Benign Prostatic Hyperplasia

Benign Prostatic Hyperplasia is also referred to as BPH or enlarged prostate or prostate enlargement. So, before knowing what BPH is, let us understand briefly about prostate gland. The prostate is a fibro-muscular-glandular organ present in males. It is a pear-shaped organ, about the size of a walnut, through which the male urethra passes. It mainly secretes prostatic fluid which is a part of the seminal fluid. During an ejaculation, the prostatic fluid along with the spermatozoa from the testis are released from the penis. Besides, the prostate is composed of a fibrous component, mainly composed of collage. Also, there are smooth muscle fibres which make up the body of the prostate.
Benign prostatic hyperplasia: How does it occur?
Benign prostatic hyperplasia refers to the proliferation of all the above 3 components. It thus results in prostate enlargement. Normally, prostate undergoes physiological hypertrophy during puberty. Later in life, it undergoes subsequent increase in size and continues to grow throughout a man’s life. An enlarged prostate can press upon the urethral neck causing various symptoms of the urinary system. It leads to an increased back pressure in the urinary bladder and thickening of bladder musculature. Eventually, beyond a certain point, the bladder wall weakens and it becomes difficult to void the urine. It is a benign condition and does not progress to malignancy. The prostate is a hormone sensitive organ. In males, the main androgen is testosterone (produced by testis) along with small amounts of oestrogen. As a man ages, the testosterone activity decreases and the relative increase in oestrogen causes a proliferative action on the prostate, leading to benign prostatic hyperplasia. Another androgen is dihydrotestosterone which is associated with BPH. Males who do not produce DHT generally do not develop BPH. It is more likely to develop in elderly males. BPH is also associated with obesity, type 2 Diabetes Mellitus and erectile dysfunction in males. Adopting a healthy lifestyle, weight reduction in obese individuals and regular exercise reduce the risk of developing BPH.
Benign Prostatic Hyperplasia: Symptoms
Image result for bph symptoms
BPH Stages
  The symptoms as experienced by the patient, depend upon the severity of enlargement and the degree of obstruction. The common signs and symptoms of BPH include:
  • Increased frequency/urge to urinate.
  • Increased tendency for micturition at night (nocturia)
  • Initial difficulty in voiding urine
  • Intermittent urine flow (not in a continuous stream)
  • Urinary dribbling after voiding the bladder
  • A feeling of incomplete bladder emptying and urinary incontinence
Less common symptoms include:
  • Urinary tract infection, characterised by burning micturition
  • Blood in urine (gross or microscopic haematuria)
Benign prostatic hyperplasia Diagnosis:
Usually, a clinical diagnosis by the treating physician is required to label the disease as benign prostatic hyperplasia. The examination and investigations include:
  1. Digital per rectal examination: The patient is asked to lie down in left recumbent position with legs flexed at the hip and shoulders bent forward. The doctor inserts his index finger with a local anesthetic to check for enlargement of prostate.
  2. Urine Analysis: A complete urinalysis is advised with respect to pH, color, hematuria, detection of any parasite or for bacterial growth. It helps to rule out urinary infections.
  3. Complete hemogram: A complete blood count with a differential leukocyte count helps to check for acute or chronic infectious etiology.
  4. Specific tests for urine formation include a 24 hour urine flow monitoring, post viral residual volume (to check for amount of urine that remains in bladder after voiding) and a urinary flow test (to determine strength of bladder contraction and urine volume)
  5. Imaging tests: They include a trans rectal ultrasonography. Besides a USG guided biopsy may also be taken for histopathological examination. A cystoscopy may also be performed (after local anesthesia, a cystoscope is inserted via the urethra, to visualize the bladder)
Benign prostatic hyperplasia Treatment:
Treatment is dependent on various factors such as the age of patient, degree of enlargement, the functional status/interference with daily routine and presence of other co-morbidities. If there is no or mild impairment of daily activities, the patient can be put on active surveillance.  The symptoms may resolve on their own or progress and subsequently worsen. The first line of treatment for mild to moderate disease is medical management. They include treatment with drugs like:
  1. Alpha blockers: They include tamsulosin, prazosin and alfuzosin. They relax the bladder neck and the urethra and allow for easy passage of urine. However, the side effect includes dizziness, hypotension and retrograde ejaculation.
  2. 5-alpha-reductase inhibitors: They include finasteride and dutasteride. They inhibit production of testosterone and thus there is negligible effect on proliferation of the prostate. However, they have a long latency, upto 6 months to be effective. They can be used in combination with alpha blockers.
  3. Tadalafil, used for erectile dysfunction has also shown to reduce prostate size.
Moderate to severe disease requires surgical treatment. It is a definitive therapy for BPH. Intrinsic cases of urethral obstruction, in complicated BPH like stones, strictures cannot be treated medically and require surgery. However, the risks of the procedure involve bleeding, retrograde ejaculation, an infection or rarely stricture fibrosis of urethra.
The surgeries for BPH include:
  1. Transurethral resection of prostate (TURP): The inner part is removed and the outer prostate with capsule is intact.
  2. Transurethral incision of prostate (TUIP): Through the urethra, nicks/cuts are given in the periurethral prostate. This eases the pressure.
  3. Transurethral microwave thermotherapy: Through the urethra, rods are inserted in prostate, which emit microwaves. They destroy inner aspects of the prostate.
  4. Transurethral needle ablation: Needlea are inserted into the prostate through the urethra. Radio waves are emitted, which heats up the tissue and destroys it
  5. LASER Therapy: The most preferred method as there are fewer adverse events. However, it is relatively costly.
  6. Prostatic urethral lift: The prostate is compressed from the sides to increase urinary voiding pressure.
  7. Robot assisted prostatectomies are in their nascent stage and are generally reserved for complex cases.
The Prostate gland: Anatomy and Physiology

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