Symptoms
Benign hyperplasia of the prostate is a typical and chronic age-related condition in men. Approximately 50% of men over 50 and 80% of men over 80 are affected. The incidence and symptoms increase with age. Age is therefore the most important risk factor. The clinical symptoms are also called “benign prostatic syndrome”, because the term hyperplasia only describes the tissue change in the prostate, which can also remain asymptomatic. Possible symptoms include:
- Urinary urgency
- Delay in the onset of bladder emptying
- Pressing to initiate the flow of urine
- Weak urine stream
- Interruptions in the flow of urine, urinary stuttering.
- Pain and burning during urination
- Feeling of an incompletely emptied bladder
- Post-drip, overflow or urge incontinence.
- Frequent urination during the day and at night.
The severity and progression can be assessed with a questionnaire. Used is the IPSS (International Prostate Symptom Score), which divides patients into a group with mild, moderate and severe symptoms, respectively. Potential complications and consequences of untreated BPH include sleep disturbances, anxiety, reduced quality of life, erectile dysfunction, and acute urinary retention, urinary tract infections, blood in the urine, and kidney disease.
Causes
The cause of the listed symptoms is considered to be the progressive increase in the epithelial and stromal cells of the prostate (= hyperplasia), resulting in increased compression of the urethra and an increase in muscle tone in the prostate and bladder neck. It is important to understand that neither hyperplasia, nor enlargement necessarily results in symptoms. The etiology has not been fully elucidated, and hormonal changes in aging men are among the factors discussed.
Diagnosis
Primary diagnosis is usually made by the primary care physician, who refers the patient to the urologic specialist for further diagnosis and therapy. Possible differential diagnoses include hyperactive bladder, uncontrolled diabetes mellitus, heart failure, urinary tract infections, bladder cancer, prostate cancer, prostatitis, and urethral stricture. Since some of these are serious conditions, patients should not self-diagnose or self-treat; instead, it is advisable to seek medical supervision and treatment for prostate symptoms. Numerous medications can trigger or exacerbate symptoms: Antidepressants, anticholinergics, 1st-generation antihistamines, opioids, sympathomimetics, and diuretics.
Nonpharmacologic treatment
Physician-prescribed and controlled watchful waiting is recommended for patients with mild symptoms. Various minimally invasive to invasive methods are available for surgical removal of prostate tissue, such as transurethral prostatic resection, Greenlight laser vaporization, laparoscopic or open prostate enucleation.
Drug treatment
Alpha blockers: this group of drugs includes alfuzosin (Xatral, generic), tamsulosin (Pradif T, generic), terazosin (Hytrin BPH), and silodosin (Urorec). Alpha blockers are approved for the treatment of functional symptoms of benign prostatic hyperplasia. Their action is based on competitive and selective inhibition of the α1-adrenoreceptors and relaxation of smooth muscle in the prostate and urethra. This increases urinary flow, improves urination and filling symptoms. The effects are rapid, unlike 5alpha-reductase inhibitors. Alpha blockers are sympatholytics and can lower blood pressure, resulting in palpable heartbeats, dizziness, weakness, and rarely, brief unconsciousness as adverse effects. Other agents in this group, such as doxazosin or prazosin, are therefore also used to treat hypertension. Tamsulosin and silodosin are selective for the α1A receptor and are thought to cause fewer cardiovascular side effects. 5alpha-reductase inhibitors: finasteride (Proscar, generic) and dutasteride (Avodart) are commercially available in many countries. Both agents inhibit 5alpha-reductase, which converts testosterone to 5α-dihydrotestosterone. 5α-Dihydrotestosterone is an important growth stimulus for prostate enlargement.The newer dutasteride inhibits not only type 2 but also type 1 5alpha-reductase and is a more potent inhibitor of the enzyme than finasteride. The drugs reduce the size of the prostate within 3-6 months, relieve symptoms and improve urinary flow. Thus, clinical improvement of symptoms does not occur immediately, but only after a long period of therapy. Unlike alpha blockers, they can affect the clinical course. The most common adverse effects include sexual dysfunction such as impotence, decrease in libido, ejaculation disorders, and enlargement of the mammary gland. The agents lower serum PSA levels by approximately 50%, which should be considered in prostate cancer screening with PSA determination. Combination drugs:
- See under dutasteride tamsulosin.
Other:
- Flavoxate (urispas)
- Phosphodiesterase-5 inhibitors such as tadalafil (Cialis).
Herbal therapy
Extracts from the fruits of saw palmetto (, for example, Prostagutt, Prostasan, Sabcaps) are among the most popular herbal medicines for this indication. They are well tolerated except for digestive problems and hardly any precautions need to be taken. There are drugs on the market that need to be taken only once a day. However, efficacy is controversial in the scientific literature (see, e.g., Tacklind et al., 2012). Nettle root extract (, e.g., Valverde prostate uno, combination preparations) have diuretic properties. Possible adverse effects include digestive discomfort. Extracts from pumpkin seeds (e.g., Granufink) are taken twice daily and are usually well tolerated as herbal remedies. Extracts from the bark of the African plum tree (, prostatonin, tadenan) are taken twice daily. Possible adverse effects include indigestion. Extracts from rye pollen are registered as medicines in many countries, but are no longer marketed. Cernilton is off the market. They should not be taken as a precaution for pollen allergy; possible adverse effects include digestive discomfort and allergic reactions. Willowherb tea is a popular medicine in folk medicine.
