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Comprehensive Guide

What is BPH?

BPH stands for benign prostatic hyperplasia. It's an overgrowth of the cells in the prostate gland, which then becomes enlarged. Benign means that it's not malignant, i.e. it's not cancer, and it won't spread to other parts of your body.

The prostate gland (or, simply, prostate) is a chestnut-shaped organ found just underneath the bladder in men. It's normally about 4cm wide and 3cm thick (approximately 1.5" by 1").13

It produces a milky fluid, which, together with sperm and other secretions, makes up semen. Women don't have a prostate.

The urethra is the tube that carries urine from the bladder out through the penis and runs through the middle of the prostate. As the prostate gets bigger, it starts to obstruct the urethra. This is what causes the symptoms of BPH.

How common is it?

BPH is very common. Young men aren't often affected but, overall, one in four (25%) men over the age of 40 can expect to suffer from it as they get older.14

What are the symptoms of BPH and what causes them?

The symptoms of BPH are called 'lower urinary tract symptoms' (LUTS) because they affect the lower urinary tract (the bladder and urethra).

Symptoms of BPH happen because the prostate presses on the urethra (the tube that carries urine), causing it to narrow. This means that urine can't pass down it as easily as before - it's obstructed. This is why some symptoms are called 'obstructive symptoms'. The following are typical obstructive symptoms:15

• Finding it difficult to start peeing (known as 'hesitancy')
• Stopping and starting during a pee ('intermittent stream')
• Having to push to get the pee out ('straining')
• Having a weak, dribbly flow of pee ('weak stream')
• Dribbling once you've finished a pee ('terminal dribbling')
• Never feeling that you've completely emptied your bladder ('incomplete voiding')

When you have obstructive symptoms, the bladder has to work to push the pee out. After a while, the muscle of the bladder wall starts to thicken because of the extra work it's been doing. This means it becomes less stretchy, so the bladder can't hold as much pee. That's why you have to go more often, including at night, and why you often can't hold on when you need to go. These are called 'irritative symptoms'.

The following are typical irritative symptoms:

• Needing to pee often ('frequency')
• Needing to pee urgently ('urgency')
• Needing to pee at night, sometimes many times ('nocturia')
• Not being able to hold on when you need a pee ('urge incontinence')

It's often these symptoms that are most bothersome and cause the most disruption to daily life.

What impact can BPH have?

Many men find that BPH really affects their enjoyment of life. For example, you might feel tired all the time because you can't get a decent night's sleep. You might feel anxious and embarrassed at social gatherings because you keep having to disappear to the loo. Maybe you always have to think about what you're drinking and when - one more drink before the journey home might mean you can't make it back without stopping for a pee.

Outings and car journeys can be frustrating, especially if you have to map out every public convenience to reassure yourself you won't be caught short. BPH can affect your relationship with your partner too. Does she get annoyed with your toilet habits? Maybe you're disturbing her sleep, which might even lead to you sleeping in separate bedrooms.

If this sounds like you, you're certainly not alone. Research among BPH sufferers has shown that 59% of men avoid drinking before bedtime, 41% of men plan their day around toilet stops and 31% of men avoid travelling long distances.16

Sex and BPH

It's not inevitable, but some men with BPH also have problems with sex (called sexual dysfunction or erectile dysfunction). Because the prostate plays a role in sexual function, prostate problems and LUTS may cause you to experience difficulties. The worse your urinary symptoms are, the poorer the erection quality can be.17

Doctors don't know why these problems occur. It may just be that the likelihood of having both sexual dysfunction and BPH increases with age. Or it could simply be because you're tired from having to get up several times at night to pee. All sorts of things can cause erectile problems, some of which (eg. heart disease and diabetes) increase with age. Other possible causes include:

• Alcohol, smoking and illegal drugs
• Some medicines, including anti-depressants and drugs for high blood pressure (such as ACE inhibitors and beta-blockers)
• Conditions affecting nerves or blood supply, including multiple sclerosis or a stroke
• Hormonal conditions, eg. too little testosterone in your body
• Conditions affecting the erectile tissue in the penis, such as prostate cancer
• Long-term conditions such as diabetes, kidney or liver failure

It's really important that you seek advice from a healthcare professional if you experience any serious or ongoing symptoms, such as problems with your peeing habits to ensure that you can get treatment, as well as identifying any underlying cause.

How do I know if I have BPH?

Lower urinary tract symptoms are a sign of BPH. You can assess and track how severe your symptoms are using the International Prostate Symptom Score (IPSS) or assess how they affect your life by keeping a diary. If you have any concerns or think you might have BPH, speak to a healthcare professional.

Can the symptoms of BPH be caused by anything else?

If you are suffering from urinary symptoms, you should talk to your doctor who will be able to determine if they are due to BPH and not another condition.

Other conditions or treatments can cause similar symptoms to BPH18:

• A urinary tract infection or some sexually transmitted infections (STI) can make you need to pee more often or feel pain when you pee. If you have an STI, there may also be some discharge from the penis. Common STIs include gonorrhoea and chlamydia. Other, nonsexually transmitted infections can also cause urinary symptoms. Infections can be treated with antibiotics.
• Certain medicines, including some antidepressants, antihistamines (eg. for hay fever) and decongestants, can cause urine retention, where you can't pee. Talk to a healthcare professional about the side-effects of any medicines you're taking, and make sure you read the leaflet that comes with the medicine.
• The urethra can become narrowed even without obstruction by the prostate, leading to a weak urine flow and dribbling.
• Diabetes can make you need to pee more often, because the body needs to get rid of excess sugar.
• Advanced prostate cancer can often cause similar symptoms to BPH. Although early prostate cancer generally has no symptoms19, early diagnosis will help to ensure you have a much better chance of successful treatment.
• Bladder or bowel cancer may cause lumps in the abdomen that can press on the urethra and lead to obstructive symptoms (weak flow, dribbling, etc).
• Penis problems, such as phimosis, where the foreskin is tight and can't be pulled back from the glans of the penis, can cause problems when you pee. There may be a poor stream of urine that sprays in different directions.
• Heart failure can make you need to pee at night.
• Problems with the nerve supply to the bladder can lead to incontinence, where you can't get to the loo in time, or problems emptying the bladder fully.

What will happen if I tell my doctor I think I have BPH?

There is no single test to diagnose BPH. Your GP will want to rule out other conditions that can cause similar symptoms, by listening to you talk about your symptoms and doing a physical examination.

He or she might go through the International Prostate Symptom Score (IPSS) with you to find out how severe your symptoms are. Lower urinary tract symptoms (LUTS) can be graded as mild, moderate, or severe. The IPSS also indicates how much your life is being disrupted by the symptoms and may help you decide on treatment. You can find out how effective a treatment has been by comparing your IPSS scores before and after treatment has begun.

Your GP will probably want to do some tests to exclude other conditions. These may include:

Urinalysis - i.e. analysis of your urine. The doctor will look for blood, which can be a sign of bladder cancer, and glucose, which might mean you have diabetes. If an infection is causing your symptoms, there may be white blood cells (leucocytes) and nitrites in your urine.

Blood test - You may also have a blood test to check your kidneys are working properly. This test measures the level of a substance called creatinine. Well-functioning kidneys keep the levels of creatinine below a certain point; raised creatinine in the blood can be a sign of kidney problems, which can cause urine retention (an enlarged, full bladder).

Digital Rectal Examination (DRE) - Your GP may check the size, shape and consistency of the prostate by doing a digital rectal examination. This involves inserting a gloved finger into your rectum (back passage). Whilst this might be uncomfortable, and you might feel a bit embarrassed, it won't hurt. Try to relax, and remember your doctor has probably done this many times before.

PSA testing - Your GP might want to measure the level of a hormone called PSA to check for prostate cancer. PSA stands for 'prostate specific antigen'. It's a type of protein produced by the prostate, and is found in the cells of the prostate. If the prostate is damaged, more PSA leaks into the blood. So raised levels of PSA in the blood could mean prostate cancer.

But PSA also increases with age and other prostate conditions, including BPH, prostatitis and even after a fall or vigorous exercise. So it’s not possible to diagnose prostate cancer or BPH just by testing PSA. It is possible to have a normal PSA level and still have prostate cancer; it’s also possible that you don't have cancer if your PSA is raised.20 The only way to find out is to have a biopsy. However, a PSA test can provide useful information, particularly if you have regular tests so your doctor can see if the PSA level is rising.

Other tests

If you have raised PSA and your doctor can feel a lump in your prostate, or if you're thinking about having prostate surgery, he or she might refer you to a specialist for further tests.21 These can include:

• Prostate biopsy - where a few samples (usually 6-12)22 of prostate tissue are taken for analysis in a laboratory. The biopsy is done via your back passage (rectum). There is some risk of bleeding or infection afterwards.
• Cystoscopy - where the doctor uses a small camera on the end of a flexible or rigid tube to see the inside of your urethra and bladder. The tube is passed up through the urethra (tube that carries urine out through the penis).
• Ultrasound scan - where a probe is inserted into your rectum to allow the doctor to see images of your prostate on a screen.
• Urine flow testing - where the speed of the urine flow, the amount of urine left in your bladder after you pee and other detailed measurements are taken.

Can BPH be treated?

Yes it can. There are various options:

Watchful waiting

Maybe your symptoms are just an inconvenience and don't trouble you too much. In this case, you may feel you're happy enough living with the symptoms once you've had your BPH diagnosed. And that's fine. You should still keep an eye on things though, and have regular check-ups. This is often referred to as "watchful waiting".

Medicines

If, like many men, the symptoms of BPH are spoiling your enjoyment of life, there's no need to put up with them. There are several drugs available to help.

Alpha-blockers
Symptoms can usually be relieved with a type of medicine called 'alpha-blockers'. They work by relaxing the muscle in the bladder and around the prostate so that pee can flow more freely in the urethra. These are often the first choice of treatment if your symptoms are bothering you, especially as they work quickly.

Somewhere between six and nine out of ten men find that alpha-blockers help them.23 They can improve your IPSS symptom score by 30-40% and urine flow rate by 16-25%. You should notice improvements within about two weeks, although it can take four to six weeks for the full effects of the drug to develop.24

There are different types of alpha-blockers available and they are all similar, although they may have slightly different side-effects. If one doesn't work for you, it's unlikely that a different one will work any better.25 But if one kind gives you side-effects, such as low blood pressure, dizziness, drowsiness or headaches, you might do better with another.

5-alpha reductase inhibitors
Another option is a type of medicine called '5-alpha reductase inhibitors', which can slow the growth or even shrink the prostate over time. These work by stopping an enzyme (called 5-alpha reductase) from converting the male hormone testosterone into the more potent dihydrotestosterone. High levels of dihydrotestosterone are linked to growth of the prostate.

These drugs can shrink the prostate by 20-30%, thereby improving flow rate and reducing obstructive symptoms. Your IPSS symptom score might improve by up to 15%.26

You should notice an improvement in your symptoms in three to six months. These drugs work quite slowly, so your symptoms might keep getting better for up to six years, when they level off.

Since 5-alpha reductase inhibitors work by reducing a potent form of testosterone, side-effects can include reduced sex drive, erectile problems and slight breast enlargement or tenderness.27 You can take 5-alpha reductase inhibitors together with an alpha-blocker if either drug is not helping on its own. Or you can take a 5-alpha reductase inhibitor on its own if you can't put up with the side-effects of an alpha-blocker.

Surgery

Surgery is an option if medicines are not suitable for you, if your prostate has enlarged so much that medicines won't help, or if you have developed complications (see What happens if I don't treat it?).

The most common operation for BPH is called 'transurethral resection of the prostate', or TURP. This involves removing the excess prostate tissue from within the urethra, a bit like coring an apple. The operation is carried out under a general anaesthetic, and usually takes about an hour. Having a TURP used to mean a hospital stay of 2-5 days, but now you might only need to stay in for one day.28

You will need to have a catheter in place after the operation for a day or two. You might notice blood in your urine for a few days afterwards.

TURP is usually very successful at treating the symptoms of BPH; improving IPSS Symptom Score markedly, and increasing the urine flow rate significantly. However, in about 1-2% of men the operation doesn't work and needs to be repeated.

Other surgical procedures

There are new alternatives to TURP on offer in some hospitals, which might be suitable for you. You should talk to your doctor if you want to find out more about them. They are minimally invasive procedures, which usually mean a shorter hospital visit, sometimes just a day, and fewer after-effects, such as bleeding.

What happens if I don't treat it?

It is essential that you speak to a healthcare professional if you have urinary symptoms or think you might be suffering from BPH. Although some men find that nothing happens if their BPH is not treated, many find their symptoms get worse and affect their quality of life more and more.29

BPH can also lead to urinary tract infections, such as cystitis (bladder infection), or pyelonephritis (kidney infection), which need treatment with antibiotics.30

There is the possibility that you could also find you eventually suffer from a serious condition known as 'acute urinary retention'. This happens when you can't pee at all and the bladder fills up. It can be painful and needs urgent medical treatment. You'll need to have a catheter (a fine tube) put in to empty the bladder.31 Sometimes acute urinary retention is triggered by an unrelated operation under general anaesthetic, a new medicine, or a urinary tract infection.

In some men where BPH has been a long-standing untreated condition, chronic (long-term) urinary retention develops32. This means the bladder is always full, becomes extremely distended and causes pressure to build up towards the kidneys. This can cause the kidneys to stop functioning properly.