Introduction, Symptoms and Complications
The prostate gland is present only in males. Enlargement of the prostate
gland causes problems in urination in elderly male. (usually over the age
of 60 years). With increase in life expectancy, the incidence of benign
prostatic hyperplasia (also called BPH) has also increased.
What is the prostate gland? What is its function?
The prostate gland is a small organ about the size of a walnut and is part
of the male reproductive system.
The prostate gland is situated just underneath the bladder and in front
of the rectum. It surrounds the initial portion of the urethra (the tube that
carries urine from the bladder). In other words, the initial portion of the
urethra (about 3 cm. long) runs through the prostate.
The prostate is a male reproductive organ. It secretes fluid that nourishes
and carries sperm into the urethra during ejaculation.
What is benign prostatic hyperplasia (BPH)?
“Benign prostatic” means the prostatic problem is not caused by
cancer and “hyperplasia” means enlargement.
Benign prostatic hyperplasia or benign prostatic hypertrophy (BPH) is
a non-cancerous prostatic enlargement that occurs in almost all men as
they get older. As men age, the prostate gland slowly grows bigger (or
enlarges). An enlarged prostate compresses the urethra, blocks the urine
stream and causes problems in urination. Because of narrowing of the
urethra, flow of urine becomes slower and less forceful.
Benign Prostatic Hyperplasia
is a disease of elderly males.
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Symptoms of BPH
The symptoms of BPH usually begin after age 50. More than half of
men in their 60s and up to 90% of men in their 70s and 80s have
symptoms of BPH. Most symptoms of BPH start gradually and worsen
over the years. The most common symptoms of BPH are:
- Frequent urination, especially at night. This is usually a very early
- Slow or weak stream of urine.
- Difficulty or straining in starting the urine flow, even when the bladder
- Urge to urinate immediately is the most bothersome symptom.
- Straining to urinate.
- Interrupted urine flow.
- Leaking or dribbling at the end of urination. Drops of urine are
expelled even after urination causing wetting of underclothes.
- Incomplete emptying of bladder.
BPH causes weak stream of urine and
frequent urination, especially at night.
Complications of BPH
Severe BPH can cause serious problems over a time in a few patients,
if left untreated. Common complications of BPH are:
- Acute urinary retention: untreated severe BPH over time can
cause sudden, complete and often painful blockage of urine flow.
Such patients require insertion of a tube called a catheter to drain
urine from the bladder.
- Chronic urinary retention: partial blockage of urine flow for a
prolonged period can cause chronic urinary retention. Chronic urinary
retention is painless and is characterized by an increased residual urine volume.
The amount of urine which remains in bladder after
normal urination is called residual urine. Its usual presentation is
incomplete bladder emptying or frequent voiding of small amount of
urine (overflow of urine).
Digital rectal examination and sonography are two
most important tests for the diagnosis of BPH.
Diagnosis of BPH
When history and symptoms suggest BPH, the following tests are
performed to confirm or rule out the presence of an enlarged prostate.
- Digital rectal examination (DRE)
In this examination, a lubricated, gloved finger is gently inserted into the
patient’s rectum to feel the surface of the prostate gland through the
rectal wall. This examination gives the doctor an idea of the size and
condition of the prostate gland.
In BPH, on DRE, the prostate is enlarged, smooth, and firm in
consistency. Hard, nodular and irregular feel of the prostate on DRE
suggests cancer or calcification of prostate gland.
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Can a person with symptoms of BPH have prostate cancer?
How is prostate cancer diagnosed?
- Ultrasound and post-void residual volume test
An ultrasound can estimate the size of the prostate and detect other
problems such as malignancy, dilatation of the ureter and the presence
of a kidney abscess.
Ultrasound imaging is also used to determine the quantity of urine left in
the bladder after urination. Post-void residual urine volume less than 50
ml indicates adequate bladder emptying. Post-void residual urine
volume of 100 to 200 ml or higher is considered to be significant and
further evaluation is needed.
- Prostate symptom score or index
The International Prostate Symptom Score (IPSS) or AUA (American
Urological Association) symptom index helps in the diagnosis of BPH. In
this diagnostic modality, patients are asked about the presence or
absence of common symptoms of benign prostatic hyperplasia. The
answers are then scored and, on the basis of the calculated prostate
symptoms score, the severity of the urinary problem is judged.
- Laboratory tests
Laboratory tests do not help diagnosing of BPH. But they help in the
diagnosis of associated complications and excluding problems with
similar presentation. Urine is tested for infection and blood is tested for
Prostate Specific Antigen (PSA) is a screening blood test for cancer
of the prostate.
- Other investigations
Different investigationsperformed to diagnose or exclude the diagnosis
of BPH are uroflowmetry, urodynamic studies, cystoscopy, prostate biopsy, intravenous pyelogram or CT urogram and retrograde
Yes. Many symptoms of prostate cancer and BPH are similar, so on
the basis of clinical symptoms it is not possible to differentiate between
the two conditions. But remember, BPH is not related to prostate cancer.
Three most important tests which can establish the diagnosis of prostate
cancer are digital rectal examination (DRE), blood test for prostate-
specific antigen (PSA) and prostate biopsy.
Blood PSA test is an important screening test
for the diagnosis of cancer of the prostate.
Life style changes and Medical treatment
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Treatment of BPH
Factors determining treatment options of BPH are severity of symptoms,
the extent to which daily life is affected due to symptoms, and the
presence of associated medical conditions. Goals of treatment of BPH
are to reduce symptoms, improve quality of life, reduce post void residual
urine volume and prevent complications of BPH.
Three different treatment options of BPH are:
A. Watchful waiting and lifestyle changes (no treatment)
B. Medical Treatment
C. Surgical Treatment
Many symptoms of prostate cancer and BPH are similar.
Thorough investigation is required for accurate diagnosis.
A. Watchful waiting and lifestyle changes (no treatment)
“Wait and watch” without any treatment is the preferred approach for
men with mild symptoms or symptoms that don’t bother them. But
watchful waiting does not mean to simply wait and do nothing to reduce
symptoms of BPH. During watchful waiting, the person should make
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changes in life style to reduce symptoms of BPH and also have regular
yearly checkups to see if the symptoms are improving or getting worse.
· Make simple changes in the habits of urination and in consumption
- Empty bladder regularly. Do not hold back urine for long. Urinate as
soon as the urge arises.
- Double void. This means urine is passed twice in succession. First
empty the bladder normally in a relaxed way, wait for a few moments,
and try to void again. Do not strain or push to empty.
- Avoid drinking alcohol and caffeine containing beverages in the
evening. Both can affect the muscle tone of the bladder, and both
stimulate the kidneys to produce urine, leading to night-time urination.
- Avoid excessive intake of fluid (take less than 3 liters of fluid per
day). Instead of consuming a lot of fluid all at once, spread out
intake of fluids over the day.
- Reduce fluid intake few hours before bedtime or going out.
- DO NOT take over-the-counter cold and sinus medications that
contain decongestants or antihistamines. These medications can
worsen symptoms or cause urinary retention.
- Change the timing of medications which increases volume of urine
- Keep warm and exercise regularly. Cold weather and lack of physical
activity may worsen symptoms.
- Learn and perform pelvic strengthening exercises as they are useful
to prevent urine leakage. Pelvic exercises strengthen the muscles of
the pelvic floor which support the bladder and help in closing the sphincter. The exercises consist of repeatedly tightening and releasing
the pelvic muscles.
BPH with mild symptoms can be managed with watchful waiting
and lifestyle changes and without medical treatment.
B. Medical Treatment
- Bladder training focused on timed and complete voiding. Try to
urinate at regular times.
- Treatment of constipation.
- Reduce stress. Nervousness and tension can lead to more frequent
Medications are the most common and preferred way to control mild
to moderate symptoms of BPH. Medications significantly reduce major
symptoms in about two-thirds of treated men. There are two classes of
drugs, alpha-blockers and anti-androgens (5-alpha-reductase
inhibitors), for an enlarged prostate.
- Alpha-blockers (tamsulosin, alfuzosin, terazosin, and doxazosin)
are prescription medicines that relax the muscles in and around the
prostate, relieve urinary obstruction and allow urine to flow more
easily. The most common side effects of alpha-blockers are light
headedness, dizziness and fatigue.
- 5-alpha-reductase inhibitors (finasteride and dutasteride) are
medicines that can reduce the size of the prostate gland. These drugs
increases urine flow rate, and decreases symptoms of BPH. They
do not work as quickly as alpha-blockers (improvement is seen
within six months of starting treatment) and generally work best on
men with severe prostate enlargement. The most common side effects
of 5-alpha-reductase inhibitors are problems with erection and
ejaculation, decreased interest in sex and impotence.
- Combination treatment: An alpha blocker and an alpha-reductase
inhibitor work differently and have an additive effect when given
simultaneously. Therefore combination of both drugs leads to
significantly greater improvement in the symptoms of BPH, than taking
either drug by itself. Combination treatment is recommended in men
with severe symptoms, large prostate and inadequate response to
the highest dose of an alpha blocker.
Conservative medical treatment is preferred for mild to
moderate symptoms of BPH. Surgery is best avoided.
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C. Surgical Treatment
Surgical treatment is recommended in persons with:
- Bothersome, moderate to severe symptoms refractory to medical
- Acute urinary retention.
- Recurrent urinary tract infections.
- Recurrent or persistent blood in the urine.
- Kidney failure due to BPH.
- Bladder stones along with BPH.
- Increasing or significant post void residual urine in bladder.
Surgical treatment can be divided into two groups: surgical therapies
and minimally invasive treatment. The standard surgical method is a
transurethral resection of the prostate (TURP). Currently several newer
methods are evolving in the surgical management of small to medium
sized glands, which aim to achieve results comparable to TURP with
less morbidity and cost.
Severe BPH symptoms, urinary retention, recurrent
UTI and kidney failure indicate need for surgery.
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Specific surgical procedures commonly used are transurethral resection
of the prostate (TURP), transurethral incision of the prostate (TUIP)
and open prostatectomy.
1. Transurethral Resection of the Prostate (TURP)
TURP remains the gold standard treatment of prostate surgery and is
more successful than medication. It relieves urinary obstruction in at
least 85% to 90% of cases, and the improvement is usually long-lasting.
TURP is a minimally-invasive operation, performed by urologists to
remove part of the prostate gland blocking urine flow. TURP does not
require any skin incision or stitches, but requires hospitalization.
During the procedure
- Before the procedure, fitness of the person is ensured.
- The patient is asked to stop smoking as smoking increases the risk
of getting a chest and wound infection, and can delay recovery.
- The patient is asked to discontinue blood-thinning medications
(warfarin, aspirin and clopidogrel).
- TURP generally takes about 60 to 90 minutes.
- TURP is usually done using spinal anesthesia. Antibiotics are given
to prevent infection.
- During TURP, an instrument (resectoscope) is inserted in the urethra
through the tip of the penis to remove the prostate.
- The resectoscope has a light and camera for vision, an electrical
loop to cut tissue and seal blood vessels, and a channel which carries
irrigating fluid into the bladder.
- Prostate tissue removed during the procedure is sent to a laboratory
for histopathological examination to exclude prostate cancer.
Advice after surgery
- The hospital stay is usually 2 to 3 days after TURP.
- Following surgery, a large triple lumen catheter is inserted through
the tip of the penis (through the urethra) into the bladder.
- A bladder irrigation solution is attached to the catheter and the bladder
is irrigated and drained continuously for about 12–24 hours.
- Bladder irrigation removes blood or blood clots that may result from
- When the urine is free of significant bleeding or blood clots, the
catheter is removed.
Following measures after TURP help in early recovery:
- Drink more fluids to flush out urine from the bladder.
- Avoid constipation and straining during defecation. Straining can result
in increased bleeding. If constipation occurs, take a laxative for a
- Do not start blood-thinning medications without advice of the
- Avoid heavy lifting or strenuous activity for 4-6 weeks.
- Avoid sexual activity for 4-6 weeks after surgery.
- Avoid alcohol, caffeine, and spicy foods.
The most effective and popular surgical
treatment of BPH is TURP.
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- Immediate common complications are bleeding and urinary tract
infection; while less common complications are TURP syndrome
and problems from surgery.
- Subsequent complications of TURP are narrowing (stricture) of the
urethra, retrograde ejaculation, incontinence and impotence.
- Ejaculation of semen into the bladder (retrograde ejaculation) is a
common sequel a of TURP, occurring in about 70% of cases. This
does not affect sexual function or pleasure but causes infertility.
- Factors which can increase the risk of complications are obesity,
smoking, alcohol abuse, malnutrition and diabetes.
TURP is done under spinal anesthesia without making the
patient unconscious, thus, requiring a shorter hospital stay.
CHP. 20. Benign Prostatic Hyperplasia (BPH) 153.
After discharge from the hospital, contact the doctor if the
2. Transurethral Incision of the Prostate (TUIP)
- Difficulty or inability to void.
- Severe pain which persists even after medications.
- Bleeding with large blood clots that block the catheter.
- Signs of infection, including fever or chills.
Transurethral incision of the prostate (TUIP) is an alternative to TURP
for men with smaller prostates or very poor health and therefore, not
suitable for TURP.
The set-up for TUIP is similar to TURP, but rather than removing tissue
from the prostate, two or more deep lengthwise incisions (cuts) are
made in the prostate. The cuts widen the urethral passage, relieve
pressure on the urethra and improve the flow of urine.
Benefits of TUIP are less blood loss, less surgery-related complications,
shorter hospital stay and recovery time; and less risk of retrograde ejaculation and urinary incontinence as compared to TURP.However,
TUIP is less effective in providing symptom relief and/or symptoms
return faster over a shorter period of time in some patients requiring a
follow up treatment with TURP. TUIP is not the most effective method
of treatment for a large-sized prostate.
Ejaculation of semen into bladder is a common complication
of TURP leading to infertility (inability to father children).
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3. Open Prostatectomy
Open prostatectomy is a type of surgery where an incision is made in
the abdomen to remove the prostate. With availability of many effective
and less invasive options, open prostatectomy is rarely used in the
treatment of BPH.
An open prostatectomy is reserved only for very few men with severely
enlarged prostates and in patients suffering from other problems that
need simultaneous correction during surgery.
Minimally Invasive Treatments (MITs)
Minimally invasive methods are those that hurt the least. With modern
technology and research, minimally invasive treatments are aimed at
treating BPH through simpler procedures with less complications.
These treatment modalities generally use heat, laser, or
electrovaporization to remove excess tissue from the prostate. All of
these treatments use a transurethral approach (going up through the
urethra in the penis).
Benefits of minimally invasive treatments are: shorter hospital stay, need
for minimal anaesthesia, less risks and complications than standard
prostate surgery, and shorter patient recovery times. Disadvantages of these methods are: less effectiveness than standard
TURP, more likely to need surgery again after 5 or 10 years, non
availability of prostate tissue for histopathological examination
(to exclude hidden prostate cancer) and fewer long-term studies for
their safety and efficacy. Important additional drawback is that minimally
invasive treatments (MITs) are not available in majority of developing
countries and are currently more expensive.
TUIP is an alternative to TURP for men with smaller prostates
or high risk patients for whom TURP is not suitable.
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Different minimally invasive treatments used in BPH are transurethral
microwave thermotherapy (TUMT), transurethral needle ablation
(TUNA), water-induced thermotherapy (WIT), prostate stents and
transurethral laser therapy.
- 1. Transurethral Microwave Thermotherapy (TUMT): In this
procedure,microwave heat is used to burn excess prostate tissue
blocking urine flow.
- 2. Transurethral Needle Ablation of the Prostate (TUNA): In this
procedure, radiofrequency energy is used to coagulate and necrose
excess prostate tissue blocking urine flow.
- 3. Water-Induced Thermotherapy (WIT): In this technique, hot water
causes heat-induced coagulation and necrosis of the excess prostate
- 4. Prostatic Stents: In this technique, a stent is placed within the
narrowed area of the prostatic urethra. The stent keeps the channel
open and allows easy urination. Stents are flexible, self-expanding
titanium wire devices shaped like small springs or coils.
- 5. Transurethral Laser Therapy: In this technique, laser energy
destroys the obstructing portions of the prostate by heating.
MIT benefits: less risks and shorter hospitalization;
Concerns: cost effectiveness and long term safety.
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When should a patient with BPH consult a doctor?
Patients with BPH should consult a doctor in case of:
- Complete inability to urinate.
- Pain or burning during urination, foul-smelling urine, or fever with
- Blood in the urine.
- Loss of control of urination causing wetting of underclothes.
Prostatic stent is a safe and effective treatment when
medications are ineffective & surgery is contraindicated.