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Benign Prostatic Hyperplasia (BPH)

What is benign prostatic hyperplasia?

Benign prostatic hyperplasia (BPH, less commonly known as benign prostatic hypertrophy) is, essentially, an abnormal enlargement of the prostate gland. During a man’s life, the prostate goes through two different stages of growth. The first stage occurs during early puberty, when the prostate tissue doubles in size, while the second happens around age 25; this second growth stage is more gradual and goes on for almost all of a man’s life.

As a man grows older, two things happen to his prostate. First, the prostate gland itself enlarges and starts pressing against his urethra, potentially causing what is now as a narrow urethra, which restricts or slows the flow of urine. Second, the bladder walls grow thicker while the bladder itself weakens, making it harder for it to fully empty and leaving some urine inside. A narrow urethra and urine retention are, as you can imagine, two of the most common issues associated with BPH.

It’s important to note that, while the two can occur at the same time, benign prostatic hyperplasia is not cancer, and it alone does not cause or lead to cancer.

What causes benign prostatic hyperplasia AKA benign prostate enlargement?

As we mentioned, the prostate gland enlarges throughout a man’s life starting at age 25, but there is no definite answer as to what causes benign prostate enlargement, although some studies have linked it to male hormones.

An imbalance of a man’s sex hormones, such as a higher level of estrogen than testosterone, can increase prostate tissue cell growth and therefore cause abnormal prostate enlargement. Another hormone, dihydrotestosterone (DHT), promotes prostate gland growth, and its accumulation can also lead to increased prostate size.

What are the symptoms of benign prostatic hyperplasia?

While men are asymptomatic during the early stages of benign prostatic hyperplasia, the following symptoms develop as the disease progresses:

Symptoms caused by urethral obstruction:

  • Hesitancy or difficulty starting to urinate (despite pushing or straining).
  • Slowness or dribbling of the urinary stream.
  • Stop-and-go urination (several interruptions in the urine stream).

Symptoms caused by bladder changes

  • Frequent urination.
  • Feeling of urgency (sudden need to urinate).
  • Need to get up at night to urinate.
  • Pain after ejaculation or while urinating.
  • Urine that looks or smells “weird” (for instance, it’s a different color).

Incontinence becomes present as the bladder grows more sensitive to urine retention, which can be made worse by the weakening of the bladder wall.

A burning or painful sensation during urination can signal a bladder infection, stone, or tumor. Urine with traces of blood (hematuria) can be present in men with BPH during the early stages, but most men do not have hematuria.

Your healthcare providers must understand the intricate dynamics of the bladder, bladder neck, prostate, and urethra in order to effectively manage your lower urinary tract symptoms.

Who is more likely to develop benign prostatic hyperplasia?

As we mentioned in the previous section, there are several uncontrollable risk factors that account for your chance of getting an enlarged prostate (BPH). Here are the three most important factors:

  1. Age. Although the second enlargement of the prostate gland begins at age 25 and BPH is more common the older you get, it’s rare for it to affect men under 40.
  2. Family history. If the male members of your family have this condition, this means you have a higher chance of getting it as well.
  3. Ethnicity. BPH typically affects white and black men more than Asian men. Also, it is common for black men to present BPH symptoms at an earlier age than others.

How can benign prostatic hyperplasia be prevented?

While there are uncontrollable risk factors for BPH such as family history and age, there are some that can be controlled or managed by men:

It is important to maintain a healthy lifestyle to manage the risk of BPH, and a healthy diet is a necessity to achieve it. Nutrition also goes hand in hand with avoiding obesity.

Physical activity
Regular exercise is another major component of a healthy lifestyle, and a great way to avoid obesity and the complications it brings, including those associated with BPH.

If you already have BPH, there are certain habits you can maintain to avoid further complications.

  • Avoid “holding it in” (delaying urination): Delaying urination can seriously aggravate the symptoms of benign prostate enlargement.
  • Limit your consumption of alcohol: While moderate alcohol consumption (one to two drinks per day) is considered safe, excessive consumption can lead to prostate irritation.
  • Practice healthy sleeping habits: Bad sleeping hygiene has been proven to have a negative impact on prostate health.
  • Quit smoking: Smoking can aggravate the symptoms of BPH and cause prostate tissue irritation.
  • Avoid certain over-the-counter drugs: There are several over-the-counter medications that can worsen BPH. Make sure to consult a physician before taking these medications.

How common is benign prostatic hyperplasia?

Unfortunately, benign prostate hyperplasia is the most common prostate affliction for men above the age of 50 in the United States. BPH is known to affect 50 percent of men between ages 50 and 60, and a staggering 90 percent of men older than 80. As we mentioned in the previous section, BPH is more prevalent in black and white male populations than in Asian male ones.

Although BPH usually does not present symptoms in men 40 years of age or younger, these only grow with age once they do present themselves

When you should seek medical assistance

While you should visit a physician when you start experiencing the symptoms of an enlarged prostate that we have described, it is also important to know when you are dealing with a medical emergency that requires immediate attention.

Can’t urinate at all.

A man might become unable to urinate at all, a problem called acute urinary retention. This issue can present itself even if his BPH is responding positively to treatment, and requires emergency attention at a hospital to be treated with catheterization.

Pain in the area of the lower abdomen or genitals while urinating.

These symptoms are related to chronic bacterial prostatitis (AKA type II). As we mentioned above, men who are already dealing with BPH should not peg these symptoms with the ones caused by it and should seek medical attention.

Pain, fever, and/or chills while urinating.

Men dealing with BPH should be on the lookout for fever, chills, and discomfort in the joints when urinating, as these symptoms are related to another prostate condition called acute bacterial prostatitis (AKA type I), which is a type of bacterial infection.

Blood in the urine.

Blood in the urine, also known as hematuria, has a tendency to cause immediate panic in men. The prostate gland is directly involved with the urinary tract and it should come as no surprise that blood leakage is caused by its enlargement. While it’s not an uncommon sight in older males, especially ones with untreated BPH, it is also worth a visit to the urologist. It is wise to remember that hematuria is a sign of not only BPH but prostate cancer as well.

How is benign prostatic hyperplasia diagnosed?

It is important to diagnose BPH early because if left untreated, it can lead to serious health problems and discomfort down the line, including recurrent urinary tract infections, kidney damage, bladder stones, and chronic incontinence. It is also important to distinguish between BPH and other, more serious diseases.

Diagnosis starts with a physical exam (digital rectal exam, urine test, and blood test). From here, you can also get recommended to get other tests done to help confirm an enlarged prostate or more if your health problem is more complex.

While tests vary from patient to patient, here are the most utilized by physicians today:

  • Symptom questionnaires
  • Urine flow
  • Digital rectal examination (DRE)
  • Prostate-specific antigen (PSA) blood test
  • Prostate MRI
  • Transabdominal ultrasound
  • Cystoscopy
  • Transabdominal ultrasound

Does benign prostatic hyperplasia (BPH) increase the risk of having prostate cancer?

There is a significant amount of debate regarding the risk of developing prostate cancer from benign prostate enlargement. These debates are still ongoing in the urological community, studies have shown that while genetic, hormonal, and inflammatory mechanisms are related to both BPH and prostate cancer, no solid evidence has been found that the tissue enlargement caused by BPH is converted into cancer.

Still, even if a causal link cannot be established between BPH and prostatic cancer, the commonality of these two diseases in older men makes it hard to entirely discard the risk from an epidemiological standpoint.

How is benign prostatic hyperplasia treated?

Currently, there is no cure for benign prostatic hyperplasia (BPH). Thankfully, there are plenty of treatment options for BPH patients, and some mild cases might not even require treatment at all. However, other cases will require some minimally invasive procedures (that is, without anesthesia), or a combination of different treatments.

The main types of treatments are:

Active Surveillance
This is the “no treatment” treatment. It means the patient will not be treated but will be closely monitored by his physician through regular visits, most commonly a yearly exam, depending on the severity of the BPH. Since BPH has no cure, this is also an option for patients who present symptoms but are not bothered too much by them.

Minimally invasive surgery
This is a type of surgery that requires only tiny cuts (or no cuts at all) done to the body. Candidates are usually men who have taken prescription medications to no effect and present weak urination, bladder stones, hematuria, or incomplete emptying of the bladder.

The types of less or minimally invasive surgery are: 

  • Prostatic Urethral Lift (PUL)
  • Water Vapor Thermal Therapy
  • Catheterization
  • Transurethral Microwave Therapy

Invasive surgery
When dealing with a more severe case of BPH, it is recommended to undergo more invasive surgery, especially when symptoms such as complete inability to pass urine, kidney damage, chronic urinary tract infections, constant bleeding, and bladder stones are present. 

The types of invasive prostate surgery are:

  • Transurethral Incision of the Prostate (TUIP)
  • Photoselective Vaporization (PVP)
  • Transurethral Resection of the Prostate (TURP)
  • Holmium Laser Enucleation of Prostate (HoLEP)
  • Transurethral Vaporization of the Prostate (TUVP)
  • Transurethral Water–Jet Ablation (TWJA)
Does the treatment for benign prostatic hyperplasia have side effects?

Side effects of some BPH treatments include incontinence, bleeding, infections, and erectile dysfunction. However, most side effects are temporary, although it may take a while until sexual function fully returns for most patients.


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