The prostate is a sex accessory gland, whose function is to produce the seminal fluid, which is the transport medium for the sperm. It is situated around the urethra, like a doughnut, at the exit of the urethra from the bladder. BPH is an enlargement of the prostate gland whereby the number of cells increases through reduced cell death, under the influence of changing hormonal factors taking place with age.
The Role of BPH in Obstruction
The commonly held notion that the symptoms of BPH (poor flow, nighttime voiding) are caused simply by mass related effects are too simplistic. The lower urinary tract symptoms (LUTS) are caused by a combination of the effects of mass (glandular component), stromal tissue (the tissue between the glands) dysfunction as well as bladder muscle dysfunction.
Genetic and Familial Factors
There is evidence that BPH has a genetic component consistent with a dominant pattern. Men with familial BPH have larger prostate volumes (83 ml), compared with men with sporadic BPH (55 ml), and have a higher incidence of surgical intervention when younger than 60 years of age. However, small prostates can also be symptomatic when stromal factors predominate. In fact, the size of the prostate does not correlate with the degree of obstruction. Both active and passive forces play a major role in the obstructive symptoms and increased urethral resistance associated with BPH.
The Bladder’s Response to Obstruction
The bladder’s response to obstruction is an adaptive one and the changes are of two basic types:
- Detrusor (bladder muscle) instability (decreased compliance) associated with symptoms of frequency and urgency
- Decreased detrusor contractility – associated with progressive deterioration of urinary stream, hesitancy, intermittency, increased residual urine.
Diet, Obesity and BPH
A Health Professionals Follow-up Study indicated a possible correlation between abdominal obesity and increase in the frequency and severity of urinary obstructive symptoms and may increase the likelihood that such men will undergo a prostatectomy.
Cold medications, antidepressants, antihistamines or bronchodilators are associated with a 2-3 point increase in the AUA Symptom Index.
Complications of BPH
- Bladder Stones
- Urinary Tract Infections
- Bladder Decompensation (loss of muscle function)
- Urinary Incontinence
- Upper Urinary Tract Deterioration and Renal Failure
- Hematuria (blood in the urine)
- Bladder Diverticula
- Acute Urinary Retention (AUR)
PSA and BPH
BPH can increase the PSA and there is a direct volume based relationship. Studies have shown a predictive correlation between PSA and AUR (acute urinary retention). In a 2-year study the rate of AUR was eightfold higher in those with a serum PSA of over 1.4 ng/ml (0.4% vs. 3.9%), and threefold higher if the prostate volume was over 40 ml (1.6% vs. 4.2%). An analysis of over 100 possible outcome predictors alone or in combination revealed a combination of serum PSA, urinating more than every 2 hours, symptom problem index, maximum urinary flow rate, and hesitancy as being only slightly superior to PSA alone in predicting AUR episodes.
Treatment for BPH
Non-symptomatic BPH does not require treatment. Symptomatic BPH treatment frequently correlates with the degree and severity of the symptoms and other correlated issues such as kidney function, the degree of urinary retention, prostate size, and patient co-morbidities. Medications, like alpha-blockers, provide the quickest response in symptom relief. 5 alpha-reductase inhibitors work on decreasing prostate volume, but they can take up to 3 months to show a benefit and sometimes longer. They tend to work best in prostates over 40 ml. in volume. Minimally invasive office treatments, like TUNA, use radiofrequency energy to heat the tissue and reduce the prostate volume. Finally, the proverbial “gold standard” is the TURP (trans-urethral resection of the prostate), which removes obstructive tissue to allow for a freer flow of urine.