JOHN, a 53-year-old taxi driver, has noticed a change in his urination.

He now makes frequent stops on his route to urinate, and has noted that his urinary stream is slow. He recalls that this has been occurring gradually for about five years.

He remembers being told by a physician that his prostate was enlarged and requires treatment for his bothersome symptoms.

John, likely, has benign prostatic hyperplasia (BPH).

Benign prostatic hyperplasia

BPH is a common condition affecting the prostate gland. It is one of the commonest conditions affecting ageing men, and one of the commonest causes of lower urinary tract symptoms. BPH is typically seen in men age 40 years and older. About 50 per cent of men 50-60 years of age have BPH.

Benign prostatic hyperplasia is simply an enlargement of the prostate gland. The likelihood of being diagnosed with it increases with age. This occurs because the prostate gland continuously grows at a rate of 2-2.5 per cent per year in older men, and the symptoms of BPH are volume-dependent.

It is important to highlight that this condition is not due to cancer and does not increase one’s risk for prostate cancer. This is important to emphasise as many individuals associate diseases of the prostate with cancer.

Whereas prostate cancer is a common condition affecting the prostate and can coexist with BPH, the two are distinct conditions affecting the prostate.

Risk factors

Scientific evidence suggests that there are several risk factors, other than increasing age, for developing benign prostatic hyperplasia.

There appears to be a strong genetic component to BPH risk, as studies have shown associations in families with male relatives. In one particular study, male relatives and brothers of men booked for BPH surgery had a four to six-fold increased risk of subsequently needing BPH surgery later in life.

In addition, some modifiable risk factors affect the natural history of BPH. Increased exercise and physical activity, as well as moderate alcohol intake, appear to reduce the risk of emergence of BPH symptoms and need for BPH surgery. It also appears that increased total energy intake, energy-adjusted total protein intake, red meat, fat, milk and dairy products, cereals, bread, poultry, and starch all potentially increase the risks of clinical BPH and BPH surgery, while vegetables, fruits, polyunsaturated fatty acids, linoleic acid, and vitamin D potentially decrease the risk of BPH.

There is also a link between obesity and BPH. Studies have consistently observed that increased adiposity is positively associated with prostate volume — the greater the amount of adiposity, the greater the prostate volume.

It is likely that inflammation plays a role in the development and progression of BPH as evidenced by the strong links between BPH and histological inflammation in specimens obtained from prostate biopsies and BPH surgery. Physician-diagnosed diabetes, increased serum insulin and elevated fasting plasma glucose have been associated with increased prostate size and increased risk of prostate enlargement, clinical BPH and BPH surgery. There is, however, no link between race and BPH.

Symptoms

The man with BPH may complain of delay in initiating the urine, a weak urinary stream, stopping and starting during urination, straining to urinate, increased frequency of urination — especially at nights — inability to delay urination once there is an urge, or the sensation of incomplete bladder emptying. These symptoms develop slowly over the years, and patients may not necessarily complain until symptoms are severe.

Diagnosis

The diagnosis of BPH can be established by establishing a history of the complaints described before.

A digital rectal examination will also reveal an enlarged prostate, which is smooth in consistency. Objective questionnaires exist, which can also establish the diagnosis and determine severity of the symptoms.

Additional tests may be done, such as urine tests to exclude infections, an ultrasound to determine the size of the prostate, the residual volume of urine after urination and exclude complications.

Kidney function tests and the prostate specific antigen (PSA) blood tests may also be done. The PSA helps to exclude cancer in these men, and kidney function tests exclude kidney failure, which is a risk in one per cent of these patients. Uroflowmetry assesses urine flow objectively, and a cystoscopy visualises the interior of the urethra and bladder with a scope.

Benign prostatic hyperplasia may be treated by medical and surgical means. We will discuss these in the next issue.

Dr Belinda Morrison-Blidgen is a consultant urologist and senior lecturer at The University of the West Indies. Contact her at: Belinda.morrison02@uwimona.edu.jm