Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia Symptoms

Only 40 to 50 percent of men actually develop any symptoms due to BPH. These symptoms may include:

• Weak or intermittent urine flow
• Difficulty starting or stopping urination
• Feeling of being unable to empty the bladder completely
• The need to urinate frequently, especially at night

Diagnosing Benign Prostatic Hyperplasia

The doctor will usually press on and manipulate (palpate) the abdomen and sides to detect signs of kidney or bladder abnormalities. The doctor will also check for signs of anemia or swelling in the legs and arms.

Certain procedures that test reflexes, sensations, and motor response may be performed in the lower extremities to rule out possible neurologic causes of the bladder dysfunction.

There are several tools and examinations the doctor may use to diagnose or rate the severity of your condition, including:

Indexing tool

An indexing tool called the International Prostate Symptoms Score (IPSS) can help evaluate the key lower urinary tract symptoms. Unlike laboratory tests or other objective tests, this scoring system measures the patient's own experience. The higher the s core, the more severe the condition. It is useful for many reasons:

• The patient's score on this test gives a highly accurate assessment of the effect of lower urinary tract symptoms on the quality of a man's life.
• It is a reasonable basis from which the patient and physician can discuss treatment options.
• The index is also often used to gauge treatment outcomes and may be a better indicator of success than objective tests, such as the measurement of the prostate gland or the rate of urine flow.

It should be noted that the IPPS is useful only as a gauge of symptom severity, and has the following limitations:

• Other conditions can produce similar scores, so the test is not used as a diagnostic tool for BPH.
• The index does not include other urinary symptoms, such as dribbling and incontinence or sexual health, which are important for the quality of life. At the very least, the patient should have a frank discussion with his physician if such symptoms are present and affect his life.
• It also does not reflect regional or ethnic differences that can vary the responses to these symptoms.

Digital rectal exam

A finger is placed into the rectum to assess the size of the prostate and to detect any abnormal nodules (lumps) that may require further investigation.

Uroflometry

• The patient is instructed not to urinate for several hours before the test and to drink plenty of fluids so he has a full bladder and a strong urge to urinate.
• To perform the test, a patient urinates into a special toilet equipped with a uroflometer.
• It is important that the patient remains still while urinating to help ensure accuracy, and that he urinates normally and does not exert strain to empty his bladder or attempt to retard his urine flow.

Many factors can affect urine flow (such as straining or holding back because of self-consciousness) so experts recommend that the test be repeated at least twice.

The rate of urine flow is calculated as milliliters of urine passed per second (mL/s). At its peak, the flow rate measurement is recorded and referred to as the Q [max]. The higher the Q [max], the better the patient's flow rate. Men with a Q [max] of less th an 12 mL/s have four times the risk for urinary retention than men with a stronger urinary flow.

The Q [max] measurement is sometimes used as the basis for determining the severity of obstruction and for judging the success of treatments. It is not very accurate, however, for a number of reasons:

• Urine flow varies widely among individuals as well as from test to test.
• The patient's age must be considered. Flow rate normally decreases as men age, so the Q [max] typically ranges from more than 25 mL/s in young men to less than 10 mL/s in elderly men.
• The Q [max] level does not necessarily coincide with a patient's perceptions of the severity of his own symptoms.

Urinalysis

A urinalysis may be performed to detect signs of bleeding or infection. A urinalysis involves a physical and chemical examination of urine. In addition, the urine is spun in a centrifuge to allow sediments containing blood cells, bacteria, and other particles to collect. This sediment is then examined under a microscope.

Although urinary infection is uncommon in younger men, it occurs more frequently in older men, particularly those with BPH. A urinalysis also helps rule out bladder cancer.

Pre- and post- massage test (PPMT)

To rule out prostatitis (inflammation of the prostate), a simple test called the pre- and post- massage test (PPMT) is about 90 percent accurate.

This test requires culture and microscopic examination of urine samples taken before and after massage of the prostate gland. To massage the prostate, the doctor simply inserts a gloved finger into the rectum and presses several times on the prostate. The fol lowing results are indicated by what is seen in the cultures after massage:

• Category II prostatitis (chronic bacterial). Bacteria are found on post-massage.
• Category IIIA prostatitis (inflammatory chronic pelvic pain syndrome). Leukocytes (white blood cells) or other cells are found that indicate inflammation.
• Category IIIB prostatitis (noninflammatory chronic pelvic pain syndrome). No signs of inflammation or bacteria.

Blood tests

In men with symptoms, blood tests are performed to measure a substance called serum creatinine, which is a marker for kidney trouble. Kidney problems exist in an average of 13.6 percent of BPH patients. Studies have reported rates as high as 30 percent and as low as 0.3 percent.

PSA tests for BPH and prostate cancer

A PSA test measures the level of prostate-specific antigen (PSA) in the patient's blood. It is the standard screening test for prostate cancer. A PSA is recommended annually for all men over 50 years old and for men over 40 who are at high risk for prostate cancer.

BPH itself can also raise PSA levels, but the test has generally been optional for men with suspected BPH. One 2000 study indicated that PSA levels may be good predictors of future prostate growth in men with BPH.

In the study, men in the lowest PSA level groups (0.2 to 1.3ng/mL) had prostate growth rates of only 0.7mL per year while those in the high PSA groups (3.3 to 9.9) had growth rates of 3.3 mL per year. Other research has detected a specific molecular form of P SA, which has been termed BPSA because it may be a specific marker for BPH. Such findings could eventually lead to a shift from focusing on symptoms and flow rates for diagnosis to a more specific and possible preventive approach.

Certain treatments for BPH, including the drug finasteride (Proscar) and the surgical procedure transurethral resection of the prostate (TURP), can reduce PSA levels and possibly mask the existence of prostate cancer.

A more recent test identifies so-called free PSA, which is found in lower levels when prostate cancer is present and in higher levels with BPH. This may be more accurate than total PSA, regardless of whether a man is taking finasteride or not.

Postvoid residual urine

One of the important subjects of tests for urinary incontinence is the postvoid residual urine volume (PVR), the amount of urine left after urination. Normally, about 50 mL or less of urine is left; more than 200 mL is a definite sign of abnormalities. Measur ements in between require further tests.

The most common method for measuring PVR is with a catheter, a soft tube, which is inserted into the urethra within a few minutes of urination. PVR can also be measured using transabdominal ultrasonography.

Ultrasound

Ultrasound of the prostate does not require a catheter and gives an accurate picture of the size and shape of the prostate gland. Ultrasound is very beneficial when planning surgery as well as determining treatment options and gauging their effectiveness.

Ultrasound may also be used for detecting kidney damage, tumors, and bladder stones. Ultrasound tests of the prostate generally use one of two methods:

• Transrectal ultrasonography (TRUS) uses a rectal probe for assessing the prostate. TRUS is significantly the most accurate method for determining prostate volume. It can sometimes detect cancer.
• Transabdominal ultrasonography uses a device placed over the abdomen. It can give an accurate measure of postvoid residual urine and is less invasive and expensive than TRUS.

Filling cystometry

Filling cystometry, also called cystometography, is used for patients who cannot urinate and in whom nerve damage or injury of the bladder is suspected.

The test is used to determine the absence or presence of a condition called uninhibited detrusor contractions (UDC), which often occurs in men with storage urinary tract symptoms.

The detrusor is the group of muscle fibers that cover the outside of the bladder. The test does not add much information to results from less invasive tests and is not used routinely. For this procedure:

• The patient is usually lying down and is told to remain as relaxed as possible.
• Sterile water (usually at body temperature) is instilled into the bladder and the pressure in the bladder is continuously measured.
• The patient informs the physician about sensations experienced, and when the urge to urinate is strong, this portion of the test is stopped.
• A fluid-inflatable balloon is inserted into the rectum for a second measurement. This reflects abdominal pressure.
• A calculation is then made using the measurements of abdominal and bladder pressures. The result provides an accurate assessment of detrusor contractions.
• If results are uncertain, the test may be repeated to provoke bladder response by having the patient stand, by increasing the speed of the filling time, or by using ice-cold water.

Urethrocystoscopy

A urethrocystoscopy, also called cystourethroscopy, may be performed in men diagnosed with BPH, particularly if they are surgical candidates or if other urinary tract problems are suspected.

Such problems include blood in the urine, infection, bladder cancer, or prior surgery or injury. The physician can determine the presence of a number of problems, including enlargement of the prostate, obstruction of the urethra or neck of the bladder, anatom ical abnormalities, or the presence of stones.

In this procedure, a flexible or rigid fiberoptic tube (an endoscope) is inserted into the urethra to allow doctors to view the lower urinary tract. The procedure is not without risks. Complications are uncommon but can include allergic response to anesthetic , urinary tract infection, bleeding, and urine retention.

Intravenous excretory urography

An x-ray called an intravenous excretory urography (IVU) is an invasive test that is used only when complications in the upper urinary tract, particularly in the kidney, are suspected. Abdominal ultrasound plus a normal x-ray may be as useful as IVU for most patients with suspected upper tract problems.

If there is any danger of kidney failure, the test should not be performed since it can exacerbate the condition. Severe side effects of the test occur in 0.1 percent of patients.

Benign Prostatic Hyperplasia Treatment

Mild cases of BPH usually require no treatment. A variety of treatments are available for moderate to severe cases, including medications, minimally invasive therapy, and conventional surgical therapy.

Urologists at UPMC provide expert diagnosis and treatment of BPH, specializing in the following treatments:

• Transurethral needle ablation (TUNA) is a simple, safe, and relatively inexpensive procedure for the treatment of BPH. The procedure usually requires only a local anesthetic. The urologist inserts a catheter into the urethra. The catheter sends out small need les into the obstructing prostate tissue. The needles give off high-frequency radio waves that heat and destroy the tissue. Clinical studies have shown that TUNA provides excellent relief of symptoms and minimal side effects.
• Transurethral resection of the prostate (TURP) is the most common surgical procedure for treating BPH. The operation involves the removal of part of the prostate gland surrounding and constricting the urethra. The urologic surgeon passes a narrow tool with a wire loop on the end into the penis and through the urethra to the prostate gland. Electricity is then passed through the wire to heat it and cut the obstructing prostate tissue.

For patient referral or consultations, contact the Department of Urology at 412-692-4100.