Benign Prostatic Hyperplasia - Causes, Symptoms and Treatment

Benign prostatic hyperplasia or benign prostatic hyperplasia (BPH) is a condition characterized by enlarged prostate with benign characteristics, ie, no relation to prostate cancer.

Normal and enlarged prostate
Normal and enlarged prostate
 


What is the prostate?

The prostate is a walnut-sized gland (3 cm in diameter), weighing approximately 20 grams, present only in males. It is located at the base of the bladder and surrounds the initial part of the urethra, a canal that carries urine from the bladder to the penis.

The prostate is part of the male reproductive system, responsible for the secretion of an alkaline fluid (with high pH) that protects sperm from the acid environment of the vagina and increases its mobility, facilitating the arrival of the spermatozoa to the egg.

Because it has an intimate relationship with the urethra (a channel that drains urine from the bladder), changes in prostate size can compress it and make it difficult to pass urine, leading to symptoms of prostatism, which will be explained later.

Because the prostate is leaning against the rectum, it can be palpated through rectal examination, one of the simplest methods of assessing the gland. An enlarged or irregularly shaped prostate due to the presence of a tumor can be easily identified by this method. We'll talk more about the rectal touch in the diagnostic part.

The prostate can grow and cause symptoms for three reasons:
  • Benign hyperplasia of the prostate
  • Prostate cancer
  • Prostatitis - prostate infection

Benign prostatic hyperplasia (BPH)

Increased prostate size is a process stimulated by the presence of the hormone testosterone and occurs throughout life in males. The older a person, the longer their prostate had to grow. This means that with age, virtually all men will have a large prostate. By age 40, 10% of men already have an enlarged prostate; at 50 years, this number jumps to 50%; after 80 years, more than 80% of the male population has benign prostatic hyperplasia.

Benign prostatic hyperplasia, as its name suggests, is benign growth, which has nothing to do with cancer. Repeating for no confusion: prostate hyperplasia is a natural aging process and NOT turns into prostate cancer. This confusion often arises because almost every patient with prostate cancer is older than 60 years, at which age the prevalence of BPH is high. By making a rough comparison, we can say that many patients with prostate cancer have white hair, but even so we do not think that having white hair causes cancer.

Symptoms

The enlargement of the prostate itself is not a problem. The problem is that the prostate is anatomically located along some structures of the urinary tract, especially the urethra. The enlarged prostate gland compresses the urethra and impairs the urine output, and may even cause obstruction, hydronephrosis (accumulation of urine in the kidney), and kidney failure. See the illustration at the beginning of the text to understand how the urethra is compressed.

The symptoms of benign prostatic hyperplasia are related to obstruction of the urethra. The first signs are loss of urinary jet strength and the need to urinate often.

Explaining: The enlarged prostate compresses the urethra and impairs the drainage of urine. Most of the time this obstruction is partial and allows some urine to pass, especially when the bladder is full and the pressure can overcome the resistance caused by the enlarged prostate. However, when the level of urine inside the bladder drops, the pressure drops and the jet, which is already weak, stops. The end result is a bladder that can no longer empty itself completely, always with some urine inside. Therefore, the patient feels like urinating frequently, but can only eliminate small volumes.

The complete emptying of the bladder causes a large volume of urine to be always dammed, favoring the growth of bacteria in the interior, since the act of urinating expels much of the microorganisms present in the urine. In patients with benign prostatic hyperplasia, there is always a urine "pond" for bacteria to reproduce. It is not surprising that cystitis (bladder infection), rare in men up to 45-50 years, becomes a common diagnosis in the elderly.

The fact that urine is trapped inside the bladder also favors the formation of stones (stones) within the bladder.

As the prostate grows, the more tightly the urethra is to the point where there may be complete obstruction of the passage of urine. Urine that is not drained accumulates in the urinary tract and eventually attacks the kidneys, leading to hydronephrosis (dilatation of the kidneys). The end result is severe renal insufficiency, and urgent hemodialysis may be required.

It is worth noting that complete suspension of urine is not necessary to have a serious kidney injury. The patient may still be able to urinate and still be with obstruction and severe hydronephrosis. It is enough that it has a lower urine elimination rate than that produced by the kidneys.

The longer the kidneys become clogged and filled with urine, the less chance of recovery after clearing the flow. After 7 to 10 days of hydronephrosis, irreversible damage to the kidneys begins, a process that is complete after 3-4 months of obstruction, at which time the patient will probably remain dependent on hemodialysis, even if he corrects the problem.

Another symptom of prostate growth is erectile dysfunction (impotence), which occurs by compression of the nerves that control erection.

In summary, the main symptoms of benign prostatic hyperplasia are:
  • Pain or difficulty urinating
  • A weak urine stream
  • Need to urinate small volumes very often
  • Inability to empty the bladder
  • Urinary infection
  • Calculation of bladder
  • Renal insufficiency in cases of severe obstruction and hydronephrosis

As many patients with enlarged prostate and hydronephrosis still manage to urinate, it is not unusual for them not to seek medical help early, neglecting their urinary symptoms. This behavior eventually makes the picture much more severe, often causing the patient to stop in the hospital, later, with a picture of advanced renal failure. It is important that any elderly person, at the first sign or symptom of prostate growth, is evaluated by urologist.

Diagnosis

There is a points table called "international prostate symptom score". There are 7 questions and each receives a score of 0 to 5:
  • How often did you feel that you did not completely empty your bladder?
  • How often did you have to urinate again less than 2 hours after you urinated?
  • How many times have you noticed that when you urinated, you stopped and started over and over again?
  • How many times have you noticed that it was difficult to contain urine?
  • How many times have you noticed that the urinary stream was weak?
  • How many times did you have to force yourself to start urinating?
  • How many times, on average, did you have to get up at night to urinate?

  • 0 = None
  • 1 = Less than 1 in 5
  • 2 = Less than half of the time
  • 3 = Half of the time
  • 4 = More than half of the time
  • 5 = Almost always

  • Mild: 0 to 7;
  • Moderate: 8 to 19;
  • Severe: 20 or more

The above score evaluates the severity of prostate symptoms, but does not differentiate between BPH, prostate cancer and prostatites, which present very similar symptoms.

The differential diagnosis involves rectal examination, PSA dosing, transrectal and abdominal ultrasonography, and prostate biopsy.

PSA


PSA is a marker of prostate disease, collected through blood tests. PSA is elevated in HPB, prostatitis and, especially, in prostate cancer.

  • PSA less than 2.5 = Low risk of cancer
  • PSA between 2.5 and 10 = intermediate risk of cancer
  • PSA greater than 10 = High risk of cancer
  • PSA greater than 20 = Very high risk of cancer and high chance of metastatic disease

Patients with low PSA rarely have cancer. When the PSA value is intermediate, the most likely diagnosis is BPH, but prostate cancer can not be ruled out. High PSA indicates high risk of cancer, but it is also possible that it is prostatitis or even only BPH. PSA greater than 20, practically only appear in cancer or in some cases of prostatitis.

Rectal touch


The rectal touch can detect the enlargement of the prostate because it is leaning against the rectum. This examination of the prostate, when done by an experienced doctor, allows in many cases to know if the enlargement of the prostate is uniform, ie caused by BPH, or localized, caused by a tumor.

The rectal touch allows the doctor to detect irregularities, nodules, asymmetries and changes in prostate consistency.

Ultrasound of the prostate


The ultrasound performed by the rectal route allows a good visualization of the prostate, allowing to calculate its size and volume, and also to detect suspicious nodules.

Abdominal ultrasound allows to calculate the volume of urine in the bladder and to evaluate the capacity of emptying it. It is also possible to see the kidneys and diagnose any serious obstructions that are causing hydronephrosis.

If after the completion of all these tests, the cancer remains a hypothesis, it is necessary to perform the biopsy of the prostate to close the diagnosis.

Treatment

Patients who present BPH diagnosed on routine exams and do not present any complaints or signs of urinary obstruction can be followed regularly without specific treatment.

If there is enlargement of the prostate and signs of moderate obstruction of the urinary tract, usually the indicated treatment is done with medicines that decrease the size of the prostate. Among the available drugs we can mention:
  • Terazosin
  • Doxazosin
  • Tamsulosin
  • Alfuzosin
  • Finasteride
  • Dutasteride

When the obstruction of the urinary tract is severe or when the treatment with medicines is not successful, that is, if there is no reduction of prostate size, surgery becomes an option.

Transurethral resection of the prostate (TURP) is currently the most commonly used surgical procedure. In this procedure the urologist removes much of the prostate with a device called resectoscope, that is introduced through the urethra. By this apparatus it is possible to introduce a blade to resect the prostate and aspirate the removed tissue. Usually the entire interior of the prostate is removed, leaving only the outside. The surgery is done with general anesthesia or regional and lasts in average 90 minutes.

If the prostate is not very large a possible surgery is the transurethral incision of the prostate (TUIP), similar to TURP, but only removing a small part of the prostate tissue, enough to unclog the urethra.

There are other techniques for resection of the prostate, such as laser, microwave, cauterization, etc. The technique depends on the severity of each case and the urologist's experience.

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