StatPearls [Internet]. Search term. Affiliations 1 Royal Devon and Exeter Hospital. Continuing Education Activity Benign prostatic hyperplasia BPH is a common condition encountered in aging men and a common cause of lower urinary tract symptoms.
Introduction Benign prostatic hyperplasia BPH refers to the nonmalignant growth or hyperplasia of prostate tissue and is a common cause of lower urinary tract symptoms in men. Etiology The etiology of BPH is influenced by a wide variety of risk factors in addition to direct hormonal effects of testosterone on prostate tissue.
Meta-analysis has demonstrated those with metabolic syndrome and obesity have significantly higher prostate volumes. Obesity has been shown to be associated with increased risk of BPH in observational studies.
Proposed mechanisms include increased levels of systemic inflammation and increased levels of estrogens. Genetic predisposition to BPH has been demonstrated in cohort studies, first-degree relatives in one study demonstrated a four-fold increase in the risk of BPH compared to control. Epidemiology Differences in case definitions make interpretation of population-based studies regarding BPH difficult. Pathophysiology Both the development of lower urinary tract symptoms and bladder outlet obstruction in men with BPH can be attributable to static and dynamic components.
Histopathology Histological examination demonstrates that BPH is a hyperplastic process with an increase in cell number on histology hyperplasia ; these occur both in the periurethral and transition zones. History and Physical History In the elective setting, a focused medical history should include all aspects of symptomatology, and this includes onset, timing, exacerbating, and relieving factors. Further bedside evaluation includes Urine dipstick rule out other causes such as infection.
Evaluation Standard investigation of BPH may include bedside urine dipstick, post-void residual, IPSS, and urine flow studies to establish if there is evidence of obstructive voiding.
Urinalysis Urine specimen testing can help detect infection, non-visible haematuria, or metabolic disorders glycosuria.
Ultrasound Ultrasound scans are used to look for evidence of hydronephrosis and are indicated in patients with high residual volumes or renal impairment. Flow Studies Urine flow studies are used to determine the volume of urine passed over time. Observation Watchful waiting is a process to manage patients by giving lifestyle advice.
Alpha-blockers: Alpha 1-adrenoreceptors are present on prostate stromal smooth muscle and bladder neck. Complications Common Complications Urinary retention. Long-term catheter complications blocked catheters, retention, haematuria, urinary tract infection. Deterrence and Patient Education Lifestyle factors such as weight loss or improved diabetic control should be explained to the patient to allow modifiable risk factors to be addressed.
Review Questions Access free multiple choice questions on this topic. Comment on this article. Figure CT of pelvis showing multiple bladder stones in 65 year old male with benign prostatic hyperplasia. References 1. Roehrborn CG. Benign prostatic hyperplasia: an overview. Rev Urol. Abrams P. Silverman WM. J Am Osteopath Assoc. New words for old: lower urinary tract symptoms for "prostatism".
Pathology of benign prostatic hyperplasia. Int J Impot Res. Parsons JK. Curr Bladder Dysfunct Rep. Benign prostatic hyperplasia. Nat Rev Dis Primers. Foster CS. Prostate Suppl. Isaacs JT. Antagonistic effect of androgen on prostatic cell death.
Metabolic syndrome and benign prostatic enlargement: a systematic review and meta-analysis. BJU Int. Int J Obes Lond. Golbidi S, Laher I. Bladder dysfunction in diabetes mellitus. Front Pharmacol.
J Urol. Metabolic factors associated with benign prostatic hyperplasia. J Clin Endocrinol Metab. Increased oxidative stress in obesity and its impact on metabolic syndrome.
J Clin Invest. The correlation between metabolic syndrome and prostatic diseases. Eur Urol. Genetic susceptibility of benign prostatic hyperplasia. Heritability of the symptoms of benign prostatic hyperplasia and the roles of age and zonal prostate volumes in twins.
Concordance rates and modifiable risk factors for lower urinary tract symptoms in twins. The development of human benign prostatic hyperplasia with age. Incidence and progression of lower urinary tract symptoms in a large prospective cohort of United States men. Prostate volume changes over time: results from the Baltimore Longitudinal Study of Aging.
Urologic diseases in America project: benign prostatic hyperplasia. Prevalence of lower urinary tract symptoms and effect on quality of life in a racially and ethnically diverse random sample: the Boston Area Community Health BACH Survey. Arch Intern Med. Trends in aging--United States and worldwide. Ethnicity and migration as determinants of human prostate size. Natural history of lower urinary tract symptoms: preliminary report from a community-based Indian study. Caine M.
The present role of alpha-adrenergic blockers in the treatment of benign prostatic hypertrophy. Foo KT. Pathophysiology of clinical benign prostatic hyperplasia. Asian J Urol. Lepor H. Pathophysiology of benign prostatic hyperplasia in the aging male population. Significant decrease of extracellular matrix in prostatic urethra of patients with benign prostatic hyperplasia. Histol Histopathol. McNeal J. Insight into etiology. Urol Clin North Am. Serum prostate-specific antigen as a predictor of prostate volume in the community: the Krimpen study.
Longitudinal study of men with mild symptoms of bladder outlet obstruction treated with watchful waiting for four years. The effect of finasteride in men with benign prostatic hyperplasia. The Finasteride Study Group.
N Engl J Med. Benign prostatic hyperplasia as a progressive disease: a guide to the risk factors and options for medical management.
Int J Clin Pract. Identifying the role of luteinizing hormone releasing hormone LHRH in regulating sex hormone in men and women was a landmark research that led to the development of LHRH agonists. Parallel developments in surgery, medical instrumentation, and radiation science also served as successful treatment for BPH. The aim of treatment of BPH is to improve symptoms, relief obstruction, improve bladder emptying, prevent UTIs, and avoid renal insult. The biological basis of androgen ablation therapy lies in the observation that the embryonic development of the prostate is dependent on the androgen dihydrotestosterone DHT [ Figure 4 ].
Furthermore, castration in men before puberty resulted into regression of prostatic enlargement. Suppression of sex steroid production on the basis of desensitization and down regulation of pituitary gonadotropin releasing hormone GnRH receptor by agonistic GnRH analogues[ 14 ] nafarelin acetate, leuprolide resulting in the blockage of gonadotropin release from the anterior pituitary gland is a well-established approach in the treatment of BPH.
Several lines of evidence indicate the role of estrogen along with androgen in BPH. Estrogens are mainly produced in men by aromatase activity by the peripheral conversion of testicular and adrenal androgen into estradiol. The estrogenic effect presumably includes its stromal and epithelial interaction that regulates the proliferative activity of the prostate and alteration in the sensitivity of the prostate toward androgens.
Though the androgen deprivation therapy has proved to be an effective treatment, their use was restricted because of associated side effects such as erectile dysfunction and loss of libido. However, excessive production of DHT is the cause of major androgen- related disorders such as prostate cancer, acne, female hirsutism, and BPH. These agents suppress the DHT concentration by blocking the enzyme, resulting in shrinkage in the size of prostate, increased peak urinary flow rates, and ultimately providing relief from the symptoms related to the static mechanical obstruction caused by BPH.
The most commonly reported side effects on finasteride long-term usage are decreased libido, ejaculatory dysfunction, or impotence, while some of the patients showed rashes and breast enlargement. At clinical dose of 0. Dutasteride was found to improve urinary flow rate, decrease the risk of AUR and need for surgery by reducing the size of enlarged prostate. The adverse effects related to prazosin were postural hypotension along with stuffy nose, headache, and retrograde ejaculation on continuous use for a long period.
The clinical efficacy and safety of terazosin and doxazosin documented in several studies have shown that terazosin therapy does not affect blood pressure control in patients receiving concurrent antihypertensive medication, whereas mild to moderate adverse events like fatigue dizziness has been observed with doxazosin.
The Veterans Affairs Cooperative Study and Prospective European Doxazosin and Combination therapy evaluated the combination of finasteride with terazosin and doxazosin, respectively, for one year. These trials were subsequently followed by Medical therapy for Prostate Symptoms, wherein combination of finasteride and doxazosin was studied over a period of 4.
It was found that risk of AUR and need for BPH-related surgery were significantly lower in finasteride and combination therapy versus placebo, whereas none of these outcomes was reduced significantly with doxazosin alone.
It would be a major step in assessing the combination therapy and the findings will assist in making treatment decision. The use of plant-derived nonnutritive compounds with protective or disease-preventive properties for urinary symptoms with BPH has gained widespread interest, probably due to perceived reduction in side effects, and desire to maintain control over their treatment. Moreover, the active ingredients and dosage of active medication is unknown, quality is not publicly controlled, and mechanism of action is not clear.
Saw Palmetto, extract of the berries of the dwarf palm tree of S. Various additional mechanisms have also been suggested, including inhibition of binding of DHT to cytosolic androgen receptors in prostate cells and anti-inflammatory effect. However, it has no effect on prostate volume or the prostate-specific antigen test, but slightly decreases the prostate epithelium. It does not cause impotence, but the herb may aggravate chronic gastrointestinal disease such as peptic ulcer.
NX has been recently announced as new treatment for the BPH. This novel drug, developed by Nymox, is currently under Phase 3 clinical trial.
It has been reported that men treated with single dose 2. In addition, there were no sexual- or blood pressure-related side effects. Surgical interventions are considered in case of severe symptoms and complications like urinary retention, renal failure and infection that are weighed carefully against the risk and benefits of the various treatment options.
The gold standard for the surgical treatment was removal of obstructing tissue by open prostatectomy[ 56 ] in early s, which is now replaced by transurethral resection of prostate TURP. TURP is the hallmark of the urologist, the one against which other therapeutic measures are compared. It takes 20 to 30 minutes to resect an average gland weighing 30 g and carry the risks for complications like bleeding, infections, retrograde-ejaculation and low semen, low PSA level, and hospital stay including impotence and incontinence.
Over the last few years, number of MIT has been established to achieve substantial improvement in the symptoms attributed to BPH. These MIT utilizes endoscopic approach to ablate the obstructing prostatic tissue. Long-term efficiency is comparable with TURP, but number of patients has been found to experience irritative side effects.
It is a simple and relatively inexpensive procedure which utilizes needle to deliver high-frequency radio waves to destroy the enlarged prostatic tissue. TUNA is a successful treatment for small-sized gland and it poses a low or no risk for incontinence and impotence. Laser prostatectomy has become an increasingly widespread form of MIT. It has been found to be safe and effective technique, with significant improvement in urinary flow rates and symptoms.
Short operative time, minimal blood loss and fluid absorption, decreased hospital stay, impotence rates, and bladder neck contractures are few of the advantages of laser prostatectomy over the TURP and other conventional techniques.
Significant increase in uroflow and a decrease in postvoid residual volume have been observed, but the cost is three times higher than that of TURP. Transurethral injection of absolute ethanol into the lateral lobes of prostate produces necrotic effect on prostatic tissues, leading to fibrosis and shrinkage.
Significant improvement has been reported in AUA symptoms score. Continual research is going on to dilute negative factors like urinary retention, pain, dysuria, and prolonged period of catheterization with the aim to deliver safe, effective, and economical potential treatment. Gyrus is a new technique under development and vaporizes the obstructing tissue by using plasma energy in a saline environment. Procedure has been found to be safe and effective with minimal risk of water intoxication TURP syndrome and generally reserved for patients on high risk.
BPH is the nonmalignant enlargement of the prostate gland and a common cause of voiding dysfunction in men. The primary goal of the treatment is not only to improve urinary flow and reduce symptoms scores, but also to prevent serious complications and improve quality of life. Selection of therapy depends on a number of factors like history, severity of symptoms, procedural complications, and associated side effects. Watchful waiting is more appropriate for men with mild symptoms.
Clinical efficacy of these agents has been further improved by using combination therapy; however, long-term outcomes of this study are still awaited. Traditional surgical treatment has been reported by TURP and minimally invasive techniques like hyperthermia and lasers.
Current research is multimodal; many more potential new therapies with combination of old and new approaches are under development that may improve the treatment outcome. National Center for Biotechnology Information , U.
Journal List Indian J Pharmacol v. Indian J Pharmacol. Neelima Dhingra and Deepak Bhagwat 1. Author information Article notes Copyright and License information Disclaimer. Correspondence to: Dr. Neelima Dhingra E-mail: ni. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
This article has been cited by other articles in PMC. Introduction Benign prostatic hyperplasia BPH is the nonmalignant enlargement of the prostate gland. Open in a separate window. Figure 1. Treatment options A more profound knowledge of the pathogenesis, the natural history, and risk of the progression enabled more differentiated therapy of elderly men with BPH.
Figure 2. A schematic presentation of management of benign prostatic hypertrophy. Summary: Holmium laser enucleation of the prostate is a more efficient procedure than competitor techniques, when grams of tissue removed per unit time are quantified. Additionally, holmium laser enucleation of the prostate is associated with a reduced length of catheterization and hospitalization when compared with other surgical therapies for men with benign prostatic hyperplasia.
Outcome measures for men undergoing holmium laser enucleation of the prostate are in many cases superior to those of other modalities. It is likely that the completeness of adenoma removal with holmium laser enucleation of the prostate confers many of these advantages.
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