Benign Prostatic Hyperplasia (BPH): A Common Urinary Obstruction in Aging Men

Benign Prostatic Hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland that affects nearly half of men over the age of 50 and up to 90% of men in their 80s. Though benign, it can significantly impact the quality of life through urinary obstruction and lower urinary tract symptoms (LUTS). BPH is not a precursor to prostate cancer, but the two conditions may coexist, especially in older individuals.

The Growing Gland

The prostate gland sits just below the bladder and surrounds the urethra. In BPH, an increase in both stromal and epithelial cells causes the gland to enlarge, constricting the urethral lumen. This leads to obstruction of urine flow, bladder wall thickening, and in some cases, incomplete emptying of the bladder.

The pathogenesis is multifactorial but largely driven by hormonal changes. With age, there’s a relative increase in dihydrotestosterone (DHT), which is a potent derivative of testosterone that stimulates prostate cell proliferation. Estrogens and growth factors also play contributory roles in prostatic growth and inflammation.

Symptoms:

The progression of BPH is often slow, with symptoms that evolve. They can be categorized into:

● Storage Symptoms: Frequency, urgency, nocturia (waking at night to urinate)

● Voiding Symptoms: Hesitancy, weak stream, straining to urinate, and a sensation of incomplete emptying

● Post-micturition Symptoms: Dribbling and prolonged urination time

In severe cases, patients may experience acute urinary retention

Diagnosing the Problem

Diagnosis includes taking a thorough history and symptom assessment using tools like the International Prostate Symptom Score (IPSS). A digital rectal examination (DRE) assesses prostate size and consistency.

Key investigations include:

● Urinalysis: To exclude infection or hematuria

● Serum PSA (Prostate-Specific Antigen): Elevated in BPH but also in prostate cancer; used to assess prostate volume and risk

● Post-void residual volume (PVR): Measured via bladder ultrasound to evaluate urine left behind

● Uroflowmetry: Assesses urine flow rate

● Prostate ultrasound or transrectal ultrasound (TRUS): For detailed imaging

BPH is typically a clinical diagnosis but may overlap with other pathologies like prostate cancer, bladder stones, or urethral strictures.

Managing the Flow

Management depends on the severity of symptoms and patient preferences. The goals are to ease symptoms, improve quality of life, and prevent complications like retention or infections.

Pharmacological Therapy:

● Alpha-blockers (e.g., tamsulosin, alfuzosin): Relax smooth muscle in the bladder neck and prostate to improve flow.

● 5-alpha reductase inhibitors (e.g., finasteride, dutasteride): Reduce prostate volume by inhibiting DHT synthesis. Particularly useful for large prostates.

● Combination therapy is often used in men with significant symptoms and larger prostates.

● Phosphodiesterase-5 inhibitors (e.g., tadalafil): May offer dual benefit for urinary symptoms and erectile dysfunction.

Minimally Invasive & Surgical Options:

● Transurethral Resection of the Prostate (TURP): Gold standard for surgical management.

● Laser therapies (e.g., HoLEP), UroLift, and TUNA provide alternatives with less morbidity.

● Prostate artery embolization (PAE) is an emerging non-surgical intervention.

Lifestyle Modifications:

● Limiting caffeine and alcohol

● Scheduled voiding

● Double voiding to reduce residual urine

● Avoiding decongestants or antihistamines that may worsen symptoms

BPH is not life-threatening, but it can cause significant distress and lead to complications such as urinary retention, recurrent urinary tract infections, and bladder damage. With timely intervention—pharmacologic or surgical—most men can achieve symptom relief and maintain a high quality of life.

References

1. McVary KT, et al. "Update on AUA guideline on the management of benign prostatic hyperplasia." J Urol. 2011; 185(5): 1793–1803.
    doi:10.1016/j.juro.2011.01.074

2. National Institute for Health and Care Excellence (NICE). "Lower urinary tract symptoms in men: management." NICE guideline [NG97], 2015.
    https://www.nice.org.uk/guidance/ng97

3. Mayo Clinic. "Benign prostatic hyperplasia (BPH) – Symptoms and causes."

4. Roehrborn CG. "Benign prostatic hyperplasia: an overview." Rev Urol. 2005;7 Suppl 9(Suppl 9): S3–S14.