Benign prostatic hypertrophy: definition, symptoms, causes, diagnosis and treatment

By Cristiano Antonino On May 10, 2023

Benign prostatic hypertrophy (BPH), also known as benign prostatic hyperplasia or prostatic adenoma, is an increase in the volume of the prostate gland

It is a benign physiological enlargement typical of advancing age.

Growth of the gland can occur as early as the age of 40, but as it is a slow and progressive phenomenon, the onset of symptoms is in most cases around the age of 50.

It affects about half of men over 50 up to 60-70% of men over 70.

Although it is a benign increase in size, it is still a clinical condition that should not be underestimated as, if neglected or left untreated, it can not only lead to urinary problems, but can also have major repercussions on bladder and kidney function.

What is the prostate

The prostate is an exocrine gland of the male genito-urinary system about the size of a chestnut located below the bladder and anterior to the rectum.

It contributes to the production of seminal fluid as it secretes prostatic fluid.

Prostate fluid accounts for about 20-40% of the ejaculate and has several tasks

creating a favourable environment for spermatozoa
keep sperm fluid
to reduce the acidity of vaginal secretions, improving sperm survival and motility at that level

Causes of prostate enlargement

The prostate is about the size of a chestnut, but tends to grow with age.

The growth of the gland is caused by a hormonal imbalance that causes a change in the ratio of androgens to oestrogens and is responsible for increased cell proliferation, which in turn causes the gland to enlarge.

This leads to a progressive compression of the urethra (the channel that in men allows urine to pass from the bladder to the outside through the penis) that hinders the physiological flow of urine and causes urinary obstruction, which is responsible for the urinary symptoms complained of by the patient.

In addition, urine stagnation in the bladder can lead to other problems such as urinary tract infections (UTI), bladder stones up to more severe pictures such as impaired kidney function.

Symptoms of benign prostatic hyperplasia

As it is linked to advancing age, prostate enlargement is gradual and therefore also the symptoms associated with it are usually blurred in the initial stages and then progressively worsen.

Many times the increased size of the prostate gland may not be perceived until major problems with urination occur.

Symptoms that may occur in those suffering from benign prostatic hypertrophy are

weak, intermittent, stringy urine stream
hesitation to urinate (waiting before the start of urination despite the presence of urinary urge)
prolonged urination time
difficulty in emptying the bladder completely
urgent need to urinate (urinary urgency)
increased frequency of urination (pollakiuria)
need to urinate at night (nocturia)
dribbling at the end of urination
painful urination
involuntary leakage of urine (urinary incontinence)
inability to urinate (urinary retention) until bladder catheterisation

Other symptoms may be

haematuria, i.e. presence of blood in the urine
haemospermia, presence of blood in the seminal fluid
disorders of the sexual sphere

Diagnosis of benign prostatic hypertrophy

The appearance of urinary symptoms should prompt the patient to refer to a urological specialist for a urological examination.

Useful tools for the specialist to diagnose benign prostatic hypertrophy and for treatment are :

anamnesis: i.e. the patient’s clinical history, both that relating to the micturition problem for which the examination is made and that relating to other pathologies for which the patient is either taking treatment or has undergone surgery;
objective examination of the patient: part of the urological examination is the rectal exploration of the prostate. By inserting a finger into the patient’s rectum, the urologist can assess the shape, size and consistency of the prostate, any pain on prostate palpation and any suspicious areas for malignancy;
PSA (Prostate Specific Antigen) assay: a blood sample that doses a marker produced by the prostate. It is an organ-specific but not tumour-specific marker. This means that alterations in this parameter can occur both in the presence of a cancerous pathology of the prostate and in the presence of benign prostatic hypertrophy, prostatitis (an inflammatory process affecting the prostate). It is therefore fundamental for its correct evaluation, its reading by the urologist;
ultrasound of the urinary apparatus: a non-invasive test to be carried out when the bladder is full, it can be useful for assessing the state of the urinary apparatus (kidneys and bladder) and to obtain information on the size, ecostructure and growth of the prostate gland. The patient is then invited to urinate and the ultrasound of the bladder is repeated to assess any post-minutional residue (RPM), i.e. whether there is residual urine in the bladder at the end of urination;
uroflowmetry: a non-invasive diagnostic test to study the patient’s urinary flow and highlight a functional problem in the lower urinary tract. The patient urinates into a special instrument that resembles a normal toilet, called a uroflowmeter that records urination from start to finish and measures parameters such as: volume of urine produced, urine flow rate and time to urinate. At the end of the test, the post-minution residue (RPM) is then assessed;
IPSS (International Prostatic Symptoms Score): this is a universally accepted questionnaire used as a tool to objectively assess urinary disorders related to benign prostatic hypertrophy in order to evaluate the extent of symptoms;
urodynamic test: invasive test using a bladder catheter and an endorectal probe, indicated in some patients with benign prostatic hypertrophy when it is necessary to study the urinary cycle and the functioning of the bladder muscles;
Multiparametric magnetic resonance imaging of the prostate and/or prostate biopsy: tests that are requested by the specialist if prostate cancer is suspected during the examination.

How BPH is treated

The treatment of benign prostatic hypertrophy depends on several factors both related to the severity of the lower urinary tract symptoms and to complications of the disease itself such as bladder stones, recurrent urinary infections, urinary retention up to bladder catheterisation and deterioration of kidney function.

There are basically two approaches to the treatment of benign prostatic hypertrophy: medical and surgical.

The medical approach is the first treatment offered to patients with BPH and makes use of both so-called ‘symptomatic’ drugs and drugs that inhibit prostate cell proliferation such as 5-alpha reductase inhibitors.

The ‘symptomatic drugs’ lead to an improvement in the patient’s symptoms without affecting the growth of the prostate gland.

As a result, the patient will urinate better but prostate enlargement is not slowed down.

Symptomatic drugs belong to two classes: alpha-lithics and muscarinic receptor antagonists.

The choice depends on the type of symptomatology the patient is suffering from.

The 5-alpha reductase inhibitors, on the other hand, slow down the growth of the prostate.

Their effects are less immediate than with symptomatic drugs and become apparent after several months of therapy.

The use of this type of drug depends not only on the patient’s symptoms but also on the size of the prostate.

Medical therapy often consists of a combination of symptomatic drugs and 5-alpha reductase inhibitors.

Surgery is resorted to when medical therapy is not sufficient to manage the patient’s symptoms, when the patient does not tolerate medical therapy, or when complications of benign prostatic hypertrophy occur despite therapy.

The objective of surgery is to remove the portion of the prostate (prostate adenoma) responsible for the urinary obstruction.

Thus, not the entire prostate is removed, but only the obstructive part.

This means that, even after the operation, the patient must continue to have regular prostate check-ups since, as the whole gland is not removed, the risk of prostate cancer is present even after the operation.

The type of operation the patient undergoes (endoscopic, open, laser) varies from patient to patient and takes into account various aspects including the size of the prostate, diseases the patient suffers from, therapies he is taking, previous surgery, etc.

BPH is an age-related physiological condition that can affect men as young as 40-45 years of age and consists of a benign enlargement of the prostate.

Depending on the complaints it causes, medical or surgical treatment may be necessary.

It would be advisable to see a urologist before symptoms appear as a preventive measure or at the time they occur in order to manage the prostate disease properly and prevent complications.

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