Benign Prostatic Hyperplasia: Is It Fatal?

Benign prostatic hyperplasia, a noncancerous enlargement of the prostate gland, is the most common benign tumor found in men.

As is true for prostate cancer, BPH occurs more often in the West than in Eastern countries, such as Japan and China, and it may be more common among black people. Not long ago, a study found a possible genetic link for BPH in men younger than age 65 who have a very enlarged prostate: Their male relatives were four times more likely than other men to need BPH surgery at some point in their lives, and their brothers had a sixfold increase in risk.

BPH produces symptoms by obstructing the flow of urine through the urethra. Symptoms related to BPH are present in about one in four men by age 55, and in half of 75-year-old men. However, treatment is only necessary if symptoms become bothersome. By age 80, some 20% to 30% of men experience BPH symptoms severe enough to require treatment. Surgery was the only option until the recent approval of minimally invasive procedures that open the prostatic urethra, and drugs that can relieve symptoms either by shrinking the prostate or by relaxing the prostate muscle tissue that constricts the urethra.

Signs and Symptoms

BPH symptoms can be divided into those caused directly by urethral obstruction and those due to secondary changes in the bladder.

Typical obstructive symptoms are:

• Difficulty starting to urinate despite pushing and straining
• A weak stream of urine; several interruptions in the stream
• Dribbling at the end of urination

Bladder changes cause:

• A sudden strong desire to urinate (urgency)
• Frequent urination
• The sensation that the bladder is not empty after urination is completed
• Frequent awakening at night to urinate (nocturia)

As the bladder becomes more sensitive to retained urine, a man may become incontinent (unable to control the bladder, causing bed wetting at night or inability to respond quickly enough to urinary urgency).

Burning or pain during urination can occur if a bladder tumor, infection or stone is present. Blood in the urine (hematuria) may herald BPH, but most men with BPH do not have hematuria.

Screening and diagnosis

The physical examination may begin with the doctor observing urination to completion to detect any urinary irregularities. The doctor will manually examine the lower abdomen to check for a mass, which may indicate an enlarged bladder due to retained urine. In addition, a digital rectal exam (DRE), which allows the physician to assess the prostate’s size, shape and consistency, is essential for proper diagnosis. During this important examination, a gloved finger is inserted into the rectum — this is only mildly uncomfortable. The detection of hard or firm areas in the prostate raises suspicion of prostate cancer. If the history suggests possible neurologic disease, the physical may include an examination for neurologic abnormalities that indicate the urinary symptoms result from a neurogenic bladder.

A urinalysis, which is performed for all patients with symptoms of BPH, may be the only laboratory test if symptoms are mild and no other abnormalities are suspected from the medical history and physical examination. A urine culture is added if a urinary infection is suspected. With more severe, chronic BPH symptoms, blood creatinine of blood urea nitrogen (BUN) and hemoglobin are measured to rule out kidney damage and anemia. Measuring prostate specific antigen (PSA) levels in the blood to screen for prostate cancer is recommended, as well as performing the DRE. PSA testing alone cannot determine if symptoms are due to BPH or prostate cancer, because both conditions can elevate PSA levels.

Treatment

When is BPH treatment necessary?

The course of BPH in any individual is not predictable. Symptoms, as well as objective measurements of urethral obstruction, can remain stable for many years and may even improve over time for as many as one-third of men, according to some studies. In a study from the Mayo Clinic, urinary symptoms did not worsen over a 3.5-year period in 73% of men with mild BPH. A progressive decrease in the size and force of the urinary stream and the feeling of incomplete bladder emptying are the symptoms most correlated with the eventual need for treatment. Although nocturia is one of the most annoying BPH symptoms, it does not predict the need for future intervention.

If worsening urethral obstruction is left untreated, possible complications are a thickened, irritable bladder with reduced capacity for urine; infected residual urine or bladder stones; and a backup of pressure that damages the kidneys.

Decisions regarding treatment are based on the severity of symptoms (as assessed by the AUA Symptom Index), the extent of urinary tract damage and the man’s overall health. In general, no treatment is indicated in those who have only a few symptoms and are not bothered by them. Intervention — usually surgical — is required in the following situations:

• Inadequate bladder emptying resulting in damage to the kidneys
• Complete inability to urinate after acute urinary retention
• Incontinence due to overfilling or increased sensitivity of the bladder
• Bladder stones
• Infected residual urine
• Recurrent severe hematuria
• Symptoms that trouble the patient enough to diminish his quality of life

Treatment decisions are more difficult for men with moderate symptoms. They must weigh the potential complications of treatment against the extent of their symptoms. Each individual must determine whether the symptoms interfere with his life enough to merit treatment. When selecting a treatment, both patient and doctor must balance the effectiveness of different forms of therapy against their side effects and costs.

Treatment Options for BPH

Currently, the main options to address BPH are:

• Watchful waiting
• Medication
• Surgery (prostatic urethral lift, transurethral resection of the prostate, photovaporization of the prostate, open prostatectomy)

If medications are ineffective in a man who is unable to withstand the rigors of surgery, urethral obstruction and incontinence may be managed by intermittent catheterization or an indwelling Foley catheter (which has an inflated balloon at the end to hold it in place in the bladder). The catheter can remain indefinitely (it is usually changed monthly). Benign prostatic hyperplasia is not fatal if treated right.