At the age of 30-35 years, the prostate begins slowly to grow. The growth is benign (benign prostatic hyperplasia or prostatic adenoma), with the shape of nodules (usually two, one for each prostate lobe, right and left; sometimes a central median lobe can be present). Benign prostatic hyperplasia (BPH) rises from the inner part of the gland, just close to the urethra, and progressively may obstruct the passage of urine, narrowing the lumen of the urethra.
Nearly 50% of men at the age of 60 experience prostatic enlargement. The occurrence of BPH reaches 90% in men over 80. About 50% of men with BPH will develop urinary symptoms.
Obesity and diabetes are risk factors for BPH.
The decreased diameter of the urethra, due to prostatic enlargement, may lead to obstruction to urine passage. The narrow way of the urethra causes an increased bladder workload; the bladder must exert a higher pressure to empty. The excess of work of the detrusor muscle can provoke urinary symptoms, due to both prostatic obstruction and bladder irritation.
The urinary flow can become weak, at times with several repeated micturitions to void the bladder. At the end of voiding, urinary dribbling may be present. Urinary frequency is increased at day and night, and the patient can be awakened several times at night by the need to urinate.  This can occur either cause the bladder doesn´t allow complete filling anymore, or cause the bladder hasn´t enough strength to empty entirely, with decreased storage capacity.
Some patients may experience the need to urinate with some delay in voiding  (hesitancy).
Sometimes, due to increased bladder work, the detrusor muscle may develop instability, with hyperactive contractions. The need to urinate may be sudden, with a strong desire to void that can´t be controlled (urgency), with some urinary leakage if the bladder is not voided within a short time (urge-incontinence). These symptoms are known as Lower Urinary Tract Symptoms (LUTS).
There are some questionnaires, which were developed to provide an objective evaluation of LUTS. They are based on a score, with classification of the symptoms in mild, moderate or severe. The most used is the IPSS, with score ranging from 0 to 35, where the symptoms are categorized as mild (0-7), moderate (8-19), or severe (20-35).
On a long run, increased bladder pressure can lead to urinary function damage, recurrent urinary tract infections, or to bladder stones formation. According to some Authors, chronic bladder inflammation, due to increased postvoiding residual urine, might be a promoter of bladder cancer.
Sometimes the patient suddenly can´t void the bladder at all (acute urinary retention), and a catheter must be placed to empty the full bladder. There is a strong desire to void, with suprapubic pain.
The catheter is removed after 3-4 days, to avoid the risk of urinary infection related to an indwelling catheter. Usually before catheter removal, treatment with alpha-blocker is started, to increase the chance of spontaneous voiding recovery.
About 50% of patients will return to spontaneous voiding at catheter removal. Additional 25% of patients can void after further catheterization for one week. One quarter of patients can´t recover bladder voiding and require surgical intervention (or indwelling catheter in case of surgery contraindications).

BHP Diagnosis

Benign prostatic hyperplasia diagnosis is initially based upon patient history. The questionnaires for objective evaluation of urinary symptoms with an overall score are not yet widely used on daily practice.
Digital Rectal Examination (DRE) gives an evaluation of prostate size, firmness, and the presence of hard nodules suspicious for cancer. All men above 50 years of age should undergo digital rectal examination once a year. It is a basic procedure for prostate evaluation.
Transrectal ultrasound (TRUS) of the prostate

is the procedure that can provide data concerning the size of the gland, its structure, size of the adenoma, tumor-suspicious nodules, and the degree and site of urinary obstruction. It is performed by inserting an ultrasound probe in the rectum. It should be done with full bladder.  The test is optional.
Uroflowmetry is a simple, non invasive test that measures urinary flow, through a graphic. When the peak flow is above 15 ml/sec, usually patients are not obstructed. When the peak flow is below 10 ml/sec, the patient is likely to have a significative obstruction. The test is optional (but the European Urology Association recommends it).
Pressure/flow studies and cystometry (known, together with flowmetry, as urodynamics) provide important data on bladder capacity and sensitivity, on bladder pressure at voiding, but they are invasive. They are not routinely diagnostic tests, but they can be helpful in difficult cases.

Treatment of prostatic benign hyperplasia

The treatment of symptomatic benign prostatic hyperplasia must relief the voiding obstruction and  decrease or end obstructive and irritative symptoms.
Medical therapy is based upon oral drugs. Main indication is mild or moderate urinary obstruction. Mostly used are Finasteride and Dutasteride, and alpha-blockers.
Finasteride and Dutasteride block the metabolism of the male hormone testosterone inside the prostatic cells, preventing cellular growth. Prostate size can be reduced by approximately 18-25% with prolonged (at least 3-6 months) therapy.
On long term, the risk of prostatic surgery for urinary obstruction and/or acute urinary retention are reduced by 50%. The drugs are especially effective for the treatment of medium-large size prostates (over 40 cc). In a few patients (3-5%) some degree of erectile dysfunction may occur; the side effect disappears by discontinuing the treatment.
NOTE:  Finasteride and Dutasteride can decrease the plasmatic level of PSA (significant marker for prostate cancer detection). When starting therapy, the presence of a prostatic cancer should be reasonably excluded. In patients under treatment with one of these drugs, the value of PSA should be doubled to obtain a practical approximation to real value.

Alpha-blockers are a group of drugs (i.e. alfuzosin, terazosin, doxazosin, tamsulosin) which act selectively on special biochemical receptors, stimulating relaxation of bladder neck and prostatic urethra smooth muscle fibers. Nearly half patients experience a 30% improvement of urinary flow and of LUTS.
Some alpha blocker may have side effects like decreased bladder pressure or (tamsulosin) retrograde ejaculation (at the moment of the orgasm, the semen flows back toward the bladder, rather then being expelled outside the urethra).
Some studies have shown that the best therapeutic results are obtained with a combination therapy with an alpha blocker plus Finasteride or Dutasteride.
Phytotherapy has been proposed for the treatment of benign prostatic hyperplasia. Plant extracts mostly used are Serenoa Repens and Pygeum Africanum. The mechanism of action and the efficacy are not well clear, and there is lack of large series or long-term studies. However, a recent meta-analysis of the literature has shown some moderate, but significant improvement of LUTS after treatment with Serenoa Repens.

The options for invasive treatment of benign prostatic hyperplasia have recently expanded, with the introduction of new techniques. However, transurethral resection of the prostate (TURP)

remains the mainstay of the therapy of BPH, and all new treatments must be compared to this gold standard.
The procedure is performed all over the world. A fibre optic instrument is introduced through the urethra, and under direct vision the prostatic tissue is resected in small "chips" by an electric cutting device. All the adenoma is removed in small pieces. Usually the operation is performed under epidural (peridural) anaesthesia: the patient is fully awake, but all the pain feeling is temporary abolished in the lower part of the body.
Mean operating time is 45-75´, according to prostate size. Postoperatively an indwelling catheter is left for 2 days. Possible complications are bleeding (quite rare, the transfusion rate is low), strictures of the urethra (postoperative narrowing of the urethral calibre (1-2%). Physical efforts and straining should be avoided for 2-3 weeks postoperatively. After the operation retrograde ejaculation is common (the semen flows toward the bladder, instead of being propelled outside), and so infertility must be expected. No erectile dysfunction has been scientifically proven after TURP.
In selected cases, with small prostate size, the procedure can be simplified with transurethral incision of the prostate (TUIP). One or two incisions are performed inside the prostate, "splitting" the tissue and creating a path through the prostate to help voiding. The prostatic tissue is not resected and most patients preserve ejaculation (retrograde ejaculation occurs in 5-15% of cases only). Usually the urethral catheter is left indwelling for 24 hours.
For very large prostates, with estimated adenoma weight above 60 grams, an open procedure is the preferred option. Through a suprapubic incision, the prostate is reached directly (Millin operation) or through an opening in the bladder wall. The adenoma is surgically cleaved from the prostate. Some bleeding may be more common, and 1-2 unit of blood should be available for the procedure.
An indwelling catheter is left for 5-6 days.
The patients must understand that these procedures aim to remove prostatic obstruction, and the true prostate remains in its location: the prostate must be regularly checked for the risk of cancer development, which is unchanged after the operation.
Alternative treatments have been proposed for symptomatic benign prostatic hyperplasia.
TransUrethral Needle Ablation (TUNA) is performed under direct endoscopic vision with the insertion of thin needles inside the prostate gland, through the urethra.
High frequency energy is delivered in several prostate sites for a few minutes time. Generally local anaesthesia and a single session are required. Mid term results are promising, with 60% symptoms decrease and 60-70% peak flow increase.
A LASER has been used to vaporize or remove obstructing prostatic tissue. With a Laser extremely high energy can be focused in very thin beams. The optic fibres can be used under direct endoscopic vision on the tissue, or introduced directly in the prostate (Interstitial Laser). High energy release destroys the prostatic tissue by vaporization or necrosis (cell death). Mid term studies are encouraging. Five-year results with last generation Laser for the treatment of BPH are comparable, but not superior, to TURP results.  The main advantage of the Laser is a decreased blood loss. The operation can be performed as office procedure. Patients with severe bleeding risk can be treated. Major disadvantages are a need for prolonged indwelling catheter, persistent irritative symptoms, the lack of pathology of prostatic tissue, though with some last generation LASER these side effects are decreased. The high cost of optic fibers and Laser generator must be considered.
Several forms of Laser treatment are available for BPH. Intraprostatic interstitial therapy is known as ILC (Interstitial Laser Coagulation). Direct delivery of the energy on the prostatic tissue is named VLAP (Visual Laser Ablation of the Prostate). The transurethral resection of very large adenomas (otherwise suitable for open surgery) is called HoLEP (Transurethral Holmium Laser Enucleation of the Prostate): the adenoma is cleaved from the true prostate and pushed into the bladder, where it is removed through the sheath of the endoscopic instruments in tiny pieces.
High temperature can be used for the treatment of benign prostatic hyperplasia, with hyperthermia and thermotherapy. Hyperthermia is the release of heat energy at temperature below Celsius 45°, while with thermotherapy the temperature reaches levels above Celsius 45°.
Hyperthermia is performed with transrectal approach, with reported symptoms improvement up to 50%, with mild (2-3 ml/sec) increase of peak urinary flow. However, long term results are conflicting. Thermotherapy (TUMT, TransUrethral Microwave Thermotherapy) usually requires a transurethral approach. Some generators need multiple sessions to obtain final result.
Immediately after treatment most patients can experience temporary urinary retention.
The main outcome is a 60% symptoms improvement, with moderate peak urinary flow increment (20%). Long term studies are needed to confirm the efficacy of the procedure.
Prostatic vaporization can be obtained also with a special endoscopic device, provided with a small rotating cylinder. Though blood loss is reduced, the different characteristics of prostatic tissue may decrease the efficacy of the procedure.
Some Authors have suggested the use of a transurethral high pressure balloon to dilate the prostatic urethra. Results are debatable and often transitory.
Very high risk patients and/or with short life expectancy may be treated with intraprostatic stents to relieve urinary obstruction. They are tubular structures which are inserted through the urethra inside the prostate. They are self-retaining and they have the goal to maintain the prostatic urethra open.
Some of them are permanent (metallic), some are disposable and must be substituted, some others are reabsorbable. They represent an acceptable alternative to indwelling catheter in poor conditions patients with prostatic obstruction. On mid term these stents may dislodge, or may cause irritative symptoms, encrustation and urinary infections. Due to morbidity, stent removal is required in 14-33% of cases.

International prostate symptom score (IPSS)

Within the last month	Never	Less than 1 time in 5	Less than half the time	About half the time	More than half the time	Almost Always
1) How often have you had a sensation of not emptying your bladder completely after you finish urinating?	0	1	2	3	4	5
2) How often have you had to urinate again less than two hours after you finished urinating?	0	1	2	3	4	5
3) How often have you found you stopped and started again several times when you urinated?	0	1	2	3	4	5
4) How difficult have you found it to postpone urination?	0	1	2	3	4	5
5) How often have you had a weak urinary stream?	0	1	2	3	4	5
6) How often have you had to push or strain to begin urination?	0	1	2	3	4	5
7) How many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?	0	1	2	3	4	5

Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic