Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland. It is one of the most common health conditions in men during middle and old age.

Prostate growth is a natural occurrence as men age. As the prostate enlarges, it begins to compress the urethra (canal that carries urine out of the body). This may cause bladder and kidney problems.

More than half of men with BPH do not experience symptoms. However, others experience problems with urination. Some men may experience a weak or interrupted urine stream, and others may leak or dribble urine. Other signs of BPH include increased urgency to urinate or more frequent urination, particularly at night.

Diagnosis involves a physical examination and may include tests such as ultrasound, a specialized x-ray procedure or cystoscopy. A blood test can help rule out prostate cancer and prostatitis.

Mild cases of BPH typically do not require treatment. However, treatment becomes necessary when BPH causes major inconveniences or results in medical problems such as urinary tract infections or kidney damage. Two classes of medications have been approved to treat BPH. Severe cases may require surgery.

Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland. It is a common condition among men during middle and old age.

The prostate is a walnut-sized gland in the pelvis that consists of two regions (lobes) encircled by a layer of tissue. Anatomically, it is located in front of the rectum but below the bladder. It surrounds the urethra, the canal that carries urine and semen out of the body.

Although some of the functions of the prostate remain a mystery, one of its known primary roles is to supply the fluid that nourishes sperm and helps transport it through the urethra during sexual ejaculation. This fluid also helps to neutralize the acidic environment in the vaginal canal. In addition, the prostate constricts the neck of the bladder during ejaculation.

As men age, the prostate gland usually becomes larger in size, growing around the urethra and potentially obstructing its flow. This stresses the bladder wall and may cause it to become irritated and thickened. The bladder may become overly sensitized,  contracting with even small amounts of urine, resulting in frequent urination. Eventually the bladder can weaken and lose its ability to empty properly.

The size of the prostate does not necessarily correlate with the severity of symptoms. Some patients with large prostates have no symptoms, whereas others with small prostates can have symptoms.

Other problems that can arise from this condition include difficulty urinating, urinary tract infections, and risk of developing kidney damage long-term due to “back pressure.” Thus, recognizing BPH in its early stages can lower the risk of developing complications.

Recent research indicates that patients with a gene called JM-27 are prone to a severe form of BPH that is more likely to result in damage to the bladder and kidneys. A blood test for this gene is pending approval.

Benign prostatic hyperplasia (BPH) is a result of the natural growth of the prostate gland. The prostate undergoes two periods of growth during a man’s lifetime. Early in puberty, the prostate doubles in size. Beginning around age 25, the prostate gradually begins to grow again.

It is during this second growth period that the cells in the central part of the prostate begin to reproduce rapidly. When the prostate enlarges, the tissue (capsule) that surrounds it prevents it from expanding. This forces the prostate to grow inward, causing it to constrict the urethra (the canal that carries urine out of the body), thus restricting urine outflow. This may cause the bladder wall to thicken and to contract even when small amounts of urine are present, resulting in frequent urination. Over time, the bladder continues to weaken until it is unable to empty completely.  

All of these changes within the prostate and surrounding area trigger the symptoms associated with BPH.

Physicians are unclear as to why the prostate gradually enlarges as a man becomes older. However, a few theories have been suggested. For example, younger men produce large quantities of the hormone testosterone and much smaller quantities of the hormone estrogen. 

As men age, the amount of testosterone production decreases, resulting in a higher percentage of estrogen. One theory suggests that estrogen may promote cell growth in the prostate, causing it to increase in size.

Another theory suggests that a hormonal substance derived from testosterone called dihydrotestosterone (DHT) may be responsible for prostate growth. Other experts believe prostate growth is a result of “instructions” coded in the body that cause certain cells to become active later in life and signal other cells to grow.

The testicles may also be associated with prostate enlargement. It has been noted that men who have their testicles removed at a young age, such as during the treatment of testicular cancer, do not experience enlargement of the prostate.

However, age is the primary risk factor associated with BPH. Men rarely experience symptoms before age 40, but the condition affects up to half of all men in their 60s. Ninety percent of men who are age 80 or older have experienced prostate enlargement, according to the National Institutes of Health, but do not necessarily have symptoms.

A family history of BPH also increases a man’s risk of developing the condition. BPH is more common in North American and European men than in Asian men. BPH also appears to be more common in married men than in single men, although scientists have not found a link between sexual activity and incidence of prostate growth.

Several studies have indicated overweight or obese men are more prone to BPH. However, recent findings from the long-term Air Force Health Study found the condition to be more common in tall men but not the overweight. Some research has found high blood sugar (hyperglycemia) or diabetes to be risk factors for BPH.

More than half of men with benign prostatic hyperplasia (BPH) do not experience any symptoms. However, obstruction of the urethra (the canal that carries urine and semen out of the body) and loss of bladder function associated with BPH cause various problems with urination for many others. Some men may experience a weak or interrupted urine stream. Others may leak or dribble urine.

Other signs of BPH include increased urgency to urinate or more frequent urination, particularly at night. Some men may also experience pain or bleeding during urination. Others may develop pelvic pain or experience sexual pain during ejaculation. Symptoms of BPH are sometimes referred to as lower urinary tract symptoms (LUTS).

In some cases, no symptoms will appear until a man suddenly finds himself unable to urinate at all. This condition is called acute urinary retention and may be triggered by use of certain over-the-counter cold, allergy, sleep or analgesic medications that contain a decongestant (sympathomimetic) which prevents the opening of the bladder from relaxing. Alcohol, cold temperatures and long periods of immobility can also cause this condition. It is an emergency and needs medical attention immediately to prevent permanent damage. Placing a urethral catheter can relieve the symptoms.

In some cases, men with benign prostatic hyperplasia (BPH) notice symptoms and schedule an appointment with a physician for an examination. In other cases, the problem may be discovered by a physician during a routine physical examination.

A physician will review the patient’s medical history and perform a physical in making the diagnosis. The physician will ask the patient about his symptoms. 

The physician will want to rule out other medical conditions, such as  sexually transmitted diseases, prostatitis or diabetes, that could cause similar symptoms. Most patients with symptoms of acute urinary retention (the inability to urinate) have BPH. However, some patients may have other serious conditions, such as prostate cancer, bladder stones, bladder infection or interstitial cystitis.

If BPH or another urological condition is suspected, the patient likely will be referred to a urologist, a physician who specializes in problems associated with the urinary tract in males and females and in the male reproductive system.

Several tests can be used to help make an accurate diagnosis. These include:

• Digital rectal examination (DRE). The physician inserts a gloved, lubricated finger in the patient’s rectum and manually feels the prostate to determine its size and condition. A patient’s regular physical examination often includes a DRE.
  
  
• Questionnaire. The American Urological Association has developed a questionnaire about symptoms associated with an enlarged prostate. This pain assessment form can help determine the severity of the condition and monitor the condition over time.
  
  
• Prostate specific antigen (PSA) test. This blood test detects PSA, a protein produced by prostate cells. Prostate cancer and prostatitis are among the conditions that may elevate PSA.
  
  
• Postvoid residual volume test. A catheter (flexible tube used to drain urine from the bladder) can be inserted into the urethra or, more often, noninvasive ultrasound is used to see how well the patient is able to empty his bladder during urination.
  
  
• Other imaging tests. During a rectal ultrasound, a probe is inserted into the rectum to assess structural characteristics of the prostate by reflecting sound waves off the gland. This forms an image of the prostate on a display screen. An x-ray of the urinary tract called intravenous pyelography (IVP) also may be used.
  
  
• Urine flow study. The patient urinates into a device that detects how quickly urine is flowing. A reduced flow may suggest BPH.
  
  
• Cystoscopy. A thin tube called a cystoscope is inserted through the opening of the urethra (the canal that carries urine out of the body) in the penis. It contains a light and a lens that allows the physician to see the inside of the urethra and the bladder and to determine the size and state of the prostate gland. A local anesthetic jelly is used to reduce discomfort.
  
  
• Urodynamic studies. A catheter is inserted into the urethra and water is injected into the bladder to check internal bladder pressure and to determine how effectively the bladder contracts.
  
  
• Biopsy. Sometimes the urologist may want to take a tissue sample from the prostate gland to verify the diagnosis or to rule out cancer.

A urine test may be performed to check for infection or for blood in the urine and to rule out other causes of pelvic pain, such as prostatitis.

Researchers have developed a new blood test for the JM-27 gene, a marker of severe BPH. It has not yet been approved by the U.S. Food and Drug Administration.

In recent years, experts have become more convinced that mild cases of benign prostatic hyperplasia (BPH) do not require treatment. Symptoms related to such cases may clear on their own and merely require monitoring. Patients may receive evaluation forms that can help a physician determine how symptoms change over time.

Some men take herbal supplements such as saw palmetto and stinging nettle in an effort to control or prevent BPH. Some studies have found that saw palmetto, which is made from berries of a southeastern U.S. palm, might reduce symptoms of mild but not severe BPH. Side effects may include mild gastrointestinal distress. Patients are advised to consult their physician before trying any complementary or alternative therapy.

Several treatment options are available when BPH becomes a major inconvenience or a health threat. Two classes of drugs are used long term to treat BPH:

• Alpha blockers. Though a type of antihypertensive (blood pressure drug), alpha blockers are used primarily to treat BPH. They improve urine flow by relaxing the smooth muscle of the prostate and the neck of the bladder. The U.S. Food and Drug Administration (FDA) has approved four alpha blockers to treat BPH: alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax) and terazosin (Hytrin).

People having surgery for cataracts, another common condition of middle and old age, should tell their eye surgeon in advance if they have ever taken alpha blockers. These drugs can affect the iris (colored part of the eye) and may require the surgeon to use modified surgical techniques, but they are safe and effective, according to the American Urological Association and the American Academy of Ophthalmology.

Other possible side effects of alpha blockers include dizziness, runny nose, drowsiness, weakness, sleep difficulties or (rarely) sexual problems or fast heartbeat.

• 5-alpha reductase inhibitors. These drugs slow the prostate’s growth or shrink it by impeding production of a hormone called DHT. The FDA has approved two 5-alpha reductase inhibitors to treat BPH: dutasteride (Avodart) and finasteride (Proscar).

Side effects may include sexual difficulties (often lessening after the first year) and tenderness and sometimes enlargement of the breast. Women should not take or even handle 5-alpha reductase inhibitors because of the risk of a birth defect.

The Medical Therapy of Prostatic Symptoms Trial (MTOPS) found the combination of an alpha blocker and a 5-alpha reductase inhibitor more effective than either one alone.  

Various forms of minimally invasive heat therapy also are available to treat BPH. Transurethral microwave therapy (TUMT) uses computer-controlled heat in the form of microwaves to destroy excess prostate tissue. Another procedure called transurethral needle ablation (TUNA) uses low-level radiofrequency energy to remove a portion of the enlarged prostate. These procedures do not cure BPH and do not work well in men with very large prostates. But for many patients, they reduce urinary frequency, urgency, straining and intermittent flow.

Other forms of heat therapy include:

• Electrovaporization. Uses a special metal instrument that emits a high-frequency electrical current.
  
  
• Laser therapy. Uses heat-generating laser to remove excess prostate cells.
  
  
• Transurethral evaporation of prostate (TUEP). Similar to electrovaporization, except that laser energy is substituted for electrical current.
  
  
• Visual laser ablation of the prostate (VLAP). Uses laser energy to dry up and destroy excess prostate cells.
  
  
• Interstitial laser therapy. Directs laser energy inside the prostate growths instead of at the urethral surface.
  
  
• Photoselective vaporization of the prostate (PVP). Similar to transurethral resection of the prostate (TURP) (see below), except that it uses laser energy instead of an electrical current.

However, in some cases medication and heat therapy are not viable treatment options. This is especially true if the patient experiences incontinence, recurrent blood in the urine, urinary retention or recurrent urinary tract infections. In such cases, an operation may be necessary to treat BPH.

Transurethral surgery involves providing regional or local anesthesia and then inserting an instrument through the urethra (the canal that carries urine and semen out of the body) and removing enough tissue to enhance urine flow. TURP is the surgery most commonly used to treat BPH. In this procedure, obstructive tissue is removed a small piece at a time with an instrument called a resectoscope. Transurethral incision of the prostate (TUIP) is often used in men who have a relatively small or only moderately enlarged prostate. It involves widening the urethra by making small cuts in the prostate gland.

In some cases, transurethral or laser surgery is not an option. Open surgery requiring general anesthesia may be necessary to remove the prostate gland. This procedure, prostatectomy, involves making an incision in the abdomen or perineal area (between the anus and genitals). A prostatectomy is reserved for cases when the prostate is greatly enlarged, if there are other complications or if there is cancer.

Patients who undergo invasive surgeries such as TURP, a laser procedure or prostatectomy will likely require a hospital stay. Patients sometimes have to wear a catheter (flexible tube used to drain urine from the bladder) for several days following the procedure. Surgery is usually very effective, and many patients experience increased urine flow within just a few days.

During recovery, it is important for patients to drink plenty of water (e.g. at least eight glasses a day) to flush the bladder and speed the healing process. In addition, it is important to rest for several weeks after surgery. Overexertion and heavy lifting should be avoided.

Surgery can sometimes cause temporary or permanent impotence, urinary incontinence, retrograde ejaculation (a dry climax during sexual intercourse), infertility and narrowing of the urethra. Complications such as a blood clot or buildup of scar tissue in the bladder are most likely after a prostatectomy (the most invasive procedure) and least likely after TUIP (a less invasive procedure). Men often continue to experience normal sexual function after prostate surgery.

Patients are urged to call a physician right away if they pass less urine than usual following surgery. Other complications that require medical care include blood or pus in the urine, fever or chills, and pain in the abdomen, back or side.

Patients who are unable or unwilling to tolerate surgery or other treatments may have a tiny metal coil called a prostatic stent placed inside the urethra. This widens the urethra and helps keep it open. However, complications such as irritation, frequent urinary tract infections and migration (movement) of the stent have made this option less popular than it once was. 

Despite successful treatment, BPH recurs in about 10 percent of men, according to the National Institutes of Health. This is more likely to occur when BPH surgery occurs at an early age and in rare cases when scar tissue develops in the bladder after surgical treatment.

Prostate growth is a natural occurrence. Some men take supplements including saw palmetto in an effort prevent or control benign prostatic hyperplasia (BPH). Food rich in a plant pigment called lycopene, such as cooked tomatoes, may benefit prostate health. Men interested in using diet or supplements are advised to ask their urologist or other physician for recommendations.

Recent research suggests that long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen could help prevent BPH. However, these researchers advised men not to take NSAIDs solely for this potential benefit because of the risk of side effects such as damage to the stomach or kidneys.

Men who have BPH can take steps to reduce their symptoms. For example, urinating frequently can help prevent discomfort. Patients are encouraged to avoid retaining urine and to urinate even if they do not feel a strong urge to do so.

Patients also are urged to avoid alcohol and caffeine, particularly after dinner. It is best to spread out consumption of fluids during the day rather than drinking a lot of liquid at once. Liquids should be avoided for two hours before bedtime.

Patients with BPH are advised to avoid cold and allergy medications, sleep aids and analgesics that contain decongestants and antihistamines. These ingredients may increase symptoms related to BPH.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about benign prostatic hyperplasia (BPH):

1. What are some early signs that may indicate I have BPH?
   
   
2. I don’t have symptoms but am over 50. Should I have any special testing for BPH?
   
   
3. How will you diagnose my BPH?
   
   
4. What are my treatment options?
   
   
5. What are the risks and side effects of these treatments? Will I have any danger of urinary incontinence or erection problems?
   
   
6. What are the potential drawbacks of the medication, heat therapy or surgery you are recommending?
   
   
7. What will happen if I opt not to undergo treatment at this time?
   
   
8. What are the odds that my BPH will recur in the future?
   
   
9. How can I prevent or reduce my BPH symptoms?
   
   
10. Should I take aspirin or other NSAIDs to reduce my risk of BPH, or do the risks of these drugs outweigh the benefits for me?
    
    
11. Can taking supplements, eating certain foods or doing certain exercises promote the health of my prostate?