TRPROF. LUTFI TUNCUROLOGY, ROBOTIC & LAPAROSCOPIC SURGERY
What is BPH? What are the causes?

Benign Prostate Hyperplasia

Benign Prostate Hyperplasia

Benign prostate hyperplasia is generally seen in older men without any obvious cause. Prostate hyperplasia causes urethral obstruction, which presents itself as bladder outlet obstruction. So, the patients need more force to overcome this resistance and to empty their bladders.

Subsequently, the patients cannot totally empty their bladders and residual urine is seen inside the bladder. Usually, it is seen in men over the age of 50. Actually, in literature, younger patients at the age of 29 are also seen.

What are the signs of prostate diseases?

  • Frequency,
  • Nocturia,
  • Urgency,
  • Urge incontinence,
  • Hesitancy,
  • Strain to void,
  • Intermittent voiding,
  • Post voiding residue,
  • Inability to void

What is Benign Prostate Hyperplasia (BPH)?

Prostate has two important periods of development and growth. In the early periods of adolescence, prostate gland grows by twice in size. At the age of 25, a re-growth is expected for prostate.This second growth may end up with BPH in the following years.

Except for the elderly men, growth of prostate is not expected to be problematic. Actually under the age of 40, it is randomly symptomatic while over the age of 60, 50% of men and over the age of 70s, 90% of men are severely symptomatic.

In time, prostate blocks urethra passing through it and the patient cannot void easily. So, the detrusor muscle of bladder gets thicker and more sensitive as it tries to overcome the outlet obstruction. By the time muscular layer of bladder (detrusor) gets weaker and the patient cannot completely void and residual urine stays inside.

With longer life expectancy and enlarged prostate, more male patients see urologists.

What is the cause of BPH?

The exact cause of BPH is not well-documented yet, because of potential uncertain risk factors. What is known for sure is that old men suffer from BPH while men with a history of orchiectomy (the surgical excision of testicles) never suffer from BPH. Age and testicular function are main factors influencing the development of BPH.

During a man’s lifetime, testicles produce testosterone as the main male hormone while estrogen is also present in rare amounts in his body. With aging, active testosterone levels decrease and estrogen levels increase. Animal studies show that estrogen induces some cell evolutions inside the prostate in the elderly population.

Another theory is relevant to the active state of testosterone called dihydrotestosterone (DHT). Some researchers state that, during aging, testosterone levels decrease while DHT levels inside the prostate increase and accumulate. So, this state of testosterone is thought to induce prostate cell growth. Enzyme deficieny which normally takes place during the conversion of testosterone to DHT supports this theory as BPH does not develop in the presence of enzyme deficiency.

Some researchers also think that chemical and genetic changes during the early evolution period may be responsible for BPH with aging.

What are the signs of BPH?

Social life disturbances such as daytime frequency and nocturia are among the main signs of BPH. Somnolence, fatigue and looking for toilets everywhere are the main problems. Therefore, the calibration of voiding is weaker and problems such as hesitancy and post-voidal dripping may be expected. International prostate symptom score (IPSS) is composed of 7 main questions listed below.

  • How often have you had the sensation of not emptying your bladder?
  • How often have you had to urinate less than every two hours?
  • How often have you found you stopped and started again several times when you urinated?
  • How often have you found it difficult to postpone urination?
  • How often have you had a weak urinary stream?
  • How often have you had to strain to start urination?
  • How many times did you typically get up at night to urinate?

Prostate hyperplasia is actually a benign tumoral growth. Except for social life disturbances, signs are not so significant to lead to another health problem.

Complaints are classified as mild, moderate and severe. Prostate examination, serum tests and prostate needle biopsy can all help in the diagnosis of BPH. Based on the complaints of patients, medical treatment or surgical approaches are recommended.

In the presence of prostate cancer, those complaints listed above are the main signs of advanced stage disease. Surgical approaches regarding the treatment of early stage disease do not bring about any significant prognostic value. Therefore, all men with no symptoms over the age of 50 are recommended to get their prostate examined and get their serum PSA levels checked on a yearly basis (Figure-4).

In the presence of a diagnosed prostate cancer in the first-degree relative (father, brother etc.),annual controls should be performed over the age of 45. Men with a first degree relative with diagnosed prostate cancer have an elevated risk by 2-6 folds.

Diagnostic tools for BPH are as follows:

  • Digital rectal examination
  • Serum PSA (total and free PSA),Creatinine
  • Ultrasonography
  • Prostate biopsy (if needed)
  • Urine flow test -uroflowmetry-
  • Cystoscopy (if needed).

Treatment options?

The first option should be medical treatment. In case of unsatisfactory results from medical treatment or recurrence after a certain period of time, alternative treatments should be considered.

Two main drugs are available. Smooth muscle relaxants such as alpha-blockers with urethral relaxation effect and 5-alpha reductase inhibitors (5-ARI) aimed at controlling the prostate growth may be used.

  • Alpha blockers (Active ingredients; Tamsulosin, Alfuzosin, Terazosin, Doxazosin).
  • 5-alpha reductase inhibitors (Finasteride, Dutasteride).

Alpha-blockers have relaxation effects on bladder neck and prostatic urethral smooth muscle layers. Its effect is valid for about 24 hours. Therefore, daily intake of one tablet is recommended for continuous therapy.

5-ARIs play a role on blocking the transmission of testosterone into active DHT molecule which mainly induces the prostate growth and even decreases the prostate dimensions. Actually, the impact is visible in prostates larger than 50 cc and these drugs need to be used for at least 6 months for shrinkage.

In case of insufficient medical treatment modalities, interventional treatment options should be considered. The best approaches are listed below including their activity levels;

  • Transurethral resection (TUR),with bipolar energy, plasma kinetic energy or monopolar energy
  • Laser vaporisation, CTP, diode, thulium laser
  • Laser enucleation, Holmium laser (HoLEP)

Open or laparoscopic surgery is considered when the size of prostate is over 100-120 cc.

Chronic prostatitis is another well-known disease in young population. Frequency, pain in testicles-groin-anal region, painful ejaculation and dysuria are the main symptoms of chronic prostatitis. If tolerated and succesfully completed, a long-term antibiotic regimen would be the first choice. In the presence of inflammation without any evident ethiological pathogen, longer treatment regimens are needed with anti-inflammatory drugs.

PROF. LUTFI TUNCPROF. LUTFI TUNCUrology, Da Vinci Robotic & Laparoscopic Surgery
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