As men get older, problems urinating become more common. Up to 90 percent of men aged 45-80 suffer from some form of urination difficulty.1 These symptoms include irritative or frequent urination (going to the bathroom too often), urgency (the sudden desire to rush to the bathroom), nocturia (waking at night to urinate), and dysuria (a burning sensation during urination). Other symptoms include obstructive urination (feeling like the urine flow is weak), intermittency (the urinary stream keeps starting and stopping), and hesitancy (standing for a long time before the urine stream begins).2 While these symptoms can often be a source of distress to men because of fear of bladder or prostate cancer, they are commonly due to a benign condition called benign prostatic hyperplasia (BPH).3 Discuss these problems with your family physician, who sees these problems often and can determine if they are related to BPH or more worrisome problems. Your doctor can also initiate therapy to alleviate the symptoms.

Benign Prostatic Hyperplasia (BPH) – Causes and Effects

Prostate growth and development largely depend upon hormones, primarily testosterone. In the prostate gland, the testosterone is converted to a highly potent hormone called dihydrotestosterone (DHT).4 Think of DHT as a highly nutritious power bar for the prostate gland. Prostate gland cells undergo a constant cycle of growth followed by death and replacement. When you’re younger, DHT helps the prostate grow and develop but as you get older, prostate cell growth sometimes exceeds cell death and this can cause the gland to grow bigger. The prostate sits below the bladder and when urine that is stored in the bladder is emptied it has to pass through a channel (the urethra), which is surrounded by the prostate. The bladder is, in fact, a large muscular pump that relaxes to store urine and contracts to empty urine. As the prostate enlarges, the urethra channel becomes more narrow and the bladder pump has to work harder to empty urine.4,5 Initially, the pump compensates by getting stronger. However, over time, the pump cannot compensate. When that happens, the irritative and obstructive symptoms described above become more bothersome and the bladder may not be able to empty all of the urine.

What symptoms should I watch out for that may be due to BPH?

  • Irritative voiding symptoms
    – Frequency – going to the bathroom to urinate very often
    – Urgency – sudden compelling desire to urinate
    – Nocturia – waking up at night to urinate frequently
    – Dysuria – burning pain when urinating
  • Obstructive voiding symptoms
    – Sense of incomplete emptying – at the end of urination, it still feels like there is more in the bladder
    – Hesitancy – standing for a long time before the start of urination
    – Intermittency – urine stream keeps starting and stopping
    – Double voiding – immediately after finishing urinating, you have to urinate again
  • Blood in the urine

Other Effects Of BPH

  • Recurrent urinary tract infections
  • Blood in the urine and bleeding
  • Bladder stones – calcifications that grow inside the bladder and irritate the bladder wall
  • Acute urinary retention – sudden inability to urinate
  • Kidney failure – over time, when the bladder contracts and squeezes against the obstruction from the prostate gland, the urine that cannot pass the obstruction can get pushed backwards up into the kidneys, leading to the devastating complication of kidney failure. (Kidneys normally filter urine and clear toxins from the body).

What Should I Do If I Am Having Difficult Or Bothersome Urination?

  • See your doctor – An assessment by your doctor is imperative. Your physician can help determine if BPH is the culprit causing difficulties with urination or if the symptoms are from other causes.
  • Diet modification – Certain substances can exacerbate urinary symptoms by irritating the bladder; avoiding these substances can often help alleviate symptoms. These substances include:
    – Caffeine – coffee/tea/soda pop
    – Spicy foods
    – Foods with high citrus content
  • Lifestyle modifications
    – Avoiding fluid intake less than one hour before bedtime can help decrease waking up at night to urinate.
    – If you are on a diuretic, discuss with your doctor about taking it during the daytime and not in the evening.

What Treatment Options Are Available For BPH?

  • Conservative management – If symptoms are not too bothersome, one option is to periodically get reassessed by your doctor and just watch and wait. If symptoms start getting worst, then opt for treatment at that time.
  • Medications:
    – Various medications have shown efficacy in treating BPH
    – Alpha blockers – These medications work to relax the smooth muscle in the bladder neck and prostate. Examples include tamsulosin (Flomax), alfuzosin (Uroxatral), doxazosin (Cardura), terazosin (Hytrin) and silodosin (Rapaflo). A study of 3,000 men with BPH treated with an alpha blocker showed an improvement in symptoms and an increased flow rate of urine.6 Side effects of these medications include retrograde ejaculation (during ejaculation, semen shoots backwards into bladder instead of forwards), dizziness, low blood pressure, fatigue and nasal congestion. Be sure to let your doctors know if you plan to undergo cataract surgery as these medications can affect this surgery.
    – 5-alpha reductase inhibitors (5-ARI) – This class of medication prevents the conversion of testosterone into the more potent hormone DHT and helps to shrink the prostate gland. Finasteride (Proscar) and dutasteride (Avodart) belong to this class of medications. Maximum improvement in symptoms may take from six to nine months. Known benefits of these medications shown in studies include a 20-percent reduction in prostate volume, a 10% increase in urinary flow rate, improvement in symptoms and a decrease in disease progression. Side effects include decreased libido, impotence, decreased volume of ejaculate and gynecomastia (breast enlargement).7
    – Combination therapy – Alpha blockers can be combined with 5-ARI. Studies have shown this is most effective especially for larger prostate glands. The risk of acute urinary retention and need for subsequent surgery is reduced the most by using combination treatments.6,8,7
    – Anticholinergics – If you’re having a lot of irritative symptoms with urination, adding an anticholinergic such as oxybutynin (Ditropan), solifenacin (Vesicare), fesoterodine (Toviaz), or trospium (Sanctura) to the other medications for BPH can help. Side effects include dry mouth, dry eyes, constipation, blurry vision, increased or decreased heart rate, as well as confusion.9-11 Check with your doctor to see if this drug is appropriate for you as it may worsen urinary retention!
    – Phosphodiesterase inhibitors (PDE5 inhibitors) – Tadalafil (Cialis), a drug used to treat erectile dysfunction, has been approved for use in Canada in men with erectile dysfunction and voiding problems. Studies have shown improvement in BPH-related quality of life, erectile function and voiding symptoms.12-14 Men with known heart disease must speak to their doctor, because these medications are dangerous when taken with nitroglycerin.
    – Phytotherapies – Natural remedies such as saw palmetto, African plum, stinging nettle and African star grass have been used in the treatment of BPH. The data with respect to efficacy is lacking and the American Urological Association (AUA) guidelines currently do not recommend treatment of BPH with phytotherapy.3,15,16
  • Surgery
    – If medications are not able to help with the condition, there are numerous surgical options. Some options are minimally invasive, including transurethral microwave therapy (TUMT) and transurethral needle ablation (TUNA). More invasive options include transurethral resection of the prostate (TURP) or laser prostatectomy. Finally, open surgery can also be done in select cases.17-19 By the time surgical therapy is required, a thorough discussion about the options with your urologist can help you choose the best treatment for your situation.

BPH is a common condition affecting men and typically gets worse with age. Numerous treatment options are available to relieve symptoms and prevent disease progression. The most important first step is to meet with your doctor and come up with a diagnostic and therapeutic plan. BPH is problematic but does not need to be a permanent problem.

References:

  1. McVary KT: BPH: epidemiology and comorbidities. Am. J. Manag. Care 2006; 12: S122-8.
  2. Oelke M, Bachmann A, Descazeaud A, et al: Guidelines on the Treatment of Non-neurogenic Male LUTS.
  3. AUA Education and research: American Urological Association guideline: management of benign prostatic hyerplasia. 2010. Available at: https://www.auanet.org/education/guidelines/benign-prostatic-hyperplasia.cfm, accessed February 12, 2017.
  4. Barry MJ, Fowler FJJ, Bin L, et al: The Natural History of Patients With Benign Prostatic Hyperplasia as Diagnosed by North American Urologists. J. Urol. 1997; 157: 10–15.
  5. Jacobsen SJ, Jacobson DJ, Girman CJ, et al: Natural History of Prostatism: Risk Factors for Acute Urinary Retention. J. Urol. 1997; 158: 481–487.
  6. McConnell JD, Roehrborn CG, Bautista OM, et al: The Long-Term Effect of Doxazosin, Finasteride, and Combination Therapy on the Clinical Progression of Benign Prostatic Hyperplasia. N. Engl. J. Med. 2003; 349: 2387–2398.
  7. Roehrborn CG, Siami P, Barkin J, et al: The Effects of Dutasteride, Tamsulosin and Combination Therapy on Lower Urinary Tract Symptoms in Men With Benign Prostatic Hyperplasia and Prostatic Enlargement: 2-Year Results From the CombAT Study. J. Urol. 2008; 179: 616–621.
  8. Roehrborn CG: BPH progression: concept and key learning from MTOPS, ALTESS, COMBAT, and ALF-ONE. BJU Int. 2008; 101: 17–21.
  9. Abrams P, Kaplan S, De Koning Gans HJ, et al: Safety and Tolerability of Tolterodine for the Treatment of Overactive Bladder in Men With Bladder Outlet Obstruction. J. Urol. 2006; 175: 999–1004.
  10. Kaplan SA, Roehrborn CG, Dmochowski R, et al: Tolterodine extended release improves overactive bladder symptoms in men with overactive bladder and nocturia. Urology 2006; 68: 328–332.
  11. Kaplan SA, Walmsley K and Te AE: Tolterodine extended release attenuates lower urinary tract symptoms in men with benign prostatic hyperplasia. J. Urol. 2005; 174: 2273–2276.
  12. CARSON CC: Combination of phosphodiesterase-5 inhibitors and alpha-blockers in patients with benign prostatic hyperplasia: treatments of lower urinary tract symptoms, erectile dysfunction, or both? BJU Int. 2006; 97: 39–43.
  13. Gacci M, Andersson K-E, Chapple C, et al: Latest Evidence on the Use of Phosphodiesterase Type 5 Inhibitors for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. Eur. Urol. 2016; 70: 124–133.
  14. Laydner HK, Oliveira P, Oliveira CRA, et al: Phosphodiesterase 5 inhibitors for lower urinary tract symptoms secondary to benign prostatic hyperplasia: a systematic review. BJU Int. 2011; 107: 1104–1109.
  15. Tacklind J WT: Cochrane Database of Systematic Reviews Serenoa repens for benign prostatic hyperplasia (Review) www.cochranelibrary.com Serenoa repens for benign prostatic hyperplasia (Review). Cochrane Database Syst. Rev. Art 2012.
  16. Dedhia RC and McVary KT: Phytotherapy for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. J. Urol. 2008; 179: 2119–2125.
  17. Blute ML, Tomera KM, Hellerstein DK, et al: Transurethral microwave thermotherapy for management of benign prostatic hyperplasia: results of the United States Prostatron Cooperative Study. J. Urol. 1993; 150: 1591–6.
  18. Hoekstra RJ, Van Melick HHE, Kok ET, et al: A 10-year follow-up after transurethral resection of the prostate, contact laser prostatectomy and electrovaporization in men with benign prostatic hyperplasia; long-term results of a randomized controlled trial. BJU Int. 2010; 106: 822–826.
  19. Wasson JH, Reda DJ, Bruskewitz RC, et al: A Comparison of Transurethral Surgery with Watchful Waiting for Moderate Symptoms of Benign Prostatic Hyperplasia. N. Engl. J. Med. 1995; 332: 75–79.