Benign prostatic hyperplasia (BPH)

The cause of BPH is unknown, but it’s believed to be linked to hormonal changes as a man gets older.

The balance of hormones in your body changes as you get older, and this may cause your prostate gland to grow.

Other causes of an enlarged prostate include:

• prostatitis (inflammation of the prostate)
• prostate cancer

Prostate cancer:

Whilst prostate cancer is unrelated to BPH, the symptoms of prostate cancer can be difficult to distinguish from those of prostate enlargement. They may include:

• needing to pee more frequently, often during the night
• needing to rush to the toilet
• difficulty in starting to pee (hesitancy)
• straining or taking a long time while peeing
• weak flow
• feeling that your bladder has not fully emptied
• blood in urine or blood in semen

You should consult your GP if you have these symptoms. Whilst it’s much more likely to be benign prostate enlargement, it’s important to rule out cancer.

BPH can usually be diagnosed by your GP from the symptom history, physical examination and a few basic tests.

A prostate examination is performed by inserting a gloved finger into the back passage. This allows your doctor to feel the prostate gland and will give an indication of the size of the prostate and whether it feels normal/healthy.

The most common tests performed include:

• A urine dipstick test for infection, sugar (glucose) and blood (a urine sample may also be sent to the hospital to confirm the dipstick findings).
• A blood test for glucose to rule out diabetes.
• Depending upon the examination findings, a PSA test may be suggested (see below).

Depending upon the severity of your symptoms, you may be referred to have an ultrasound scan on your bladder and urinary tract.

You may also be referred to a specialist nurse or consultant (urologist) for tests on your urinary system (urodynamic tests). Urodynamic studies test the working of the bladder and are used to see how the urinary system and pelvic floor work. You may be asked to keep a diary. In your diary make a note of the times you pass urine and the amount (volume) that you pass each time. Also, make a note of the times you leak urine (are incontinent).

Prostatic Specific Antigen (PSA):

The PSA test is a blood test to help detect prostate cancer but it’s not perfect and will not find all prostate cancers. The test, which can be done at a GP surgery, measures the level of prostate-specific antigen (PSA) in your blood. PSA is a protein made only by the prostate gland. Some of it leaks into your blood, but how much depends on your age and the health of your prostate. There is currently no national screening programme for prostate cancer in the UK because the PSA test is not always accurate.

Before deciding to have the PSA test, you should talk to a GP or practice nurse, as well as your partner.

You have a higher risk of prostate cancer if you:

• have a family history of prostate cancer
• are of black ethnic origin
• are overweight or obese

The treatment for an enlarged prostate gland will depend on how badly the symptoms are affecting your qualify of life.

The main treatments are:

• lifestyle changes
• medicine
• catheters
• surgery and other procedures

Selfcare and lifestyle changes

Lifestyle changes may help with your symptoms, these include:

• Drinking less alcohol, caffeine, artificial sweeteners and fizzy drinks. Fizzy drinks and drinks that contain alcohol, caffeine (such as tea, coffee or cola) and artificial sweeteners can irritate the bladder and make urinary symptoms worse.
• Exercising regularly
• Drinking less fluid in the evening. Try to reduce the amount of fluid you drink in the evening and avoid drinking anything for 2 hours before you go to bed. This might help you avoid getting up in the night. Make sure you’re still drinking enough fluid earlier in the day.
• Remembering to empty your bladder. Remember to go to the toilet before long journeys or when you know you will not be able to reach a toilet easily.
• Double voiding. Double voiding involves waiting a few moments after you have finished peeing before trying to go again. It can help you empty your bladder properly. But take care not to strain or push.
• Eating more fibre. Eating more fibre (which is found in fruit, vegetables and wholegrain cereals) can help you avoid constipation, which can put pressure on your bladder and make the symptoms of an enlarged prostate worse.
• Bladder training. Bladder training is an exercise programme that aims to help you last longer without peeing and hold more pee in your bladder. It employs a target, such as waiting at least 2 hours between each time you pee. It’s a good idea to use a bladder training chart to record each time you pass urine and the volume of urine passed. You can download a bladder training chart (PDF, 115KB) from Bladder Matters. You’ll need a plastic jug to measure this.
• Using pads or a sheath. Absorbent pads and pants can be worn inside your underwear or may replace your underwear altogether. These will soak up any leaks. Urinary sheaths can also help with dribbling. They look like condoms with a tube coming out of the end. The tube connects to a bag that you can strap to your leg under your clothing (these are usually available through your district nurse in the first instance).
• Checking your medicines. Check with your pharmacist or doctor whether any medicines you take, such as antidepressants or decongestants, might be making your urinary symptoms worse.

Medication

Medicine (tablets) to reduce the size of the prostate and relax your bladder may be recommended to treat moderate to severe symptoms of an enlarged prostate.

• Alpha-blockers

Alpha blockers relax the muscle in your prostate gland and at the base of your bladder, making it easier to pee. Commonly used alpha- blockers are tamsulosin and alfuzosin.

• Anticholinergics

Anticholinergics relax the bladder muscle if it’s overactive.

• 5-alpha reductase inhibitors

5-alpha reductase inhibitors shrink the prostate gland if it’s enlarged. It is important to realise that it can take up to 6 months for these medications to take full effect. Finasteride and dutasteride are the two 5-alpha reductase inhibitors available.

• Diuretics

Diuretics speed up urine production. If taken during the day, they reduce the amount of urine you produce during the night.

• Desmopressins

Desmopressins slow down urine production so less urine is produced at night.

• Botulinum toxin

The use of botulinum toxin involves a specialist procedure in which botulinum toxin is injected into the walls of your bladder. It may help men whose bladder muscle contracts before the bladder is full.

Alternative treatments

Your doctor should not offer you homeopathy, herbal treatments or acupuncture to treat urinary symptoms. This is because there is not enough reliable evidence about how well they work or how safe they are.

• Saw Palmetto:

Whilst saw palmetto is promoted as an over the counter (non-prescription) dietary supplement for urinary symptoms associated with BPH, two large, high-quality studies funded by the National Institutes of Health (NIH), each using a different preparation of saw palmetto, found it was no more effective than a placebo (an inactive substance) for BPH symptoms.

Saw palmetto products are made in a variety of ways and differ in composition. Some studies of saw palmetto products other than those used in the NIH-sponsored studies have suggested that they might be helpful for BPH symptoms, but many of these studies were of low quality. No saw palmetto product has been conclusively shown to be effective for BPH.

There isn’t enough research on saw palmetto for conditions other than BPH to allow any conclusions to be reached.

• Catheters

Due to BPH restricting urinary outflow from the bladder, it can lead to incomplete emptying of the bladder with a portion of urine left behind (a “residual”). This is known as chronic urinary retention and can result in a number of problems including urinary infection and acute urinary retention. Acute urinary retention occurs when the outflow from the bladder is obstructed completely, preventing urination completely.

Acute urinary retention is treated by using a urinary catheter. A urinary catheter is a soft tube that carries urine out of the body from the bladder. It can be passed through your penis, or through a small hole made in your tummy, above your pubic bone (“suprapubic catheter”) and can prevent/treat urinary retention.

Urinary catheters may be sited temporarily (for example, to alleviate acute urinary retention) for a few weeks, or as a long-term solution when surgery is not appropriate (“indwelling catheter”).

• Surgery

Most men with urinary symptoms do not need to have surgery, but it may be an option if other treatments have not worked. Your specialist will advise you about appropriate surgical options if required.

• Transurethral resection of the prostate (TURP)

TURP involves removing part of the prostate gland using a device called a resectoscope that’s passed through the urethra (the tube through which urine passes out of the body). It’s suitable for men who have an enlarged prostate.

• Open prostatectomy

During an open prostatectomy, the prostate gland is removed through a cut in your body. It’s suitable for men who have an enlarged prostate over a certain size.

• Holmium Laser Enucleation

Holmium Laser Enucleation of the Prostate (HoLEP) uses a laser to destroy sections of the prostate which are passed into the bladder and then fragmented before removal via the urethra. HoLEP can be performed on patients with large prostates that would otherwise have to be treated with an open prostatectomy.

• Urolift (Prostatic urethral lift implants)

A prostatic urethral lift is performed using adjustable, permanent implants to pull excess prostatic tissue away from the urethra to stop it narrowing or blocking it. The Urolift procedure can be conducted as a day case procedure.

• GreenLight XPS

This treatment uses a 180 watt GreenLight XPS laser which operates at a wavelength which is absorbed by oxyhaemoglobin in blood and tissue, causing tissue vaporisation.

• Prostate artery embolisation

A catheter is inserted into an artery in your groin or wrist. Using X‑ray guidance, it’s passed into the blood vessels that supply the prostate gland. Tiny plastic particles are injected into these vessels to reduce the prostate gland’s blood supply, which shrinks it.

N.B. Aquablation (transurethral water jet ablation) and Rezum (steam) treatments are not currently commissioned in Devon.