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| {{Infobox_Disease |
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| Name = {{PAGENAME}} |
| | '''For patient information, click [[{{PAGENAME}} (patient information)|here]] |
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| Caption = |
| | {{Benign prostatic hyperplasia}} |
| DiseasesDB = 10797 |
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| ICD10 = {{ICD10|N|40||n|40}} |
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| ICD9 = {{ICD9|600}} |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = med |
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| eMedicineTopic = 1919 |
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| MeshID = D011470 |
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| {{Search infobox}} | |
| {{SCC}} | | {{SCC}} |
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| {{Editor Help}} | | {{SK}} Hyperplasia of the Postate; Prostate hyperplasia, benign; prostatic hypertrophy; adenofibromatous hypertrophy of prostate; benign prostatic hypertrophy |
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| ==Overview== | | ==[[Benign prostatic hyperplasia overview|Overview]]== |
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| '''Benign prostatic hyperplasia''' ('''BPH''') also known as '''Nodular hyperplasia''', '''Benign prostatic hypertrophy''' or '''Benign enlargement of the prostate (BEP)''' refers to the increase in size of the [[prostate]] in middle-aged and elderly men. To be accurate, the process is one of [[hyperplasia]] rather than [[Organ hypertrophy|hypertrophy]], but the nomenclature is often interchangeable, even amongst urologists. It is characterized by hyperplasia of prostatic [[stromal cells|stromal]] and epithelial cells, resulting in the formation of large, fairly discrete nodules in the periurethral region of the prostate. When sufficiently large, the nodules compress the urethral canal to cause partial, or sometimes virtually complete, obstruction of the [[urethra]] which interferes the normal flow of [[urine]]. It leads to symptoms of urinary hesitancy, frequent [[urination]], increased risk of [[urinary tract infection]]s and [[urinary retention]]. Although [[prostate specific antigen]] levels may be elevated in these patients, because of increased organ volume and inflammation due to urinary tract infections, BPH is not considered to be a premalignant lesion.
| | ==[[Benign prostatic hyperplasia historical perspective|Historical Perspective]]== |
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| ==Symptoms== | | ==[[Benign prostatic hyperplasia pathophysiology|Pathophysiology]]== |
| Benign prostatic hyperplasia symptoms are classified as obstructive or irritative. | |
| Obstructive symptoms include hesitancy, intermittency, incomplete voiding, weak urinary stream, and straining.
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| Irritative symptoms include frequency of urination, which is called [[nocturia]] when occurring at night time, and urgency (compelling need to void that can not be deferred). These obstructive and irritative symptoms are evaluated using the [[International Prostate Symptom Score]] (IPSS) questionnaire, designed to assess the severity of BPH.<ref>Barry MJ, Fowler FJ Jr, O'Leary MP, ''et al'' (1992). The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. ''J Urol'' '''148(5)''': 1549-57. PMID 1279218</ref>
| | ==[[Benign prostatic hyperplasia causes|Causes]]== |
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| BPH can be a progressive disease, especially if left untreated. Incomplete voiding results in stasis of [[bacterium|bacteria]] in the [[urinary bladder|bladder]] residue and an increased risk of [[urinary tract infection]]s. Urinary [[bladder stone]]s, are formed from the crystallisation of salts in the residual urine. [[Urinary retention]], termed acute or chronic, is another form of progression. Acute urinary retention is the inability to void, while in chronic urinary retention the residual urinary volume gradually increases, and the bladder distends. Some patients who suffer from chronic urinary retention may eventually progress to renal failure, a condition termed obstructive [[uropathy]].
| | ==[[Benign prostatic hyperplasia differential diagnosis|Differentiating Benign Prostatic Hyperplasia from other Diseases]]== |
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| ==Etiology== | | ==[[Benign prostatic hyperplasia epidemiology and demographics|Epidemiology and Demographics]]== |
| [[Androgen]]s ([[testosterone]] and related [[hormone]]s) are considered to play a permissive role in [[BPH]] by most experts. This means that [[androgen]]s have to be present for BPH to occur, but do not necessarily directly cause the condition. This is supported by the fact that [[castration|castrated]] boys do not develop BPH when they age, unlike intact men. Additionally, administering exogenous testosterone is not associated with a significant increase in the risk of BPH symptoms. [[Dihydrotestosterone]] ([[DHT]]), a [[metabolite]] of testosterone is a critical mediator of prostatic growth. DHT is synthesized in the prostate from circulating testosterone by the action of the enzyme 5α-reductase, type 2. This enzyme is localized principally in the stromal cells; hence, these cells are the main site for the synthesis of [[DHT]]. | |
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| DHT can act in an [[autocrine]] fashion on the stromal cells or in [[paracrine]] fashion by diffusing into nearby [[epithelium|epithelial cells]]. In both of these cell types, DHT binds to nuclear [[androgen receptor]]s and signals the [[Transcription (genetics)|transcription]] of [[growth factor]]s that are mitogenic to the epithelial and stromal cells. DHT is 10 times more potent than testosterone because it dissociates from the androgen receptor more slowly. The importance of DHT in causing [[nodule (medicine)|nodular]] hyperplasia is supported by clinical observations in which an [[inhibitor]] of 5α-reductase is given to men with this condition. Therapy with 5α-reductase inhibitor markedly reduces the DHT content of the prostate and in turn reduces prostate volume and, in many cases, BPH symptoms.
| | ==[[Benign prostatic hyperplasia risk factors|Risk Factors]]== |
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| There is growing evidence that [[estrogen]]s play a role in the [[etiology]] of BPH. This is based on the fact that [[BPH]] occurs when men generally have elevated estrogen levels and relatively reduced free testosterone levels, and when prostate tissue becomes more sensitive to estrogens and less responsive to [[DHT]]. Cells taken from the prostates of men who have [[BPH]] have been shown to grow in response to high [[estradiol]] levels with low androgens present. [[Estrogen]]s may render cells more susceptible to the action of [[DHT]].
| | ==[[Benign prostatic hyperplasia screening|Screening]]== |
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| On a microscopic level, BPH can be seen in the vast majority of men as they age, particularly over the age of 70 years, around the world. However, rates of clinically significant, symptomatic BPH vary dramatically depending on lifestyle. Men who lead a western lifestyle have a much higher incidence of symptomatic BPH than men who lead a traditional or rural lifestyle. This is confirmed by research in China showing that men in rural areas have very low rates of clinical BPH, while men living in cities adopting a western lifestyle have a skyrocketing incidence of this condition, though it is still below rates seen in the West.
| | ==[[Benign prostatic hyperplasia natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| Much work remains to be done to completely clarify the causes of BPH.
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| ==Diagnosis== | | ==Diagnosis== |
| [[Rectal examination]] (palpation of the prostate through the [[rectum]]) may reveal a markedly enlarged [[prostate]].
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| Often, [[blood test]]s are performed to rule out prostatic malignancy: elevated [[prostate specific antigen]] (PSA) levels needs further investigations such as reinterpretation of [[PSA]] results, in terms of [[PSA]] density and [[PSA]] free percentage, rectal examination and [[transrectal ultrasonography]]. These combined measures can provide early cancer detection.
| | [[Benign prostatic hyperplasia history and symptoms|History and Symptoms]] | [[Benign prostatic hyperplasia physical examination|Physical Examination]] | [[Benign prostatic hyperplasia laboratory findings|Laboratory Findings]] | [[Benign prostatic hyperplasia ultrasound|Ultrasound]] | [[Benign prostatic hyperplasia other imaging findings|Other Imaging Findings]] | [[Benign prostatic hyperplasia other diagnostic studies|Other Diagnostic Studies]] |
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| [[Medical ultrasonography|Ultrasound]] examination of the testicles, prostate and kidneys is often performed, again to rule out malignancy and [[hydronephrosis]]. | |
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| ==Epidemiology==
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| More than half of the men in the United States between the ages of 60 and 70 and as many as 90% between the ages of 70 and 90 have symptoms of BPH. For some men, the symptoms may be severe enough to require treatment.
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| ==Treatment== | | ==Treatment== |
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| ===Lifestyle===
| | [[Benign prostatic hyperplasia medical therapy|Medical Therapy]] | [[Benign prostatic hyperplasia surgery|Surgery]] | [[Benign prostatic hyperplasia primary prevention|Primary Prevention]] | [[Benign prostatic hyperplasia secondary prevention|Secondary Prevention]] | [[Benign prostatic hyperplasia cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Benign prostatic hyperplasia future or investigational therapies|Future or Investigational Therapies]] |
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| Patients should decrease fluid intake before bedtime, moderate the consumption of [[alcohol]] and [[caffeine]]-containing products, and follow timed voiding schedules.
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| ===Medications===
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| [[Alpha blocker]]s (α<sub>1</sub>-[[adrenergic receptor]] [[receptor antagonist|antagonist]]s) provide symptomatic relief of BPH symptoms. Available drugs include [[doxazosin]], [[terazosin]], [[alfuzosin]] and [[tamsulosin]]. Older drugs, [[phenoxybenzamine]] and [[prazosin]] are not recommended for treatment of BPH <ref>AUA Practice Guidelines Committee.AUA guideline on management of benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. ''J Urol'' '''170(2 Pt 1)''': 530-47. PMID 12853821</ref>. Alpha-blockers relax smooth muscle in the prostate and the bladder neck, and decrease the degree of blockage of urine flow. Alpha-blockers may cause ejaculation back into the bladder ([[retrograde ejaculation]]).
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| The [[5-alpha-reductase inhibitor|5α-reductase inhibitors]] ([[finasteride]] and [[dutasteride]]) are another treatment option. When used together with alpha blockers a reduction of BPH progression to acute urinary retention and surgery has been noted in patients with larger prostates.<ref>Kaplan SA, McConnell JD, Roehrborn CG, ''et al'' (2006). Combination therapy with doxazosin and finasteride for benign prostatic
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| hyperplasia in patients with lower urinary tract symptoms and a baseline total | |
| prostate volume of 25 ml or greater. ''J Urol'' '''175(1)''': 217-20. PMID 16406915.</ref>
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| There is also extensive evidence of the efficacy of ''Serenoa repens'' (saw palmetto) fruit extracts in alleviating mild-to-moderate BPH symptoms; a [[systematic review]] of evidence found comparable efficacy to [[finasteride]].<ref>Wilt TJ, Ishani A, MacDonald R, (2002). Serenoa repens for benign prostatic hyperplasia. ''[[Cochrane Library|Cochrane Database Syst Rev]]'' '''2002''' (3), CD001423. ([http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12137626 Medline abstract])</ref> Other herbal medicines that have solid research support in systematic reviews include beta-sitosterol from ''Hypoxis rooperi'' (African star grass) and pygeum (extracted from the bark of ''Prunus africana''), while there is less substantial support for the efficacy of ''Cucurbita pepo'' (pumpkin) seed and ''Urtica dioica'' (stinging nettle) root.<ref>Wilt TJ, Ishani A, Rutks I, MacDonald R (2000) Phytotherapy for benign prostatic hyperplasia ''Public Health Nutr'' 3(4A):459-72 ([http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11276294&query_hl=5&itool=pubmed_docsum Medline abstract])</ref> At least one double-blind trial has also supported the efficacy of rye flower pollen.<ref>Buck AC, Cox R, Rees RWM, et al. (1990) Treatment of outflow tract obstruction due to benign prostatic hyperplasia with the pollen extract, Cernilton. A double-blind placebo-controlled study ''Br J Urol'' 66:398-404 ([http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1699628&query_hl=1&itool=pubmed_docsum Medline abstract])</ref>
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| [[Sildenafil]] shows some symptomatic relief, suggesting a possible common etiology with [[erectile dysfunction]]<ref>McVary KT, Monnig W, Camps JL Jr, ''et al'' (2007). Sildenafil citrate improves erectile function and urinary symptoms in men with
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| erectile dysfunction and lower urinary tract symptoms associated with benign
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| prostatic hyperplasia: a randomized, double-blind trial. ''J Urol'' '''177(3)''' :1071-7. PMID 17296414</ref>. | |
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| ===Surgery===
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| If medical treatment fails, [[transurethral resection of prostate]] (TURP) surgery may need to be performed. This involves removing (part of) the prostate through the [[urethra]]. There are also a number of new methods for reducing the size of an enlarged prostate, some of which have not been around long enough to fully establish their safety or side effects. These include various methods to destroy or remove part of the excess tissue while trying to avoid damaging what's left. Transurethral electrovaporization of the prostate (TVP), laser TURP, visual laser ablation (VLAP), TransUrethral Microwave ThermoTherapy (TUMT), [[Transurethral needle ablation of the prostate|TransUrethral Needle Ablation]] (TUNA), ethanol injection, and others are studied as alternatives.
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| Newer techniques involving lasers in urology have emerged in the last 5-10 years. Starting with the VLAP technique involving the [[Nd:YAG laser]] with contact on the prostatic tissue. A similar technology called Photoselective Vaporization of the Prostate (PVP) with the GreenLight (KTP) laser have emerged very recently. This procedure involves a high powered 80 Watt KTP laser with a 550 micrometre laser fiber inserted into the prostate. This fiber has an internal reflection with a 70 degree deflecting angle. It is used to vaporize the tissue to the prostatic capsule. KTP lasers target haemoglobin as the chromophore and have typically have a penetration depth of 2.0mm (four times deeper than holmium).
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| Another procedure termed Holmium Laser Ablation of the Prostate (HoLAP) has also been gaining acceptance around the world. Like KTP the delivery device for HoLAP procedures is a 550um disposable side-firing fiber that directs the beam from a high powered 100 Watt laser at a 70degree from the fiber axis. The holmium wavelength is 2,140nm, which falls within the infrared portion of the spectrum and is invisible to the naked eye. Where KTP relies on haemoglobin as a chromophore, water within the target tissue is the chromophore for Holmium lasers. The pentration depth of Holmium lasers is <0.5mm avoiding complications associated with tissue necrosis often found with the deeper penetration and lower peak powers of KTP.
| | ==Case Studies== |
| | [[Benign prostatic hyperplasia case study one|Case #1]] |
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| Both wavelengths, KTP and Holmium, ablate approximately one to two grams of tissue per minute.
| | ==Related chapters== |
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| ==See also== | |
| *[[Prostate]] | | *[[Prostate]] |
| *[[Prostate cancer]] | | *[[Prostate cancer]] |
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| *[[Uvula of urinary bladder]] | | *[[Uvula of urinary bladder]] |
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| ==References==
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| {{Reflist|2}}
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| {{Urologicals}} | | {{Urologicals}} |
| {{Diseases of the pelvis, genitals and breasts}} | | {{Diseases of the pelvis, genitals and breasts}} |
| {{Geriatrics}} | | {{Geriatrics}} |
| {{SIB}}
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| [[Category:Andrology]]
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| [[Category:Urology]]
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| [[de:Benigne Prostatahyperplasie]] | | [[de:Benigne Prostatahyperplasie]] |
| [[es:Hipertrofia benigna de próstata]] | | [[es:Hipertrofia benigna de próstata]] |
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| | [[Category:Andrology]] |
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| | [[Category:Surgery]] |
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