Benign prostate diseases – BPH (prostate enlargement), Prostatitis (Inflammation); and Pelvic Pain Syndromes

Benign Prostatic Diseases, Prostatitis and Pelvic Pain Syndromes

BPH

BPH is a urological term to denote Benign Prostatic Hyperplasia. It is used in the common clinical setting referring to benign (non-cancerous) enlargement of the prostate gland is associated with urinary symptoms such as difficulty in urination and increased frequency of urination.

Strictly speaking it has nothing to do with an enlargement of the prostate gland, but rather it is actually related to prostatic compression – the amount of compression exhibited by the prostate on the urethra.

In simpler words, it is not the centrifugal enlargement of the prostate that matters, but rather the centripetal compression of the urethra on the prostate that results in poor flow and the various symptoms of BPH. For this some people denote this disease as BPO (Benign Prostatic Obstruction) rather than just BPH.

An enlarged prostate compresses and gradually obstructs the urethra which is the outlet channel for urine stored in the bladder. In the early stages of BPH, the patient may notice that the flow is reduced.

Patients with BPH subsequently suffer from obstructive and irritative lower urinary tract symptoms including:

  • Nocturia (getting up in the night to pass urine)
  • Poor urine flow and straining to urinate
  • Inability to completely empty the bladder
  • Hesitancy (Difficulty to initiate urination)
  • Urgency, frequently urinating and sometimes urge incontinence
  • Accidentally leaking urine (urinary incontinence)

To confirm BPH various tests may be required which includes uroflowmetry, ultrasound of the kidneys and bladder before and after passing urine, PSA and rectal examination to assess the prostate.

BPH – Pic From North Island Urology NIU

Uroflowmeter to assess urine flow

A poor flow may denote a compression of the flow of urine and may be related to BPH

Uroflowmetry tracing to assess urine flow

Poor urine flow suggests either an obstruction to the urinary flow, or a weakness of the bladder to expel the urine

Rectal examination of the prostate (Pic from Urology Care Foundation)

This is done to assess if there is a nodule in the prostate, which will then raise the suspicion of an underlying prostate cancer

Assessment

The International Prostate Symptom Score (IPSS) is an eight-question written screening tool used to screen for, rapidly diagnose, track the symptoms of, and suggest management of the symptoms of benign prostatic hyperplasia (BPH).

Treatment of BPH is directed towards alleviation of bothersome symptoms which may be assessed using the IPSS scoring.

Complications of BPH

BPH can sometimes lead to complications, such as:

  • Urinary tract infection (UTI)
  • Acute urinary retention (completely unable to pass urine)
  • Hydronephrosis (swelling of the kidneys)
  • Bladder stones
  • Gross hematuria (blood in the urine)
  • Progressive kidney damage

The treatment of BPH includes:

Medications – alpha blockers, 5-ARI inhibitors may be indicated

Endoscopy procedures

There are times when medications may not work when the disease has already progressed to a very severe state. For this an endoscopic procedure will be required.

Your urologist can discuss on the various procedures that may be required, which in general is TURP (Transurethral Resection of the Prostate) or its various modifications of the procedure including TUIP, TUNA, bipolar TURP, laser TURP, etc.

TURP involves placing in a scope into the urethra under anesthesia, and then resecting or scraping the prostate. It is a relatively painless procedure done under anesthesia.

There are many other minimally invasive procedures for BPH, but most of them have not been as effective as TURP in the treatment of BPH.

Transurethral resection of the prostate (TURP). Tissue is removed from the prostate using a resectoscope (a thin, lighted tube with a cutting tool at the end) inserted through the urethra. Prostate tissue that is blocking the urethra is cut away and removed through the resectoscope.

TURP procedure – Pic from National Cancer Institute NCI

Pic from Urology Care Foundation

Prostate artery embolization (PAE) as a new treatment option for men with benign prostatic hyperplasia (BPH), or an enlarged prostate has been investigated. Advice may be obtained from the urologist first if this is a suitable indication in the first place. However, PAE for the treatment of BPH is not supported by current data and trial designs, and benefit over risk remains unclear; therefore, PAE is currently not recommended outside the context of clinical trials.

Informative links:

https://www.youtube.com/watch?v=T6Y9tal56Cc

https://www.youtube.com/watch?v=ExLrO84Ojtw

https://www.youtube.com/watch?v=Ic4-sjJpWGc

Take Home Message

Prostatitis (Inflammation) and Pelvic Pain syndromes (Painful bladder syndrome / Interstitial Cystitis, Pelvic Floor tension Myalgia)

Prostatitis is inflammation (swelling) of the prostate gland. It can be very painful and distressing, but will often get better eventually.

Prostatitis can come on at any age. But usually between 30 and 50.

There are 2 main types of prostatitis:

    • chronic prostatitis – where the symptoms come and go over several months; it’s the most common type
    • acute prostatitis – where the symptoms are severe and come on suddenly; it’s rare, but potentially life-threatening and requires immediate treatment

There are 4 different subcategories of prostatitis:

    • Acute bacterial prostatitis
    • Chronic bacterial prostatitis
    • Chronic non-bacterial prostatitis / Chronic Pelvic Pain Syndrome (CP / CPPS)
    • Asymptomatic prostatitis

Acute prostatitis

Symptoms of acute prostatitis include:

    • pain, which may be severe, in or around your penis, testicles, anus, lower abdomen or lower back – passing stools can be painful
    • pain when urinating, needing to urinate frequently (particularly at night), problems starting or “stop-start” urinating, an urgent need to urinate and, sometimes, blood in the urine
    • not being able to urinate, which leads to a build-up of urine in the bladder known as acute urinary retention – this needs urgent medical attention
    • generally feeling unwell, with aches, pains and possibly a high temperature
    • lower back pain and pain on ejaculation

Chronic prostatitis and Chronic Pelvic Pain Syndromes

You may have chronic prostatitis if you have had some of the following symptoms for at least 3 months:

    • pain in and around your penis, testicles, anus, lower abdomen or lower back
    • pain when urinating, a frequent or urgent need to urinate, particularly at night, or “stop-start” urinating
    • an enlarged or tender prostate on rectal examination
    • sexual problems, such as erectile dysfunction, pain when ejaculating or pelvic pain after sex

These symptoms can have a significant impact on your quality of life.

But in most cases, they’ll gradually improve over time and with treatment.

Chronic prostatitis may not necessarily originate from your prostate, but may be due to pain arising from your pelvic area. Hence this condition is usually termed chronic prostatitis / chronic pelvic pain syndrome.

Painful Bladder Syndrome / Interstitial Cystitis, Pelvic floor tension myalgia

Painful Bladder Syndrome / Interstitial cystitis, pelvic floor tension myalgia and various other very vague pain syndromes may also be classified within this same group of chronic pelvic pain syndrome.

The treatment of acute and chronic prostatitis, as well as chronic pelvic pain syndrome, need a range of treatment depending on the cause. It is best to discuss with your doctor for the possible treatments.

Chronic prostatitis and Chronic Pelvic Pain Syndromes

Chronic prostatitis may not necessarily originate from your prostate, but may be due to pain arising from your pelvic area. Hence this condition is usually termed chronic prostatitis / chronic pelvic pain syndrome.

You may have chronic prostatitis if you have had some of the following symptoms for at least 3 months:

  • pain in and around your penis, testicles, anus, lower abdomen or lower back
  • pain when urinating, a frequent or urgent need to urinate, particularly at night, or “stop-start” urinating
  • an enlarged or tender prostate on rectal examination
  • sexual problems, such as erectile dysfunction, pain when ejaculating or pelvic pain after sex

These symptoms can have a significant impact on your quality of life.

But in most cases, they’ll gradually improve over time and with treatment.

Chronic prostatitis may not necessarily originate from your prostate, but may be due to pain arising from your pelvic area. Hence this condition is usually termed chronic prostatitis / chronic pelvic pain syndrome.

Chronic Pelvic Pain Syndrome is associated with a long-term pelvic pain and lower urinary tract symptoms (LUTS) without evidence of a bacterial infection. It affects about 2-6% of men. The cause is unknown.

Painful Bladder Syndrome / Interstitial cystitis, pelvic floor tension myalgia and various other very vague pain syndromes may also be classified within this same group of chronic pelvic pain syndrome.

The treatment of acute and chronic prostatitis, as well as chronic pelvic pain syndrome, need a range of treatment depending on the cause. It is best to discuss with your doctor for the possible treatments.