Benign Prostate Hyperplasia

What is Benign prostate hyperplasia?

Benign prostate hyperplasia (HBP) – the enlargement of the prostate – is one of the most common diseases in men.

This medical condition stems from an increase in the number of prostate cells.

This occurs over many years because of the stimulated proliferation of these cells due to testosterone, the “male hormone”.

The growth in number of cells causes the volume and size of the prostate to increase with the consequent compression of the urethra and urinary problems.

However, it must be realised that the dilation of the prostate in this case is not caused by cancer.

BPH mainly develops in an area known as the transitional zone, located around the urethra. Malignant prostate cancer, on the other hand, usually occurs in the peripheral area (which accounts for around 70% of all tumours).

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Causes of Benign Prostate Hyperplasia

The exact causes of BPH are not fully known. However, there are various risk factors that contribute and are associated with the development of the disease. The only factors known are:

Age

Men aged over 50 are at higher risk. Ageing leads to the loss of the bladder muscle’s ability to contract normally, contributing to a worsening of the symptoms.

Testosterone

Testosterone is responsible for "feeding" the growth of the prostate cells that cause BPH

Fat-rich diets

This favours the development of benign prostate hyperplasia due to bodily changes. Furthermore, it is known that vegetables play a protective role.

Family history

A family history of large prostates, particularly in younger patients, is an influencing factor.

Some studies have associated diabetes with a greater probability of developing this disease, but more scientific evidence is required to prove this theory.

The same applies to physical exercise. It appears to lessen urinary symptoms, but there is no clear cause and effect to suggest it should be prescribed to prevent BPH.

Symptoms of Benign Prostate Hyperplasia

In its early stages, not all men show any symptoms. But as the prostate enlarges, it starts to compress the urethra and cause urinary issues.

If not treated effectively, these symptoms significantly affect patients’ well-being and quality of life.

It can lead to changes in bladder and kidney function with severe consequences, such as formation of bladder stones, urinary infections, blood in the urine and even kidney failure in more extreme cases (needing catheterisation).

Lower urinary tract symptoms (LUTS) are divided into 3 categories.

Bladder emptying symptoms:

Reduced urine jet – either weak and/or thin;
Time needed before starting to urinate;
Length of time needed to urinate;
Urinating several times with pauses in-between;
Need for abdominal effort in order to urinate;
Burning sensation when urinating;
Urinary retention (completely unable to urinate);
Incontinence (urine leakage) during sleep.

Bladder filling symptoms

Sudden need to urinate;
Inability to retain urine when there is a sudden need to urinate;
Increased frequency of urinating;
Increased number of times urinating during the night;
Pain/heavy sensation below the navel.

Post-void symptoms:

Sensation of not emptying the bladder completely;
Dribbling after urination.

Other symptoms

The same symptoms can be caused by various other situations, such as narrowing of the urethra (strictures), bladder cancer, neurological changes to the bladder, anxiety, unhealthy habits or certain medications.

The presence of blood in the urine can also occur. It has to be confirmed whether this is due to another pathology, cancer in particular, but it may also stem from a haemorrhage of the prostate (one of the situations in which BPH surgery is indicated).

Note also that it is possible to have BPH without any of these symptoms.

Benign Prostate Hyperplasia Diagnosis

Diagnosis is via a set of data from the patient’s clinical history and objective testing which is later confirmed by complementary diagnostic exams adapted to the clinical situation.

Clinical History

The diagnosis is based on the patient’s clinical history.

This assessment aims to determine and quantify the patient’s symptoms through symptom surveys:

Duration of symptoms;
Evolution over time;
Repercussions on well-being and quality of life.

The symptoms tend to worsen with age, but this is not an absolute rule. There are situations where they stabilise or improve spontaneously.

Very often, the symptoms fluctuate over time, progressively and slowly worsening.

Other possible causes for the urinary symptoms must be researched and the patient’s habits and medication studied, as well as other diseases or previous surgery.

The patient must also be asked whether they have ever had a catheter or urethral infection which might be associated with strictures and cause identical symptoms to BPH.

Objective Examination

Objective exams include a DRE and are used to confirm benign enlargement and help to exclude the possibility of cancer.

Complementary diagnostic exams

Besides a patient’s clinical history and an objective exam, some complementary exams are generally necessary, such as:

Blood tests (e.g. PSA to exclude cancer);
Urine tests;
Ultrasound scans;
Other exams such as uroflowmetry.

The doctor may feel it is important to perform an ultrasound scan of the bladder and kidneys, an endoscopy of the urethra and bladder, or a full urodynamic test for greater diagnostic accuracy and disease characterisation.

José Santos Dias explains what BPH is.

Do you have any symptoms indicating BPH?

A DRE and PSA test can confirm or allay suspicions of BPH and detect changes that may suggest prostate cancer. They are fast and at the cutting edge of diagnostics for this type of cancer.

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Treatments for Benign Prostate Hyperplasia

There are several ways to treat BPH. Some patients with BPH do not need any treatment. They merely need regular surveillance.

This applies to patients with no or slight symptoms with no significant repercussions on their well-being and quality of life.

Most patients with BPH need treatment with medication. This applies to patients with moderate or even severe symptoms that significantly impact their quality of life. In these cases, it is possible to use various therapeutic approaches, i.e., various drugs, with different effects that can be adapted to each patient and case.

There are three large groups of drugs to treat BPH: alpha-blockers (silodosin, tamsulosin and alfuzosin), 5-alpha-reductase inhibitors (finasteride and dutasteride) and phytotherapy (plant extracts such as Serenoa repens). Other drugs can be used with these to reduce some urinary symptoms, in particular increased urinary frequency and the sudden need to urinate (antimuscarinics like trospium and solifenacin or the beta 3 agonist mirabegron), or urinating during the night (like desmopressin).

The doctor and patient will decide on the best approach to take. Besides drugs, other more or less invasive treatments with excellent results exist.

Prostate laser for BPH

Laser treatment is a new and innovative technology with very positive results in treating patients with BPH.

See Treatment

Rezum and Other BPH Procedures

This new procedure treats BPH more effectively and less aggressively than other minimally invasive techniques.

See Treatment

Classical Open Surgery for BPH

Classical open surgery, also known as open prostatectomy, is a surgical technique that involves the removal of enlarged hyperplastic tissue.

See Treatment

Endoscopic Surgery for BPH

The aim of this operation is to remove the enlarged part of the prostate endoscopically.

See Treatment

Laparoscopic Surgery for BPH

The surgery involves removal of the internal part of the prostate causing the obstruction and urinary issues.

See Treatment

Medical Therapy for BPH

Medical therapy includes the use of drugs and the adoption of measures to relieve symptoms of BPH.

See Treatment

Dr. José Santos Dias presents a summary of all the information about BPH.

Prognosis of BPH

BPH is a benign disease that in some cases may cause very severe consequences, such as kidney failure or bad infections which, if not treated, can cause kidney failure, sepsis (urosepsis) and even death.

Even without these devastating consequences, BPH can cause a number of symptoms that significantly affect patients’ quality of life.

If not treated or even if treated with medication, the following generally occur:

A gradual worsening of the symptoms with age;
A growing risk of haemorrhage;
A growing risk of acute urinary retention ("trapped urine");
Also a gradual risk of the need for surgery.

After surgery, a direct and significant improvement of the symptoms generally occurs. The need for new treatments is very low, with the rate of reintervention standing at around 1–2% per year.

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Dr. José Santos Dias

Clinical Director of the Instituto da Próstata

Bacherlor's Degree from the Faculty of Medicine at the University of Lisbon
Specialist in Urology
Fellow of the European Board of Urology
Autor dos livros "Tudo o que sempre quis saber Sobre Próstata", "Urologia fundamental na Prática Clínica", "Urologia em 10 minutos","Casos Clínicos de Urologia" e "Protocolos de Urgência em Urologia"

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