Human life expectancy has more than doubled in the last two centuries. Initially, it was mainly driven by the decrease in infant mortality, but soon enough drastic advances in medical and surgical care resulted in a stark reduction in mortality in older population. This ongoing demographic transition is closely paralleled by increase in incidence of age-associated diseases. Most of the age-associated changes, for example urinary disorders, are shared among both, males, and females. Only males have a prostate and are therefore susceptible to diseases of prostate. Benign Prostatic Hyperplasia (BPH) and Lower Urinary Tract Symptoms (LUTS) have been often discussed in popular literature. I often get visits from well-read and well-informed patients complaining of LUTS and assuming BPH to be their diagnosis. Because LUTS has a multifactorial etiology, sometimes of non-urologic origin, it is important to exclude other more serious complications. Here I will briefly discuss BPH which rarely causes symptoms before age 40 but affects, to a varying degree, about half of all men between the ages of 51 and 60 and up to 90 per cent of men older than 80 and its association with lower urinary tract symptoms (LUTS).
Etiology Prostate is a gland composed of smooth muscles, epithelial cells, and stroma. BPH is a histological diagnosis associated with unregulated, non-cancerous proliferation of smooth muscle, glandular epithelium and connective tissue. This overgrowth of prostatic tissue may result in pressure against the urethra. This results in blockage of urine flow to a various extent, from hardly noticeable to complete. This bladder pathology may present clinically with LUTS, urinary tract infection (UTI), post-void residual urine or retention of urine, acute or chronic. If bladder outlet obstruction is not corrected timely, increased pressure generated in the bladder may destroy the vesico-ureteral valves allowing urine reflux and severely damage the kidneys. BPH does not have any pathognomonic signs or symptoms which allow physicians to diagnose it specifically. The same prostate size on gross examination may present with significant inter-patient differences in LUTS, post-void residual urine ranging between normal and severe, presence or absence of UTIs or hematuria (presence of blood in urine), and manifestation of acute or chronic retention of urine. Like BPH, the incidence and prevalence of LUTS are directly proportional to increase in patient age. LUTS can be a consequence of urological abnormalities like bladder or prostate cancer, UTIs due to bladder outlet obstruction, urethral stricture, and acute or chronic prostatitis. Common medical and neurological conditions such as diabetes mellitus, congestive heart failure, Parkinson’s disease, and hemiparesis after a cerebrovascular accident too, can result in LUTS. BPH-LUTS is manifested in two ways. One is the obstruction or problems with voiding. Symptoms under this category include difficulties in initiating urination (hesitancy), decreased urinary flow, voiding with straining and intermittency, prolonged urination with dribbling towards the end and feeling of incomplete evacuation of the bladder. Symptoms of second category happen due to bladder irritation, which include increased frequency, urgency to urinate (with or without urinary leakage) and frequent need to urinate at night (nocturia). When these BPH symptoms remain unrecognised or are inadequately addressed, severe complications such as impaired bladder emptying, detrusor muscle instability, UTI, acute retention of urine, chronic retention of urine (leading to renal failure) and hematuria may ensue. While all of these are important, hematuria is an emergency and should be taken very seriously. Bleeding may frequently stop without any sort of intervention and give a false impression that “everything is now fine”. However, while hematuria in BPH is due to bursting of dilated veins in the bladder or the kidneys, other causes that a urologist can exclude are renal stones and bladder cancer. The definitive diagnosis of BPH can only be done histologically. Per definition BPH is diagnosed when proliferation of cellular elements is seen on biopsy under the microscope regardless of prostate size. Because biopsy is invasive, it is done only after prostate surgery. For clinical diagnosis, a urologist evaluates LUTS such as bladder outlet obstruction symptoms and how they affect voiding, whether they cause signs of bladder irritation, and if present, extent of complications in the patient. Ultrasonography is used to provide information on the size of the prostate and the post-void residual volume. It also provides details on the enlarged part encroachment into the bladder and the resultant effect on bladder muscles. It is a valuable tool in identifying any damage to the kidney and the rest of the upper urinary tract in advanced cases. Because prevalence of moderate to severe BPH-LUTS increases with patient age, a reduction in maximum flow rate is observed when urine flow is recorded by graphically plotting voided volume against flow time using uroflowmetry, another important diagnostic tool. Increase in maximum urine flow rate is seen when the patient subjectively responds to treatment and is an important objective correlate that helps urologists monitor the patient. Some other tests or procedures are performed on patients on a case-by-case basis. Prostate specific antigen (PSA) in blood is a screening test frequently ordered by urologists. The results of this test, however, are not cancer specific.
Management of BPH As with many clinical diagnoses, BPH requires that patients speak with their physicians and together plan lifestyle alterations conducive to patients’ well-being regardless of treatment status. Patients report tangible benefits due to regular exercise, distribution and control of daily liquid intake, reduction of weight, and control of blood pressure and sugar. Medical therapy is the initial treatment of choice to relax the prostate and bladder neck smooth muscles to relieve bladder outlet obstruction. When medical treatment does not suffice, prostate surgery is performed to remove the obstructing prostate tissue to widen the bladder neck. Except in rare cases surgeries are performed endoscopically without external incision. BPH is an age-associated disease that presents with LUTS. Because LUTS has a multifactorial etiology, potentially of non-urologic origin, it is important to exclude other, sometimes more serious causes.
(Dr Bhatta, who did MD, PhD, DSc, is the chief consultant urologist at the Medicare)