Benign prostatic hyperplasia

Introduction

Benign prostatic hyperplasia (BPH), a noncancerous enlargement of the prostate gland, makes urination difficult and uncomfortable. Your prostate gland is located underneath your bladder and surrounds your urethra, which empties urine from the bladder. As the prostate gland expands, it squeezes the urethra or causes the muscles around the urethra to contract, making it difficult to urinate.

Prostate enlargement is very common as men age -- symptoms usually develop around age 50 and by age 60, most men have some degree of BPH. At age 85, men have a 90% chance of having urination problems caused by BPH. It’s important to note that BPH is not cancer, and it does not put you at increased risk for developing prostate cancer.

Signs and Symptoms

Symptoms may include:

  • Needing to urinate frequently
  • Difficulty starting urination
  • Stopping and starting while urinating
  • Urinating frequently at night (nocturia)
  • Dribbling after urination ends
  • Being unable to empty your bladder
  • Blood in the urine (BPH can cause small blood vessels to burst)
  • Recurrent urinary tract infections (UTIs)

Causes

Nobody knows the basic cause of BPH. Research shows that testosterone, the male hormone, or dihydrotestosterone, a chemical produced when testosterone breaks down in a man's body, may cause the prostate to keep growing. Another theory is that changes in the ratio of testosterone and estrogen (female hormone) as men age cause the prostate to grow.

Some over the counter medications for colds or allergies can drastically worsen BPH.

Diagnosis

Your health care provider may check the size of your prostate gland directly by putting a gloved finger in your rectum and feeling the back wall of the prostate. Your health care provider will also order blood tests and possibly a urine sample. Other tests may include:

  • Urinary flow test -- Your doctor may ask you to urinate into a device that measures the flow of urine.
  • Intravenous pyelography -- Your doctor injects a dye into a vein to make the flow of urine visible on an x-ray.
  • Transrectal ultrasound -- Your doctor will insert an ultrasound probe in your rectum to get an image of your prostate gland.

In addition, you may be asked to complete a self screening form to evaluate the severity of your symptoms and the impact on your daily life. Your doctor can use this to monitor your condition over time.

Treatment Approach

Treatment will depend on your age, overall health, and the severity of your symptoms. BPH symptoms may come and go, so it’s important to receive regular check-ups to monitor the progression of symptoms. There are many ways to successfully treat BPH, including some simple lifestyle changes and several herbal remedies and medications. If no other therapies work and the symptoms are severe enough, there are also several types of surgery to correct the condition.

Lifestyle

Many men with BPH have only minor symptoms. Some simple lifestyle changes may be all you need to feel better:

  • Urinate when you first get the urge.
  • Go to the bathroom when you have the chance, even if you don't feel a need to urinate.
  • Avoid alcohol and caffeine, especially after dinner. Try not to drink within 2 hours before going to bed.
  • Spread out your fluid intake throughout the day -- avoid drinking large amounts of fluid at one time.
  • Avoid cold and sinus medications. Decongestants and antihistamines can worsen BPH symptoms.
  • Exercise regularly.
  • Do Kegel exercises to strengthen your pelvic floor.
  • Reduce stress.

Medications

Alpha blockers -- Also known as alpha-adrenergic antagonists, these medicines cause the muscles around your bladder to relax, making it easier to urinate. These drugs were originally used to treat high blood pressure. They seem to work best in men with moderately enlarged prostates. Common side effects include decreased ejaculation and low blood pressure. These drugs should not be taken with medications for erectile dysfunction, such as Viagra or Cialis. Alpha blockers include:

  • Terzosin (Hytrin)
  • Doxazosin (Cardura)
  • Tamsulosin (Flomax)
  • Alfuzosin (Uroxatral)

Enzyme inhibitors -- Also known as 5-alpha-reductase inhibitors, these medicines shrink the prostate gland by reducing the amount of testosterone the body converts into dihydrotestosterone, a hormone the prostate needs to grow. These drugs take longer to work than alpha blockers. They also lower PSA levels (a high level of PSA can indicate prostate cancer), making it harder to screen for prostate cancer. Enzyme inhibitors include:

  • Finasteride (Proscar)
  • Dutasteride (Avodart)
  • Botulinum toxin (Botox)

Your doctor may suggest combination therapy -- taking an alpha blocker and an enzyme inhibitor at the same time.

Surgery and Other Procedures

Prostate surgery may be recommended if you have:

  • Incontinence
  • Recurrent blood in the urine
  • Urinary retention
  • Recurrent urinary tract infections

Which procedure is best for you usually depends on the severity of your symptoms and the size and shape of your prostate gland.

Minimally invasive techniques

These techniques may be better at relieving symptoms than medications, but are often not as effective as surgery. However, they are less likely to cause side effects than surgery.

Transurethtral microwave therapy -- uses heat from microwaves to shrink the prostate. This procedure works best for men with moderate symptoms and enlargement of the prostate.

Transurethral needle ablation -- uses radio waves to get rid of the part of the prostate that is blocking urine flow. It works best for men with mild to moderate enlargement of the prostate.

Interstitial laser therapy -- uses a laser to destroy excess tissue and shrink the prostate. It works best for men who have mild to moderate enlargement of the prostate and don’t experience urinary retention.

Surgery

Surgery is the most effective way to reduce your symptoms, but potential side effects include a small risk of erectile dysfunction or urinary incontinence.

Transurethral resection of the prostate (TURP) -- is the most common surgical treatment for BPH. TURP is performed by inserting a scope through the penis. The primary advantage of this procedure is that it does not involve an incision, reducing the risk of infection. One potential side effect is retrograde ejaculation, where semen goes into the bladder instead of out the urethra.

Transurethral incision of the prostate (TUIP) -- similar to TURP, but is usually performed in men who have a relatively small prostate. Like the TURP, a scope is inserted through the penis until the prostate is reached. Then, rather than removing prostate tissue, a small incision is made in the tissue to let the urethra expand and make urination easier. This procedure is usually performed on an outpatient basis and does not require a hospital stay.

Laser surgery -- Two types of laser surgery are used to destroy excess prostate tissue. Photosensitive vaporization of the prostate (PVP) is used for men with mild to moderate prostate enlargement, while holmium laser enucleation of the prostate (HoLEP) is usually used for men with severely enlarged prostates. Side effects can include retrograde ejaculation.

Open prostatectomy -- An open prostatectomy is usually performed using general or spinal anesthesia. An incision is made through the abdomen or perineal area (through the pelvic floor, including the region between the scrotum and the anus). This is a lengthy procedure, and usually requires a hospital stay of 5 - 10 days.

Most men who have prostate surgery see improvement in urine flow rates and symptoms. Possible complications include impotence, urinary incontinence, retrograde ejaculation, infertility, and urethral stricture (narrowing).

Nutrition and Dietary Supplements

Beta-sitosterol (60 - 130 mg per day) -- Beta-sitosterol is a cholesterol-like compound found in plants. It has been studied for BPH and found to significantly improve urinary flow and decrease the amount of urine left in the bladder. It does not shrink the prostate, however. Beta-sitosterol is also used to lower cholesterol, making it a good option for men whose cholesterol levels are high. Plants that are high in beta-sitosterol, such as pumpkin seeds (Cucurbita pepo), are sometimes suggested for BPH. Talk to your doctor before adding any supplements to your BPH treatment regimen.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs only under the supervision of a health care provider.

  • Saw palmetto (Serenoa repens, 320 mg per day) -- Several studies have examined whether saw palmetto can relieve BPH symptoms, and many (though not all) showed positive results. Saw palmetto appears to work like Proscar and Avodart, which prevent testosterone from being converted into dihydrotestosterone (needed for prostate growth) in the body. Some studies have shown saw palmetto to be as effective as Proscar and finasteride and with fewer side effects. A European study showed that half of German urologists preferred saw palmetto over pharmaceuticals for treatment of BPH. However, it does not shrink the overall prostate, but shrinks the inner lining of the gland. It should be noted that, unlike previous studies, a newer, high quality study found that saw palmetto had no effect on BPH symptoms. Talk to your doctor if you want to try saw palmetto for your symptoms, and look for a fat soluble saw palmetto extract that has been standardized to contain 85% - 95% fatty acids and sterols.
  • Pygeum or African plum extract (Pygeum africanum, 75 - 200 mg per day) -- Pygeum has been used historically for urinary problems. In several scientific studies, pygeum relieved BPH symptoms including nocturia (increased urination at night) and improved urine flow.
  • Grass pollen (Secale cereale) -- Two studies that compared a standardized extract of rye grass pollen to placebo found that the grass pollen improved BPH symptoms, including reducing frequency of nighttime urination and the amount of urine left in the bladder. One study also indicated that grass pollen decreased the size of the prostate as measured by ultrasound. The brand of rye grass pollen most often used in studies is Cernilton. People who have allergies to grass pollens should not take grass pollen supplements.

Prognosis and Complications

While the majority of men get better with treatment of BPH, men who have had long standing BPH may develop:

  • Sudden inability to urinate
  • Urinary tract infections
  • Urinary stones
  • Damage to the kidneys
  • Blood in the urine

Supporting Research

 Altavilla D, Bitto A, Polito F, Irrera N, Marini H, Arena S, Favilla V, Squadrito F, Morgia G, Minutoli L. The combination of Serenoa repens, selenium and lycopene is more effective than Serenoa repens alone to prevent hormone dependent prostatic growth. J Urol. 2011;186(4):1524-9.

Barry MJ, Meleth S, Lee JY, Kreder KJ, Avins AL, Nickel JC, Roehrborn CG, Crawford ED, Foster HE Jr, Kaplan SA, McCullogh A, Andriole GL, Naslund MJ, Williams OD, Kusek JW, Meyers CM, Betz JM, Cantor A, McVary KT: Complementary and Alternative Medicine for Urological Symptoms (CAMUS) Study Group. Effect of increasing doses of saw palmetto extract on lower urinary tract symptoms: a randomized trial. JAMA. 2011;306(12):1344-51.

Berges RR, Kassen A, Senge T. Treatment of symptomatic benign prostatic hyperplasia with beta-sitosterol: an 18-month follow-up. BJU Int. 2000;85:842-6.

Bondarenko B, Walther C, Funk P, Schlafke S, Engelmann U. Long-term efficacy and safety of PRO 160/120 (a combination of sabal and urtica extract) in patients with lower urinary tract symptoms (LUTS). Phytomedicine. 2003:10 Suppl 4:53-55.

Boy S, Seif C, Braun PM, Junemann KP. Botulinum toxin in the treatment of benign prostatic hyperplasia: an overview. Urologe A. 2008;47(11):1465-71.

Chapple CR. Clinical study of benign prostatic disease, current concepts and future prospects randomized controlled trials versus real life practice. Curr Opin Urol. 2003;13(1):1-5.

Delongchamps N, de la Roza G, Chandan V, Jones R, Sunheimer R, Threatte G, Jumbelic M, Haas GP. Evaluation of prostatitis in autopsied prostates -- is chronic inflammation more associated with benign prostatic hyperplasia or cancer? J Urol. 2008;179(5):1736-40.

Edwards J. Diagnosis and Management of Benign Prostatic Hyperplasia. American Family Physician. 2008;77(10).

Ernst E. The risk-benefit profile of commonly used herbal therapies: Ginkgo, St. John's Wort, Ginseng, Echinacea, Saw Palmetto, and Kava. Ann Intern Med. 2002;136(1):42-53.

Ferri: Ferri's Clinical Advisor 2010, 1st ed. Philadelphia, PA: Mosby Elsevier, Inc. 2009.

Garimella PS, Fink HA, Macdonald R, Wilt TJ. Naftopidil for the treatment of lower unrinary tract symptoms compatible with benign prostatic hyperplasia. Cochrane Database Syst Rev. 2009;(4):CD007360.

Gerber GS. Saw palmetto for the treatment of men with lower urinary tract symptoms. J Urol. 2000;163(5):1408-1412.

Gerber GS, Kuznetsov D, Johnson BC, Burstein JD. Randomized, double-blind, placebo-controlled trial of saw palmetto in men with lower urinary tract symptoms. Urology. 2001;58(6):960-965.

Gilling PJ, Wilson LC, King CJ, Westenberg AM, Frampton CM, Fraundorfer MR. Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the porostate: results at 7 years. BJU Int. 2011 Aug 32. [Epub ahead of print]

Gonzales GF. Ethnobiology and ethnopharmacology of lepidum meyenii (maca), a plant from the Peruvian highlands. Evid Based Complement Alternat Med. 2011 Oct 2. [Epub ahead of print]

Gordon AE, Shaughnessy AF. Saw palmetto for prostate disorders. Am Fam Physician. 2003;67(6):1281-1283.

Ishani A, MacDonald R, Nelson D, et al. Pygeum africanum for the treatment of patients with benign prostatic hyperplasia: a systematic review and quantitative meta-analysis. Am J Med. 2000;109:654-64.

Katz AE. Flavonoid and botanical approaches to prostate health. J Altern Complemet Med. 2002;8(6):813-821.

Klingler HC. New innovative therapies for benign prostatic hyperplasia: any advance? Curr Opin Urol. 2003;13(1):11-15.

Koch E. Extracts from fruits of saw palmetto (Sabal serrulata) and roots of stinging nettle (Urtica dioica): viable alternatives in the medical treatment of benign prostatic hyperplasia and associated lower urinary tracts symptoms. Planta Med. 2001;67(6):489-500.

MacDonald R, Ishani A, Rutks I, Wilt TJ. A systematic review of Cernilton for the treatment of benign prostatic hyperplasia. BJU Int. 2000;85:836-41.

Managing lower urinary tract symptoms in men. Drug Ther Bull. 2003;41(3):18-21.

Marks LS, Partin AW, Epstein JI, et al. Effects of saw palmetto herbal blend in men with symptomatic benign prostatic hyperplasia. J Urol. 2000;163(5):1451-1456.

Na Y, Ye Z, Zhang S. Efficacy and safety of dutasteride in Chinese adults with symptomatic benign prostatic hyperplasia: A randomized, double-blind, parallel-group, placebo-controlled study with an open-lable extension. Clic Drug Investig. 2011 Oct 21. [Epub ahead of print]

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Penson DF, Munro HM, Signorello LB, Blot WJ, Fowke JH; Urologic Diseases in America Project. Obesity, physical activity and lower urinary tract symptoms: results from the southern community cohort study. J Urol. 2011;186(6):2316-22.

Pittler MH. Complementary therapies for treating benign prostatic hyperplasia. FACT. 2000;5(4):255-257.

Porst H, Kim ED, Casabé AR, Mirone V, Secrest RJ, Xu L, Sundin DP, Viktrup L; LVHJ study team. Efficacy and safety of tadalafil once daily in the treatment of men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia: results of an international randomized, double-blind, placebo-controlled trial. Eur Urol. 2011;60(5):1105-13.

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Shi R, Xie Q, Gang X, Lun J, Cheng L, Pantuck A, Rao J. Effect of saw palmetto soft gel capsule on lower urinary tract symptoms associated with benign prostatic hyperplasia: a randomized trial in Shanghai, China. J Urol. 2008;179(2):610-5.

Sinescu I, Geavlete P, Multescu R, Gangu C, Miclea F, Coman I, Ioiart I, Ambert V, Constantin T, Petrut B, Feciche B. Long-term efficacy of Serenoa repens treatment in patients with mild and moderate symptomatic benign prostatic hyperplasia. Urol Int. 2011;86(3):248-9.

Suzuki S, Platz EA, Kawachi I, Willett WC, Giovannucci E. Intakes of energy and macronutrients and the risk of benign prostatic hyperplasia. Am J Clin Nutr. 2002;75(4):689-697.

Tacklind J, MacDonald R, Rutks I, Wilt TJ. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2009;(2):CD001423.

Willets KE, Clements MS, Champion S, Ehsman S, Eden JA. Serenoa repens extract for benign prostate hyperplasia: a randomized controlled trial. BJU Int. 2003;92(3):267-270.

Wilt T, Ishani A, Mac Donald R, et al. Pygeum africanum for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2002;CD001044.

Wilt T, Ishani A, Mac Donald R. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2002;(3):CD001423

Wilt TJ, Ishani A, Rutks I, MacDonald R. Phytotherapy for benign prostatic hyperplasia. Public Health Nutr. 2000;3(4A):459-472.

Alternative Names

BPH; Prostate enlargement

Version Info

  • Last Reviewed on 12/15/2011
  • Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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