Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) also known as nodular hyperplasia, benign prostatic hypertrophy (technically a misnomer) or benign enlargement of the prostate (BEP) refers to the increase in size of the prostate in middle-aged and elderly men. To be accurate, the process is one of hyperplasia rather than hypertrophy, but the nomenclature is often interchangeable, even amongst urologists. It is characterized by hyperplasia of prostatic stromal and epithelial cells, resulting in the formation of large, fairly discrete nodules in the periurethral region of the prostate. When sufficiently large, the nodules compress the urethral canal to cause partial, or sometimes virtually complete, obstruction of the urethra which interferes the normal flow of urine. It leads to symptoms of urinary hesitancy, frequent urination, increased risk of urinary tract infections and urinary retention. Although prostate specific antigen levels may be elevated in these patients because of increased organ volume and inflammation due to urinary tract infections, BPH is not considered to be a premalignant lesion. Adenomatous prostatic growth is believed to begin at approximately age 30 years. An estimated 50% of men have histologic evidence of BPH by age 50 years and 75% by age 80 years. In 40-50% of these patients, BPH becomes clinically significant.

Benign prostatic hyperplasia symptoms are classified as obstructive or irritative. Obstructive symptoms include hesitancy, intermittency, incomplete voiding, weak urinary stream, and straining. Irritative symptoms include frequency of urination, which is called nocturia when occurring at night time, and urgency (compelling need to void that can not be deferred). These obstructive and irritative symptoms are evaluated using the International Prostate Symptom Score (IPSS) questionnaire, designed to assess the severity of BPH. BPH can be a progressive disease, especially if left untreated. Incomplete voiding results in stasis of bacteria in the bladder residue and an increased risk of urinary tract infections. Urinary bladder stones, are formed from the crystallisation of salts in the residual urine. Urinary retention, termed acute or chronic, is another form of progression. Acute urinary retention is the inability to void, while in chronic urinary retention the residual urinary volume gradually increases, and the bladder distends. Some patients who suffer from chronic urinary retention may eventually progress to renal failure, a condition termed obstructive uropathy.

Rectal examination (palpation of the prostate through the rectum) may reveal a markedly enlarged prostate, usually affecting the middle lobe. Often, blood tests are performed to rule out prostatic malignancy: elevated prostate specific antigen (PSA) levels needs further investigations such as reinterpretation of PSA results, in terms of PSA density and PSA free percentage, rectal examination and transrectal ultrasonography. These combined measures can provide early cancer detection. Ultrasound examination of the testicles, prostate and kidneys is often performed, again to rule out malignancy and hydronephrosis. Screening and diagnostic procedures for BPH are similar to those used for Prostate Cancer. Some signs to look for include

* Weak urinary stream

* Prolonged emptying of the bladder

* Abdominal straining

* Hesitancy

* Irregular need to urinate

* incomplete bladder emptying

* Post-urination dribble

* Irritation during urination

* Frequent urination

* NocturiaвЂ" need to urinate during the night

* Urgency

* Incontinence-involuntary leakage of urine.

* Bladder pain

* DysuriaвЂ" painful urination

Patients should decrease fluid intake before bedtime, moderate the consumption of alcohol and caffeine-containing products, and follow timed voiding schedules.

Medications Alpha blockers (О±1-adrenergic receptor antagonists) provide symptomatic relief of BPH symptoms. Available drugs include doxazosin, terazosin, alfuzosin and tamsulosin. Older drugs, phenoxybenzamine and prazosin are not recommended for treatment of BPH. Alpha-blockers relax smooth muscle in the prostate and the bladder neck, and decrease the degree of blockage of urine flow. Alpha-blockers may cause ejaculation back into the bladder (retrograde ejaculation).

The 5О±-reductase inhibitors (finasteride and dutasteride) are another treatment option. This medication inhibits 5a-reductase, which in turn inhibits production of DHT, a hormone responsible for enlarging the prostate. When used together with alpha blockers a reduction of BPH progression to acute urinary retention and surgery has been noted in patients with larger prostates.

Though former research indicated the efficacy of Serenoa repens (saw palmetto) fruit extracts in alleviating mild-to-moderate BPH symptoms, a recent double-blind study did not demonstrate any efficacy greater than that of a placebo for moderate-to-severe symptoms. Herbal medicines that have research support in systematic reviews include beta-sitosterol from Hypoxis rooperi (African star grass) and pygeum (extracted from the bark of Prunus africana), while there is less substantial support for the efficacy of Cucurbita pepo (pumpkin) seed and Urtica dioica (stinging nettle) root. At least one double-blind trial has also supported the efficacy of rye flower pollen.

Sildenafil shows some symptomatic relief, suggesting a possible common etiology with erectile dysfunction. Surgery If medical treatment fails, transurethral resection of prostate (TURP) surgery may need to be performed. This involves removing (part of) the prostate through the urethra. There are also a number of new methods for reducing the size of an enlarged prostate, some of which have not been around long enough to fully establish their safety or side effects. These include various methods to destroy or remove part of the excess tissue while trying to avoid damaging what's left. Transurethral electrovaporization of the prostate (TVP), laser TURP, visual laser ablation (VLAP), Transurethral microwave thermotherapy (TUMT), TransUrethral Needle Ablation (TUNA), ethanol injection, and others are studied as alternatives.

Newer techniques involving lasers in urology have emerged in the last 5-10 years, starting with the VLAP technique involving the Nd:YAG laser with contact