Benign prostatic Hyperplasia


benign prostatic hyperplasia


Enlargement and swelling of the prostate gland in men is called Benign prostatic Hyperplasia (BPH) if the reason for this swelling and enlargement is a benign increase in the number of prostate gland cells. In the following you will find out more about this not welcomed men urinary tract guest.


Benign prostate swelling

Anatomy of the prostate gland

The location of the prostate gland

The difference between benign and malignant prostate

Why Benign Prostatic Hyperplasia (BPH) happens?

What are the risk factors for Benign Prostatic Hyperplasia (BPH)?

Symptoms of benign prostatic hyperplasia

Classification of Benign Prostatic Hyperplasia (BPH) symptoms

How  Benign Prostatic Hyperplasia is diagnosed?

Which treatment method is right for you?

Types of treatments for benign prostatic hyperplasia

BPH treatment with minimally invasive methods

What are the complications of untreated BPH?


Benign prostate swelling

During the life of every men, the prostate gland enlarges in two phases. The first phase is during puberty where the size of the prostate doubles. The second phase begins around the age of twenty-five and continues until the end of the men's life. When we talk about benign prostatic hyperplasia, in medical terminology, we actually mean the end of the second phase, which affects all men to varying degrees.

Anatomy of the prostate gland

The prostate is an organ that weighs about twenty-eight grams and is about the size of a walnut. The prostate is part of the male reproductive system. This organ is responsible for making semen fluid. The sperm that is made in the testicles during ejaculation, pass through the vas deferens to reach the urethra. At this time, semen fluid, an essential fluid for sperm life, enters the urethra from the prostate gland and seminal vesicles and is excreted during ejaculation.


The location of the prostate gland

Familiarity with the location of the prostate gland is necessary to understand better the signs and symptoms of benign prostatic hyperplasia. The prostate gland is located below the bladder, near the exit of the bladder. The end of the large intestine or rectum is located behind the prostate. The prostate is located around the urethra.


The difference between benign and malignant prostate

Benign prostatic hyperplasia is different from prostate cancer and will not lead to cancer. But BPH and malignant prostate cancer can both occur at the same time. BPH affects 50% of men in their sixth decade of life.


Why BPH happens?

Although the exact cause of BPH is not known yet, hormonal changes appear to be the main cause.

The first reason:

With rising age in men, the blood dose of testosterone decreases. Blood estrogen levels are constant, and these changes cause the prostate to grow.

The second reason:

Increased levels of the Dihydrotestosterone hormone occur through the time. This increased hormone, in the presence of a decrease in the blood level of the Testosterone hormone, causes the prostate to grow.


What are the risk factors for BPH?

The following increase the chances of developing BPH or malignant prostate:

  • Age 
  • Family history of BPH
  • Obesity
  • Lack of physical activity
  • Erectile dysfunction
  • Alcohol consumption
  • Race (African or American men are more susceptible to BPH than Asian and European men)


Symptoms of benign prostatic hyperplasia

Because of the location of the prostate, it is obvious that the size of this gland will disrupt or even block the bladder outlet. Enlarged prostate will push pressure to the urethra (the tube that connect bladder to outside of our body) and narrows it, therefore the passage of urine into the urethra (the urethra or urethra passes right through the middle of the prostate) is decreased or sometimes blocked. This pressure also force patients with BPH to urinate frequently (every two hours). 

  • Frequent urination

    • It is the most common symptom that people with BPH complain about (These people need to urinate every one to two hours).
  • Nocturnal urination

    • Increased frequency of urination during nighttime sleep, wakes a patient with BPH at night.
  • Difficulty in starting to urinate

  • Strain or force when urinating

  • Poor urine flow

  • Drop urine (especially at the end of urination)

  • Incomplete emptying of urine

    • Patients feel that their bladder is not empty even after urinating.
  • Urinary tract infection (UTI)

    • Due to incomplete emptying of urine
  • Bladder stones

  • Complete obstruction of the bladder outlet and urinary retention

    • In this case, there is an urgent need to go to the medical center

The number of symptoms and the severity of the symptoms vary from person to person. Usually, people experience less and less severe symptoms at the beginning, which increase in number and severity over time. Many African-American men also develop symptoms before the age of 50.


Classification of BPH symptoms:

The classification of BPH symptoms is as the following:

  • Obstructive urinary symptoms include:

    • Hesitancy (difficulty in starting to urinate)
    • Intermittency (intermittent urinary flow)
    • Poor urine flow (weak stream)
    • Stringing (straining when urinating)
    • Feeling of incomplete emptying of the bladder 
    • Prolonged intensity of duration of each urination (Prolong micturition)
  • Irritative symptoms:

    • urgency (BPH patients urgently need to urinate)
    • Frequency (BPH increases the number of times patients urinate)
    • Nocturnal urination (night urine)
    • Urge incontinence: (some patients suddenly experience a feeling of urination, which if they do not have access to the toilet at the time, they will develop urinary incontinence)


How Benign Prostatic Hyperplasia (BPH) is diagnosed? 

Using the Symptom Score Index (SSI):

 The American Urological Association for ease and homogenization of diagnosis throughout the world has developed and designed a set of questions about BPH symptoms. For each question related to a specific symptom, doctor will assign points, ranging from mild to severe. The doctor will read each question to you during the visit, and you will choose the right option according to the severity of the symptom. He or she may even provide you with a list of these questions and possible answers. The list includes a set of questions and clinical examinations about the presence or absence as well as the severity of each symptom. For example, you will be asked about:

How many times a day do you urinate?

Options include numbers from low to high that must be chosen by the person affected.

Clinical examination of the prostate:

Includes a few-second examination called digital rectal exam. After explaining how to examine, the doctor will ask you to lie on the examination table with your back to the side or sit on the bed, put your hand on the bed from the front, and bend your head and neck on your hands. The doctor takes a glove for the examination and inserts a finger soaked in lubricant into your rectum to examine and touch the prostate. The prostate is located in front of the rectum so touching the front wall of the rectum lasts only ten to fifteen seconds. This provides the physician with information about the size, consistency, and other characteristics of the prostate gland.

Urine tests:

Sometimes it is necessary to use the urine tests to better study the degree of urethral obstruction or bladder condition. The presence of blood, infected cells, sugar, protein, urinary cysts, etc. will be obtained from the results of this test.

Bladder ultrasound:

Bladder ultrasound will be performed to determine the volume of urine remaining in the bladder after urination.


 to study urine flow for any reason.

Urodynamic studies on the bladder:

Studies the pressure in the bladder when urinating.

 Blood level of PSA:

PSA is a protein made by cells of the prostate gland. As the prostate enlarges for any reason, the blood level of this substance increases.

The following can increase PSA blood levels:

  • Prostatitis (inflammation of the prostate)
  • Benign enlargement of the prostate
  • Prostate cancer

If the PSA is elevated in a patient, the doctor will usually repeat the test one more time. If the PSA is also elevated in the second test, prostate examination or (TR) will be performed. PSA and rectal examination are followed at regular intervals If PSA levels continue to rise in series of PSA checking. If your physician is suspicious about the results of clinical examination, additional diagnostic procedures such as cystoscopy and even prostate biopsy may be necessary.


Which treatment method is right for you?

There are several treatments for BPH, and your doctor will recommend the best treatment based on the following:

  • Age
  • Prostate size
  • Severe discomfort of the patient
  • Patient general health
  • Underlying diseases
  • History of medications


Types of treatments for benign prostatic hyperplasia

Drug treatments:

If a person has BPH with mild to moderate symptoms, medication is usually recommended. There are various drug groups in the treatment of BPH, including:

  • Alpha blockers with the following benefits:

    •  Relaxation of smooth muscle in the bladder and prostate
    • These drugs improve urinary flow very well
    • They reduce the severity of symptoms but these drugs do not reduce the size of the prostate. It is best not to take this medication in men who are considering cataract surgery. The following are examples of drugs in this category:
      • Doxazosin
      • Alfuzosin
      • Silodosin
      • Tamsulosin
      • Terazosin
  • Alpha Reductase Inhibitors:

These drugs inhibit the activity of the enzyme needed to make the dihydrotestosterone hormone, called five alpha reductase. The dihydrotestosterone hormone in men causes the prostate to grow and enlarge. So these drugs reduce the volume of the prostate and regulate the flow of urine. These drugs are suitable for people with large prostates. It takes several months to see the therapeutic results of these drugs. Side effects of these drugs are erectile dysfunction and decreased libido. This category includes the following oral medications:

  1. Finasteride
  2. Dutasteride
  • Combined treatments:

Usually in men with large prostate, a combination of the above two drugs is used. It means with the use of alpha blocker drugs, the patient's symptoms improve and urinary flow is established quickly, and with the use of five alpha reductase inhibitors, prostate enlargement is stopped. The following combinations are commonly used:

  1. Doxazosin plus finasteride
  2. Dutasteride plus tamsulosin (this compound is available as a single oral drug on the market)
  • Antimuscarinics:

Sometimes these drugs are used for people who have symptoms of overactive bladder such as frequent urination which relax the bladder muscles. Sometimes a combination of alpha blockers as well as antimuscarinics are used.


BPH treatment with minimally invasive methods:

Prostatic urethral lift (PUL):

In this method a needle-like device is inserted in the prostate. This procedure can be performed under both local anesthesia and general anesthesia. It is actually an outpatient procedure without incisions and you can return home after the operation. This method is suitable for men who are unable to tolerate the medication.

Transurethral Microwave Therapy (TUMT):

In this method, microwaves are used to destroy the prostate. A wire-like device is inserted through the urethra and directed to the adjacent prostate, sending microwave heat waves selectively to specific parts of the prostate. This heat can remove excess prostate tissue from the prostate. People who for various reasons cannot take medication or cannot undergo surgery due to the underlying disease can benefit from this method.


These include inserting an interstitial tube called a catheter to drain urine. The catheter can be inserted into the urethra or into the bladder. Catheter insertion is a temporary procedure and is suitable for men with complete obstruction and retention. Long-term stay of the catheter is not recommended due to side effects such as infection and increased risk of bladder cancer and destruction of the structure of the penis. Catheterization is suitable for men who are on the waiting list for prostate surgery.

Thulium laser de-inoculation of the prostate (a type of laser therapy in urology)

Holmium laser prosthesis inoculation of the prostate (a type of laser therapy in urology)

Transurethral vaporization of the prostate (shaving the prostate through the urethra)

Laser therapy in the prostate:

Usually high-energy laser waves are placed near the prostate through the tip of a tube that enters the urethra, destroying part of the extra prostate tissue.  Lasers are used for the following purposes in the treatment of BPH:

  • Removal of extra prostate tissue: By evaporating excess tissue they eliminate urinary tract obstruction.
  • Complete prostate evacuation: Holmium laser is effective for complete removal of prostate tissue.

Embolization in the treatment of BPH:

This method is still being studied in the laboratory and it prevents the growth of the prostate by blocking blood flow.

Transurethral resection of the prostate (TURP):

After anesthetizing the patient, a thin tube (resectoscope) enters the urethra from the tip of the penis. The surgeon uses this device to remove the extra prostate tissue that presses on the urethra and the neck of the bladder. In addition to cutting, the same device is able to close the bleeding vessels. Usually, a catheter or bladder catheter is inserted in the patient one to two days after this surgery. Most of the results of this treatment last up to fifteen years. Men with medium to large prostate size who can tolerate anesthesia are good candidates for this surgery. It takes six weeks to fully recover after surgery. Retrograde ejaculation (dry orgasm) and erection disorders are side effects of this procedure.

Open prostatectomy:

This procedure is performed in men with a very large prostate, a damaged bladder, or other accompanying problems. A lower abdominal incision is made.


Common side effects of invasive treatment of BPH:

  • Infection
  • Bleeding
  • Urinary incontinence
  • Erectile dysfunction
  • Scar creation
  • Retrograde ejaculation (dry orgasm)


What are the complications of untreated BPH?

Urinary tract infection:

Failure to completely empty the bladder increases the risk of urinary tract infections.

bladder stones:

Incomplete emptying of the bladder causes the formation of bladder stones, which manifests itself by burning when urinating, bloody urine, infection and obstruction.

Bladder muscle damage:

When the bladder is not completely emptied, the muscles of the bladder wall are constantly stretched, and over time their contractile strength decreases and weakens.

Kidney damage:

Urinary retention, bladder obstruction and inadequate bladder emptying will be associated with kidney damage and infection (pyelonephritis).




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