BPH - Benign Prostatic Hyperplasia

What is BPH?

As men get older, it is common that the prostate gland enlarges. This is part of the normal ageing process. In some men (but by no means all), this enlargement can cause problems with urination, which can be troubling and inconvenient.

Urinary Symptoms caused by BPH

These urinary/waterworks symptoms are called Lower Urinary Tract Symptoms (LUTS).

Hesitancy – trouble starting the flow or a slow start to the flow
Weak Stream – the force behind the urinary stream is reduced
Stop/Start flow
A feeling of incomplete emptying
Dribbling of urine – either towards the end stream, or after you have finished
Frequency – need to urinate more often than before
Getting up more than once at night to urinate
Urgency – a feeling of needing to urinate that comes on quickly
Incontinence – losing control of your urine.

You may suffer from a few of these symptoms, or a number of them. The severity of symptoms varies greatly between individuals. It is also important to remember that these symptoms may be caused by other factors such as an overactive or underactive bladder, or a narrowing of the urethra that is not related to BPH. Your urologist is experienced in helping work out the exact cause of your symptoms.

The consultation for BPH

When you see a urologist, he or she will talk to you about your symptoms and do some straightforward tests. The aim of the consultation is threefold:

To find out what exactly is causing your symptoms
To work out how badly these symptoms are affecting you
To work out what the best treatment is for your symptoms

Talking to you about your symptoms helps your urologist work out what is causing your urinary symptoms (LUTS). There are specific questions that you will be asked that help with this. These are similar to the standard questions on the IPSS (International Prostate Symptom Score) sheet, which most patients fill out before the consultation:

International Prostate Symptom Score (IPSS)

Please click the answers that apply to you.

	Not at all	Less than 1 time in 5	Less than half the time	About half the time	More than half the time	Almost always	Your score
Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?							0
Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating?							0
Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated?							0
Urgency Over the last month, how difficult have you found it to postpone urination?							0
Weak stream Over the past month, how often have you had a weak urinary stream?							0
Straining Over the past month, how often have you had to push or strain to begin urination?							0

	None	1 Time	2 Times	3 Times	4 Times	5 Times	Your score
Nocturia Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?							0

Total IPSS score							0

Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.

Quality of life

Delighted Pleased Mostly satisfied Equally satisfied/dissatisfied Mostly dissatisfied Unhappy Terrible Your score

Quality of life due to urinary symptoms

If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?

Download a Blank IPSS Form

Print Your Results

These questions also help to give an idea of how badly you are affected by your symptoms, and can indicate if you might need treatment to help with these.

It is also important to consider your other medical history and any medications you may already be taking, as this has an impact on the type of treatments that may be used to help your symptoms.

Tests that may be done at the time of consultation

Digital rectal examination

Your prostate is examined to get an impression of its size, and also to check for any other abnormalities.

Urine flow rate

You will be asked to come to the clinic with a full bladder, and to urinate into a flow rate machine. This is just like a bucket, and it measures the force of your urine stream. Nothing touches you and is just like urinating into a urinal.

Ultrasound scan of your bladder

After you have done the flow rate, your abdomen will be scanned with an ultrasound (again, completely painless) to see if there is any urine remaining in the bladder.

Ultrasound of the prostate

Occasionally, it is helpful to know the exact size of the prostate, and this can be done by performing an ultrasound of the prostate. This is mildly uncomfortable, but not painful. A small probe is inserted into the rectum to allow accurate measurement of prostate size.

Tests that may be done after the consultation

Blood tests for glucose and kidney function

These are not needed in all patients, but can help to check that the kidneys are working well, and that blood glucose is not too high (sometimes a cause of waterworks symptoms).

PSA (prostate specific antigen) blood test

This test is helpful in predicting if your symptoms are likely to progress in the future. We know that a PSA above 1.4 predicts a higher chance of worsening symptoms in the future.

Urine tests

By sending a sample of urine to the laboratory, your urologist is able to check for the presence of infection or blood in the urine.

Flexible cystoscopy

This is only performed occasionally. Flexible cystoscopy is a short procedure, usually performed under local anaesthetic, which allows visual inspection of the urethra and bladder. It is sometimes helpful in working out the cause of waterworks symptoms if this is not otherwise clear. It is mildly uncomfortable, but should not be painful. A local anaesthetic jelly (there is no needle) is used to numb and lubricate the urethra and the telescope is inserted, along with some fluid into the bladder to fill it. The inspection only takes a few minutes.

Options for managing symptoms of BPH

By gathering all this information, your urologist will be able to guide you in the right direction for treatment options. The decision about treatment takes into account a number of factors including:

How you wish to be managed
How bad your symptoms are
How much trouble they cause you
How likely it is that the symptoms will get worse over time
Your other medical problems, medications and medical fitness

The treatment options are watchful waiting, medical treatment, or surgery.

Watchful Waiting and BPH

This approach avoids active treatment, and involves monitoring your symptoms. It is suitable for men with mild symptoms that are not too troubling to them. Many men find that their symptoms remain stable over time, and that monitoring is all that is needed. If symptoms do worsen, other treatment can be started.

Medications for BPH

For men with troublesome symptoms, medical treatment may be the best way forward. There are three options that Nick will discuss with you in detail. The reasons for choosing one over another are complex and the side effect profiles are different, so below is just a brief summary.

Alpha-blockers

These tablets relax muscle in the bladder neck and prostate, so that it is easier for urine to pass. The beneficial effect starts quickly (within days). These tablets can produce good results, but you may find that you need to keep taking them for months or years. Generally, if you stop the tablet, your symptoms will revert back to how they were. The alpha-blockers have no effect on prostate size, and do not reduce the risk of progression of symptoms in the future, or reduce the possible need for surgery in the future. Side effects include, low blood pressure, dizziness, tiredness, and postural hypotension. Retrograde ejaculation is possible, but not dangerous.

5-alpha reductase inhibitors

These tablets reduce the size of the prostate over time. The effect is slow, and you may not see a beneficial effect for months, but need to keep taking the tablet as it takes 3 to 6 months to achieve a beneficial effect. They produce and improvement in symptoms, and also have been shown to reduce the risk of acute retention of urine and the possible need for surgery in the future.

Side effects include reduced libido and erection problems (again, this is not a complete list of side effects).

Combined treatment

This treatment uses an alpha-blocker and a 5-alpha reductase inhibitor combined in a single tablet. The idea is to combine the advantages of both forms of treatment; the alpha-blocker with is fast effect on symptoms, and the 5-alpha-reductase inhibitor, with its effect on reducing prostate size and reduction of progression of symptoms over time. The side effect profile is similar to the two individual treatments combined.

Surgery

If symptoms are particularly troublesome, or if there is thought to be a reasonable chance of acute retention in the future, or if you have tried medications and they have not helped, then you may want to consider surgery for the prostate.

There are different ways of doing this operation, but all of them aim to reduce the amount of prostate tissue and create a better flow for urine.

Briefly, the operations that Nick performs are:

TURP (transurethral resection of the prostate)
Bipolar TURP and Plasma Vaporisation of the prostate
Greenlight Laser vaporisation of the prostate

Again, the choice of operation depends on a number of factors and will require consideration of your situation and a full discussion with you.

Disclaimer

This information is intended as an educational guide only, and is here to help you as an additional source of information, along with a consultation from your urologist. The information does not apply to all patients.

Not all potential complications are listed, and you must talk to your urologist about the complications specific to your situation.

BPH - Benign Prostatic Hyperplasia

What is BPH?

Urinary Symptoms caused by BPH

The consultation for BPH

International Prostate Symptom Score (IPSS)

Please click the answers that apply to you.

Incomplete emptying

Frequency

Intermittency

Urgency

Weak stream

Straining

Nocturia

Total IPSS score