Benign prostatic hyperplasia

Benign prostatic hyperplasia, or BPH, is very common in older men. The prostate is enlarged, but it is not cancerous. Over time, an enlarged prostate may press against the urethra, making it hard to urinate.

Diagnosis

BPH may cause dribbling after urinating or a need to urinate often, especially at night. A doctor will do a rectal exam to check for BPH. And he may suggest having special x-rays or scans to check the urethra, prostate, and bladder.

The physical examination has limited ability to measure the prostate volume: The normal prostate is about the size of a walnut or less than 30 ml.

• Estimating a volume of more than 30 ml on rectal examination has a sensitivity of less than 50% in detecting a gland of more than 30 ml.
• Estimated a posterior surface area of more than 7 cm² has a sensitivity of 70% for detecting a volume of more than 30 ml. Of note, an area of 7 cm² indicates a circle with diameter of 3 cm or a square with diameter of approximately 2.5 cm².

The American Urological Association Urinary symptom score is a validated measure of severity of symptoms.

The prostate specific antigen (PSA) level in the blood may predict size.

American Urological Association Urinary symptom score: ASK THE FOLLOWING QUESTIONS: Over the past month: How often have you had a sensation of not emptying your bladder after you finish urinating? How often have you had to urinate again after you finish urinating? How often have you found you stopped and started again several times when you urinated? How often have you found it difficult to postpone urination? How often have you had a weak urinary stream? How often had you had to push or strain to begin urination? How many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? ANSWER THE QUESTIONS AS FOLLOWS, POINTS ARE BELOW: Not at < 1 < than 1/2 About 1/2 > than 1/2 Almost all time in 5 the time the time the time always 0 1 2 3 4 5 Total Score: 0-7 mild 8-19 moderate 20-35 severe

Ultrasonography

Estimation of post-void residual volume by ultrasonography may not always show elevated values.

Treatment

If the symptoms are not too bad, the doctor may suggest "watchful waiting" before starting any treatment. This includes regular checkups. Treatment can start later on if symptoms get worse.

Medications

• Alpha adrenergic blockers can reduce the symptoms. Drug toxicity may include headaches, dizziness, or feeling lightheaded or tired. Vascular drug toxicity may be less with tamsulosin due to more selectivity to α₁-A and α₁-D adrenergic receptors according to a meta-analysis supported by Boehringer Ingelheim Pharmaceuticals, the maker of tamsulosin.
• Testosterone 5-alpha-reductase inhibitors such as finasteride (Proscar®) can lower the amount of the male hormone (testosterone) in the body. The result is that the prostate shrinks and urinary problems get better. Drug toxicity can include less interest in sex and problems with erection or ejaculation.
• Saw palmetto plant extract (Serenoa repens). Despite initial positive reports, a more recent randomized controlled trial found no benefit.
• If symptoms of urge and overactive urinary bladder are present, an antimuscarinic cholinergic antagonist such as tolterodine can be combined with an alpha adrenergic blocker such as tamsulosin.

Combination therapy

Finasteride combined with doxazosin is better than either drug alone according to a meta-analysis by the Cochrane Collaboration. Alfuzosin and finasteride are generic.

Randomized controlled trials of combination therapy for benign prostatic hypertrophy.

Trial	Patients	Intervention	Control	Outcome	Results (% AUA score increase by ≥ 4 points)
					Combination	Alpha adrenergic blocker only	5-alpha-reductase inhibitor only
CombAT 2009 Uncontrolled factorial trial Industry sponsored	Mean prostate volume was 54 ml	tamsulosin 0.4 mg and/or dutasteride 0.5 daily	Placebo	Composite at 4 years	8.6%	14.2%	13.1%
Medical Therapy of Prostatic Symptoms (MTOPS) Research Group 2003 Factorial trial Government sponsored	Mean prostate volume was 36 ml	doxazosin 8 mg and finasteride 5 mg daily	Placebo	Composite at 4.5 years	5%	7%	9%
Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group 1996 Factorial trial Government sponsored		terazosin 10 mg and finasteride 5 mg daily	Placebo	Various at one year

Alpha adrenergic blockers have been combined with testosterone 5-alpha-reductase inhibitors in randomized controlled trials.

Surgery

An operation can improve the flow of urine but it can also cause other problems. Usually, men have surgery only if medicine hasn’t worked. This surgery does not protect against prostate cancer. Regular check-ups are important after BPH surgery. There are three kinds of surgery:

• Transurethral resection of the prostate (TURP) is the most common type of surgery. The surgeon takes out part of the prostate through the urethra.
• Transurethral incision of the prostate (TUIP) may be used when the prostate is not too large. The doctor makes a few small cuts in the prostate near the opening of the bladder.
• Open surgery is used only when the prostate is very large. The doctor removes the prostate through a cut in the belly or behind the scrotum.