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Benign prostatic hyperplasia (BPH), also known as enlarged prostate, is a noncancerous enlargement of the prostate gland that occurs when the cells of the prostate gland multiply. It is typically caused by age, and usually does not require treatment.
The prostate gland is a walnut-sized organ located in front of the rectum and right below the bladder. Its function is to produce part of the seminal fluid, the solution that carries sperm.
The prostate gland surrounds the urethra, the tube that carries urine and semen through the penis and out of the body.
BPH affects the inner part of the prostate first, the part that encircles the urethra as it leaves the bladder. As the prostate grows, it may begin to squeeze the upper part of the urethra and restrict the flow of urine.
The chance of developing BPH increases with age. More than half of men over age 50 have BPH. By age 80, about 80 percent of men have enlarged prostates.
Additional causes include:
Only 40 to 50 percent of men actually develop any symptoms due to BPH. These symptoms may include:
The doctor will usually press on and manipulate (palpate) the abdomen and sides to detect signs of kidney or bladder abnormalities. The doctor will also check for signs of anemia or swelling in the legs and arms.
Certain procedures that test reflexes, sensations, and motor response may be performed in the lower extremities to rule out possible neurologic causes of the bladder dysfunction.
There are several tools and examinations the doctor may use to diagnose or rate the severity of your condition, including:
An indexing tool called the International Prostate Symptoms Score (IPSS) can help evaluate the key lower urinary tract symptoms. Unlike laboratory tests or other objective tests, this scoring system measures the patient's own experience. The higher the s core, the more severe the condition. It is useful for many reasons:
It should be noted that the IPPS is useful only as a gauge of symptom severity, and has the following limitations:
A finger is placed into the rectum to assess the size of the prostate and to detect any abnormal nodules (lumps) that may require further investigation.
Many factors can affect urine flow (such as straining or holding back because of self-consciousness) so experts recommend that the test be repeated at least twice.
The rate of urine flow is calculated as milliliters of urine passed per second (mL/s). At its peak, the flow rate measurement is recorded and referred to as the Q [max]. The higher the Q [max], the better the patient's flow rate. Men with a Q [max] of less th an 12 mL/s have four times the risk for urinary retention than men with a stronger urinary flow.
The Q [max] measurement is sometimes used as the basis for determining the severity of obstruction and for judging the success of treatments. It is not very accurate, however, for a number of reasons:
A urinalysis may be performed to detect signs of bleeding or infection. A urinalysis involves a physical and chemical examination of urine. In addition, the urine is spun in a centrifuge to allow sediments containing blood cells, bacteria, and other particles to collect. This sediment is then examined under a microscope.
Although urinary infection is uncommon in younger men, it occurs more frequently in older men, particularly those with BPH. A urinalysis also helps rule out bladder cancer.
To rule out prostatitis (inflammation of the prostate), a simple test called the pre- and post- massage test (PPMT) is about 90 percent accurate.
This test requires culture and microscopic examination of urine samples taken before and after massage of the prostate gland. To massage the prostate, the doctor simply inserts a gloved finger into the rectum and presses several times on the prostate. The fol lowing results are indicated by what is seen in the cultures after massage:
In men with symptoms, blood tests are performed to measure a substance called serum creatinine, which is a marker for kidney trouble. Kidney problems exist in an average of 13.6 percent of BPH patients. Studies have reported rates as high as 30 percent and as low as 0.3 percent.
A PSA test measures the level of prostate-specific antigen (PSA) in the patient's blood. It is the standard screening test for prostate cancer. A PSA is recommended annually for all men over 50 years old and for men over 40 who are at high risk for prostate cancer.
BPH itself can also raise PSA levels, but the test has generally been optional for men with suspected BPH. One 2000 study indicated that PSA levels may be good predictors of future prostate growth in men with BPH.
In the study, men in the lowest PSA level groups (0.2 to 1.3ng/mL) had prostate growth rates of only 0.7mL per year while those in the high PSA groups (3.3 to 9.9) had growth rates of 3.3 mL per year. Other research has detected a specific molecular form of P SA, which has been termed BPSA because it may be a specific marker for BPH. Such findings could eventually lead to a shift from focusing on symptoms and flow rates for diagnosis to a more specific and possible preventive approach.
Certain treatments for BPH, including the drug finasteride (Proscar) and the surgical procedure transurethral resection of the prostate (TURP), can reduce PSA levels and possibly mask the existence of prostate cancer.
A more recent test identifies so-called free PSA, which is found in lower levels when prostate cancer is present and in higher levels with BPH. This may be more accurate than total PSA, regardless of whether a man is taking finasteride or not.
One of the important subjects of tests for urinary incontinence is the postvoid residual urine volume (PVR), the amount of urine left after urination. Normally, about 50 mL or less of urine is left; more than 200 mL is a definite sign of abnormalities. Measur ements in between require further tests.
The most common method for measuring PVR is with a catheter, a soft tube, which is inserted into the urethra within a few minutes of urination. PVR can also be measured using transabdominal ultrasonography.
Ultrasound of the prostate does not require a catheter and gives an accurate picture of the size and shape of the prostate gland. Ultrasound is very beneficial when planning surgery as well as determining treatment options and gauging their effectiveness.
Ultrasound may also be used for detecting kidney damage, tumors, and bladder stones. Ultrasound tests of the prostate generally use one of two methods:
Filling cystometry, also called cystometography, is used for patients who cannot urinate and in whom nerve damage or injury of the bladder is suspected.
The test is used to determine the absence or presence of a condition called uninhibited detrusor contractions (UDC), which often occurs in men with storage urinary tract symptoms.
The detrusor is the group of muscle fibers that cover the outside of the bladder. The test does not add much information to results from less invasive tests and is not used routinely. For this procedure:
A urethrocystoscopy, also called cystourethroscopy, may be performed in men diagnosed with BPH, particularly if they are surgical candidates or if other urinary tract problems are suspected.
Such problems include blood in the urine, infection, bladder cancer, or prior surgery or injury. The physician can determine the presence of a number of problems, including enlargement of the prostate, obstruction of the urethra or neck of the bladder, anatom ical abnormalities, or the presence of stones.
In this procedure, a flexible or rigid fiberoptic tube (an endoscope) is inserted into the urethra to allow doctors to view the lower urinary tract. The procedure is not without risks. Complications are uncommon but can include allergic response to anesthetic , urinary tract infection, bleeding, and urine retention.
An x-ray called an intravenous excretory urography (IVU) is an invasive test that is used only when complications in the upper urinary tract, particularly in the kidney, are suspected. Abdominal ultrasound plus a normal x-ray may be as useful as IVU for most patients with suspected upper tract problems.
If there is any danger of kidney failure, the test should not be performed since it can exacerbate the condition. Severe side effects of the test occur in 0.1 percent of patients.
Mild cases of BPH usually require no treatment. A variety of treatments are available for moderate to severe cases, including medications, minimally invasive therapy, and conventional surgical therapy.
Urologists at UPMC provide expert diagnosis and treatment of BPH, specializing in the following treatments:
For patient referral or consultations, contact the Department of Urology at 412-692-4100.
