BPH and Prostate Cancer Deconstructed: Essential Knowledge for HCPs

Overview

Benign prostatic hyperplasia (BPH), also known as prostate gland enlargement, is a medical condition characterised by the non-malignant enlargement of the prostate gland. This condition primarily affects men aged 60 and older. Prostate enlargement can result in various lower urinary tract symptoms (LUTS) as it compresses the urethra, which lies between the prostate. In contrast, prostate cancer is a malignant condition that arises from uncontrolled cell division in prostate cells, eventually forming a tumour. Early detection of prostate cancer is essential to prevent its spread to other parts of the body (1,2).

Table 1: Definition of BPH and Prostate Cancer

Figure 1: Difference between normal and enlarged prostate

Prevalence

Around 94.0 million men are affected by BPH. It is one of the leading problems that affects approximately one-third of men aged 50 and above (3). According to the Ministry of Health Malaysia, 2002, about 50% of Malaysian men experience BPH by the time they reach 60 years of age (4). On the other hand, prostate cancer is the 4th most common cancer in the world, with 1.4 million new cases reported in 2020 alone. In the context of Malaysia, prostate cancer is the third most prevalent cancer, with a lifetime risk of 1 in 117 males (5, 6). It is safe to say that both BPH and prostate cancer are among the top health challenges faced by men worldwide.

Figure 2 : BPH and prostate cancer worldwide prevalence.

What may cause BPH & prostate cancer?

Causes of BPH

• Ageing: Hormonal changes with age, such as increased dihydrotestosterone (DHT) and oestrogen levels, can lead to prostate enlargement.

• Obesity and Diabetes: Long-term obesity and diabetes can affect hormonal changes in the body and contribute to BPH (7).

Causes of prostate cancer

• Genetic Mutations: Inherited gene mutations, such as RNASEL, BRCA1, and BRCA2, play a role in around 10% of prostate cancers (8).

• Environmental factors Prostate cancer risk increases due to chemical exposure such as pesticides, cadmium and chromium (9). 

Signs and Symptoms

Signs and symptoms of BPH

Patients are usually presented with lower urinary tract symptoms (LUTS) such as urinary frequency, nocturia, dribbling at the end of urination, nocturia, pain after ejaculation or urination, and weak urine stream (10). These symptoms are further categorised into storage or voiding symptoms.

Table 2: storage and voiding symptoms of BPH (4).

It is safe to state that lower urinary tract symptoms will be presented in the majority of BPH patients. Ejaculatory disorders (EjD), which are occasionally present in BPH cases in addition to LUTS, are typically overlooked during the initial evaluation. There are many different symptoms that patients with ejaculatory problems may experience, including pain or discomfort while ejaculating. Therefore, if BPH is suspected, healthcare professionals should be careful in spotting EjD symptoms (11).

Signs and symptoms of prostate cancer

• Weak urinary stream, incomplete bladder emptying

• Polyuria, nocturia

• Hematuria

• Erectile dysfunction

• Pelvic pain, back pain, chest pain

• Lower extremity weakness or numbness

• Loss of bladder or bowel control (12,13).

Diagnosis of BPH and prostate cancer

It is well established that both BPH and prostate cancer have quite a few similarities in terms of symptom presentation. Therefore, the first diagnostic steps in both BPH and prostate cancer are the prostate-specific antigen (PSA) test and the digital rectal exam (DRE). PSA is a type of protein that the prostate gland produces in large quantities during prostate enlargement.

A DRE is a common way to check the prostate. The procedure allows the doctor to feel the prostate through the rectum. This test helps the doctor check:

1. The size, firmness, and feel of the prostate.

2. For any hard spots, lumps, or growths that go beyond the prostate.

3. Whether touching the prostate causes any pain.

DRE is an important test that aids in differentiating between BPH and prostate cancer. Although prostate enlargement is present in both BPH and prostate cancer, the texture of the growth is different. In BPH, the growth feels smooth and solid, but in prostate cancer, it might feel tough and bumpy (14,15).

Conducting PSA and DRE tests is essential for patients suspected of having BPH or prostate cancer because these tests play a vital role in guiding healthcare professionals for the next laboratory test in the diagnosis procedure.

Although PSA is a common diagnostic tool for prostate cancer, it has a high false negative rate. around 1 in 7 of those with normal PSA levels may show false-negative results, so many cases can go without notice. Hence, DRE should be carried out as part of the annual physical examination for the purpose of early-detection of prostate cancer.

Figure 3: Digital Rectal Examination (DRE)

The next step in the diagnosis of prostate cancer is a prostate biopsy. Prostate cancer is just like other cancers and can only be confirmed by examining prostate tissue under a microscope. If the biopsy results show cancer, a pathologist will assign a Gleason score, which is a number from 2 to 10. This score helps predict how likely the cancer is to spread. The treatment choices depend on the cancer's stage (ranging from 1 to 4), Gleason score, PSA level, as well as the patient's age and overall health (15).

Table 3: Differential diagnosis of BPH and Prostate cancer (16).

Both BPH and prostate cancer have similar signs and symptoms, however, there are few district characteristics that aid in differentiating both conditions.

Table 4: Similarities and Differences of symptoms between BPH and Prostate Cancer

BPH and prostate cancer are two distinct medical conditions that share similar symptoms. Therefore, it is important for healthcare providers to have a thorough understanding of the fundamental differences between these two diseases in order to deliver the highest quality of care to their patients.

Want to know more about BPH and prostate cancer from DOC2US? Stay tuned for our upcoming articles, where we will delve deeper into the significance of early detection, as well as the management of BPH and prostate cancer!

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References

1. Farhan KK. SAS Journal of Surgery (SASJS) Prevalence of Benign Prostatic Hyperplasia in Hospital Pakar Sultanah Fatimah Muar. 2018 [cited 2023 Sep 17]; Available from: http://www.sassociety.com/sasjs/ 

2. What Is Prostate Cancer? About Prostate Cancer. [cited 2023 Sep 17]; Available from: https://www.cancer.org/content/dam/CRC/PDF/Public/8793.00.pdf 

3. Awedew AF, Han H, Abbasi B, Abbasi-Kangevari M, Ahmed MB, Almidani O, et al. The global, regional, and national burden of benign prostatic hyperplasia in 204 countries and territories from 2000 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Healthy Longev [Internet]. 2022 Nov 1 [cited 2023 Sep 17];3(11):e754–76. Available from: http://www.thelancet.com/article/S2666756822002136/fulltext

4. 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

5. Benign Prostatic Hyperplasia (BPH): Practice Essentials, Background, Anatomy [Internet]. [cited 2023 Sep 17]. Available from: https://emedicine.medscape.com/article/437359-overview

6. Lim J, Malek R, Sathiyananthan JR, Toh CC, Sundram M, Woo SYY, et al. Prostate cancer in multi-ethnic Asian men: Real-world experience in the Malaysia Prostate Cancer (M-CaP) Study. Cancer Med [Internet]. 2021 Nov 1 [cited 2023 Sep 17];10(22):8020–8. Available from: https://pubmed.ncbi.nlm.nih.gov/34626088/

7. Breyer BN, Sarma A V. Hyperglycemia and Insulin Resistance and the Risk of BPH/LUTS: an Update of Recent Literature. Curr Urol Rep [Internet]. 2014 Oct 7 [cited 2023 Sep 17];15(12):462. Available from: https://www.ncbi.nlm.nih.gov/pmc/articlesPMC4527683#:~:text=Alternatively%2C%20diabetes%2Drelated%20insulin%20resistance,prostatic%20cells%20thereby%20influencing%20growth

8. What Causes Prostate Cancer?| Causes of Prostate Cancer | American Cancer Society [Internet]. [cited 2023 Sep 17]. Available from:https://www.cancer.org/cancer/types/prostate-cancer/causes-risks-prevention/what-causes.html

9. Krstev S, Knutsson A. Occupational Risk Factors for Prostate Cancer: A Meta-analysis. J Cancer Prev [Internet]. 2019 Jun 30 [cited 2023 Sep 17];24(2):91. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6619854/#:~:text=In%20that%20way%20we%20identified,%2C%20rubber%20industry%2C%20ionizing%20radiation%2C

10. Benign Prostatic Hyperplasia Treatment | MIMS Malaysia [Internet]. [cited 2023 Sep 17]. Available from: https://specialty.mims.com/benign%20prostatic%20hyperplasia/treatment

11. Couteau N, Duquesne I, Frédéric P, Thiounn N, Timsit MO, Mejean A, et al. Ejaculations and Benign Prostatic Hyperplasia: An Impossible Compromise? A Comprehensive Review. J Clin Med [Internet]. 2021 Dec 1 [cited 2023 Sep 26];10(24):5788. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8704358/

12. Prostate Cancer Signs And Symptoms | MIMS Malaysia [Internet]. [cited 2023 Sep 17]. Available from:https://specialty.mims.com/prostate%20cancer/signs%20and%20symptoms?channel=urology

13. Abdulelah M, Hajjaj N, Abu-Rumaileh MA, Clanon D, Bader H. Tenesmus: An Unusual Presentation of Delayed Prostate Adenocarcinoma Recurrence. Cureus [Internet]. 2021 Jul 25 [cited 2023 Sep 26];13(7). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8312991/

14. Differentiating between prostate cancer and prostate enlargement [Internet]. [cited 2023 Sep 17]. Available from: https://www.news-medical.net/health/Differentiating-between-prostate-cancer-and-prostate-enlargement.aspx

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16. Ng M, Baradhi KM. Benign Prostatic Hyperplasia. StatPearls [Internet]. 2022 Aug 8 [cited 2023 Sep 17]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK558920/

Written by

Tasnim Jaman Raisa