What is benign prostatic hyperplasia and why does it occur?
Benign prostatic hyperplasia (BPH) is a benign growth of the prostate associated with age, which usually appears after the age of 50. This growth leads to an obstruction in the outflow of urine from the urinary bladder, which translates clinically into the appearance of lower urinary tract symptoms (LUTS). Therefore, the concept of BPH should be reserved for patients who meet 3 conditions: they have LUTS, an increased prostatic size (more than 30cc) and are obstructed (have a peak flow less than 15 ml/sec).
It is not known exactly how it originates, but two factors are necessary for the development of BPH: age and the presence of testosterone, because of the hormone-dependent nature of the prostate.
Do all men develop it?
Histological studies indicate that there is no BPH in men under 30 years of age. The prostate begins to grow from the age of 40 years and continues to grow progressively with age, so that at the age of 90 years 88% of the patients present BPH.
The importance of this pathology, which does not seriously compromise the patient’s health but alters his quality of life, is that it is the main cause of consultation with the urologist and the second most frequent surgical intervention in men. This generates a high health care cost that is growing due to the increase in life expectancy.
What symptoms can it cause?
The symptoms of BPH are classified into obstructive or voiding symptoms (weak stream, difficulty in initiating urination, intermittent stream, sensation of incomplete voiding and postvoiding dribbling) and irritative or filling symptoms (pollakiuria, nocturia, urgency and incontinence). All these symptoms, which are included in the clinical picture known as “prostatism”, are not specific to BPH, so the term LUTS is preferred as it is considered more accurate. In fact, these symptoms can also occur in men with normal prostate size and in women.
Does it require treatment?
The goal of treatment is to improve LUTS and therefore the patient’s quality of life, as well as to prevent disease progression and the development of complications and reduce the need for surgery. In general, all patients are recommended lifestyle changes such as avoiding constipation, restricting alcohol consumption, avoiding spicy foods, asparagus, coffee and carbonated beverages, not riding horses, bicycles or motorcycles, regular sexual activity and not drinking fluids at least 2 hours before bedtime. Treatment options include watchful waiting (recommended in patients with mild symptoms IPSS ≦ 7), pharmacological treatment (predominant option in patients with moderate or severe symptoms) or surgery (when there are complications arising from BPH or no response to medication).
What pharmacological treatments are recommended?
There are several types of drugs recommended to treat BPH, alone or in combination: alpha-blockers, 5αreductase inhibitors and antimuscarinics. As for phytotherapy or plant extracts, so widely used in the past, there is no evidence in the literature to support their prescription.
Alpha-blockers (currently the most widely used are Tamsulosin and Silidoxyna) are usually the initial treatment because of their rapid action and good tolerance, although they can cause retrograde ejaculation as a side effect and, on the other hand, they do not modify the natural evolution of BPH.
The 5α-reductase inhibitors (Finasteride and Dutasteride), unlike alpha-blockers, modify the long-term course of BPH, thus reducing the risk of acute urinary retention as well as the risk of developing prostate cancer and the need for surgery. However, they are not free of side effects, mainly in the sexual sphere. Their efficacy is not immediate, as is the case with alpha-blockers, and is related to the initial size of the prostate, so that to be effective they require a minimum prostate volume (generally greater than 40 cc). In any case, they are an option for patients with hematuria or recurrent hemospermia secondary to BPH, and we currently have a commercial presentation that combines Tamsulosin and Dutasteride.
Antimuscarinics, alone or in combination, are recommended in patients with predominant filling symptoms due to bladder hyperactivity, without increasing the incidence of the risk of urinary retention. Phosphodiesterase inhibitors have recently joined the therapeutic arsenal, drugs used to treat the erectile dysfunction that is so prevalent in older men.
In which cases is surgery necessary and what does it consist of?
Surgery is reserved for patients with BPH complications (repeated infections and hematuria, bladder lithiasis, renal failure or urinary retention with impossibility of catheter removal) or for those who do not respond to pharmacological treatment.
The standard treatment is transurethral resection of the prostate and for large prostates (greater than 80-100 cc) open surgery or adenotomy. In recent years, the option of treatment with laser technology is becoming a favorable choice as it avoids one of the usual complications of BPH surgery, post-operative bleeding, and reduces hospital stay, although the cost of the process is higher.