Benign prostatic hyperplasia

Benign prostatic hyperplasia: Description

Benign prostatic hyperplasia (BPH) is an enlargement of the prostate gland due to a proliferation of benign cells. This is only considered a disease when certain symptoms develop, for example: weak urinary stream, frequent urination (also at night: nocturia), acute urge to urinate or acute urinary retention. Benign prostatic obstruction (BPO) is the urological term for increased bladder outflow resistence. Benign prostatic syndrome (BPS) is the general term for symptoms occurring during urination (micturition).

BPH is the most common benign tumor in men: about 50% of men over the age of 60 are affected.

Benign prostatic hyperplasia: Symptoms

Typical symptoms of BPH include, above all, irritant complaints and urinary dysfunctions which can be divided into three stages. During the initial stage, symptoms such as a weak urinary stream, pollakisuria (frequent urination), nocturia (excessive urination at night), acute urge to urinate or urinary retention may occur. In the second stage there may additionally be - due to a buildup of residual urine - urinary tract infections, pain during urination, and even bleeding. In the third stage (so-called overflow incontinence), besides the symptoms described above, prostate enlargement may result in urinary obstruction up to the kidneys, and even kidney failure.

Benign prostatic hyperplasia: Causes and Risks

The background and causes of the development of BPH are not yet clear. However, there are a range of factors that can lead to the enlargement of the gland. The increasing age of the patient plays an important role, and a relationship between the male hormone testosterone and prostate enlargement is also evident: if no more testosterone is formed (e.g. by removal of the testicles), there is no further growth of the prostate gland. In addition, other hormones, the metabolism or genetic predisposition may have an impact on BPH.

Benign prostatic hyperplasia: Examination and Diagnosis

First, in the medical history interview, the exact symptoms are obtained from the patient. The standardized, validated IPSS (international prostate symptom score) questionnaire is generally used to request details about 7 different issues relating to urination symptoms and health-related quality of life. After recording the medical history there is a physical examination and rectal digital palpation to detect enlargement of the prostate, as well as possible pain as an indication of inflammation, or suspicious hardening of the prostate gland as an indication of prostate cancer. By means of a transvesical ultrasound examination (conducted from the outside through the full bladder) the residual urine and the volume of the prostate gland can be checked. Through a transrectal ultrasound (where a rod-shaped ultrasonic probe is carefully inserted through the rectum), the exact size of the prostate as well as structural changes in the gland and the seminal vesicles are determined. Sonography in the upper part of the urinary tract can evaluate possible urinary obstruction. The use of computerized tomography (CT) or magnetic resonance imaging (MRI) is usually not necessary in constructing a clinical picture of BPS, except in cases of suspected damage to the upper urinary tract or other anomalies.

In a laboratory test, urine is analyzed for signs of infection and hematuria (blood in the urine). The levels of prostate specific antigen (prostate tumor marker) in the blood are crucial in the question of whether a tissue sample (biopsy) is required to detect or exclude the presence of prostate cancer. It is quite possible for a patient to have both a benign enlargement in the inner portion of his prostate and simultaneously a prostate cancer in the outer portion of the gland.

Benign prostatic hyperplasia: Treatment

Only when debilitating symptoms that diminish quality of life occur is treatment of BPH necessary. Besides drug therapy, whose goals include reduction of symptoms and of prostate growth, minimally invasive surgical and treatment methods are used. The standard medicinal therapy to alleviate the clinical symptoms is treatment with alpha blockers (e.g. alfuzosin, tamsolusin, silodosin). This leads to a slackening in the prostatic urethra area and the neck of the bladder, so that the urine can better escape. Alpha blockers are known for being relatively well tolerated and can therefore be taken long-term. The various herbal supplements (phytotherapeutics) have only a small effect in reducing disease symptoms compared to the alpha blockers. The long-term use of hormone preparations (5-alpha reductase inhibitors such as finasteride or dutasteride) can achieve a reduction of BPH in some men. This works by blocking the conversion of testosterone into dihydrotestosterone (DHT), which is the active hormone in the prostate. However, 5-alpha reductase inhibitors often have a negative effect on sexuality.

The standard procedure (so-called "gold standard") in the surgical treatment of BPH is transurethral resection of the prostate (TURP). In this procedure, under anesthesia, the problematic inner gland tissues are resected and removed with a special instrument. After surgery the patient requires a transurethral indwelling catheter in the bladder for about 2 days. Other methods include the open surgical removal of the prostate through the bladder (enucleation), which is often used for very large glands. Otherwise there are a number of technical variants by which problematic prostate tissue can be destroyed (e.g. heat, cold or laser energy). The laser procedures for this are widespread and technically mature. There is a distinction between techniques where the prostate tissue is vaporized by laser energy (vaporization with a Greenlight Laser) and those in which the tissue is resected in a manner similar to TURP (HoLEP). A new minimally invasive procedure is the UROLIFT® method. Here, numerous small subcutaneous tissue retractors (surgical sutures with locking clips on the inside and outside) are introduced endoscopically into the prostate, pushing the excess tissue aside and thus improving the urine flow. Using this process, ejaculation is preserved, which is usually lost in the other treatment methods (emptying "backwards" into the bladder).

Benign prostatic hyperplasia: Course and Prognosis

Even without treatment, the progression of prostate enlargement is slow. If a patient diagnosed with BPH does not respond to drug therapy, then the most successful treatment method is removal of the benign prostatic hyperplasia. The prognosis here is quite good, meaning that a surgical procedure usually achieves a very long-term improvement of symptoms.

Benign prostatic hyperplasia: Miscellaneous/Other Comments

The Prostate Center in the Department of Urology at the Medical Center - University of Freiburg is the contact point for all patients with prostate disease. Comprehensive information about the patient is the basis for individual and holistic diagnosis and treatment. The clinic offers every kind of diagnostic and therapeutic procedure in order to enable optimal patient care. These also include various laser therapies (Greenlight Laser, HoLEP laser) and the new UROLIFT® method. The Prostate Center involves a range of disciplines such as urology, radiotherapy, oncology, radiology, nuclear medicine and pathology.