Benign Prostatic Hyperplasia

Dr. Cid June 21, 2023

Benign Prostatic Hyperplasia: Disease & Background

1. Identification of Disease Condition

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland, characterized by the proliferation of glandular epithelial tissue within the prostatic transition zone. This condition leads to Lower Urinary Tract Symptoms (LUTS), significantly affecting the quality of life in aging men. Hyperplasia refers to an increase in the number of cells within a tissue or organ.

2. Incidence and Prevalence in the US

BPH is a common condition among older men, with the incidence rising notably with age. The prostate gland typically begins to enlarge around the age of 40-45 years. By the age of 60, the prostate has increased in size by approximately 60%, and by the age of 80, it has increased by about 80% (Management of Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms, 2021). This prevalence highlights the widespread nature of BPH and its significant impact on the elderly male population in the United States.

3. Pathophysiology

The prostate gland consists of two main sections: the inner section, which produces secretions to keep the urethra moist, and the outer section, which contributes to seminal fluids. The pathophysiology of BPH involves the activity of the enzyme 5 alpha-reductase, which converts testosterone into dihydrotestosterone (DHT). DHT is a potent androgen that plays a crucial role in prostate growth. As men age, the activity of 5 alpha-reductase increases, leading to higher levels of DHT. This hormonal change causes prostate cells to live longer and multiply faster, resulting in hyperplasia and the subsequent enlargement of the prostate gland (McConnell et al., 2003).

4. Typical Clinical Presentation

Subjective Symptoms:

Patients with BPH often present with a variety of lower urinary tract symptoms, which can be both obstructive and irritative. Common subjective symptoms include:

• Decreased force of stream
• Hesitancy
• Post-void dribbling
• Sensation of incomplete bladder emptying
• Overflow or urge incontinence
• Inability to voluntarily stop the stream of urine
• Urinary retention
• Straining
• Nocturia
• Frequency
• Urgency
• Dysuria

Objective Findings:

During a physical examination, several objective findings may be observed, including:

• Distended bladder
• Gross hematuria (visible blood in urine)
• Digital rectal examination (DRE) findings, although the size of the prostate does not necessarily correlate with the severity of symptoms (Barry et al., 1992)

Management Strategies

Management of BPH can be divided into conservative, medical, and surgical approaches, depending on the severity of symptoms and the impact on the patient’s quality of life.

Conservative Management:

Lifestyle modifications and watchful waiting are recommended for patients with mild symptoms. These may include:

• Reducing fluid intake, especially before bedtime
• Limiting consumption of caffeine and alcohol
• Practicing double voiding (urinating, waiting a few moments, and then urinating again)
• Avoiding medications that can exacerbate symptoms, such as decongestants and antihistamines

Medical Management:

Several pharmacological treatments are available for BPH, including:

• Alpha-blockers: These medications, such as tamsulosin and alfuzosin, help relax the smooth muscles of the prostate and bladder neck, improving urine flow and reducing symptoms (Lepor, 2005).
• 5 Alpha-Reductase Inhibitors: Medications like finasteride and dutasteride work by inhibiting the conversion of testosterone to DHT, thereby reducing the size of the prostate over time (McConnell et al., 2003).
• Combination Therapy: For some patients, a combination of alpha-blockers and 5 alpha-reductase inhibitors may be more effective in managing symptoms (McConnell et al., 2003).

Surgical Management:

Surgical intervention is considered for patients with severe symptoms or complications, such as urinary retention, recurrent urinary tract infections, or bladder stones. Common surgical procedures include:

• Transurethral Resection of the Prostate (TURP): TURP is the gold standard for surgical management of BPH. It involves removing a portion of the prostate tissue to relieve obstruction (Reich et al., 2008).
• Laser Therapy: Laser procedures, such as Holmium Laser Enucleation of the Prostate (HoLEP), use laser energy to remove excess prostate tissue with minimal bleeding.
• Prostatic Urethral Lift (PUL): PUL involves the placement of small implants to lift and hold the enlarged prostate tissue away from the urethra, thereby reducing obstruction.

Epidemiology of BPH

Benign prostatic hyperplasia is a common condition affecting older men. The incidence increases with age, with a significant rise after the age of 40. Studies have shown that by the age of 80, nearly 80% of men exhibit some symptoms of BPH (Kumar, Abbas, & Aster, 2017).

Pathophysiological Mechanisms

The hyperplasia in BPH is predominantly caused by the increased activity of the enzyme 5 alpha-reductase, which converts testosterone into dihydrotestosterone (DHT). DHT is a more potent androgen that promotes prostate cell proliferation and inhibits apoptosis, leading to an increased number of prostate cells (McConnell et al., 2003).

Clinical Assessment

Clinical assessment of BPH involves both subjective and objective evaluations. The International Prostate Symptom Score (IPSS) is commonly used to quantify the severity of symptoms. Physical examination includes a digital rectal examination (DRE) to assess prostate size and consistency. However, the severity of symptoms does not always correlate with the size of the prostate (Barry et al., 1992).

Conclusion

Benign prostatic hyperplasia is a prevalent condition among aging men, significantly impacting their quality of life. Understanding its pathophysiology, clinical presentation, and management options is crucial for providing effective patient care.

References

Barry, M. J., Fowler, F. J., O’Leary, M. P., Bruskewitz, R. C., Holtgrewe, H. L., Mebust, W. K., & Cockett, A. T. (1992). The American Urological Association symptom index for benign prostatic hyperplasia. The Journal of Urology, 148(5), 1549-1557. Retrieved from https://www.auajournals.org/doi/10.1016/S0022-5347(17)36966-5

Kumar, V., Abbas, A. K., & Aster, J. C. (2017). Robbins Basic Pathology. Elsevier Health Sciences.

Lepor, H. (2005). Medical treatment of benign prostatic hyperplasia. Reviews in Urology, 7(Suppl 7), S42. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477638/

McConnell, J. D., Roehrborn, C. G., Bautista, O. M., Andriole, G. L., Dixon, C. M., Kusek, J. W., … & Foley, J. P. (2003). The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. New England Journal of Medicine, 349(25), 2387-2398. Retrieved from https://www.nejm.org/doi/full/10.1056/nejmoa030656

Reich, O., Gratzke, C., Bachmann, A., Seitz, M., Schlenker, B., Hermanek, P., … & Stief, C. G. (2008). Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients. The Journal of Urology, 180(1), 246-249. Retrieved from https://www.auajournals.org/doi/10.1016/j.juro.2008.03.024