Benign Prostate Hyperplasia
Benign prostatic hyperplasia (BPH), also called 'enlarged prostate,' generally affects men over age 50. In fact, nearly all men over the age of 50 have an enlarged prostate to some degree and by age 85, about 90 percent of all men will report lower urinary tract symptoms, also known as LUTS. Not all cases require treatment.
The prostate is a gland located under the bladder and behind the pubic bone. Its primary role is helping in the production and secretion of semen. The prostate partially surrounds the urethra and gets larger with age. It causes many of the LUTS that men experience.
BPH occurs when noncancerous cells of the prostate divide to make more cells. While BPH is not associated with the development of cancer, the two often go together. Distinguishing between them is an important part of the diagnosis process.
Age: It is common knowledge that the prevalence of BPH markedly increases with age. The incidence of LUTS also increases with age. Studies have demonstrated incidence and progression rates increased with age.
Obesity: It has been observed that men who have increased levels of fatty tissue have larger prostates. In addition, increased weight as measured by how large your waist is. For each 0.05 increase in waist-to-hip ratio (a measure of abdominal obesity) there was an associated 10% increased risk of BPH.
Diet: There is evidence to suggest that various macro- and micronutrients may affect the risk of BPH and LUTS development. Previously, the consumption of milk and other dairy related products have been associated with an increased risk of BPH. Fruit on the other hand has been shown to have a protective role in the body for the prevention of the development of BPH. In addition, the low occurrence of BPH in Asian populations as well as in vegetarians is due to a low-fat and high-fiber diet.
Metabolic Syndrome: Metabolic syndrome is a combination of several metabolic abnormalities, including central obesity, high cholesterol, high blood pressure, and diabetes. Many of the factors, which are associated with developing cardiovascular problems, may also lead to BPH and LUTS. These are important as they may allow for novel treatment and prevention programs.
Men with BPH experience a variety of symptoms such as:
- Needing to urinate frequently, particularly at night - also called nocturia
- Feeling an urgent need to urinate shortly after urinating
- Experiencing difficulty starting to urinate or maintaining the flow
- Decreased force of urinary stream
- Having a stop-start pattern in urinating (intermittency)
- Feeling as though there is urine left in the bladder after urinating
- Blood in the urine (called hematuria)
When symptoms become severe, you may find you cannot hold your urine long enough to find a toilet (urge incontinence) or may stop urinating entirely (urinary retention). Not urinating can sometimes lead to kidney damage.
LUTS secondary to BPH occurs because of the location of the prostate gland (a walnut-sized gland that is part of the male reproductive system) which sits under the urinary bladder. Urine must pass through the prostate on its way out of the body. BPH obstructs this flow, slowing the urine stream, making it harder to empty the bladder, and causing it to empty incompletely. If we do not treat BPH, the bladder is left constantly fighting the obstructed prostate. This can lead to worsening symptoms, urinary tract infections, and kidney problems.
The first and most important tool in the assessment of BPH is your medical history. This helps us analyze potential causes of your LUTS and relevant co-morbidities. A detailed medication history is also necessary as are your lifestyle habits, such as fluid intake.
We use several diagnostic tools.
You will be asked to complete a validated questionnaire to objectively assess your symptoms. International Prostate Symptom Score (IPSS) is a symptom sheet that helps us determine how severe your symptoms are and then monitor your treatment. The IPSS consists of 8 questions, 7 questions relate to voiding or storage symptoms while the 8th question relates to quality of life. The 7 symptom questions are scores 0 to 5 and the sum of the 7 questions added together. Patients with a score of 1 to 7 are referred to as ‘mildly symptomatic’, score of 8 to 19 as ‘symptomatic’ and a score of 20 to 35 as ‘severely symptomatic’. Another tool recommended for assessment of LUTS is a frequency volume chart or bladder diary. For a frequency volume chart, you will measure the volume and time of each void. A bladder diary includes additional information such as the type of fluid, the use of incontinence pads, or activities at the time of documenting.
A physical exam will be performed. This includes examining your lower abdomen and suprapubic area to make sure you are not retaining urine. A neurological exam should also be performed on the lower limbs. Digital rectal exams (DRE) enable us to identify any abnormalities of the prostate, such as cancer or prostatitis. In addition, a DRE allows the prostate volume to be estimated. DRE also allows us to assess the shape and texture of your prostate and to determine the presence of firm/hard areas or nodules, which may raise suspicions for prostate cancer.
A urine specimen should be collected for analysis. Urine studies (culture and cytology) help us rule out infection, hematuria (blood in the urine), glucosuria (sugar in the urine as can be seen in diabetics), or cancer.
Uroflow testing records how much urine you void, the speed (force) of your urination, and the time it takes to urinate, pointing out any abnormalities. We can also determine whether there is any residual urine in your bladder using a bladder scan, which is similar to an ultrasound of the bladder. If either test is abnormal, we will likely conduct further testing, using urodynamics.
Urodynamics is a two-phase process that uses a computer to determine bladder function. The first phase is a filling phase, followed by a urinating phase. In the filling phase, we evaluate your bladder for involuntary contractions (overactive bladder), compliance (elasticity), incontinence (involuntary loss of urine) and capacity (amount of fluid the bladder can comfortably hold). During the urinating phase, we record your bladder pressure to see if it is normal, weak (hypocontractile) or blocked altogether (obstructed). We usually do this test in our office and it takes about 15 minutes.
Ultrasound helps us evaluate whether your kidneys are swollen (hydronephrosis), especially when you have residual urine in the bladder either due to a hypocontractile bladder or obstruction from BPH. Sometimes we use a bladder ultrasound to evaluate prostate size, amount of residual urine, or the presence of bladder stones.
Measuring prostate specific antigen (PSA) is performed to help exclude suspicions of prostate cancer We perform PSA to help us in decision-making in patients at risk of progression of prostate enlargement.
Cystoscopy lets us evaluate the size of your prostate before or during treatment for BPH. We perform this office procedure using a local anesthetic. It helps us assess any other causes of obstruction (i.e., strictures) and provides additional information about your prostate and bladder. We often put the camera on the cystoscope so you can see what we do.
Mount Sinai is currently engaged in a study of a new BPH treatment. We are seeking male volunteers, between the ages of 50 and 79, who have had symptomatic BPH for at least six months and are candidates for transurethral resection of the prostate treatment (TURP). This study will use a new therapy called Aquablation Water Jet System which uses both Robotic technology and a waterjet to remove prostate tissue. For more information, please call Cynthia Knauer, RN of the Department of Urology at 212-824-7877.