Patient education: Benign prostatic hyperplasia (BPH) (Beyond the Basics)

BPH OVERVIEW — 

Benign prostatic hyperplasia (BPH) is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream. Other names for benign prostatic hyperplasia include benign prostatic hypertrophy, an enlarged prostate, and BPH. BPH occurs only in male patients; approximately 8 percent of males aged 31 to 40 have BPH. In males over age 80, more than 80 percent have BPH.

Many males with BPH have no symptoms. In patients with symptoms, the most common include needing to urinate frequently (during the day and night), a weak urine stream, and leaking or dribbling of urine. These symptoms are called lower urinary tract symptoms. For men with bothersome symptoms in whom lifestyle changes have fallen short, treatment with one or more medicines or surgery is available.

More detailed information about BPH is available by subscription. (See "Medical treatment of benign prostatic hyperplasia" and "Surgical treatment of benign prostatic hyperplasia (BPH)".)

THE PROSTATE GLAND — 

The prostate is a small gland that is part of the male reproductive system. It sits just below the bladder and in front of the rectum (figure 1). The prostate is normally approximately the size of a walnut.

The prostate is composed of several lobes or zones, covered by an outer layer of tissue. The prostate surrounds the urethra, the tube that carries urine from the bladder through the penis and outside the body.

BPH CAUSES — 

It is not clear why some patients develop symptoms of BPH or lower urinary tract symptoms and others do not. The prostate normally enlarges to some degree in all male patients with advancing age, although not all patients require treatment. Several hormones are required for BPH to develop, but these hormones alone do not cause the condition.

Some experts believe that a family history of the condition increases a man's risk of developing BPH. Frequency of sex and having a vasectomy do not increase a patient's chances of developing BPH. There is very consistent evidence that higher levels of physical activity reduce the likelihood of developing BPH. Likewise, physical inactivity relates to a higher risk of this disease.

BPH SYMPTOMS — 

The symptoms of BPH usually begin after age 45. The most common symptoms of BPH include:

●Frequent urination, especially at night

●A hesitant, interrupted, or weak stream of urine

●The need to urinate frequently

●Leaking or dribbling of urine

These symptoms tend to appear over time and may gradually worsen over the years. However, some patients have an enlarged prostate that causes few or no symptoms, while others have symptoms of BPH that later improve or stay the same. Some patients are not bothered by their symptoms, while others are bothered a great deal.

In a small percentage of patients, untreated BPH can cause urinary retention, meaning that there is difficulty with bladder emptying. The risk of urinary retention increases with age and as symptoms worsen.

Symptoms of BPH also can be caused by other conditions, including prostate or bladder cancer, kidney stones, and overactive bladder. Overactive bladder causes a strong, frequent, uncomfortable need to urinate immediately.

BPH DIAGNOSIS — 

To know if BPH or another problem is causing your symptoms, a doctor or nurse will ask you questions, perform an examination, and do blood and urine tests. (See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia".)

●Rectal examination – Your doctor or nurse will need to perform a rectal examination to feel the size and shape of the prostate gland. A rectal examination can help to determine if there are signs of prostate cancer (figure 2).

●Urinalysis – You might be asked for a urine sample to see if you have a bladder infection, diabetes, or certain kidney disorders. (See "Patient education: Urinary tract infections in adults (Beyond the Basics)".)

●Blood tests – A blood test to check the prostate-specific antigen (PSA) level is often recommended. PSA is a protein produced by prostate cells; the PSA level may be increased in male patients with BPH. Patients who have prostate cancer often have a highly disproportionately elevated PSA level, although prostate cancer is also found in patients who do not have an elevated PSA.

Having BPH does not increase your risk for prostate cancer. However, it is possible to have both BPH and prostate cancer at the same time. If your PSA test is higher than normal, you will need further testing to be sure that you do not have prostate cancer. (See "Patient education: Prostate cancer screening (Beyond the Basics)".)

Urodynamic studies — A bladder test, known as a urodynamic study, might be recommended for some patients who have signs or symptoms of BPH. This test can give information about how well the bladder and urethra are working.

BPH TREATMENT — 

Treatments for BPH can help to reduce urinary symptoms. Treatment options include medicines and surgery.

Patients with mild BPH might not need treatment. In this case, most experts recommend a "wait and watch" approach. This means that you will watch your symptoms over time. In some cases, BPH symptoms improve without treatment. However, patients with moderate to severe symptoms usually require treatment.

Lifestyle changes — Behavioral modifications and therapies may be helpful, particularly as an adjunct to medication. Lifestyle changes include avoiding fluids prior to bedtime or before going out as well as reducing consumption of mild diuretics such as caffeine and alcohol. Pelvic floor muscle training, including the use of biofeedback, may be particularly helpful for patients with urgency symptoms.

All patients with BPH should avoid medicines that can worsen symptoms or cause urinary retention. These include certain antihistamines (such as diphenhydramine [Benadryl]) and decongestants (eg, pseudoephedrine, found in some cold medicines).

Lifestyle changes are recommended if you are bothered by having to go to the bathroom frequently. This includes:

●Stop drinking fluids a few hours before bedtime or going out.

●Avoid or drink less fluids that can make you go more often, like caffeine and alcohol.

●Double void. This means that after you empty your bladder, you wait a moment and try to go again. Do not strain or push to empty.

Medicines — The types of medicine used to treat BPH include alpha blockers, phosphodiesterase inhibitors, and alpha-reductase inhibitors. Patients who also have erectile dysfunction may consider a phosphodiesterase inhibitor over the other options. Most patients with BPH who start taking a medicine will need to take it indefinitely to relieve symptoms unless they have some type of prostate surgery. (See "Medical treatment of benign prostatic hyperplasia".)

Alpha blockers — These medications relax the muscle of the prostate and bladder neck, which allows urine to flow more easily. Medications in this category include terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral), and silodosin (Rapaflo). Terazosin and doxazosin were initially developed to treat high blood pressure but were later found to be useful for patients with BPH.

Alpha blockers are usually recommended as a first-line treatment for men with mild to moderate symptoms as they improve symptoms within days.

The most important side effects of alpha blockers are dizziness and low blood pressure after sitting or standing up. Terazosin and doxazosin are usually taken at bedtime (to reduce lightheadedness). The dose can be increased over time if needed.

You should not take terazosin and doxazosin if you take a medicine for erectile dysfunction (ED), such as sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), or avanafil (Stendra). Tamsulosin and alfuzosin usually do not interact with ED medications.

Phosphodiesterase inhibitors — Tadalafil is a reasonable treatment to consider if you have ED and mild or moderate lower urinary symptoms. Daily tadalafil has been demonstrated to improve symptoms; however, some studies failed to show significant difference in urine flow.

Phosphodiesterase inhibitors must not be used by patients who take nitrates or have very decreased kidney function.

Alpha-reductase inhibitors — Alpha-reductase inhibitors (also known as 5-alpha-reductase inhibitors or ARIs) are medicines that can stop the prostate from growing further or even cause it to shrink. Finasteride (Proscar) and dutasteride (Avodart) are alpha-reductase inhibitors.

This type of medicine works better in patients with a larger prostate. It can reduce the risk of urinary retention (not being able to empty the bladder) and the need for surgery. Most patients see an improvement within six months of starting treatment.

A small percentage of patients who take alpha-reductase inhibitors have decreased sex drive, difficulty with erection or ejaculation, or symptoms of depression. Sometimes, these problems are significant enough to prompt discontinuation of BPH treatment. These symptoms resolve when the medication is stopped.

Prostate-specific antigen (PSA) levels decrease by approximately 50 percent in men who take finasteride or dutasteride. This is important to remember if you have PSA testing to screen for prostate cancer. (See "Patient education: Prostate cancer screening (Beyond the Basics)".)

Combination treatment — A combination of an alpha blocker and an alpha-reductase inhibitor might be recommended for certain men. This may benefit men:

●With severe symptoms

●With a large prostate

●Who do not improve with the highest dose of an alpha blocker

Herbal medicines — Herbal therapies for BPH, such as saw palmetto, are commonly used in Europe for treatment of BPH. However, the best studies of saw palmetto have shown no benefit in reducing the symptoms of BPH. For this reason, we do not recommend the use of saw palmetto or other herbal medicines to treat BPH. (See "Clinical use of saw palmetto".)

Transurethral procedures — If medicines do not relieve your symptoms of BPH, a treatment to remove or destroy some of the prostate tissue around the urethra may be recommended (figure 3). Most procedures are performed through the urethra using a special scope. Each treatment has advantages and disadvantages, and the best treatment depends upon the size and location of the excess prostate tissue, your surgeon's expertise, and your preferences. Your doctor can help you choose the best course of treatment. (See "Surgical treatment of benign prostatic hyperplasia (BPH)".)

●Minimally invasive procedures – Several minimally invasive procedures are designed to treat prostate enlargement. They can be performed as same-day procedures, usually under local anesthesia, and are less likely to cause sexual dysfunction. However, patients may develop recurrent symptoms, which may require additional treatment in the future.

•Water vapor thermal therapy – Water vapor thermal therapy (eg, Rezūm system, or Rezūm water vapor therapy) uses thermal energy from steam to remove prostatic tissue. The procedure can be performed in the office with minimal requirements for anesthetic or pain medications.

•Prostatic lift – The prostatic lift (eg, prostatic urethral lift, or UroLift) procedure uses a device that is introduced into the urethra to increase the size of the urethral opening and reduce obstruction to urine flow. Then, one or more small implants are placed to keep the urethra open.

•Temporary implanted prostatic devices – Temporary implanted prostatic devices (TIPD) are specialized devices placed in the prostatic urethra to overcome the blockage of BPH. After five to seven days, these are removed, having reshaped the urethra. Candidacy for TIPD is determined by the patient's prostate volume and shape.

●Resection of the prostate – Transurethral resection of the prostate (TURP) has been used extensively in the past and remains a common transurethral procedure for BPH. The urologist inserts special instruments through the urethra to remove pieces of the enlarged prostate. The procedure is done while you are asleep and takes 60 to 90 minutes. Most patients stay in the hospital overnight after TURP. Complications can include bleeding, sexual dysfunction (most commonly problems with ejaculation), and problems with urination.

●Ablation of the prostate – These procedures ablate (destroy) the prostate tissue using electrical, light, or heat energy. Compared with TURP, these procedures have less bleeding and may be preferred for patients with medical problems, particularly those who must take blood-thinning medications (eg, warfarin).

•Plasma vaporization – Plasma vaporization is similar to standard TURP except that it uses a special probe that destroys the prostate tissue between two electrodes. This procedure is also called the "button procedure."

•Laser ablation or enucleation – Light energy in the form of a laser can also be used to ablate or remove prostate tissue. Terms used to describe common laser ablation techniques include photoselective vaporization (PVP) and Holmium laser enucleation of the prostate (HoLEP, also THuLEP; uses Thulium laser).

•Incision of the prostate – With transurethral incision of the prostate (TUIP), prostate tissue is not removed but the urethra is widened (figure 1). TUIP is sometimes recommended for patients who cannot empty their bladder but do not have a very large prostate, especially if they have other medical problems. Another treatment for BPH is sometimes needed a few years after TUIP.

•Robotic waterjet treatment – Under ultrasound guidance, a robotically controlled waterjet is used to ablate prostate tissue. This is an emerging technique with limited information on risks and long-term efficacy.

Other procedures — Other surgical procedures may be available for patients with BPH.

●Removal of the prostate – Surgery to remove the prostate (prostatectomy) might be recommended for men who are healthy and have a very large prostate (over 100 g). This procedure can be done as an open simple prostatectomy or by robotic assisted (DaVinci) laparoscopic simple prostatectomy. Recovery is much easier for the patient after the robotic-assisted laparoscopic procedure.

●Suprapubic catheter – A catheter placed directly into the bladder might be used as a temporary measure to manage bladder outlet obstruction prior to surgery; or, in some circumstances (uncommon), it may be a permanent option.

WHERE TO GET MORE INFORMATION — 

Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Urinary retention – Discharge instructions (The Basics)
Patient education: Benign prostatic hyperplasia (enlarged prostate) (The Basics)
Patient education: Prostate cancer screening (PSA tests) (The Basics)
Patient education: Bacterial prostatitis (The Basics)
Patient education: Chronic prostatitis and chronic pelvic pain syndrome (The Basics)
Patient education: Urinary incontinence in males (The Basics)
Patient education: Hydronephrosis in adults (The Basics)
Patient education: Surgery for benign prostatic hyperplasia (The Basics)
Patient education: Prostatectomy (The Basics)
Patient education: Prostate biopsy (The Basics)
Patient education: Suprapubic catheter placement (The Basics)
Patient education: Bladder training (The Basics)
Patient education: Urinary retention (The Basics)
Patient education: Urinalysis (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Urinary tract infections in adults (Beyond the Basics)
Patient education: Prostate cancer screening (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia
Clinical use of saw palmetto
Epidemiology and pathophysiology of benign prostatic hyperplasia
Medical treatment of benign prostatic hyperplasia
Surgical treatment of benign prostatic hyperplasia (BPH)

The following organizations also provide reliable health information.

●National Library of Medicine

●American Urological Association

●National Institute of Diabetes and Digestive and Kidney Diseases

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ACKNOWLEDGMENTS — 

The UpToDate editorial staff acknowledges Glenn Cunningham, MD, and Dov Kadmon, MD, who contributed to earlier versions of this topic review.