What is benign prostatic hyperplasia and how is it treated?

Benign prostatic hyperplasia (BPH) is a benign tumor developing growing in different parts of the prostate. This disease leads to the impassability of the lower urinary way.

In BHP, a small nodule (or nodules) is developed in the prostate, which grows and gradually narrows down the urethra. As a result of this compression, a violation of urination occurs. BPH is a benign process, that is, does result in metastases. This fundamentally distinguishes BPH from prostate cancer. The main reference point for the onset of malignant degeneration of the prostate is the level of certain prostatic antigen. Although the antigen levels may be elevated in BPH, it doesn’t promote the risk of prostate cancer.

According to statistics, 50% of men aged 40-50 go to their doctors with the symptoms of BPH. In rare cases, benign prostatic hyperplasia develops in men of a younger age but the risk grows as a man gets older. It is believed that over time, it develops in 85% of men. In 15-20% of men of advanced and senile age, instead of BPH, there is an increase in the gland to varying degrees or its atrophy.

BPH is the most frequent urological disease in older men.

Short information

The average age for the onset of manifestations of the disease is 60 years, although, in the U.S., 40% of diagnosed men are aged 50-59. In men, whose fathers suffered from BPH, the incidence is higher. The diagnosis can be made through physical examination in 20% of men aged around 60 years and in 43% of men around 80 years old.

The causes of BPH are not yet fully understood. It is believed that the onset of BPH is one of the manifestations of male menopause. Risk factors include only age and blood levels of androgens. With age, the physiological balance between androgens and estrogens is disrupted in a man’s body, which leads to a violation of control over the growth and functioning of prostate cells. No reliable relationship was found between the occurrence of BPH and sexual activity, sexual orientation, tobacco and alcohol use, and inflammatory and venereal diseases of the genital organs.

BPH is more likely to be developed at the central part of the gland and spread to the sides. Its growth is related to the growth of paraurethral glands which leads to the shifting of the gland tissue and the formation of a capsule on a growing adenoma. The tissue can grow towards the bladder and rectum causing the shifting of the opening of the bladder up and lengthening of the back of the urethra.

Based on the type of growth three types of BHP are distinguished:

- Tumor grows towards rectum;

- Tumor growth towards bladder;

- Tumor is located under the triangle of the bladder (Lieto triangle formed by the mouths of the ureters and the internal opening of the urethra). There is a so-called double block: the tumor complicates not only the outflow of urine from the bladder, but also the passage of the latter through the mouth of the ureters.

Often there is multifocal tumor growth.

Symptoms of BPH by stages

The symptoms depend on the tumor localization, its size, growth speed, and the degree of violation of the contractile function of the bladder. There are three stages of the disease:

- I stage - Compensated. It manifests in trouble initiating urination, the flow of urine is weak, frequent urination urges especially during the night. At this stage, the gland is enlarged, has a dense-elastic consistency, its borders are clearly defined, the median groove is well palpated, palpation of the gland is painless. The bladder empties completely - there is no residual urine. The first stage lasts 1-3 years.

- II stage- Suncompensated. The growth of the tumor constricts the urethra significantly so that the bladder cannot be fully emptied. This results in accumulation of residue urine, incomplete emptying of the bladder, the walls of the bladder significantly thicken; patients urinate in small portions, and then urine begins to be released involuntarily due to overflow of the bladder (paradoxical ischuria); sometimes the urine is cloudy or mixed with blood, acute urinary retention is observed, and symptoms of chronic renal failure develop.

- III stage – Decompensated. Due to a large amount of residue urine, the bladder is severely stretched, urine comes out in drops, and it is cloudy or mixed with blood. The deterioration of the outflow of urine from the kidneys leads to impaired renal function (renal failure). Other common symptoms are weakness, weight loss, dry mouth, the smell of urine in the exhaled air, poor appetite, anemia, and constipation.

Diagnosis of BPH

The diagnosis is made based on the patient’s complaints, physical examination, and such methods as:

- Physical analysis of the prostate gland through the rectum. This allows identifying the size and consistency of the gland, painfulness, and other details.

- Laboratory tests including urine test, biochemical blood test, determination of the level of PSA (prostatic specific antigen) in the blood.

- Ultrasound examination. This allows detecting the precise size of the prostate, the structure of the tissue, presence of node, stones, and residue urine. - Urine flow rate analysis.

- X-ray. This method allows identifying the presence of complications of the course of prostate adenoma: kidney and bladder stones, expansion of the pyelocaliceal system of the kidneys, and the formation of their diverticula.

Treatment of BPH

There are various methods for BHP treatment that can be divided into three groups:

- Medicinal treatment;

- Surgical treatment;

- Non-surgical treatment.

In the occurrence of first signs of the disease, treatment with medicines is appointed.

This therapy is aimed at the improvement of the blood circulation in the pelvic organs, slowing down of hyperplastic tissue growth, reduction of the accompanying inflammation, elimination of constipation, lowering or elimination of urine retention, facilitation of urination and elimination of secondary infection of the urethra. Besides, men are advised to do physical exercises, limit liquid consumption before bed. A patient must also refuse alcohol, tobacco smoking, and spicy food.

Androgen replacement therapy is appointed only in the presence of clinically-proven age-related androgens deficiency.

In acute urine retention that can develop due to alcohol consumption or overcooling, a patient is urgently hospitalized for the bladder catheterization.

Drugs used for benign prostatic hyperplasia

For the treatment of BPH are used the following medicines:

- Alpha-1-blockers (silodosin, doxazosin, and others). These medicines relax the smooth muscles of the pelvic area, preventing occlusion of the urethra and passage of urine. Their action can be short or prolonged.

- PDE5 inhibitors (Tadalafil) also relax the smooth muscles of the pelvic organs preventing difficulty urinating and urine retention.

- 5-alpha reductase inhibitors (finasteride, dutasteride, and others). Medicines of this group prevent the formation of dihydrotestosterone (a biologically active form of testosterone), which helps to reduce the size of the prostate gland and counteracts urethral obstruction.

Surgery for BPH

In severe cases, surgical treatment is required. Surgery on the prostate implies excision of hyperplastic tissue (adenomectomy), or total resection of the prostate gland (prostatectomy). These operations are one of the most common in elderly men. Around 30% of men need this kind of surgery.

There are two types of surgery:

1. Open (transvesical adenomectomy) - with access through the wall of the bladder. They are used in advanced cases, they are more traumatic, but provide a complete cure for the disease. An absolute indication for transvesical adenomectomy is the intraregional growth of adenomatous nodes.

2. Endoscopic surgery through urethra.