BPH and its progression: what should we know?

Key Takeaway Points 

• BPH: BPH symptoms arise from resistance to urinary outflow.
• Progression of BPH: BPH is progressive: worsening symptoms over time with increased age and prostate volume.
• Treatment Options: Lifestyle modifications may help mild cases while medical therapy or surgical interventions could be needed for moderate-severe cases.
• Reducing Progression Risk: Initiating early treatment in patients at risk of progression could help them to reduce risk of acute urinary retention and need for BPH surgery.

Welcome back! In the last article, we discussed benign prostatic hyperplasia (BPH) and prostate cancer. In this article, we will dive deeper into the disease progression of BPH, how to reduce the risk of BPH disease progression, and the need for BPH-related surgery. 

Figure 1: BPH vs normal prostate

Two mechanisms: Static and Dynamic ^[1]

Two types of mechanisms cause the main reasons behind BPH symptoms: static and dynamic mechanisms. Both of which are responsible for urinary flow resistance.

BPH as a progressive disorder

BPH is a progressive disorder that is not life-threatening but has a negative impact on a patient's life. Disease progression is when clinical symptoms of the disease intensify over time without any medical intervention. The disease progression in BPH includes:

1. Worsening disease-specific symptoms such as straining, hesitancy, urgency, incomplete emptying and quality of life.
2. Lower urine flow rates over time.
3. Increase in prostate volume.
4. Consequences such as the need for surgery to treat acute urine retention (AUR) or other symptoms.

Although BPH is a progressive disease, certain risk factors increase the chances of disease progression in some patients. The main risk factors for BPH progression are age, PSA level, and prostate volume. 

• Olmsted County study concluded that age increases the risk of acute urinary retention (AUR) in BPH patients.

Therefore, it is possible to identify a group of patients at higher risk of disease progression and start early preventive treatment for them [2,5].

Clinical symptoms and diagnostic tests ^[3]

Treatment options for symptomatic BPH 

Lifestyle modifications

In mild cases, the patients' symptoms can be managed without medical intervention. Therefore, lifestyle modifications are highly recommended for these patients. They should reduce water intake at night or before going out and limit the consumption of alcohol and caffeinated beverages, as these can increase the urge to urinate [4].

Medical and Surgical Intervention

Medical therapies include medications such as α1-blockers which relax prostate smooth muscles and 5-alpha-reductase inhibitors which reduce prostate size or combination of the two based on clinician's assessment. Furthermore, patients may be recommended surgical options for prostate size reduction or removal of part or in full prostate based on their clinical status. Surgical options are now available as daycare and through minimally invasive approaches [1].

Reducing the risk of progression

With consequences such as AUR and the need for surgery, it is important to take into account the risk of BPH progression and implement treatment plans to reduce the risk of further disease progression. Hence, physicians must accurately and quickly identify the group of patients at high risk of disease progression and suggest treatment plans accordingly to avoid BPH disease progression among such groups [5]. Age, PSA levels, and prostate volume are the key risk factors for BPH progression.

Medication intervention represents an effective approach to mitigating the need for surgeries and the progression of diseases. Specifically, 5-α-reductase inhibitors have gained recognition for their capacity to improve the bothersome symptoms associated with benign prostatic hyperplasia (BPH), such as LUTS [6].

In conclusion, BPH is a progressive disease and certain patients are at high risk of experiencing disease progression. However, there are medical interventions such as finasteride available which are proven to decrease BPH disease progression when given at an early stage. Therefore, physicians must be able to identify patients with higher chances of progression and start immediate medical treatment to avoid the need for surgery. 

List of Abbreviations

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Reference 

1. Unnikrishnan R, Almassi N, Fareed K. Benign prostatic hyperplasia: Evaluation and medical management in primary care. Cleve Clin J Med [Internet]. 2017 Jan 1 [cited 2024 Jan 1];84(1):53–64. Available from: https://www.ccjm.org/content/84/1/53

2. Emberton M, Andriole GL, De La Rosette J, Djavan B, Hoefner K, Vela Navarrete R, et al. Benign prostatic hyperplasia: a progressive disease of aging men. Urology. 2003 Feb 1;61(2):267–73. Available from https://www.goldjournal.net/article/S0090-4295(02)02371-3/abstract 

3. MEDICAL MANAGEMENT OF SYMPTOMATIC BENIGN health technology assessment. [cited 2023 Sep 17]. Available from: https://www.moh.gov.my/moh/resources/auto%20download%20images/587f118ec4d43.pdf 

4. Management of Non-neurogenic Male LUTS - DISEASE MANAGEMENT - Uroweb [Internet]. [cited 2024 Aug 8]. Available from: https://uroweb.org/guidelines/management-of-non-neurogenic-male-luts/chapter/disease-management

5. Roehrborn CG. Reducing the Risk of Benign Prostatic Hyperplasia Progression. Rev Urol [Internet]. 2002 [cited 2024 Jan 4];4(Suppl 5):S29. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1476011/ 

6. Kim EH, Brockman JA, Andriole GL. The use of 5-alpha reductase inhibitors in the treatment of benign prostatic hyperplasia. Asian J Urol [Internet]. 2018 Jan 1 [cited 2024 Jan 4];5(1):28. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5780290/#:~:text=Thus%2C%205%2Dalpha%20reductase%20inhibitors,of%20BPH%E2%80%94finasteride%20and%20dutasteride. 

Written by

Tasnim Jaman Raisa