Definition

A non-cancerous condition that affects many men
past 50 years of age, enlarged prostate makes urinating
more difficult by narrowing the urethra, a tube running
from the bladder through the prostate gland. It can be
effectively treated by surgery and, today, by certain
drugs.

Description

The common term for enlarged prostate is BPH,
which stands for benign (non-cancerous) prostatic
hyperplasia or hypertrophy. Hyperplasia means that the
prostate cells are dividing too rapidly, increasing the
total number of cells, and, therefore, the size of the
organ itself. Hypertrophy simply means “enlargement.”
BPH is part of the aging process. The actual changes in
the prostate may start as early as the 30s but take place
very gradually, so that significant enlargement and
symptoms usually do not appear until after age 50. Past
this age the chances of the prostate enlarging and causing
urinary symptoms become progressively greater.

More than 40% of men in their 70s have an enlarged
prostate. Symptoms generally appear between ages
55–75. About 10% of all men eventually will require
treatment for BPH.

BPH has been viewed as a rare condition in African,
Chinese and other Asian peoples for reasons that are not
clear.

Causes and symptoms

The cause of BPH is a mystery, but age-related
changes in the levels of hormones circulating in the
blood may be a factor. Whatever the cause, an enlarging
prostate gradually narrows the urethra and obstructs the
flow of urine. Even though the muscle in the bladder wall
becomes stronger in an attempt to push urine through the
smaller urethra, in time, the bladder fails to empty completely
at each urination. The urine that collects in the
bladder can become infected and lead to stone formation.
The kidneys themselves may be damaged by infection or
by urine constantly “backing up.”

When the enlarging prostate gland narrows the urethra,
a man will have increasing trouble starting the urine
stream. Because some urine remains behind in the bladder,
he will have to urinate more often, perhaps two or
three times at night (nocturia). The need to urinate can
become very urgent and, in time, urine may dribble out
to stain a man’s clothing. Other symptoms of BPH are a
weak and sometimes a split stream and general aching or
pain in the perineum (the area between the scrotum and
anus). Some men may have considerable enlargement of
the prostate before even mild symptoms develop.
If a man must strain hard to force out the urine,
small veins in the bladder wall and urethra may rupture,
causing blood to appear in the urine. If the urinary stream
becomes totally blocked, the urine collecting in the bladder
may cause severe discomfort, a condition called
acute urinary retention. Urine that stagnates in the bladder
can easily become infected. A burning feeling during
urination and fever are clues that infection may have
developed. Finally, if urine backs up long enough it may
increase pressure in the kidneys, though this rarely causes
permanent kidney damage.

Diagnosis

When a man’s symptoms point to BPH, the first
thing the physician will want to do is a digital rectal
examination, inserting a finger into the anus to feel
whether—and how much—the prostate is enlarged. A
smooth prostate surface suggests BPH, whereas a distinct
lump in the gland might mean prostate cancer.

The next step is a blood test for a substance called
prostate-specific antigen or PSA. Between 30–50% of
men with BPH have an elevated PSA level. This does
not mean cancer by any means, but other measures
are needed to make sure that the prostate enlargement
is in fact benign. An ultrasound exam of the prostate,
which is entirely safe and delivers no radiation, can
show whether it is enlarged and may show that cancer
is present.

If digital or ultrasound examination of the prostate
raises the suspicion of cancer, most urologists will recommend
that a prostatic tissue biopsy be performed. This
is usually done using a lance-like instrument that is
inserted into the rectum. It pierces the rectal wall and,
guided by the physcian’s finger, obtains six to eight
pieces of prostatic tissue that are sent to the laboratory
for microscopic examination. If cancer is present, the
prognosis and treatment are changed accordingly.
A catheter placed through the urethra and into the
bladder can show how much urine remains in the bladder
after the patient urinates—a measure of how severe the
obstruction is. Another and very simple test for obstruction
is to have the man urinate into a uroflowmeter,
which measures the rate of urine flow. A very certain—
though invasive—way of confirming obstruction from an
enlarged prostate is to pass a special viewing instrument
called a cystoscope into the bladder, but this is not often
necessary.

It is routine to check a urine sample for an increased
number of white blood cells, which may mean there is
infection of the bladder or kidneys. The same sample
may be cultured to show what type of bacterium is causing
the infection, and which antibiotics will work best.

The state of the kidneys may be checked in two ways:
imaging by either ultrasound or injecting a dye (the intra-
venous urogram, or pyelogram); or a blood test for creatinine,
which collects in the blood when the kidneys cannot
eliminate it.

Prevention

Whether or not BPH is caused by hormonal changes
in aging men, there is no known way of preventing it.
Once it does develop and symptoms are present that
interfere seriously with the patient’s life, timely medical
or surgical treatment will reliably prevent symptoms
from getting worse. Also, if the condition is treated
before the prostate has become grossly enlarged, the risk
of complications is minimal. One of the potentially most
serious complications of BPH, urinary infection (and
possible infection of the kidneys), can be prevented by
using a catheter to drain excess urine out of the bladder
so that it does not collect, stagnate, and become infected.