What is BPH disorder

Benign prostatic hyperplasia (Prostate enlargement, BHP)

Benign prostatic hyperplasia (BPH for short) is a benign enlargement of the male prostate gland.

Short version:

  • A benign enlargement of the prostate is often noticeable through problems urinating.
  • In the western industrialized nations, BPH can be detected in around half of men over 60 years of age.
  • The exact causes of benign prostate enlargement have not yet been clarified. The most significant risk factor is certainly age.
  • Prostate enlargement is treated with drugs or surgery.

Usually the prostate is roughly the shape and size of a chestnut. The organ belonging to the male urogenital tract lies below the urinary bladder and encircles the ureter that begins there up to the pelvic floor.

The prostate produces some of the semen that is expelled during ejaculation. In addition, during ejaculation, their muscle cells ensure that the seminal fluid reaches the outside through the urethra with the necessary momentum.

How often does prostate enlargement occur?

A benign enlargement of the prostate becomes noticeable primarily through problems with urination. In the meantime, the general term "benign prostate syndrome" is preferred in specialist circles, which summarizes prostate enlargement, the irritation symptoms and the resulting bladder dysfunction.

Benign prostatic hyperplasia can definitely be described as a widespread disease. In the western industrialized nations, BPH can be detected in around half of men over 60 years of age.

For those over 80, the rate is around 90 percent. The figures make it clear that the likelihood of the disease increases with age. However, BPH is only so pronounced in about 20 percent of those affected that it requires therapy.

The exact causes of BPH have not yet been clarified. The most significant risk factor is certainly age.

What are the symptoms of benign prostatic hyperplasia?

The first symptom of the disease is often a weakening of the urine stream. The symptoms of benign prostatic hyperplasia arise because the urethra is increasingly narrowed by the enlarged prostate gland. The consequences are problems with urination and other bladder disorders. Depending on the severity of the symptoms, the following problems can arise:

  • Weakening of the urine stream
  • Delayed emptying of the bladder
  • After dribbling
  • Frequent need to urinate
  • Residual urine sensation
  • Nocturnal urge to urinate
  • Urinary tract infections

Delayed emptying of the bladder

In addition, the onset of emptying the bladder is delayed, which means that it takes longer when using the toilet for urine to emerge and also for urination to stop. Several attempts are required to completely empty the bladder, often with the help of the abdominal muscles.

Dribbling and frequent urination (pollakiuria):

A trickle of urine is also typical in this so-called irritation stage, in addition to which there may be noticeably frequent urination and a sudden, strong urge to urinate.

Residual urine sensation

As a result, the bladder can no longer be completely emptied, which leads to a feeling of residual urine.

Nocturia (nocturia)

The characteristic symptoms are the constant need to urinate and frequent urination, even during the night.

++ More on the topic: Nocturnal urge to urinate ++

Urinary tract infections

If urine also remains in the bladder, the germs make it easier to settle and multiply there. This increases the risk of a urinary tract infection or cystitis. The residual urine also promotes the formation of bladder stones.

What are the stages of benign prostatic hyperplasia?

The BHP can also be divided into the following three stages:

  • Stage I.: This stage is also referred to as the irritation stage and manifests itself through symptoms such as a weakened urine stream, dripping, frequent and nocturnal urination. However, there is no residual urine formation at this stage.
  • Stage II: In the second stage there is an intensification of the symptoms. The remaining amount of urine is between 50 and 100 ml. The functional bladder capacity decreases at the same time.
  • Stage III: At this stage, urinary retention and an overflow bladder, in which it comes to an involuntary leakage of urine, are typical complaints. In addition, it can lead to increasingly decreased kidney function and other impairments of the kidneys.

+++ More on the topic: 7 Prostate Facts for Beginners +++

What are the risks of an enlarged prostate?

Without treatment, the dysfunction in the bladder and prostate area can progress and lead to serious sequelae. If the congestion of the urine continues into the kidneys, there is a risk of permanent kidney damage and even kidney failure. Often overflow incontinence also occurs: here there is an involuntary leakage of urine, since virtually every drop of urine flowing from the kidney into the bladder causes the bladder to overflow.

Another possible complication is urinary retention or obstruction, in which no urine can be released at all. The result is that the bladder expands more and more, causing enormous pain. Urinary retention is a medical emergency and must be treated immediately.

+++ More on the topic: prostate cancer +++

How is prostatic hyperplasia diagnosed?

The description of the symptoms gives the doctor important information about benign prostatic hyperplasia. When talking to the patient, he will pay particular attention to how severe the symptoms are and how much they affect the quality of life. The anamnesis discussion is followed by a physical examination. This includes:

Digital rectal exam

This always includes a digital rectal examination in which the prostate gland in the rectum is scanned with a finger. In this way, the doctor can assess whether the organ is enlarged, hardened or painful.

Laboratory examination

Part of the basic diagnosis is also a laboratory test of the urine and usually also of the blood. In order not to miss a malignant change, the so-called prostate-specific antigen (PSA) is determined. PSA is an important marker of prostate cancer.

Uroflowmetry

With a uroflowmetry, the strength and speed of the urine stream can be measured and thus assessed whether a bladder emptying disorder is present.

Ultrasonic

Residual urine can be detected by an ultrasound examination (sonography) of the bladder. Sonography of the prostate itself and of the upper urinary tract - that is, of the ureters and kidneys - is also part of the standard diagnosis of suspected BHP.

biopsy

If, after assessing all of these test results, there is the slightest suspicion that it is a malignant change in the prostate, a biopsy must be performed. Tissue samples are taken from the prostate gland with a thin needle and examined in the laboratory. This procedure allows a reliable differentiation between benign prostatic hyperplasia and prostate cancer.

How is benign prostatic hyperplasia treated?

In the case of minor complaints that are not or only slightly disruptive to the patient, treatment guidelines recommend controlled waiting without treatment. In this case, however, regular check-ups with the urologist are necessary in order to identify changes that require treatment in good time.

What treatment options are there?

In most cases, benign enlargement of the prostate can be treated with lasting success. In the case of moderate but annoying symptoms, BHP is usually first treated with medication. There are essentially three groups of preparations:

Phytotherapeutic agents

Phytotherapeutics are plant extracts. Various preparations are available in various combinations. Randomized, controlled studies found evidence of effectiveness in benign prostatic hyperplasia for four phytotherapeutic agents. A substance from the sawtooth palm or its combination with other extracts such as the stinging nettle root has been particularly well researched.

However, there are contradicting results here as well. The proof of a long-term, clinically relevant efficacy in patients with enlarged prostate or a positive influence on the size of the prostate has not yet been provided for any phytotherapeutic agent. However, side effects are very rare with this group of substances.

Alpha-Receptor Blockers

These drugs relax the muscles of the prostate and urinary bladder. This reduces the resistance at the bladder outlet, which should make it easier to empty the bladder. Studies have shown that alpha-blockers at least slightly improve the symptoms of benign prostatic hyperplasia.

A positive influence on the size of the prostate gland could not be proven. Possible side effects include fatigue, dizziness, headache, and low blood pressure.

5 alpha reductase inhibitors

These drugs prevent testosterone from being converted to dihydrotestosterone in the prostate gland, thus acting on a mechanism that promotes prostate growth.

In fact, 5-alpha reductase inhibitors can decrease the size of the organ, improve symptoms, and reduce the risk of urinary retention or prostate surgery. Side effects include loss of libido, erectile dysfunction and ejaculation disorders.

If the symptoms cannot be relieved by medication to a degree that is satisfactory for the patient, surgery should be considered. Surgical treatment is necessary for recurring urinary tract infections, repeated urinary retention, recurring blood in the urine, bladder stones and kidney damage caused by the enlarged prostate. There are now a number of methods here.

Transurethral electrical resection

The standard procedure is still the transurethral electroresection of the prostate - TUR-P for short. The enlarged glandular tissue is peeled off with the help of an endoscope pushed through the urethra while looking from the inside to the outside. The aim is to shrink the prostate so that it no longer constricts the urethra.

Other surgical interventions used also aim to remove excess prostate tissue and / or widen the urethra, such as:

  • special laser processes (e.g. the HoLEP method - Holmium L.aser E.nucleation of P.rostata)
  • open prostate surgery (prostate enucleation)

Which side effects can occur?

All operations can have undesirable side effects. This includes, for example, what is known as retrograde ejaculation, in which the seminal fluid is not passed out through the urethra but into the urinary bladder.

Unintentional leakage of urine (incontinence), caused by damage to the urinary bladder sphincter, or potency problems can occur in a few individual cases. Overall, however, the TUR-P is a safe surgical method that is rarely associated with complications.

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Authors:
Ulrich Kraft (first author 2011), Tanja Unterberger, Bakk. phil. (2018)
Medical review:
PD Dr. Anton Ponholzer, specialist in urology and andrology

Status of medical information:
swell

AWMF guideline: Therapy of Benign Prostate Syndrome (BPS). 2014 https://www.awmf.org/leitlinien/detail/ll/043-035.html (last accessed: 02/08/2018)

Ulrike Zwergel, Jürgen Sökeland: Benign prostatic hyperplasia: Basics and therapy. Springer Verlag, 1999

Brunett & Wein: Benign prostatic hyperplasia in primary care: what you need to know.
In: J Urol 175, No. 3 Pt 2, pp. S19-24, 2006

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ICD-10: N40