With sustained improvements in lifestyle, disease prevention, and medical therapies, Americans are living longer. By the year 2020, the number of people now over the age of 60 years is expected to triple. Consequently, diseases and illnesses that are primarily seen in elderly people are becoming more prevalent. One that affects older men is benign prostatic hyperplasia, which is usually referred to by its initials BPH and is commonly known as “enlarged prostate.”
What Is the Prostate?
The prostate is a walnut-sized gland found deep in the pelvis in men. It is located just under the bladder and surrounds a tube (urethra) through which urine exits when we urinate. The prostate is rich in nerves and muscle. The function of the prostate is not clearly understood, though it produces 20% of the fluid found in the semen and other substances that are thought to help sperm survive and make penetration easier during sexual intercourse. However, these substances are not essential for fertility. In addition, the prostate is a source of other hormones and enzymes, but these are also not crucial for men to stay healthy. It is common for our prostates to enlarge as we age. Because of where the prostate is located, men may experience problems with urination as it enlarges.
At What Age Is BPH Likely?
It is difficult to know how many men have BPH because we as men often do not have symptoms even though our prostates have enlarged. However, estimates have been made based on examining a representative sample of men in the Untied States:
- Over 30% of men in their 50s- and 46% of men in their 70s have moderate to severe BPH.
- In men who have had their bladder function tested, over half have diminished rates of urinary flow or are unable to fully empty their bladder.
- More than one in three Caucasian men over the age of 50 may have some symptomatic BPH.
- In European men, it has been estimated that 24% aged 50-59 and 40% aged 70-79 have symptoms of BPH.
As a prostate enlarges, it goes through three different stages:
- Microscopic (small areas of the prostate are enlarged that can only be detected using a microscope)
- Macroscopic (larger areas are seen under a microscope and felt on rectal examination)
- Symptomatic (causing changes in urinary habits).
As BPH continues to progress, the microscopic areas can increase in size and stimulate certain prostate cells to grow, leading to the development of the next stage: macroscopic BPH. During this stage of enlargement, there is significant growth as well as distortion of your prostate. You may or may not have symptoms, but at this stage your doctor will be able to tell if your prostate is enlarged during a rectal examination.
BPH is considered to be in its final stage when you develop symptoms, most likely difficulty urinating. You may also experience symptoms related to other disorders common in older men, such as those caused by decreased blood supply to the prostate, inflammation or infection of the prostate, and cancer of the prostate.
The progression of BPH is related to age. BPH begins as early as 25-30 years of age in 1 out of 10 men. As we age, the presence of the first stages of BPH (microscopic BPH) increases progressively. And although the size of the prostate increases with age, the rate of growth slows down the older we get. For this reason, only 1 out of 4 men who have microscopic BPH go on to develop symptoms.
What Exactly Are the Symptoms of BPH?
The symptoms of an enlarged prostate -- generally called "prostatism" -- are thought to result from several factors. The prostate surrounds the tube (urethra) that goes from the bladder to the penis, and as the prostate enlarges, it may squeeze this tube. If your urethra becomes partially or completely blocked, you will typically experience one or more of the following symptoms:
- difficulty initiating urination
- decreased force of the urinary stream
- dribbling of urine at the end of the stream
- straining to urinate
- complete inability to urinate, also known as retention. (Urinary retention is often very painful and dangerous because it can result in a backward flow of urine, which can put pressure on the kidneys. Pressure on the kidneys can result in kidney failure, requiring immediate medical treatment.)
- painful urination
- urgency to void
- frequent urination during the day or at night
Individual patients will suffer from different symptoms because of the differences in how the prostate has enlarged and how much pressure it is putting on the urethra. And although these symptoms are typical of BPH, they may be caused by a completely different problem (like infection of the prostate or bladder) that only your doctor can determine.
If you have BPH, the particular symptoms you are experiencing and how they are affecting your quality of life are important in determining the most appropriate therapy for you. Clinicians are faced with the challenge of documenting these symptoms, in order to develop correlations between symptoms and the severity of BPH. A standard symptom questionnaire known as the American Urological Association (AUA) Symptom Index has been developed to assess specific symptoms and determine the severity of the BPH. This survey may be given to you and you will be asked questions about your symptoms within the last month, such as frequency of nighttime urination (nocturia), incomplete emptying, starting and stopping while urinating, hesitancy before urinating, inability to postpone urination, decreased force of stream, and the need for straining. Depending on your score, your BPH would be considered as mild, moderate, or severe. A total score of 0-7 would reflect mild symptoms; 8-19 would reflect moderate symptoms; and 20-35 would reflect severe symptoms.
As mentioned above, it is important for you to know that symptoms commonly associated with an enlarged prostate can also be produced by age-related changes in bladder muscle tone and by other things unrelated to urinary flow obstruction caused by BPH. In fact, many older women have AUA Symptom Scores in the moderate-to-severe range. Nevertheless, the survey is still useful when used as part of your doctor’s overall assessment.
Symptoms of BPH can also vary with time. In a 2-year study, 26% of the men with no urinary symptoms developed some problem with urination within the first year. Of men with moderate symptoms, 34% to 41% worsened, and approximately 36% improved. Almost 50% of men with severe symptoms spontaneously improved on their own to some degree over the first year. However, although symptoms may vary with time, men with moderate to severe symptoms are not as likely to improve that much.
How Dangerous is BPH?
If left untreated, symptomatic BPH may cause serious injury and even death. Bacteria in the urine are found in 9% of men with symptomatic BPH. Decreased kidney function is found in 7% of men at the time of surgical treatment for BPH. If your bladder becomes completely obstructed by an enlarged prostate, you may experience urinary retention or inability to urinate, which may result in kidney failure. In fact, 25% of acute kidney failure patients requiring hospitalization had failure related to urinary obstruction, with 14% of these men having BPH as the cause of obstruction. Another complication of BPH is bladder stones, which occur in 3.4% of men over the age of 60 compared to only 0.4% of men without BPH (similar to women at 0.3%).
Mortality from BPH is most commonly related to kidney failure, infection, and complications of surgery. The mortality rate for BPH is the United States was 3 patients per 1,000,000 in the period between 1985-1989, substantially lower than the 1950s when the mortality rate was 7.5 per 100,000. This improving trend has been noted worldwide with few exceptions and is occurring despite the fact that there are greater numbers of older men alive today.