPH. The trigone, a part of the bladder that tells the brain when it’s time to urinate, becomes more and more sensitive as the bladder muscles become overgrown. Simply put, the trigone sends off too many “gotta go” messages. So you run to the bathroom, expecting a major flood, and a little trickle is all you get. Frequent urination is also caused by incomplete urination.
BPH is normally diagnosed as part of a general examination and may involve various tests, an analysis of any BPH symptoms as well as discussion of any indications of BPH arising from answers to a Prostate Symptoms Test (see the Alarcon learning center). Additonally here are some of the tests Dr. Alarcon may perform:
- DRE: The Digital Rectal Examination (DRE) is the standard and necessary test when it comes to detecting problems with the prostate including BPH. During the DRE, Dr. Alarcon will insert his or her finger into your rectum and press on the prostate to feel for any irregularities in shape and size. If Dr. Alarcon detects any abnormalities during the DRE, he may order other tests designed to confirm the diagnosis of BPH, determine the extent of the problem, and/or rule out other causes of your symptoms, such as prostatitis and prostate cancer.
- PSA: The PSA blood test used to detect prostate problems and to identify the amount of prostate specific antigen in your bloodstream; which rises in response to aggravation or disease of the prostate. Note there is no absolute correlation between an elevated PSA and BPH, because prostate infections and prostate cancer can raise your PSA level as well. In addition, if you normally have a small prostate and a lower PSA level, the PSA test results may remain within normal limits even after the prostate has grown and your level has risen. On the other hand, if you normally have a large prostate and a slightly higher PSA, even a small increase may make your level look high. The bottom line is, although the PSA is an important diagnostic test, its results are not always definitive.
- Urinalysis: A urinalysis is a routine part of a physical examination and involves collecting a urine sample in a cup from the patient and then examining the sample under a microscope. It may be the only test your doctor orders if you have mild symptoms and your medical history and physical examination do not show any other abnormalities. Although a urinalysis cannot produce a definitive diagnosis of BPH, it can tell the doctor if the urine contains red blood cells (which indicates bleeding in the urinary tract), white blood cells (an indication of an infection such as a urinary tract infection), proteins (a sign of a problem with the kidneys), bacteria, or other warning signals.
- Blood Tests: Dr. Alarcon may order a blood test if you have severe or chronic symptoms of BPH. In such cases, a blood test can identify signs of kidney damage or anemia, such as abnormalities in creatinine, hemoglobin, or blood urea nitrogen levels.
- Filling Cystometry: In this test, Dr. Alarcon fills your bladder with fluid and measures the amount of pressure that builds up in your bladder. This test is typically only done in men who have a history of urological or neurological problems that could affect bladder function.
- The “Long and Strong” Test: This is a test (uroflowmetry) that measures how “long and strong” your urinary flow is. The types of equipment used can vary, but the main idea is that you urinate into a funnel that is attached to a device that measures the flow rate and flow time, the amount of urine you void from your bladder, and so on. A normal flow rate is 15 milliliters per second or greater. If you demonstrate a slow flow rate, this suggests you have an obstructed urethra. If your flow rate is high, you likely do not have a urethral obstruction and treatment for BPH will probably not be effective.
- Cystoscopy: For this procedure, Dr. Alarcon uses a cystoscope, a long thin tube that is inserted into the penis and pushed through the urethra until it enters the bladder. When Dr. Alarcon looks through the tube, he can visually inspect the urethra and bladder and get an idea of how vigorously the prostate is squeezing the urethra as well as how much, if any, urine remains in the bladder after voiding.
- Pressure-Flow Urodynamic Study: This is a series of studies in which Dr. Alarcon will measure the bladder’s ability to empty steadily and completely and its pressure during urination. A cystometrogram measures how much urine your bladder can hold, how much pressure builds up when it stores urine, and how full it is when you feel the urge to urinate. This test involves using a catheter to empty your bladder, and then another catheter to measure pressure in the bladder, and yet another catheter in the rectum to measure pressure there as well. The differences in pressure between the bladder and the rectum provide useful information. A high pressure along with a low urine flow rate suggests a urethral obstruction, while low pressure with a low urine flow rate indicates an abnormality in the bladder.
- Ultrasound of the Prostate: Dr. Alarcon can also order ultrasound or other imaging tests to visualize the prostate, bladder, and kidneys to look for any symptoms of prostate disease (such as urinary retention in the bladder). Ultrasound is usually performed in men who have lower urinary tract symptoms. Dr. Alarcon may use a hand-held device called a transducer that is passed over the pelvic area and emits sound waves. Ultrasonography can detect structural abnormalities in the bladder and kidneys, identify bladder stones, estimate the size of the prostate, and determine how much urine remains in the bladder. Imaging studies are generally reserved for men who have blood in their urine, a urinary tract infection, abnormal kidney function, or a history of urinary tract surgery or urinary tract stones.
Specific treatment for BPH will be determined by you and Dr. Alarcon based on:
- Your age, over all health, and medical history
- The extent of your disease
- Your tolerance for specific medications, procedures, or therapies
- Your Expectations for the course of the disease
- Your opinion or preference
Eventually, BPH symptoms usually require some kind of treatment. When the gland is just mildly enlarged, treatment may not be needed, as research has shown that some of the symptoms of BPH clear up without treatment in some mild cases. This determination can only be made after careful evaluation of your individual condition. Treatments may include:
- Watchful Waiting: Also known as watch and wait, this may be the advice your doctor gives to you once it’s been determined that you do not have another disease and that BPH is the diagnosis. If your symptoms of BPH are mild and tolerable, you and your doctor may decide that no further action is required at this time and so you’ll just wait to see if anything new develops.
- Medications: Medications for BPH include alpha-blockers to relax the muscles in the prostate and the neck of the bladder so that urine flows more easily and 5-alpha reductase inhibitors to slow the growth of the prostate and cause it to shrink by altering the actions of certain male hormones.
- Nonsurgical Treatment Options:
If medications for BPH do not provide relief, Dr. Alarcon may recommend one of the following procedures to help keep the urethra open:
During the GreenLight procedure, Dr. Alarcon uses a tiny laser fiber to remove the excess prostate tissue. The fiber delivers high-powered laser light which heats the prostate tissue causing it to vaporize.
This process is continued until the enlarged prostate tissue has been removed. The result is a larger channel for urine flow to pass through.
GreenLight™ Laser therapy highlights include:
- A minimally invasive alternative to surgery
- An outpatient procedure
- Immediate relief of lower urinary tract symptoms (LUTS)
- A virtually bloodless procedure
- Suitable for patients who cannot undergo traditional surgery
- Well-documented safety and success data since 1997
- Over 500,000 patients treated worldwide
TherMatrx® Microwave Therapy
TherMatrx® Microwave Therapy is a simple, relatively painless way to treat BPH that is performed in our office by Dr. Alarcon. No anesthesia is needed and it can be performed in 40-60 minutes. There is no cutting or incision. Instead, Dr. Alarcon temporarily inserts a small, flexible catheter into your urethra; the system begins to work by slowly raising the temperature in a very specific area of the prostate causing changes in the prostate tissue that results in increased urine flow. TherMatrix highlights include:
- In-Office – No surgery or hospital visit required.
- Well Tolerated – Typically only minor discomfort during the procedure.
- No Drug Interactions – Not a drug so there is no danger of medication interactions
- Insured – Covered by Medicare and most private insurers.
- Minimal Decrease in Sexual Function – Typically < 1% decrease in sexual function.
- Fast Recovery – Return home right away and resume activities in 3 days.
TUNA: Transurethral Needle Ablation
TUNA (Transurethral Needle Ablation) is a procedure that delivers low level radio frequency (RF) energy to the prostate, relieving obstruction without causing damage to the urethra. A small probe is inserted through the urethra and into the prostate. Two small electrodes are deployed into the prostate and a low level of radio frequency energy is applied. The energy heats the prostate tissue and shrinks it, relieving the obstruction while protecting the urethra and surrounding areas.
The TUNA procedure can be performed in our clinic outpatient center in less than 1 hour using minimal anesthesia. Clinical studies have demonstrated that TUNA provides significant improvements in urine flow and other symptoms of BPH. Its long-term side effects are minor compared with those of such conventional procedures as TURP. Most patients are able to return to their normal activities within 24 hours. Possible complications include blood in the urine, discomfort or pain during urination, urinary retention, and sexual dysfunction. Most complications resolve without intervention during the healing period.
Surgery for BPH
Advances in medical technology have made surgery for BPH less common, now that clinicians can blast, vaporize, and burn away extra prostate tissue using invasive nonsurgical treatment options for BPH. But surgery for BPH is still an option for some men who may have severe symptoms that do not respond to other approaches or who have complications that make surgery a wiser choice. Surgical procedures available to treat BPH include:
- TUIP: Transurethral Incision of the Prostate
- TURP: Transurethral Resection of the Prostate
- TVP: Transurethral Vaporization of the Prostate
UroLift® Procedure for Men with BPH
The UroLift System is a minimally invasive treatment for benign prostatic hyperplasia (BPH) that involves placing a small, permanent implant in a man’s urethra to hold back tissue blocking urinary continence. For men over the age of 50 suffering from lower urinary tract symptoms (LUTS) caused by BPH, the UroLift System offers a simple and safe solution without surgery.