Figure 1
BPH (Benign Prostatic Hyperplasia)
Figure 1
| What is BPH (Benign Prostatic
Hyperplasia)? How common is BPH? What symptoms can arise from BPH? What test would the doctor do? How is BPH treated? |
What is BPH (Benign Prostatic Hyperplasia)?
Benign Prostatic Hyperplasia (BPH) is a condition afflicting men in their later age. The prostate gland, situated just below the urinary bladder (figure 1), is an organ of reproduction in the male and secrete some of the seminal fluid that helps to nourish the sperms. Normally the size of a walnut, the gland starts to enlarge in a benign fashion as a normal process of aging after about 40 years old. This process of enlargement, medically termed BPH, continues into old age and as a consequence, the older the man, the larger in general, is his prostate. As the prostate gland envelops the urine passage, this enlargement may occlude the urine passage (figure 2) and gives rise to symptoms. |
 Figure 2 |
How
common is BPH?
The older a man is, the more likely he is to suffer from BPH. The
condition itself is very prevalent in the developed world and one
in every three to four men will need some treatment. Although the
true incidence is not known in Malaysia, BPH forms a significant portion
of the work load of urologists in Malaysia. For every man who
presented himself to the doctors, there are many more who do not
seek help despite the fact that the quality of their lives is
severely hampered by severe voiding symptoms. With the
anticipated rise in the aged population, the incidence is set to
rise.
What symptoms can arise from BPH?
BPH gives rise to symptoms by causing an obstruction of the
bladder outlet. Not all patients with BPH have symptoms. However,
most men with BPH would find are an increased frequency of
urination, urgency of urination and a weak and hesitant stream. The
severity of symptoms can be quantified using the International Prostate
Symptoms Score (table 1). Severe obstruction would result in
retention of urine (inability to urinate at all) which is generally
associated with very severe pain (figure: 3). Very occasionally, kidney
failure can develop as a result of severe bladder outlet
obstruction.
Table 1: The International
Prostate Symptom Score (IPSS) Questionnaire
| . | Over the past month, how often have you
had a weak urinary stream? This response indicates that you experienced this symptom less than one out of every five times you urinated over the last month |
|
|
|
|
|
|
| 1 | Over the past month, how often have you had a sensation of not emptying your bladder completely after you have finished urinating? | 0 |
1 |
2 |
3 |
4 |
5 |
| 2 | Over the past month, how often have you had to urinate again less than two hours after you finished urinating? | 0 |
1 |
2 |
3 |
4 |
5 |
| 3 | Over the past month, how often have you had to urinate again less than two hours after you finished urinating? | 0 |
1 |
2 |
3 |
4 |
5 |
| 4 | Over the past month, how often have you found it difficult to postpone urination? | 0 |
1 |
2 |
3 |
4 |
5 |
| 5 | Over the past month, how often have you had a weak urinary stream? | 0 |
1 |
2 |
3 |
4 |
5 |
| 6 | Over the past month, how often have you had to push or strain to begin urination? | 0 |
1 |
2 |
3 |
4 |
5 |
| 7 | Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? | 0 |
1 |
2 |
3 |
4 |
5 |
| Total I-PSS Score = |
(Figure: 3)
What test would the doctor do?
After obtaining an account of the symptoms, the doctor would
proceed to examine the abdomen, the external genitalia and a
finger examination of the prostate gland from the back passage.
Urine specimen is obtained to exclude an infection and blood
specimen taken for assessment of kidney function and PSA
(Prostate specific antigen) assay. The PSA test helps to exclude
prostate cancer. Generally, an ultrasound scan of the kidneys and
bladder and a urine flow rate test (figure 4) are also
recommended. Figure 5 shows a typical tracing from a patient with
poor urinary flow.
 Figure 4 |
 Figure 5 |
How is BPH treated?
Management of symptomatic BPH depends on severity of symptoms and
they can be categorized into mild (IPSS score 0 - 7), moderate
(IPSS score 8 - 19) and severe (IPSS score 20 - 35). Most cases
with mild symptoms can be managed expectantly. However, in some
55% of patients, symptoms will worsen with time and therapy will
be indicated. Patients with moderate symptoms form the bulk of
patients with symptomatic BPH. In this group of patients, medical
therapy could significantly improve quality of life. Before a doctor decides
to treat this group of patients with drugs, he or she has to be
satisfied that there are no contraindications to drug treatment.
Two groups of drugs are used in the treatment of symptomatic BPH. Alpha-blockers
help to relax the prostate gland and are useful in most patients
and work promptly in most patients. 5-alpha reductase inhibitors can
help to shrink down the enlargement and reduce symptoms. They generally
work better with grossly enlarged prostate. Before a patient can
be considered for drug treatment, prostate carcinoma has to be
confidently excluded. Additionally, any documented episodes of haematuria (presence
of blood in the urine) need further urological assessment.
Patients with a significant urine retention, renal insufficiency, recurrent
urine infection and bladder stones are not suitable for drug
therapy and are best treated surgically. Medical therapy can be
definitive or interim while patients wait for their definitive
treatment. Generally, patients receiving drug treatment are
reviewed at regular intervals to gauge response. As BPH is a progressive
disease, some patients can expect further deterioration of
symptoms despite drug treatment and most of these patients will
require surgery.
| Patients with severe symptoms and patients who cannot urinate altogether are best treated surgically provided they are fit to surgery. Transurethral resection of the prostate (TURP) (figure 6) remains the gold standard treatment for these patients and is highly effective. Very grossly enlarged prostate occasionally requires open prostatectomy. TURP and open prostatectomy result in the loss of normal ejaculation in the majority of those patients who were sexually active. Newer and less invasive therapy had been used to treat BPH. Most of these involve the destruction of the prostate gland with an energy source such as laser and microwave. None of these treatment modalities had matched TURP/prostatectomy in terms of efficacy and they are generally still regarded as experimental. |  Figure 6a |
Figure 6b
| Disclaimer Thank you for visiting the MUA web-site. We hope that you have found the information contained here both helpful and informative. However, all clinical material published in the MUA web-site are for information purposes only and not intended as medical advice. Visitors to our web-site are strongly encouraged to confirm the information contained herein with other sources. In addition, all information should be carefully reviewed with a trained professional medical care provider. The information is in no way intended to take the place of medical advice offered by physicians. The MUA (and its homepage sponsor - Pfizer Malaysia, webmaster - Cornerstone Perspectives) will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising therefrom. |