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Benign prostatic hypertrophy

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Benign prostatic hypertrophy


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Genito-urinary system
Benign prostatic hypertrophy, also known as benign prostatic hyperplasia or an enlarged prostate and frequently referred to as BPH, is a non-cancerous condition that leads to an increase in the size of the prostate gland, which can make it difficult for men to urinate.

The prostate gland is only found in males, not females, and therefore BPH is a condition that only affects men.

BPH tends to develop in men after the age of 40. The numbers affected and the extent to which urinating is restricted both increase as men get older. For example, an estimated 25% of men between the ages of 40 and 50 are considered to have some degree of prostate enlargement but its effect on urinating may be so slight that the condition may go unnoticed. Between the ages of 70 and 80, an estimated 80% of men are considered to have BPH and almost all will have obvious signs of some difficulty urinating.
The prostate gland is a small gland, located just below the bladder, which surrounds the urethra, the tube carrying urine from the bladder to the penis. The main function of the prostate gland is to store and secrete a fluid that makes up about a quarter of the volume of semen, the fluid that carries the sperm made by the testicles. Contraction of the muscles of the prostate gland also helps during ejaculation, the release of sperm from the penis during the male orgasm.

BPH is largely due to two effects: a static effect related to an increase in the amount of prostate tissue, and a dynamic effect related to an increase in the tone of the muscles in the prostate gland and at the neck of the bladder.

The static effect, produced by an increase in the amount of prostate tissue, is caused by the male sex hormone called testosterone. As men get older, age-related hormonal changes are thought to cause an imbalance in the level of testosterone that stimulates the cells of the prostate gland to get bigger (hypertrophy) or increase in number (hyperplasia). As the prostate gland grows in size it puts pressure on the urethral tube, making it narrower and so restricting the flow of urine through it.

The dynamic effect, caused by the tone of the muscles in the prostate gland and at the neck of the bladder, is controlled by nerve activity relayed through receptors in the muscles called alpha-receptors. As the tone of the muscles increases, the gland's grip around the urethra tightens, so obstructing the flow of urine.
BPH interferes with a man's ability to urinate. Symptoms may include:
  • Difficulty when starting to urinate
  • Urinating for longer or more frequently than usual
  • Needing to urinate again within a short period of time
  • Needing to get up to go to the toilet several times during the night
  • Often needing to rush to the toilet
  • Sometimes finding it difficult to go and having to push or strain
  • A weak or slow urine stream
  • An inability or difficulty in stopping the flow of urine
  • Bladder never feeling completely empty
Symptoms can affect many areas of life. Socially, many men find it embarrassing to have to spend longer than normal in the toilet, or if damp patches appear on the front of their trousers after going to the toilet. Some of the most common problems can also affect wives and partners, who often find their sleep is disturbed by their partner's need to get up to go to the toilet at night. In addition, often needing to rush to the toilet may disrupt work or social life.

BPH is a progressive disease and if left untreated may lead to acute urinary retention, a complete inability to urinate.
In BPH, the aim is to help the flow of urine and reduce the impact that symptoms have on daily activities. In mild forms of the condition, this may be achieved by some simple changes in lifestyle. For example, avoiding drinking large volumes of liquid at night, particularly tea, coffee and cola drinks that contain caffeine, may help reduce the urge to get up to go to the toilet during the night.

If these measures do not work, then there are drugs available that can help. These drugs fall into two main types, known as 5-alpha reductase inhibitors and alpha-blockers.

5-alpha reductase inhibitors include dutasteride and finasteride. They act by inhibiting the enzyme that is responsible for converting testosterone into a more potent hormone called dihydrotestosterone or DHT. It is the action of DHT that is responsible for the enlargement of the prostate gland. By inhibiting the enzyme, both dutasteride and finasteride have been shown to reduce the size of the prostate gland and so help remove the obstruction to the urethra and restore the normal flow of urine. There is a herbal remedy derived from the palm tree, saw palmetto (Serenoa repens, Serenoa serrulata) that has been used in the treatment of BPH. There is evidence to suggest that saw palmetto has a similar mechanism of action to finasteride in that it prevents the formation of DHT and causes shrinkage of the prostate gland.

Alpha-blockers include alfuzosin, doxazosin, indoramin, prazosin, tamsulosin and terazosin. These drugs all block the nerve activity controlling the muscles in the prostate gland and at the neck of the bladder. The muscles relax, loosening the tension that the prostate exerts on the urethra and so helping the flow of urine.

As 5-alpha reductase inhibitors and alpha-blockers act in different ways, combinations of both types of drug may also be used to relieve symptoms.

If drug treatment is inadequate, surgery can be used to remove parts of the prostate that are pressing on the urethra. The most commonly performed operation is transurethral resection of the prostate or TURP, where an instrument is inserted through the urethra to remove the obstructing prostate tissue.
When to consult your pharmacist
If you recognise any of the symptoms listed above, there is no need to suffer in silence as your pharmacist may be able to help. A simple and effective treatment is available without a prescription, but there is a procedure to follow.

If you are aged between 45 and 75 and you have any of the symptoms described above, talk to your local pharmacist. Your pharmacist will ask about your symptoms, how long you've had symptoms and whether you are taking any medicines or health supplements to treat the symptoms or any other illnesses. If your pharmacist decides that you have BPH and that you are not taking any other medicines nor have any other medical conditions that could interfere with your treatment, the pharmacist is able to make an initial 2 week supply of tamsulosin, one of the alpha-blockers named above. If your symptoms improve, your pharmacist is allowed to make a further 4 week's supply. The pharmacist must refer you to your doctor for assessment of your condition if your symptoms have not improved after the initial 2 week supply, or within 6 weeks of starting treatment. The pharmacist can continue to make further supplies if you confirm that your doctor has carried out a clinical assessment and agreed further supplies are suitable. Your pharmacist will advise that you see your doctor every 12 months for your condition to be reviewed.

If you have already been diagnosed with BPH and are being treated, let your pharmacist know, especially when purchasing over the counter medicines for other illnesses. Certain drugs such as antihistamines used for the treatment of hayfever and other allergic conditions may make urinating difficult and make your condition worse. The drugs used to treat BPH may also interact with other medicines and it is important that your pharmacist knows what these medicines are to be able to advise you appropriately.

If you have tried saw palmetto as a herbal remedy, it is important that you tell your pharmacist and doctor as this herbal remedy can interfere with the diagnosis and treatment of BPH.

Your pharmacist will also be able to provide advice about the range of absorbent products that are available and which can be used if accidental leakage of urine is a problem.
When to consult your doctor
Some men may put off seeing their doctor because they are embarrassed or feel a little uncomfortable discussing this type of problem. Be reassured that these symptoms are common and doctors are used to helping their patients with these types of problems. Worry, due to concern about cancer or the need for surgery, is another factor. However, for the vast majority these symptoms are not caused by cancer and for most men the problems they have can be treated simply and effectively with medicines without the need for surgery.

Your doctor will ask you about your symptoms and how often you pass urine. Your doctor may perform a digital rectal examination. This is when a doctor inserts a gloved finger into the rectum to feel the prostate gland through the front wall of the rectum. An enlarged prostate feels smooth and even, while a cancerous prostate feels lumpy or irregular.

If your doctor decides that you have BPH you will probably be prescribed one of the medicines or a combination of two of the different types of medicine described above. If drug treatment does not work, you may be referred to an urologist for surgery.

If your doctor suspects prostate cancer, you may be referred to an urologist for further tests to confirm any diagnosis and to decide if any surgical procedures are necessary.
Living with BPH
Some simple lifestyle changes can make it easier to reduce the inconvenience of BPH and help you enjoy everyday life:
  • Avoid drinking large volumes of liquid at night, particularly alcohol, tea, coffee and cola drinks. This may help reduce the urge to get up to go to the toilet during the night.
  • Go to the toilet at regular intervals throughout the day. Even if you do not feel that you really need to go, use a toilet whenever the opportunity presents itself.
  • Do not rush when you are urinating, take your time to make sure that your bladder is as empty as possible.
  • Avoid situations where it is awkward to use the toilet or where you feel that you will draw attention to yourself if you do go. For example, try to book an aisle seat on trains or planes, or when going to the theatre or cinema.
  • Plan your journeys and make regular stops to go the toilet.
  • If you are taking diuretics for the treatment of heart failure or high blood pressure, ask your doctor if the dosage can be reduced.
  • Avoid cough and cold medicines or hayfever medicines that contain antihistamines or decongestants as these drugs may affect your bladder and make it more difficult to urinate.
  • Try to keep warm when working or walking outside as cold temperatures can increase the urge to urinate.
  • Learn to relax as tension and stress can increase the urge to urinate.
  • If accidents happen and leakage of urine wets your trousers, try using absorbent products such as pads, pouches or drip collectors that are readily available from pharmacies or supermarkets.

Reviewed on 18 April 2010