Health and Prostate

The most common sequelae of benign prostatic hyperplasia (BPH) include lower urinary tract symptoms (LUTS), such as hesitancy, interrupted weak urine stream, urgency and leaking or dribbling, and more frequent urination, especially at night (Table 1). The size of the prostate does not always correlate to the severity or range of symptoms. Some men with greatly enlarged glands have little obstruction and few symptoms, whereas other men whose glands are less enlarged have more blockage and increased symptoms. It is also possible that some men may not demonstrate any symptoms until there is severe partial or complete obstruction, known as acute urinary retention. This condition can prevent the patient from voiding at all and usually requires immediate attention. In general, however, BPH progresses very slowly and acute urinary retention is uncommon. Men with benign prostatic hyperplasia who are at highest risk for this complication tend to be elderly and tend to have moderate-to-severe LUTS. Acute urinary retention can result from taking over-the-counter cold medications, allergy medicines, antihypertensive drugs, or antiarrhythmics. Other causes of acute urinary retention include ingestion of alcohol, exposure to cold temperatures, and prolonged periods of immobility. Benign prostatic hyperplasia left undiagnosed and untreated can lead to urinary retention, urinary tract infections, cholelithiasis, and overflow urinary incontinence. If the bladder is permanently damaged, treatment for BPH may be ineffective.

A number of structural or medical conditions, either independently or in conjunction with BPH, can cause LUTS. Such conditions can produce obstruction, impair or weaken the detrusor muscles surrounding the bladder, or cause other damage that impacts the urinary tract.

The normal aging process weakens the detrusor muscles that surround the bladder, which causes the bladder to become unstable and lose capacity. Unstable detrusor muscles may also impair bladder storage capacity, which then produces irritative or storage symptoms. There are also indications that as men get older they produce more urine at night.

Chronic bacterial prostatitis can mimic signs and symptoms of benign prostatic hyperplasia. This condition may persist for weeks or months with low-grade symptoms, including an urgent need to urinate, frequent urination, and the need to urinate at night. Pain may occur in the lower back or rectum, or it may develop after ejaculation. A urine culture should always be taken, which, in the case of both acute and chronic bacterial prostatitis, will reveal bacteria and confirm a diagnosis. Antibiotics such as fluoroquinolones and trimethoprim-sulfamethoxazole are usually effective in managing chronic bacterial prostatitis.

Nonbacterial prostatitis and prostatodynia are more difficult to diagnose differentially from benign prostatic hyperplasia because there is no evidence of bacterial contamination. Treatment is usually aimed at symptom relief.

On occasion, prostate cancer can mimic BPH, since both conditions may cause obstruction of the urethra. Because benign prostatic hyperplasia causes prostate enlargement, men are often concerned that it may be related to prostate cancer. Current evidence indicates that prostate enlargement is not indicative of prostate cancer. The two conditions develop in different parts of the prostate; BPH occurs in the inner transition zone of the prostate, while cancer tends to develop in the peripheral outer zone. Unsuspected prostate cancer is detected during surgery in about 15% of benign prostatic hyperplasia patients, but the risk of this slow-growing cancer is high in all older men.

Bladder cancer can sometimes cause urinary bleeding, frequency of urination, or a sense of urgency — these symptoms are also consistent with a BPH presentation. Diseases that affect the central nervous system, such as diabetes, multiple sclerosis, and shingles, can desensitize the nerves so that they fail to sense fullness and do not trigger the contraction of the bladder. Bladder obstruction can also cause bladder stones, blood in the urine, urinary tract infection, and incontinence. Unfortunately, at this time no tests are available that can accurately predict which men are at higher risk than others for these complications, although men with a weak urine stream and larger prostates are at higher risk for urinary retention.