What is benign prostatic hyperplasia (BPH) or enlarged prostate?

This article is the first one from a small series of 3 articles on Benign Prostate Hyperplasia. In the second one we talk about medical treatment and the third one about surgical treatment.


Defining BPH

There are different reasons why a person may have bothersome symptoms related to urination. The most common in men, however, is that they are due to an obstruction of the outflow of urine from the bladder caused by a benign growth of the prostate. This growth is called Benign Prostatic Hyperplasia or BPH.

Sometimes there may be more than one cause of a patient's discomfort, such as a narrowing of the urethra, a stone or foreign body in the urinary tract, alterations in the functioning of the bladder, or others. This is why it is very important that your doctor make a complete evaluation of the different possible causes of your symptoms [1].

Discomfort to urinate is very common among men, especially after the age of 50. It is estimated that approximately one-third of men over the age of 60 will experience urinary discomfort that requires treatment [2].


The urethra is the tube through which urine passes from the bladder to the outside. The prostate is located below the bladder and completely surrounds the urethra, like a tire.


What happens in the case of BPH is that the prostate decreases the width of the urethra. When a growth of the prostate occurs, it can partially obstruct the lumen of the urethra.


It is important to know that the size of the prostate is not always directly related to the degree of obstruction. In some cases, an insignificant prostatic growth can occur, but it greatly obstructs the urethra and causes significant discomfort when urinating. In these cases, even though the prostate is small, treatment is needed.


In other cases, even significant prostate growth does not affect the lumen. There are people who in an ultrasound detect that they have a very large prostate, but they do not report discomfort while urinating. In these cases, no matter how large the prostate is, if there are no symptoms, no treatment is necessary.


What symptoms can BPH present?

In order to understand the causes and better define the treatments, the symptoms of patients with BPH are usually classified into two groups:

  1. Emptying symptoms: Some symptoms are experienced during urination, such as:
  • Having a weak or fine stream.
  • Delay or difficulty starting urination.
  • Having a broken or choppy stream.
  • Having to squeeze or strain to get urine to come out.

As a general rule, these symptoms are more directly related to an obstruction in the outflow of urine from the bladder.

2. Filling symptoms: They are those that are perceived during the time in which the bladder is filling, that is, between urination. The main ones are:

  • Increased daytime urinary frequency, or the need to urinate more times during the day.
  • Nocturia or the need to wake up at night to urinate.
  • Urgency or the appearance of a need for fast and intense urine that is difficult to hold.
  • Incontinence; involuntary urine leakage.

As a general rule, these symptoms are due to the bladder not functioning correctly, which could be caused by a problem directly in the bladder, or by a poor adaptation of the organ to an obstruction caused by the prostate over time [3].


How is BPH diagnosed?

The first thing to do is find out important data about the patient such as current known illnesses, medications that they usually take, lifestyle, as well as emotional and psychological factors that can affect how a person urinates.

To assess symptoms, validated questionnaires are useful. The most frequently used in our environment is the IPSS [4].

There are different tests that will help clarify the origin of the patient's problems:

  • A urinalysis will help rule out medical problems such as urine infection, blood in the urine, or diabetes mellitus [5].
  • To assess the volume of the prostate, either a digital rectal examination or an imaging test can be performed, often via ultrasound. Knowing the prostate size is important to select the appropriate treatment, both medical and surgical, as we will see in the following articles.
  • A blood test is useful to assess prostate-specific antigen or PSA, which helps us assess the risk of prostate cancer, as well as the risk of prostate growth [6,7]. It also allows assessing the proper functioning of the kidneys by measuring creatinine levels.This is important, as patients with BPH are at increased risk of kidney problems [8].
  • A test that provides very useful information is flowmetry. This test consists of assessing the speed of urine flow among other parameters. Patients urinate into a device that performs the measurement [9].

These are the most used tests in the initial evaluation of a patient with symptoms compatible with BPH. This is not an exhaustive list of tests, and it is very important to know that none of these tests individually can conclusively diagnose BPH. The tests must be evaluated as a whole, and clinics should take into account unique characteristics of each patient.  


FINAL MESSAGE
  • BPH is not the only cause of voiding symptoms (LUTS).
  • The size of the prostate does not define the need for treatment.
  • There are filling symptoms and emptying symptoms.
  • Complete medical history.

Bibliography

[1]           S.G. (Chair), J.N.Cornu, M. Gacci, C. Gratzke, T.R.W. Herrmann, C. Mamoulakis, M. Rieken, M.J. Speakman, K.A.O. Tikkinen, M. Karavitakis, I. Kyriazis, S. Malde, V.I. Sakalis, R. Umbach, Management of Non-neurogenic Male LUTS, in: EAU Guidel. Edn. Present. EAU Annu. Congr. Amsterdam 2020, 2020. http://uroweb.org/guidelines/compilations-of-all-guidelines/.

[2]           C.G. Roehrborn, Benign Prostatic Hyperplasia: Etiology, Pathophysiology, Epidemiology, and Natural History, in: Campbell-Walsh-Wein Urol., 12th editi, Elsevier Inc., 2021: pp. 2425–2462.

[3]           F.J. Brenes Bermudúdez, J. Carballido Rodriguez, J.M. Cozar Olmo, A. Fernandez-Pro Ledesma, C. Hernandez Fernandez, B. Miñana Lopez, J.M. Molero Garcia, Hiperplasia Benigna de Próstata (HBP), 2nd ed., IMC, Madrid, 2017.

[4]           M.J. Barry, F.J. Fowler, M.P. O’Leary, R.C. Bruskewitz, H.L. Holtgrewe, W.K. Mebust, A.T.K. Cockett, J.G. Blaivas, A.J. Wein, The American Urological Association symptom index for benign prostatic hyperplasia, J. Urol. 148 (1992) 1549–1557. https://doi.org/10.1016/S0022-5347(17)36966-5.

[5]           C.G. Roehrborn, G. Bartsch, R. Kirby, G. Andriole, P. Boyle, J. De La Rosette, P. Perrin, E. Ramsey, J. Nordling, G. De Campos Freire, S. Arap, Guidelines for the diagnosis and treatment of benign prostatic hyperplasia: A comparative, international overview, Urology. 58 (2001) 642–650. https://doi.org/10.1016/S0090-4295(01)01402-9.

[6]           C.G. Roehrborn, J.D. McConnell, M. Lieber, S. Kaplan, J. Geller, G.H. Malek, R. Castellanos, S. Coffield, B. Saltzman, M. Resnick, J. Waldstreicher, Serum prostate-specific antigen concentration is a powerful predictor of acute urinary retention and need for surgery in men with clinical benign prostatic hyperplasia, Urology. 53 (1999) 473–480. https://doi.org/10.1016/S0090-4295(98)00654-2.

[7]           C.G. Roehrborn, P. Boyle, A.L. Gould, J. Waldstreicher, Serum prostate-specific antigen as a predictor of prostate volume in men with benign prostatic hyperplasia, Urology. 53 (1999) 581–589. https://doi.org/10.1016/S0090-4295(98)00655-4.

[8]           G.S. Gerber, E.R. Goldfischer, T.G. Karrison, G.T. Bales, Serum creatinine measurements in men with lower urinary tract symptoms secondary to benign prostatic hyperplasia, Urology. 49 (1997) 697–702. https://doi.org/10.1016/S0090-4295(97)00069-1. [9]             J.M. Reynard, Q. Yang, J.L. Donovan, T.J. Peters, W. Schafer, J.J.M.C.H. De La Rosette, N.F. Dabhoiwala, D. Osawa, A.T.L. Lim, P. Abrams, The ICS-’BPH’ Study: Uroflowmetry, lower urinary tract symptoms and bladder outlet obstruction, Br. J. Urol. 82 (1998) 619–623. https://doi.org/10.1046/j.1464-410X.1998.00813.x.

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