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Benign Prostatic Hyperplasia Information for Patients

Normal vs Enlarged Prostate


What is BPH?

Benign prostatic hyperplasia (BPH) is a nonmalignant growth of the prostate stroma and epithelial glands that cause enlargement of the prostate gland. Androgens, more specifically dihydrotestosterone (DHT), are required for the development of BPH. Inside the prostate, androgens not only increase cellular proliferation but also inhibit cell death. The proliferation of smooth muscle and epithelial cells within the prostatic transition zone causes the gland to grow slowly over several years. The decreased cell death is believed to be the main component in BPH eventually increasing up to 10 times the normal adult prostate size.

As the prostate grows, it begins to obstruct the urethra gradually decreasing the passage of urine that exits the bladder. Obstruction to urinary outflow leads to bladder adaptation. The detrusor muscle, found in the wall of the bladder, remains relaxed to allow the bladder to store urine. The muscle contracts during urination to release urine. When the urethra becomes obstructed there is an increase in urine retention. The bladder must adapt and the detrusor muscle increases in size to force urine through the obstructed urethra. This leads to detrusor overactivity or instability which manifests as urinary urgency and frequency. This is later followed by bladder distention and decreased detrusor contractility manifested by a decrease in the force of the urinary stream, hesitancy, and increased residual urine volume. The inability to empty the bladder and urine retention increase the risk of infection.

 

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Symptoms
•Increased urinary frequency
•Nocturia (the need to wake and pass urine at night)
•Difficulty in starting and stopping the stream of urine
•Overflow dribbling
•Dysuria (painful urination)
•Sudden inability to urinate (usually requiring emergency catheterization)

 

Who is Affected by BPH?
BPH is extremely common in men over age 50. Race has some influence on the risk for BPH severe enough to require surgery. While the age-adjusted relative risk of BPH necessitating surgery is similar in black and white men, black men less than 65 years old may need treatment more often than white men.

Digital Rectal Exam (DRE)



Why do Doctors Request Digital Rectal Exams (DRE)?
DRE is an essential part of the assessment that can independently predict prostate cancer in the setting of a normal PSA level. The normal prostate gland is a firm, rubbery, bilobed mass with a central furrow. With age, the prostate becomes firmer and with prostatic enlargement, the sulcus begins to disappear and the gland is often asymmetrical. A very hard nodule is apparent when a carcinoma, or cancer, of the prostate is present. African-American men and those with a family history of prostate cancer in a first-degree relative should discuss screening with a health care provider. Prostate examinations are no longer routinely done on men with no symptoms or those who are at low risk of developing prostate cancer.

 

Prostate Specific Antigen (PSA) Test
Both digital rectal examination (DRE) and prostate specific antigen (PSA) testing form two of the key components of the assessment of the prostate gland. A PSA test can find prostate cancer earlier than no screening at all. However, the PSA test may have false positive or false negative results. This can mean that men without cancer may have abnormal results and get tests that are not necessary. It could also mean that the test could miss cancer in men who may need to be treated.

 

Treatment of BPH
Mild cases may be treatable by decreasing fluid intake, moderating alcohol and caffeine and following timed voiding schedules. The most commonly used pharmacologic treatment are α-blockers, which decrease prostate smooth muscle tone by inhibiting α1-adrenergic receptors, and 5-α-reductase inhibitors, which inhibit the synthesis of dihydrotestosterone (DHT) and in some occasions shrinks the size of the prostate. In moderate to severe cases, Transurethral resection of the prostate (TURP) has been the gold standard. Other treatment options include high-intensity focused ultrasound, laser therapy, hyperthermia, transurethral electro vaporization, and transurethral needle ablation using radiofrequency. Each year more than 400,000 men in the united states must undergo TURP surgery to correct the problems caused by an oversized prostate.

 

References:
  1. Michael J Sullivan, Jack Geller. The effectiveness of reducing the daily dose of finasteride in men with benign prostatic hyperplasia. BMC Urology20022:2, DOI: 10.1186/1471-2490-2-2, BioMed Central Ltd. http://bmcurol.biomedcentral.com/articles/10.1186 /1471-2490-2-2 Published: 15 January 2002.
  2. Walsh AL, Considine SW, Thomas AZ, Lynch TH, Manecksha RP. Digital rectal examination in primary care is important for early detection of prostate cancer: a retrospective cohort analysis study. The British Journal of General Practice. 2014;64(629):e783-e787. doi:10.3399/bjgp14X682861.
  3. Christoph Nikendei, Katja Diefenbacher, Nadja Köhl-Hackert, Heike Lauber, Julia Huber, Anne Herrmann-Werner, Wolfgang Herzog, Jobst-Hendrik Schultz, Jana Jünger, and Markus Krautter. Digital rectal examination skills: first training experiences, the motives and attitudes of standardized patients. BMC Med Educ. 2015; 15: 7. Published online 2015 Feb 1. doi:  10.1186/s12909-015-0292-7.
  4. Walsh, Anna Lucy et al. “Digital Rectal Examination in Primary Care Is Important for Early Detection of Prostate Cancer: A Retrospective Cohort Analysis Study.” The British Journal of General Practice 64.629 (2014): e783–e787. PMC. Web. 18 Jan. 2017.
  5. Schröder FH, Hugosson J, Carlsson S, Tammela T, Määttänen L, Auvinen A, Kwiatkowski M, Recker F, Roobol MJ. Screening for prostate cancer decreases the risk of developing metastatic disease: findings from the European Randomized Study of Screening for Prostate Cancer (ERSPC). Eur Urol. 2012 Nov;62(5):745-52. doi: 10.1016/j.eururo.2012.05.068. Epub 2012 Jun 7.
  6. Walsh, A. L., Considine, S. W., Thomas, A. Z., Lynch, T. H., & Manecksha, R. P. (2014). Digital rectal examination in primary care is important for early detection of prostate cancer: a retrospective cohort analysis study. The British Journal of General Practice, 64(629), e783–e787. http://doi.org/10.3399/bjgp14X682861

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Juan Antonio Aguilar Garcia, M.D.

Having the knowledge to help people live healthier and longer lives is a privilege. Sharing that knowledge with the world is an obligation.