Benign Prostatic Hyperplasia: Information and Specialists in Benign Prostatic Hyperplasia

Benign prostatic hyperplasia is the most commonly diagnosed urological condition in male patients. Among men aged 50 to 60, one in two is affected.

Increased growth of tissue cells in the prostate gland leads to an enlargement of the organ. Normally, the prostate weighs only 25 grams and is about the size of a chestnut. Due to this cell growth, the prostate can reach a weight of up to 150 grams.

However, the proliferating cells are non-invasive; that is, they do not grow into neighboring tissues. It is therefore a benign tumor.

The prostate is located below the bladder, directly in front of the rectum. The enlargement of the prostate therefore causes corresponding symptoms.

Benign prostatic hyperplasia cannot be prevented. However, a healthy lifestyle and regular physical activity can reduce an individual’s risk of developing the condition. Key components of a healthy lifestyle include maintaining a normal weight and avoiding nicotine.

In the literature, the term “prostate adenoma” is often used as a synonym for BPH. However, this is not medically correct: in benign prostatic hyperplasia, the number of glandular, muscle, and connective tissue cells increases. In an adenoma, however, there is only an increased number of glandular cells.

Prostate enlargement is primarily characterized by the following symptoms:

• a weak urine stream, up to urinary retention
• intermittent urine stream
• delayed urination
• Straining during urination
• frequent urge to urinate, but only small amounts of urine
• Nighttime urge to urinate
• Dribbling
• Feeling of residual urine
• Pain when urinating (in isolated cases)
• Erectile dysfunction

If you are experiencing one or more of these symptoms, you should see a urologist as soon as possible.

If you are unable to pass any urine at all, go to the emergency room of a hospital as soon as possible. This can lead to urine backup all the way up to the kidneys, causing uremia. In uremia, toxins from the urine enter the bloodstream, posing a life-threatening risk.

An enlarged prostate presses on the urethra, among other things, making it difficult to urinate © bilderzwerg | AdobeStock

The diagnostic process begins with a digital rectal exam performed by a urologist. During this exam, the urologist inserts a finger into the patient’s rectum and palpates the prostate gland. If the prostate is enlarged due to hyperplasia, it has a smooth, elastic surface.

The doctor then checks the function of the sphincter muscle and the reflexes to rule out other conditions, such as Parkinson’s disease.

To rule out a possible urethral infection, the doctor has the patient’s urine sample analyzed in a laboratory. A tiny tissue sample from the prostate provides information on whether the cells are truly benign or indicate prostate cancer. The tissue sample is obtained through the rectum.

The ultrasound image reveals potential complications such as diverticula (outpouchings of the organ wall) and bladder stones. For this purpose, transrectal ultrasound (TRUS) is used. The probe is inserted into the patient’s rectum. Conventional abdominal ultrasound shows the size of the prostate and the volume of residual urine.

Uroflowmetry is used to measure the strength of the urine flow. In healthy patients, this is approximately 20 milliliters per second. However, if the value is below 10 milliliters, this is an indication of a narrowed urethra. During uroflowmetry, the patient urinates into a funnel equipped with special sensors.

In certain cases, a cystoscopy is also performed to confirm a suspected diagnosis of benign prostatic hyperplasia.

The prostate glands produce a secretion that protects sperm and stimulates their activity. This fluid is released into the urethra. The glands within the prostate are surrounded by smooth muscle cells and connective tissue cells.

In benign prostatic hyperplasia, the number of muscle and connective tissue cells, as well as glandular cells, increases significantly. According to current medical understanding, this occurs because the aging cells die off later than normal. As a result, the outer layer of the prostate becomes thinner. Furthermore, the organ is no longer able to produce enough secretion.

Medical research has not yet been able to fully clarify what causes the cells to live longer than normal. However, dihydrotestosterone (DHT) appears to play a key role. This is the more potent form of the male sex hormone testosterone found in the body.

The female sex hormone estrogen, which is also present in the male body, may also contribute to prostate hyperplasia. In men past menopause, estrogen occurs in higher concentrations than in younger men, whereas DHT levels in the blood are lower. This increase in estrogen, in turn, raises the risk of developing benign prostatic hyperplasia.

A high proportion of fat cells in the body further increases the concentration of estrogen in the blood. Therefore, men who are severely overweight generally have a higher risk of developing an enlarged prostate.

The interstitial space between the glands also plays a role in the development of the condition: if it binds excessive amounts of growth factors, this promotes cell proliferation or prevents their natural death.

Prostate hyperplasia is usually caused by genetic factors only in patients in whom it occurs in earlier decades of life. Medical experts estimate that only about 9% of cases of benign prostatic hyperplasia in men over 60 are genetically caused.

If the condition is not yet causing any symptoms, it is sufficient to monitor it at regular intervals.

Medication

In Stage I of the condition—or, in milder cases, in Stage II—the patient is prescribed medication.

Among the most commonly used remedies are herbal preparations. They are very well tolerated but are only effective for milder symptoms. These include, for example, preparations containing

• nettle root,
• pumpkin seeds,
• rye,
• African plum, or
• saw palmetto.

They prevent the formation of growth factors, 5-alpha-reductase—the enzyme that converts testosterone into DHT—or cause cells to die off more quickly. They also block the male sex hormone.

Alpha-blockers are synthetically produced medications that relax the prostate and urethral muscles. This makes it easier to urinate. Examples of this class of active ingredients include tamsulosin, doxazosin, and alfuzosin.

Chemical 5-alpha-reductase inhibitors include the active ingredients dutasteride and finasteride.

Patients prescribed these medications are more likely to experience erectile dysfunction and a loss of sexual desire. For this reason, PDE inhibitors such as tadalafil are now the preferred treatment. They have a similar effect to plant-based enzyme blockers.

To reduce the strong urge to urinate, medications are used that inhibit the activity of the bladder muscle.

All medications used to treat benign prostatic hyperplasia slow the progression of the disease. In some cases, the prostate may even shrink.

Prostate Embolization

Prostate embolization (PAE) was first performed in 2008 and is therefore still a relatively new method. Nevertheless, it is increasingly becoming an alternative to drug therapy or a TURP (see below). It is a minimally invasive procedure that does not require general anesthesia and can be performed on an outpatient basis.

Recent studies show that prostate embolization is associated with significantly fewer complications than surgical procedures such as TURP:

• low risk of infection
• no bleeding and no postoperative bleeding through the urinary tract
• no risk of incontinence

The principle behind prostate embolization is to reduce blood flow to the prostate. Doctors achieve this using a catheter, which is guided through a tiny puncture site into the prostate artery via the pelvic artery. Doctors monitor the catheter’s position during the procedure using computed tomography (CT). Tiny plastic particles are then delivered through the catheter into the branching arteries of the prostate until blood flow is blocked.

Due to the reduced blood supply, the enlarged prostate can shrink again in the weeks or months that follow. This restores the patient’s quality of life. Doctors report success in 75–94% of all procedures.

However, prostate embolization cannot always be performed. Exclusion criteria include various medical conditions, such as

• an acute urinary tract infection,
• prostate cancer, and
• and, in some cases, chronic kidney failure.

Surgical Treatment

There are various surgical procedures available for treating benign prostatic hyperplasia. Which one is ultimately used depends on the individual.

The gold standard remains transurethral resection of the prostate (TURP). The procedure is similar to a cystoscopy: The surgeon inserts a narrow tube into the urethra, the open end of which is equipped with a high-resolution camera and a light source. An electrified metal loop removes the excess tissue layer by layer.

The technically improved TURP procedure used today leads to unwanted side effects only in isolated cases. However, the complication rate increases as the prostate grows larger.

Transurethral incision of the prostate (TUIP) is only considered in cases of mild to moderate benign prostatic hyperplasia. Excess tissue is incised only at the junction between the prostate and the bladder neck to ensure that the urethra is not narrowed.

Another surgical method is transurethral microwave therapy (TUMT): The microwaves destroy the benign tissue through heat, causing the prostate to shrink.

Lasers are also used to treat benign prostatic hyperplasia. They destroy the prostate tissue or remove it layer by layer. The HoLEP method, in particular, is nearly as effective as the standard procedure.

Open surgery is necessary only in cases of a severely enlarged prostate. The surgeon makes an incision in the bladder and removes the prostate from there (prostatectomy).