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Frequently Asked Questions about BPH


How common is BPH?

Benign prostatic hyperplasia (BPH) is the commonest condition to affect men beyond middle age.  Around 43% of men over the age of 65 have troublesome symptoms and by the age of 80 almost 80% of men are afflicted.

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What causes BPH?

It's caused by a benign (ie non-cancerous) overgrowth of tissue in the middle part of the prostate, but we don't know what actually starts this process off or allows it to progress.  We do know that the male hormone testosterone is involved, as men who have been castrated at an early age (and so don't produce testosterone) never develop BPH.  We also know that testosterone triggers the release of substances in the body called growth factors which can stimulate tissue growth.  But why this happens in some men but not others is still not clear.  The condition does seem to run in some families.

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Which are the most troublesome symptoms?

Many men find that having to get up and go to the toilet at night is the most troublesome aspect of this condition, as it makes them tired during the day.  Having to urinate frequently during the day, sometimes with a sense of urgency, can also be trying for patients, and can make travelling or attending events, such as the theatre or cinema, rather difficult.  Incomplete emptying of the bladder can be progressive and eventually result in complete retention of urine.  If this occurs a catheter (tube into the bladder) will be necessary as the bladder rapidly becomes over distended and painful.

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Can I ignore them?

If you've read this far, you'll know that the symptoms of BPH can be similar to those of prostate cancer.  For this reason alone you should see your GP.  Even if you do have BPH, an enlarged prostate can cause back pressure effects in the bladder and kidneys.  Pouches called 'diverticula' can form in the bladder and can predispose you to urinary infections (cystitis).  Bladder stones can also form, and can be painful, while continued obstruction of the urethra can cause kidney damage, which may be permanent.  Bleeding may also occur.  The moral of the story is see your doctor sooner rather than later!

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What should I do if I am suddenly unable to pass urine?

Acute urinary retention (the sudden, painful inability to urinate) is a common complication of BPH.  It is usually, but not always, preceded by symptoms of prostatic obstruction.  If you find that you cannot pass urine at all, contact your doctor or go to your nearest Accident & Emergency Department.  Try to drink less fluid because your bladder will already be uncomfortably full.  Tell the doctor and nurses how much discomfort you are in so that you do not wait longer than necessary to have a catheter passed via the penis to drain your over distended bladder.  After this, you will usually be admitted to hospital.  Often the doctor will remove the catheter after an alpha-blocker has been given orally to see if you can pass urine normally.  If retention recurs, another catheter will be put in and then you will either be scheduled to have a TURP within the next few days, or sent home with a catheter in place, to await readmission for an operation to restore normal voiding.

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So what should I look out for?

Regularly having to get up more than once a night to urinate can be a sign that your bladder is not emptying properly.  You may notice that your urine stream isn't what it used to be in terms of volume or 'force', and/or you may develop a urinary infection (which will make you want to urinate often, give you a burning sensation when you urinate, and possibly also a temperature).  Finally, if you pass blood in your urine, see your doctor urgently.

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Why would I be referred to a specialist?

BPH can often be managed by your GP, but some men will be referred to a specialist urologist.  You'll usually be referred if:

  • Your symptoms appeared suddenly or are severe
  • You have had repeated urinary infections
  • You have passed blood in your urine
  • Your PSA level is over 4 ng/ml
  • Your GP thinks you may have a bladder stone
  • The results from your blood tests suggest you might have kidney damage.

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What will the specialist do?

He'll ask about your symptoms and examine you.  To see how efficiently you are emptying your bladder, you will probably have a flow test and ultrasound.  Your PSA level may be rechecked, and if it's found to be higher than normal (that is, above 4 ng/ml), you may have a transrectal ultrasound-guided biopsy to check that the swelling is not cancerous.
These tests are not unduly uncomfortable.  Nobody enjoys a digital rectal examination, but it's over in a few seconds.  The flow test and bladder ultrasound are totally painless.  Only a proportion of patients need a biopsy, and the procedure is now much less uncomfortable with the use of local anaesthetic - it is certainly worth asking for this.  More biopsy information from the Prostate Cancer FAQs

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Which drug is best for BPH?

Alpha 1-blockers such as Flowmaxtra (tamsulosin) XL, Xatral (alfuzosin) and Cardura (doxazosin) all act quickly to relieve symptoms regardless of the size of your prostate.  5 alpha-reductase inhibitors such as Proscar (finasteride) or Avodart (dutasteride) work more slowly, but as they seem to shrink the prostate, they seem to help avoid complications and reduce the need for surgery.  Alpha-blockers therefore are a 'quick fix' but do not cure the underlying problem.  5 alpha-reductase inhibitors work better in patients with larger glands, but take 6 months or so to become effective.  Sometimes a combination of an alpha blocker and a 5 alpha-reductase inhibitor is appropriate, especially in patients with a large prostate and severe symptoms.

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What are the side effects of medical therapy for BPH?

The alpha blockers can all cause dizziness, headaches and nasal stuffiness.  The older drugs also caused low blood pressure and fainting but this is now uncommon.  The 5 alpha-reductase inhibitors cause loss of libido and reduced erections in 3- 5% of patients, as well as a reduction in the volume of ejaculate.  1% of patients develop minor breast enlargement on these medications.  All these side-effects disappear if treatment is stopped.

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Are microwave and laser treatments safe? And do they work?

A great deal of work has gone into developing alternatives to traditional surgery.  Both microwave and laser treatment appear to be safe and they probably have less effect on ejaculation than TURP.  In terms of how well they work, results with these techniques are improving as the technology develops, but heat-based treatments such as these still do not produce the rapid and reliable results achieved with TURP.  Patients also complain of a burning sensation during the passage of urine and this may persist for many weeks after the procedure.

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What can go wrong if I opt for a TURP?

The equipment with which a TURP is accomplished is improving all the time.  Although this procedure is largely safe and effective, complications can occasionally occur (as with any operation).  The main problem is bleeding, either at the time of the surgery or afterwards.  It can usually be dealt with by washing out the area with relatively large volumes of liquid (irrigation and bladder washouts), but sometimes the patient needs a second anaesthetic and a telescopic examination (cystoscopy) to find and repair by diathermy the source of the bleeding.  In the longer term, incontinence after a TURP is quite rare, but does affect a tiny proportion of men, as does scarring (stricture) of the urethra, which may need further surgery to remedy.

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How will having a TURP affect my sex life?

It shouldn't affect your sex drive, erection or sensation at orgasm, but it will mean that you have a dry orgasm with no ejaculate. This doesn't usually bother patients as long as they know about it before they have the surgery.  If it was OK before the operation, most men report that their sex life after a TURP is quite satisfactory.  In addition, you should need to get up less often during the night to urinate, and should have an improved urinary stream.

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What are the chances that I'll need a second operation?

Because the prostate continues to grow after a TURP, a proportion of men will need a second operation eventually.  One man in ten undergoing TURP will need a second operation sometime during the following 5 years.

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What questions should I put to my urologist before I agree to surgery?

Ask him who will actually carry out the operation, how many times that person has performed the same type of surgery, and what his results are.  You are looking for an experienced surgeon (one who has carried out the operation at least 100 times previously) who has a high rate of success and a low rate of complications.  Also ask how long you'll have to wait for your operation, and check the cancellation rate (through bed shortages).  If you find it difficult to ask the surgeon these questions directly, you can always telephone his secretary and ask her.

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What should I discuss at my follow-up visit?

The most important thing to check is the results from the pathology laboratory, where they will have examined, under a microscope, the pieces of prostate tissue removed during the TURP.  Most men (nine out of ten) undergoing TURP will simply have signs of BPH.  But one man in ten also has small quantities of prostate cancer in the tissue fragments.  If this is the case, further investigations will be needed such as a PSA check and, possibly, further biopsies from the remaining prostate tissue; depending on these results, further treatment may be necessary.

After prostate surgery your flow rate should be much stronger, but frequency and urgency of urination take longer to improve.  Tell your doctor about your symptoms and ask him how long it will be before everything is back to normal.

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