BPH: A Common Part of Aging
It is common for the prostate gland to become enlarged as a
man ages. Doctors call the condition benign prostatic hyperplasia (BPH), or
benign prostatic hypertrophy.
Normal urine flow.
Urine flow with BPH.
As a man matures, the prostate goes through two main periods
of growth. The first occurs early in puberty, when the prostate doubles in size.
At around age 25, the gland begins to grow again. This second growth phase often
results, years later, in BPH.
Though the prostate continues to grow during most of a man's
life, the enlargement doesn't usually cause problems until late in life. BPH
rarely causes symptoms before age 40, but more than half of men in their sixties
and as many as 90 percent in their seventies and eighties have some symptoms of
As the prostate enlarges, the layer of tissue surrounding it
stops it from expanding, causing the gland to press against the urethra like a
clamp on a garden hose. The bladder wall becomes thicker and irritable. The
bladder begins to contract even when it contains small amounts of urine, causing
more frequent urination. Eventually, the bladder weakens and loses the ability
to empty itself. Urine remains in the bladder. The narrowing of the urethra and
partial emptying of the bladder cause many of the problems associated with BPH.
Many people feel uncomfortable talking about the prostate,
since the gland plays a role in both sex and urination. Still, prostate
enlargement is as common a part of aging as gray hair. As life expectancy rises,
so does the occurrence of BPH. In the United States in 2000, there were 4.5
million visits to a physician for BPH.
Why BPH Occurs
The cause of BPH is not well understood. No definite
information on risk factors exists. For centuries, it has been known that BPH
occurs mainly in older men and that it doesn't develop in men whose testes were
removed before puberty. For this reason, some researchers believe that factors
related to aging and the testes may spur the development of BPH.
Throughout their lives, men produce both testosterone, an
important male hormone, and small amounts of estrogen, a female hormone. As men
age, the amount of active testosterone in the blood decreases, leaving a higher
proportion of estrogen. Studies done with animals have suggested that BPH may
occur because the higher amount of estrogen within the gland increases the
activity of substances that promote cell growth.
Another theory focuses on dihydrotestosterone (DHT), a
substance derived from testosterone in the prostate, which may help control its
growth. Most animals lose their ability to produce DHT as they age. However,
some research has indicated that even with a drop in the blood's testosterone
level, older men continue to produce and accumulate high levels of DHT in the
prostate. This accumulation of DHT may encourage the growth of cells. Scientists
have also noted that men who do not produce DHT do not develop BPH.
Some researchers suggest that BPH may develop as a result of
"instructions" given to cells early in life. According to this theory, BPH
occurs because cells in one section of the gland follow these instructions and
"reawaken" later in life. These "reawakened" cells then deliver signals to other
cells in the gland, instructing them to grow or making them more sensitive to
hormones that influence growth.
Many symptoms of BPH stem from obstruction of the urethra and
gradual loss of bladder function, which results in incomplete emptying of the
bladder. The symptoms of BPH vary, but the most common ones involve changes or
problems with urination, such as
- a hesitant, interrupted, weak stream
- urgency and leaking or dribbling
- more frequent urination, especially at night
The size of the prostate does not always determine how severe
the obstruction or the symptoms will be. Some men with greatly enlarged glands
have little obstruction and few symptoms while others, whose glands are less
enlarged, have more blockage and greater problems.
Sometimes a man may not know he has any obstruction until he
suddenly finds himself unable to urinate at all. This condition, called acute
urinary retention, may be triggered by taking over-the-counter cold or allergy
medicines. Such medicines contain a decongestant drug, known as a
sympathomimetic. A potential side effect of this drug may be to prevent the
bladder opening from relaxing and allowing urine to empty. When partial
obstruction is present, urinary retention also can be brought on by alcohol,
cold temperatures, or a long period of immobility.
It is important to tell your doctor about urinary problems
such as those described above. In 8 out of 10 cases, these symptoms suggest BPH,
but they also can signal other, more serious conditions that require prompt
treatment. These conditions, including prostate cancer, can be ruled out only by
a doctor's exam.
Severe BPH can cause serious problems over time. Urine
retention and strain on the bladder can lead to urinary tract infections,
bladder or kidney damage, bladder stones, and incontinence. If the bladder is
permanently damaged, treatment for BPH may be ineffective. When BPH is found in
its earlier stages, there is a lower risk of developing such complications.
You may first notice symptoms of BPH yourself, or your doctor
may find that your prostate is enlarged during a routine checkup. When BPH is
suspected, you may be referred to a urologist, a doctor who specializes in
problems of the urinary tract and the male reproductive system. Several tests
help the doctor identify the problem and decide whether surgery is needed. The
tests vary from patient to patient, but the following are the most common.
Digital Rectal Exam (DRE)
This exam is usually the first test done. The doctor inserts a
gloved finger into the rectum and feels the part of the prostate next to the
rectum. This exam gives the doctor a general idea of the size and condition of
Prostate Specific Antigen (PSA) Blood Test
To rule out cancer as a cause of urinary symptoms, your doctor
may recommend a PSA blood test. PSA, a protein produced by prostate cells, is
frequently present at elevated levels in the blood of men who have prostate
cancer. The U.S. Food and Drug Administration has approved a PSA test for use in
conjunction with a digital rectal exam to help detect prostate cancer in men age
50 or older and for monitoring prostate cancer patients after treatment.
However, much remains unknown about the interpretation of PSA levels, the test's
ability to discriminate cancer from benign prostate conditions, and the best
course of action following a finding of elevated PSA.
A fact sheet titled "Questions and Answers About the
Prostate-Specific Antigen (PSA) Test" can be found on the National Cancer
Institute website at
If there is a suspicion of prostate cancer, your doctor may
recommend a test with rectal ultrasound. In this procedure, a probe inserted in
the rectum directs sound waves at the prostate. The echo patterns of the sound
waves form an image of the prostate gland on a display screen.
Urine Flow Study
Sometimes the doctor will ask a patient to urinate into a
special device that measures how quickly the urine is flowing. A reduced flow
often suggests BPH.
In this exam, the doctor inserts a small tube through the
opening of the urethra in the penis. This procedure is done after a solution
numbs the inside of the penis so all sensation is lost. The tube, called a
cystoscope, contains a lens and a light system, which help the doctor see the
inside of the urethra and the bladder. This test allows the doctor to determine
the size of the gland and identify the location and degree of the obstruction.
Men who have BPH with symptoms usually need some kind of
treatment at some time. However, a number of recent studies have questioned the
need for early treatment when the gland is just mildly enlarged. These studies
report that early treatment may not be needed because the symptoms of BPH clear
up without treatment in as many as one-third of all mild cases. Instead of
immediate treatment, they suggest regular checkups to watch for early problems.
If the condition begins to pose a danger to the patient's health or causes a
major inconvenience to him, treatment is usually recommended.
Since BPH may cause urinary tract infections, a doctor will
usually clear up any infection with antibiotics before treating the BPH itself.
Although the need for treatment is not usually urgent, doctors generally advise
going ahead with treatment once the problems become bothersome or present a
The following section describes the types of treatment that
are most commonly used for BPH.
Over the years, researchers have tried to find a way to shrink
or at least stop the growth of the prostate without using surgery. The Food and
Drug Administration (FDA) has approved four drugs to relieve common symptoms
associated with an enlarged prostate.
Finasteride, FDA-approved in 1992 (marketed under the name
Proscar), and dutasteride, FDA-approved in 2001 (marketed as Avodart), inhibit
production of the hormone DHT, which is involved with prostate enlargement. The
use of either of these drugs can either prevent progression of growth of the
prostate or actually shrink the prostate in some men.
FDA also approved the drugs terazosin (marketed as Hytrin) in
1993, doxazosin (marketed as Cardura) in 1995, tamsulosin (marketed as Flomax)
in 1997, and alfuzosin (marketed as Uroxatral) in 2003 for the treatment of BPH.
All four drugs act by relaxing the smooth muscle of the prostate and bladder
neck to improve urine flow and to reduce bladder outlet obstruction. The four
drugs belong to the class known as alpha blockers. Terazosin and doxazosin were
developed first to treat high blood pressure. Tamsulosin and alfuzosin were
developed specifically to treat BPH.
NIDDK's Medical Therapy of Prostatic Symptoms (MTOPS) Trial
recently found that using finasteride and doxazosin together is more effective
than either drug alone to relieve symptoms and prevent BPH progression. The
two-drug regimen reduced the risk of BPH progression by 67 percent, compared to
39 percent for doxazosin alone and 34 percent for finasteride alone.
Minimally Invasive Therapy
Because drug treatment is not effective in all cases,
researchers in recent years have developed a number of procedures that relieve
BPH symptoms but are less invasive than conventional surgery.
Transurethral microwave procedures.
In May 1996, FDA approved the Prostatron, a device that uses microwaves to heat
and destroy excess prostate tissue. In the procedure called transurethral
microwave thermotherapy (TUMT), the Prostatron sends computer-regulated
microwaves through a catheter to heat selected portions of the prostate to at
least 111 degrees Fahrenheit. A cooling system protects the urinary tract during
A similar microwave device, the Targis System, received FDA
approval in September 1997. Like the Prostatron, the Targis System delivers
microwaves to destroy selected portions of the prostate and uses a cooling
system to protect the urethra. A heat-sensing device inserted in the rectum
helps monitor the therapy.
Both procedures take about 1 hour and can be performed on an
outpatient basis without general anesthesia. Neither procedure has been reported
to lead to impotence or incontinence.
Although microwave therapy does not cure BPH, it reduces
urinary frequency, urgency, straining, and intermittent flow. It does not
correct the problem of incomplete emptying of the bladder. Ongoing research will
determine any long-term effects of microwave therapy and who might benefit most
from this therapy.
Transurethral needle ablation. In
October 1996, FDA approved Vidamed's minimally invasive Transurethral Needle
Ablation (TUNA) System for the treatment of BPH.
The TUNA System delivers low-level radiofrequency energy
through twin needles to burn away a well-defined region of the enlarged
prostate. Shields protect the urethra from heat damage. The TUNA System improves
urine flow and relieves symptoms with fewer side effects when compared with
transurethral resection of the prostate (TURP). No incontinence or impotence has
Most doctors recommend removal of the enlarged part of the
prostate as the best long-term solution for patients with BPH. With surgery for
BPH, only the enlarged tissue that is pressing against the urethra is removed;
the rest of the inside tissue and the outside capsule are left intact. Surgery
usually relieves the obstruction and incomplete emptying caused by BPH. The
following section describes the types of surgery that are used.
Transurethral surgery. In this
type of surgery, no external incision is needed. After giving anesthesia, the
surgeon reaches the prostate by inserting an instrument through the urethra.
A procedure called TURP (transurethral resection of the
prostate) is used for 90 percent of all prostate surgeries done for BPH. With
TURP, an instrument called a resectoscope is inserted through the penis. The
resectoscope, which is about 12 inches long and 1/2 inch in diameter, contains a
light, valves for controlling irrigating fluid, and an electrical loop that cuts
tissue and seals blood vessels.
During the 90-minute operation, the surgeon uses the
resectoscope's wire loop to remove the obstructing tissue one piece at a time.
The pieces of tissue are carried by the fluid into the bladder and then flushed
out at the end of the operation.
Most doctors suggest using TURP whenever possible.
Transurethral procedures are less traumatic than open forms of surgery and
require a shorter recovery period.
Another surgical procedure is called transurethral incision of
the prostate (TUIP). Instead of removing tissue, as with TURP, this procedure
widens the urethra by making a few small cuts in the bladder neck, where the
urethra joins the bladder, and in the prostate gland itself. Although some
people believe that TUIP gives the same relief as TURP with less risk of side
effects such as retrograde ejaculation, its advantages and long-term side
effects have not been clearly established.
Open surgery. In the few cases
when a transurethral procedure cannot be used, open surgery, which requires an
external incision, may be used. Open surgery is often done when the gland is
greatly enlarged, when there are complicating factors, or when the bladder has
been damaged and needs to be repaired. The location of the enlargement within
the gland and the patient's general health help the surgeon decide which of the
three open procedures to use.
With all the open procedures, anesthesia is given and an
incision is made. Once the surgeon reaches the prostate capsule, he scoops out
the enlarged tissue from inside the gland.
Laser surgery. In March 1996, FDA
approved a surgical procedure that employs side-firing laser fibers and Nd: YAG
lasers to vaporize obstructing prostate tissue. The doctor passes the laser
fiber through the urethra into the prostate using a cystoscope and then delivers
several bursts of energy lasting 30 to 60 seconds. The laser energy destroys
prostate tissue and causes shrinkage. Like TURP, laser surgery requires
anesthesia and a hospital stay. One advantage of laser surgery over TURP is that
laser surgery causes little blood loss. Laser surgery also allows for a quicker
recovery time. But laser surgery may not be effective on larger prostates. The
long-term effectiveness of laser surgery is not known.
National Institutes of Health
Nutritional and Herbal Therapy for
Benign Prostatic Hyperplasia
- The Chinese herbal formula
Lie Xian Yan Wan has anti-inflammatory actions and
helps relieve symptoms of BPH.
- Include Zinc (60 mg a day) to help reduce the size
of the prostate.
- Selenium (200 mcg a day) provides antioxidant
protection of the prostate .
- Essential fatty acids (1,000 to 1,500 IU one to
two times a day)are important for their anti-inflammatory action.
- Beta-sitosterol (Between 60
(20 mg three times a day) and 130 mg a day) helps reduce the symptoms of BPH.
- Amino acids alanine, glutamic acid, and glycine
(200 mg a day of each) also help reduce symptoms of BPH.
- Pumpkin seeds are delicious and can keep the
prostate healthy. One large handful twice daily.
- Saw palmetto (160 mg twice a day) helps reduce
symptoms of BPH.
- Pygeum (100 mg twice a day) helps improve urine
- Nettle ( 120 mg of concentrated root extract twice
a day) has anti-inflammatory action and increases urine flow and volume.
- Boil Fig tea.
- Avoid the following: dairy products, rich foods, fatty
foods, all stimulants such as alcohol, caffeine, and smoking; stress,
tension, sex, and eating meat late in the day.