Benign Prostatic Hyperplasia (BPH)

What is BPH?

The term BPH used in the common clinical setting refers to the condition in which benign (non-cancerous) enlargement  of the prostate gland is associated with urinary symptoms such as difficulty in urination and increased frequency of urination.
An enlarged prostate compresses and gradually obstructs the urethra which is the outlet channel for urine stored in the bladder. In the early stages of BPH, the patient may notice that the flow is reduced. However this reduction in flow occurs very gradually such that many men become accustomed to it and hence may not necessarily perceive it as a problem. As the BPH progresses, the flow becomes slower and these men will start to notice that it takes them longer to pass urine; they may have to strain to aid the flow; the stream may stop and start and at the end it slows down to a dribble. There may also be an unsatisfied feeling after visiting the toilet because the bladder is not emptied completely. The latter may result in frequency both day and night. These are collectively known as obstructive symptoms. In the advanced stages of obstruction, a sudden inability to void (urinary retention) may occur.
As the prostate grows, it also pushes and protrudes into the base of the bladder causing irritation of the bladder. The bladder can also become irritable as a consequence of persistently having to overwork to expel urine. This irritation results in frequency and urgency perceived as not being able to hold urine, having to rush to the toilet and occasionally having leakage of urine. Collectively these are called irritative symptoms.
What causes BPH?
Exactly what causes BPH is still unknown. However, what is clear, is that BPH is an age related growth of the various components of the prostate gland. One popular theory underlying the development of BPH, is that aging leads to changes in the various hormones in the prostate as well as altering the sensitivities of the prostatic tissues to these hormones resulting in abnormal growth leading to BPH. Another theory that is gaining growing support is that of chronic inflammation being the underlying stimulus for the abnormal prostate growth. While a direct link between chronic inflammation and abnormal prostatic growth is yet to be elucidated, there is a strong association between them based on the high occurrence of chronic inflammation seen in surgical specimen from BPH patients.
Who gets BPH and how common is it?
BPH is very common in men 50 years an above. Local studies have shown that Malaysian men are equally affected by BPH as men in the west. Furthermore BPH affects men from all races equally. It is estimated that about 50% of men above 50 years are affected by symptomatic BPH.
How is BPH diagnosed?
The diagnosis of BPH is usually straight forward. History taking by the doctor focusing on the symptoms forms a major part of the diagnostic process. This can be aided by the patient filling up a questionnaire called the IPSS (International Prostate Symptom Score). This tool helps the patient express the severity of his symptoms and has been translated into local languages (see Appendix).
A general physical examination is required. A vital part of this physical examination is the digital rectal examination which is how the doctor assesses the prostate with a gloved finger inserted through the rectum. Information such as size, consistency and smoothness of the prostate is obtained from this examination. An ultrasound done with a probe on the abdomen and/or through the rectum may also yield useful information.
A urinary flow rate test (uroflowmetry) is a special test whereby the patient voids into a receptacle that collects and measures the speed of the urine flow as well as the voided volume. Finally some laboratory tests of the urine and blood may be required.
How is BPH treated?
Early BPH that is not causing significant bother to the patient can be managed by just watching and follow up assessment. However usually, by the time men seek help for their BPH, they are already significantly affected such that treatment is required. This can be either medical or surgical.
Medical treatment
Medical therapy is usually the first line treatment for men with bothersome BPH. There are two classes of drugs. The first one is called alpha blockers and they work by relaxing the muscle in the prostate thus allowing the urine to pass more easily through the urethra. There may also be relaxation of the muscle in the base of the bladder and this helps relief some of the irritative symptoms. Alpha blockers start to work within a day or two and it is the first drug that most urologists will choose. Although it is well tolerated most of the time, some patients may feel some dizziness because this drug can lower the blood pressure, especially in men who are also taking medication to treat hypertension.
The second class of drugs is called 5 alpha reductase inhibitors. These drugs work by shrinking the prostate slowly over a period of a few months. Therefore the effects are not felt immediately on starting the medication. Usually men with bigger prostates are advised to take this class of drug in combination with alpha blockers for long term prevention of progression of BPH. It is also a useful drug for men with troublesome bleeding from an enlarged prostate.
Surgical treatment
Although advancement in medical therapy has allowed many men to avoid surgery, the latter is still required when drugs have failed or their side effects are unmanageable. Men who present with urinary retention also frequently proceed straight to surgery. Despite good medication, BPH can still progress in some men and complications may develop. Bladder stone formation, incomplete bladder emptying, urinary tract infection, obstruction and dilatation of the upper urinary tract, kidney function impairment and bleeding are some of the commoner complications of BPH. Surgery is usually required when these complications have developed.
Can BPH be prevented?
It is unclear why some men develop BPH and some men do not. Only age and family history have been established as risk factors for the development of BPH and both of them are unavoidable.
Some studies have suggested high calorie intake as a stimulus to BPH. The resulting excess fat may affect hormones levels in a way that facilitates the development of BPH. On the other hand exercise can help prevent prostate growth presumably by reducing obesity and increasing hormone levels.
There are also reports that lycopene and antioxidants as found in tomatoes can slow down prostate growth.
Does BPH lead to Prostate Cancer?
There is no direct link between BPH and prostate cancer. Although both conditions become more common as a man gets older, having BPH does not predispose a man to the development of prostate cancer.
Because most men with prostate cancer are in their 50’s or above, they will also have BPH in the prostate as well. This is merely a coincidence because of age.
BPH and prostate cancer also usually arise from different parts of the prostate. Therefore having surgery for BPH does not prevent a man from the development of prostate cancer later on in life. It is important for men who have already undergone treatment for BPH to undergo follow up with their urologists because they are still at risk of developing prostate cancer. 
Prepared by Dr Chua Chong Beng. Consultant Urologist. Last review date: 2014
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  arrowMUA-BPH Article.pdf (English - pdf - 196 Kb)

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