Benign prostatic hyperplasia (BPH) in detail

If you’re a man in your 40s and 50s and you’re starting to notice increased urgency, frequency and not feeling fully empty when passing urine, it’s possible you could have benign prostatic hyperplasia (BPH).  

Leading consultant urological surgeon Mr Jyoti Basu speaks to Top Doctors in expert detail about this condition. So, if you notice any of the above symptoms, this article is a comprehensive place to start on your potential journey.

What is benign prostatic hyperplasia (BPH), and what causes it to occur in the prostate gland?

Benign prostatic hyperplasia (BPH) is rather a pathological term. It's commonly known as benign prostatic enlargement. So, what happen is, as we grow old the prostate gland grows in size as well. The prostate gland is a reproductive gland that's present in all males. Through the prostate gland, if you imagine the prostate to be like an apple; and through the centre of that apple there's a water pipe. Above the apples, it's your bladder.

That prostate gland grows in size after a certain age. Usually, it starts to grow between 40 and 50. Why does it grow at this age, and not at younger age? There are many reasons for it. There are certain changes that happen at this age where the body produces certain growth factors which cause the prostate gland to grow. 

As the name suggests, there is benign prostatic enlargement. Malignant prostate enlargement is a part of it, but that's a different issue, so we will focus on benign prostatic enlargement whereby the prostate gland grows. And the growth of the prostate gland is a part of the natural ageing process.

What are the symptoms? The symptoms of benign prostatic enlargement usually take a longer time to finish passing urine, getting up many times in the night, maybe two or three times in night; having urgency where many want to pee can't hold it much it longer. It stops and starts. It's called intermittency, which means the flow isn't a complete flow and it stops and starts again. That means you have to exert pressure to make it flow.

These are usually the features, but you can have other complications; you can have blood coming out, so that can be one of the presenting signs. You can have infection because it might have grown in size and not allowed the bladder to empty properly. As a result of which, patients come with infection because their urine isn't getting emptied completely from the bladder.

Sometimes, people have other complications which are much more serious; they can have big bladder stones forming because the bladder isn't emptying and they've kept urine in the bladder for a long time, and the stones have formed in them.

Lastly, which is a really serious complication, is that the bladder has been full and hasn't been able to empty so it's putting that pressure on the kidney and they can't drain into the bladder. Then the kidneys go into failure, and patients present with being very unwell and they can't pee. It's called high-pressure chronic retention. That's one extreme of it. By and large, patients present after a certain age with these symptoms of intermittency, poor flow, dribbling, urgency and nocturia (getting up many times in the night). 

What are the common symptoms and signs of BPH, and how does it differ from prostate cancer?

The signs and symptoms of prostate cancer, and the signs and symptoms of BPH are more or less the same. As I said, the cardinal signs of any prostate enlargement be it benign, be it malignant, they are;

• poor stream;
• dribbling;
• urgency;
• frequency;
• getting up many times in the night, and;
• generally, a feeling of not being empty. 

These can happen as a result of the prostate getting bigger in size, and straddling the water pipe inside. That can be either due to a benign enlargement of the prostate or it can be due to a malignant enlargement of the prostate. 

The difference is; that in the case of a benign enlargement, it's mostly the fleshly zones inside which cause the enlargement. Whereas for a malignant or a cancer, it's from the outside. It's a shell of the apple, if you might imagine, that's the problem in prostate cancer. 

So, the signs and symptoms are almost the same, except in prostate cancer you can have other problems like if they've spread to the bones. You can have back pain, bone pain; those sorts of symptoms. However, they aren't that common. The initial stem is common for both the conditions. 

How is BPH diagnosed, and what are the different diagnostic tests or procedures used to evaluate its severity?

So, essentially, BPH is diagnosed by the patients' complaining. When patients feel like something isn't right, their partners are getting disturbed in the night, so they go and seek advice from the doctor.

Assessment

When the doctor sees the patient, they assess these symptoms. There's a common thing called the International Prostate Scoring System questionnaire, or IPSS. It's freely available on the Internet, so you can score the patient. There are numerical scoring systems, and you can see how much you've scored. If you score about a certain point, then obviously you're very symptomatic. 

Also, there's a quality-of-life questionnaire at the end where you grade yourself from zero to six, zero being "absolutely delighted with my life, living the dream", to six: "I really want to commit suicide". With these tools you can actually quantify the disease: "How bad is it?"

Diagnosis

How do you diagnose it? Well, the symptoms are there. Then you do a rectal examination. You get an idea about how big the prostate is; how does it feel? Does it feel a bit soft - benign - or does it have a hard, lumpy feeling, which raises the possibility of cancer. 

Then, have a flow test. It's a very simple concept where people drink plenty to fill up their bladder. And when they're ready, they go and pee in a special machine where the machine can tell you how quickly you're peeing, how long does it take for you to pee, and what is the maximum force you can generate. It's called a uroflowmetry. It's a very common test used in urology clinics, and then at the end you scan the bladder to see how much is remaining in the bladder. So, uroflowmetry and a bladder scan is the absolute fundamentals of assessing someone with BPH. 

And lastly, but not the least, it's essential people who come in for prostatic symptoms have a PSA test done. It doesn't matter even if your prostate gland is benign. It doesn't really matter. Because PSA isn't a cancer marker. It's prostate specific antigen. It isn't a cancer specific antigen. It isn't a prostate cancer specific antigen.

PSA is a protein which is secreted by the prostate, and it can go up and down. So, for example; my PSA is, say 2. I'm 56 years old and it's absolutely normal. But what does that say about my prostate? That it is higher, or greater in size, than someone who has a PSA of 0.6. PSA can be a marker of the size of the prostate gland, within the confines of normality. If the PSA becomes 8, then obviously it's a cause of concern. Then you start to think: “Is there a latent prostate cancer there which my finger can't feel?” Then we go down a different set of investigations like MRI scans and biopsies. By and large, a BPH assessment should have an element of PSA incorporated into its diagnostic pathway. 

What are the treatment options available for BPH, and how do they vary based on the patient's symptoms and overall health?

Any treatment for BPH has to take into account patient comorbidities; what are they suffering from and what medications are they on? Are they on blood-thinning medications for heart or lung problems, because if they've had a stroke, heart attack or have a stent inside, they'll be on blood thinners. So, any surgical intervention is probably out of question for the time being, until they can be safely taken off that blood thinner for a duration of time.

Lifestyle changes

The management of benign prostatic enlargement starts from lifestyle changes. You can regulate your fluid, like if you're waking up four times in the night, we tell the patients “You need to take all your fluids before 7 o'clock in the evening, so that by the time you've gone to bed, you've cleared your bladder.”. So, you're reducing the number of times you’re waking up in the night. Reduce your caffeine intake. Switch to decaf. That gives your bladder the chance to not get too excited because caffeine will cause it to into overdrive. 

Medical treatments

There are medical treatments. Traditionally, we’ve used a tablet called alpha blockers or Tamsulosin, where the tablet relaxes the gland. The prostate gland is made up of glands, and there's a muscle element to it, as well. There are smooth muscles which are out of our direct control. We can't control them.

To actually relax those muscles, you need medication. That is called tamsulosin, or an alpha blocker. There's another one called alfuzosin. There are different types of alpha blockers, but primarily what they do is relax the muscle element of the prostate. Then there's another tabled called finasteride, or five alpha reductor inhibitors. These groups of drugs reduce the size of the prostate.

What they do, is stop the conversion of testosterone acting on the prostate into five dihydrotestosterone, which is the active element that drives the enlargement of the prostate. So, it stops the conversion, and as a result of which, the prostate gland shrinks in size. These drugs have been used separately, or more commonly they've been used in combination. However, I must emphasize that finasteride, or any five alpha reductor inhibitors, will only work when the prostate gland is enlarged over a certain size.

Whereas if the prostate gland is tight, it's just the muscular element being very tight and isn't very enlarged but really tight, then the alpha blockers will be enough. A combination of five alpha reductor inhibitors and tamsulosin have been shown to have been of greater benefit that individual drugs used alone. 

Surgical management of BPH

There are surgical managements as well. Traditionally, we've used a TURP - or trans-urethral resection of the prostate. That has stood the test of time and has been around for around over 70 years, I would say. Essentially what you do, is you core out the prostate. Think about a small apple and you stick a knife into one end of the apple and you start coring it, keeping the shell behind. What you're left with at the end, is a hollow apple with a shell and a bit of tissue hanging around, and that cavity which you've now cleared out so that when the water comes through that pipe, there's no blockage. This being the principle, people have used different things.

Newer versions have come in rather than using heat to cut it out. People have used lasers to completely shell out the inside and take it out. What they do is shell out the fleshy bits, put it inside the bladder, take it out and then wash it. There are various modifications, but the principle remains that you keep the shell of the prostate and you either take it out, or you completely enucleate the prostate and take it out.

The one I do is the steam treatment of prostate where I inject steam into these fleshy bits, as a result of which the heat acts on the tissue and kills it. The effect isn't available straight away and it takes about two or three months, but it does shrink. And people get symptomatic relief from it.

There's also another technique available called UroLift, whereby we use stables push the lateral lobes of the prostate away and it creates a channel for people to wee. These treatment modalities, these different types; Rezūm, TURP, HoLEP all have their own side effects. They have their own patient profile, so not everyone is suitable for every modality. We have to look at the prostate as a whole and that includes looking inside with a flexible cystoscope, to see what the prostate looks like, and then tell the patient “You’ll be suitable for this, and you won't be suitable for that."

So, summarising, lifestyle choices, medical management and surgical options, either TURP, whole enucleation of the prostate or even laser treatment of the prostate where you completely vaporise the prostate using a green light laser which achieves exactly the same. Here, the laser completely obliterates the cavity and leaves you with a shell, or you'd use slightly less invasive options like UroLift or Rezūm. There are new techniques coming in, too, like aqua ablation, but they're more in a developmental stage where they aren't widely accepted. NICE (National Institute for Health and Care Excellence) hasn't recommended all the rest, yet. The previous ones which I've just mentioned, they are in the NICE recommendations 

Are there any lifestyle modifications or self-care measures that can help alleviate the symptoms of BPH?

There’s a connection to metabolic syndrome to some of the symptoms of BPH. Now, metabolic syndrome is typically obesity, decreased testosterone, increase in cholesterol, even hypoglycaemia. All of these things that happen in middle age, unfortunately. If you can control these things like with weight loss, that usually controls some of the symptoms of prostate and may have a chance of slowing them down. 

The moment we're born, we have a finite shelf life and as we approach that, there are problems that will happen. It's inevitable. How do we deal with them, and how we are made aware these can be the things that will happen? So, if it happens and you have no control over it, that's what makes me a urologist. So, if you prevent everything, I can't pay my mortgage. There are certain things which I'll have to treat.

But by in large, you can be healthy by avoiding the things we are commonly advised against, and the main problem is obesity. Obesity, and metabolic syndrome can be controlled, and research suggests that testosterone has a big part to play. 

If you're having symptoms described - which are quite common - the only thing I'd say you need to have, is a PSA blood test. You need to get it checked. If it's benign prostatic enlargement, fine, you can live it and it's a quality-of-life issue rather than a life-threatening issue. But there will be 10 to 20 per cent of people will have a raised PSA who will then go on to have quite nasty prostate cancer.

That's an important message: if you have symptoms, don't ignore them. At least go to your GP, have rectal examination done, and at least have a PSA done. That will probably save lives. That's the message that's come from various trials which have been done for PSA surveillance or PSA screening as a tool.       

If you'd like to arrange an appointment with Mr Basu regarding the health of your prostate, you can do so via his Top Doctors profile.