Benign prostatic enlargement (BPE) refers to the normal enlargement of the prostate gland that occurs in men, with aging. It is one of the most common conditions to affect middle aged and older men.
The prostate is one of the glands of the male reproductive system. It is positioned underneath the bladder and encircles the urethra. The urethra is the tube that leads urine out of the bladder and through the penis. The prostate gland in adults remains a constant size until approximately age 40, when it begins to enlarge. The cause of the enlargement is unknown. However, it seems that the male hormone, testosterone, is in some way responsible. By the age of 80, it is estimated that approximately three quarters of all men will have BPE. Although, BPE does not produce trouble in all men, 1 out of 4 men usually require treatment.
The enlarged prostate causes trouble when it blocks the flow of urine out of the bladder. As the prostate enlarges, it compresses the urethra. The bladder then has to work harder to overcome this increased resistance to urine flow. If the blockage is severe enough, the bladder may be unable to empty, leading to a condition called urinary retention.
The onset of symptoms of BPE can be very gradual. Symptoms can include difficulty starting the flow of urine, decreased force of urination, and dribbling at the end of urination. There may be incomplete emptying of the bladder, which produces a sense of still feeling full even after attempting to pass the urine. Incomplete bladder emptying also leads to "double voiding" in which a man passes the urine and then has to urinate again within a period of 10 to 20 minutes.
As BPE progresses, other symptoms include the need to pass urine more frequently than normal and the development of a sense of urgency, which is the need to pass the urine as soon as the urge is felt. One of the most common symptoms of BPH is being awakened from sleep to urinate, called nocturia.
The diagnosis of BPE is made in a variety of ways. The most important is careful physical examination of the prostate by the physician. This is done by inserting a gloved finger into the rectum to palpate the surface of the prostate.
A blood test to measure PSA, prostate specific antigen, is done to determine if prostate cancer may be present.
Other tests may include a urinary flow study, (a test to measure the rate and force of urine flow), a bladder sonogram to check post void residual (the amount of urine left behind in the bladder after voiding) or cystoscopy. Cystoscopy is a study in which a physician can directly inspect the prostate and bladder with the use of a fiberoptic catheter.
Not all enlargement needs treatment. There are several indications for treatment of BPE. One of the foremost is urinary retention, which is the inability of the bladder to empty any urine. Another reason for intervention is when the enlarged prostate impairs drainage of urine out of the bladder and there is a large post-void residual. This residual urine can block the drainage of the kidneys and lead to inadequate kidney function. A bladder sonogram or scan is done to make sure the residual is not too high. Severe bleeding or recurrent urinary tract infections are also symptoms, which indicate the need for intervention. By far the most common indication for treatment is when difficulty with urination becomes so troublesome that the patient needs some relief.
There are varieties of ways to manage BPE. One of the most common is to "wait and watch". If the symptoms are not particularly troublesome and if there is no impending danger of damage to the urinary tract, no intervention may be necessary. Often the symptoms progress only very gradually over time. Regular follow up exams at 6-12 month intervals are recommended.
When intervention is necessary, it may be possible to manage BPE with medication. One type of pill is designed to reduce the size of the prostate. Avodart ®, a 5mg tablet taken once daily on an ongoing basis reduces the level of a derivative of testosterone that appears to contribute to prostate enlargement. Prostate size reduces somewhat in most men. However, in general, treatment with Avodart ® has not had much success in reducing urinary symptoms. It has been shown that only prostates that are larger than 40 grams in weight benefit from this therapy.
Another type of medication, called an alpha-blocker, is designed to release the "grip" of the prostate around the urethra. Xatral ® and Cardura ® are the most commonly used alpha-blockers for treating BPE. They reduce the constriction around the urethra caused by the prostate. Many patients notice an immediate improvement in symptoms. Side effects can include low blood pressure, dizziness, tiredness and nasal congestion.
When drug therapy does not work, invasive intervention is required. The current choices of intervention include transurethral resection of the prostate with laser (for prostate gland of below 70 grams) and transurethral enucleation of the prostate with laser (for prostate gland of above 70 grams).