Benign Prostate Hyperplasia (BPH)
What is BPH?
Benign prostatic hyperplasia (also called BPH) is a condition in men in which the prostate gland is enlarged and not cancerous. The prostate is a walnut-shaped gland that is part of the male reproductive system. The prostate’s primary function is to produce the fluid that nourishes and transports sperm (seminal fluid). Prostate fluid is essential for a man’s fertility.
As the prostate enlarges, the gland presses against and pinches the urethra. The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the ability to empty completely, leaving some urine in the bladder.
What causes BPH?
Throughout their lives, men produce testosterone, a male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in their blood decreases, which leaves a higher proportion of estrogen. Higher proportion of estrogen within the prostate increases the activity of substances that promote prostate cell growth.
Another theory focuses on dihydrotestosterone (DHT), a male hormone that plays a role in prostate development and growth. Older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage prostate cells to continue to grow.
How common is BPH?
Benign prostatic hyperplasia is the most common prostate problem for men older than age 50. Benign prostatic hyperplasia affects about 50 percent of men between the ages of 51 and 60 and up to 90 percent of men older than 80.
Who is more likely to develop BPH?
Men with the following factors are more likely to develop benign prostatic hyperplasia:
What are the symptoms of BPH?
Lower urinary tract symptoms suggestive of benign prostatic hyperplasia may include
- urinary frequency—urination eight or more times a day
- urinary urgency—the inability to delay urination
- trouble starting a urine stream
- a weak or an interrupted urine stream
- dribbling at the end of urination
- nocturia—frequent urination during periods of sleep
- urinary retention
- urinary incontinence—the accidental loss of urine
- pain after ejaculation or during urination
- urine that has an unusual color or smell
The size of the prostate does not always determine the severity of the blockage or symptoms. Some men with greatly enlarged prostates have little blockage and few symptoms, while other men who have minimally enlarged prostates have greater blockage and more symptoms. Sometimes men may not know they have a blockage until they cannot urinate. This condition, called acute urinary retention, can result from taking over-the-counter cold or allergy medications that contain decongestants, such as pseudoephedrine and oxymetazoline.
What are the complications of BPH?
The complications of benign prostatic hyperplasia may include
Most men with benign prostatic hyperplasia do not develop these complications. However, kidney damage in particular can be a serious health threat when it occurs.
When to Seek Medical Care?
A person may have urinary symptoms unrelated to benign prostatic hyperplasia that are caused by bladder problems, UTIs, or prostatitis—inflammation of the prostate. Symptoms of benign prostatic hyperplasia also can signal more serious conditions, including prostate cancer.
Men with symptoms of benign prostatic hyperplasia should see a health care provider.
Men with the following symptoms should seek immediate medical care:
- complete inability to urinate
- painful, frequent, and urgent need to urinate, with fever and chills
- blood in the urine
- great discomfort or pain in the lower abdomen and urinary tract
How is benign prostatic hyperplasia diagnosed?
A health care provider diagnoses benign prostatic hyperplasia based on
- a detailed personal and family medical history
- a physical exam
- medical tests that may include urinalysis, blood tests including PSA, ultrasound (abdominal or transrectal). Additional tests like uroflowmetry, urodynamic studies, cystoscopy and prostate biopsy may be required based on the initial test results
How is benign prostatic hyperplasia treated?
Treatment options for benign prostatic hyperplasia may include
- lifestyle changes
- medications
- minimally invasive procedures
- surgery
Your healthcare provider (urologist) chooses the type of treatment based on the severity of symptoms, how much the symptoms affect a man’s daily life, and a man’s preferences.
Kidney Stones (Renal Calculi, Nephrolithiaisis, Urolithiaisis)
What are Kidney Stones?
Kidney stones are hard deposits made of minerals and salts that form inside your kidneys.
What causes Kidney Stones?
Kidney stones form when your urine contains more crystal-forming substances — such as calcium, oxalate and uric acid — than the fluid in your urine can dilute. At the same time, your urine may lack substances that prevent crystals from sticking together, creating an ideal environment for kidney stones to form.
What factors can increase the risk of kidney stone formation?
Factors that may increase your risk of developing kidney stones include:
- Family or personal history. If someone in your family has had kidney stones, you’re more likely to develop stones, too. If you’ve already had one or more kidney stones, you’re at increased risk of developing another.
- Dehydration. Not drinking enough water each day can increase your risk of kidney stones. People who live in warm, dry climates and those who sweat a lot may be at higher risk than others.
- Certain diets. Eating a diet that’s high in protein, sodium (salt) and sugar may increase your risk of some types of kidney stones. This is especially true with a high-sodium diet. Too much salt in your diet increases the amount of calcium your kidneys must filter and significantly increases your risk of kidney stones.
- Obesity. High body mass index (BMI), large waist size and weight gain have been linked to an increased risk of kidney stones.
- Digestive diseases and surgery. Gastric bypass surgery, inflammatory bowel disease or chronic diarrhea can cause changes in the digestive process that affect your absorption of calcium and water, increasing the amounts of stone-forming substances in your urine.
- Other medical conditions such as renal tubular acidosis, cystinuria, hyperparathyroidism and repeated urinary tract infections also can increase your risk of kidney stones.
- Certain supplements and medications, such as vitamin C, dietary supplements, laxatives (when used excessively), calcium-based antacids, and certain medications used to treat migraines or depression, can increase your risk of kidney stones.
What are the types of kidney stones?
Types of kidney stones include:
- Calcium stones. Most kidney stones are calcium stones, usually in the form of calcium oxalate. Oxalate is a substance made daily by your liver or absorbed from your diet. Certain fruits and vegetables, as well as nuts and chocolate, have high oxalate content.
Dietary factors, high doses of vitamin D, intestinal bypass surgery and several metabolic disorders can increase the concentration of calcium or oxalate in urine.
Calcium stones may also occur in the form of calcium phosphate. This type of stone is more common in metabolic conditions, such as renal tubular acidosis. It may also be associated with certain medications used to treat migraines or seizures, such as topiramate (Topamax, Trokendi XR, Qudexy XR).
- Struvite stones. Struvite stones form in response to a urinary tract infection. These stones can grow quickly and become quite large, sometimes with few symptoms or little warning.
- Uric acid stones. Uric acid stones can form in people who lose too much fluid because of chronic diarrhea or malabsorption, those who eat a high-protein diet, and those with diabetes or metabolic syndrome. Certain genetic factors also may increase your risk of uric acid stones.
- Cystine stones. These stones form in people with a hereditary disorder called cystinuria that causes the kidneys to excrete too much of a specific amino acid.
Knowing the type of kidney stone you have helps determine its cause, and may give clues on how to reduce your risk of getting more kidney stones. If possible, try to save your kidney stone if you pass one so that you can bring it to your doctor for analysis.
What are the common symptoms of kidney stones?
Small kidney stones can usually pass on their own without causing any discomfort. Larger stones can get stuck in the ureters (the tubes through which urine flows from kidneys to bladder), which leads to intense discomfort. When a stone gets stuck in a ureter, it blocks the flow of urine and causes severe pain.
The following symptoms may be experienced when a kidney stone moves out of kidney:
- Feeling the need to urinate frequently
- Urinating in small amounts
- Painful urination
- Burning sensation when urinating
- Fever and chills
- Nausea and vomiting
- Sharp pain in the back and side below the ribs
- Blood in your urine
- Cloudy or odorous urine
If someone is experiencing these symptoms they should visit the medical practitioner immediately for further evaluation.
What are the common tests for detecting kidney stones?
If your doctor suspects that you have a kidney stone, you may have diagnostic tests and procedures, such as:
- Blood testing. Blood tests may reveal too much calcium or uric acid in your blood. Blood test results help monitor the health of your kidneys and may lead your doctor to check for other medical conditions.
- Urine testing. The 24-hour urine collection test may show that you’re excreting too many stone-forming minerals or too few stone-preventing substances. For this test, your doctor may request that you perform two urine collections over two consecutive days.
- Imaging.
Imaging tests may show kidney stones in your urinary tract. Ultrasound, a noninvasive test that is quick and easy to perform, is often the first advised test to diagnose kidney stones. Simple abdominal X-rays are used less frequently because this kind of imaging test can miss small kidney stones. Additionally, about 20% of kidney stones are not seen in X-rays, which are called radiolucent stones.
High-speed or dual energy computerized tomography (CT) may reveal even tiny stones. This test is considered the best test to diagnose kidney stones.
MRI is not the test-of-choice in detecting kidney stones (it misses nearly 80% of kidney stones). However, in certain conditions like pregnancy, CT scan is contraindicated and MRI is the only available imaging modality that may be offered apart from ultrasound.
- Analysis of passed stones. You may be asked to urinate through a strainer to catch stones that you pass. Lab analysis will reveal the makeup of your kidney stones. Your doctor uses this information to determine what’s causing your kidney stones and to form a plan to prevent more kidney stones.
What are the treatment options for kidney stones?
Medical management is available to aid in the passing of small stones and for ongoing management of stones. Medications like alpha-blockers can help passing stones that are stuck in the lower part of ureter (close to the urinary bladder).
Oral alkalinization can be used to increase urine pH and dissolve uric acid stones. Periodic surveillance with imaging modalities is necessary to ensure treatment success or to guide further changes to the treatment plan.
For large stones, obstructing stones and stones that do not pass despite medical management, the following surgical options are available:
- Non-invasive extracorporeal shock wave lithotripsy (ESWL). ESWL involves the use of sound waves to crush the kidney stone into smaller pieces so they can more easily pass into the bladder.
- Percutaneous nephrolithotomy (PCNL). PCNL uses a small hole and a tube inserted into the patient’s back to directly remove or break up larger kidney stones.
- Ureteroscopy (URS). URS involves passing a fiberoptic camera up into the ureter and kidney without any incisions, allowing specialists to use delicate instruments to remove or break up stones in the ureter and kidneys. The stone breaking is usually carried out using laser technology.
- Pyelolithotomy. This procedure involves the removal of a stone from within the renal pelvis or from the ureter, and can be done as an open or laparoscopic procedure.
What are the suggested preventive measures for kidney stones?
One of the best preventative measures against kidney stones is proper fluid intake. It is recommended that you drink at least 8 glasses or 3 liters of water each day in order to pass about 2.6 quarts (2.5 liters) of urine daily. Other general diet and prevention recommendations include:
- Moderate calcium (1000-1200 mg/day)
- Low sodium (less than 2300 mg of salt/day)
- Low refined sugar (less than 100 g/day)
- Decrease oxalate (40-50 mg/day of foods such as beets, spinach, sweet potatoes)
- Decrease intake of animal protein (1 serving/day)
- Increase citrate (lemons and limes)
- Increase intake of fruits and veggies
- Increase dietary insoluble fiber (18-22 g/day of foods such as whole grains and nuts)
- Magnesium supplement (for calcium stones)
- Potassium supplement (for uric acid and cystine stones)
Based on stone analysis and metabolic work-up studies of an individual, your doctor can provide a dedicated stone prevention protocol for each individual.
Urinary Tract Infection (UTI)
UTI is an infection in any part of your urinary system — your kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract — the bladder and the urethra. Women are at greater risk of developing a UTI than are men.
What are the risk factors of UTI?
Urinary tract infections are common in women, and many women experience more than one infection during their lifetimes. Risk factors specific to women for UTIs include:
- Female anatomy. A woman has a shorter urethra than a man does, which shortens the distance that bacteria must travel to reach the bladder.
- Sexual activity. Sexually active women tend to have more UTIs than do women who aren’t sexually active. Having a new sexual partner also increases your risk.
- Certain types of birth control. Women who use diaphragms for birth control may be at higher risk, as well as women who use spermicidal agents.
- Menopause. After menopause, a decline in circulating estrogen causes changes in the urinary tract that make you more vulnerable to infection.
Other risk factors for UTIs include:
- Urinary tract abnormalities. Babies born with urinary tract abnormalities that don’t allow urine to leave the body normally or cause urine to back up in the urethra have an increased risk of UTIs.
- Blockages in the urinary tract. Kidney stones or an enlarged prostate can trap urine in the bladder and increase the risk of UTIs.
- A suppressed immune system. Diabetes and other diseases that impair the immune system — the body’s defense against germs — can increase the risk of UTIs.
- Catheter use. People who can’t urinate on their own and use a tube (catheter) to urinate have an increased risk of UTIs. This may include people who are hospitalized, people with neurological problems that make it difficult to control their ability to urinate and people who are paralyzed.
- A recent urinary procedure. Urinary surgery or an exam of your urinary tract that involves medical instruments can both increase your risk of developing a urinary tract infection.
What are the common symptoms of UTI?
UTI may be completely silent and picked up at urine test. Common complaints include:
- A strong, persistent urge to urinate
- A burning sensation when urinating
- Passing frequent, small amounts of urine
- Urine that appears cloudy
- Urine that appears red, bright pink or cola-colored — a sign of blood in the urine
- Strong-smelling urine
- Pelvic pain, in women — especially in the center of the pelvis and around the area of the pubic bone
- When UTI spreads to kidney (a condition called pyelonephritis, which may have serious consequences), one may experience back pain or side (flank) pain, high fever, shaking and chills, nausea, vomiting
UTIs may be overlooked or mistaken for other conditions in older adults.
What are the complications of UTI?
When treated promptly and properly, lower urinary tract infections rarely lead to complications. But left untreated, a urinary tract infection can have serious consequences.
Complications of a UTI may include:
- Recurrent infections, especially in women who experience two or more UTIs in a six-month period or four or more within a year.
- Permanent kidney damage from an acute or chronic kidney infection (pyelonephritis) due to an untreated UTI.
- Increased risk in pregnant women of delivering low birth weight or premature infants.
- Urethral narrowing (stricture) in men from recurrent urethritis, previously seen with gonococcal urethritis.
- Sepsis, a potentially life-threatening complication of an infection, especially if the infection works its way up your urinary tract to your kidneys.
What are suggested prevention measures?
You can take these steps to reduce your risk of urinary tract infections:
- Drink plenty of liquids, especially water. Drinking water helps dilute your urine and ensures that you’ll urinate more frequently — allowing bacteria to be flushed from your urinary tract before an infection can begin.
- Drink cranberry juice. Although studies are not conclusive that cranberry juice prevents UTIs, it is likely not harmful.
- Wipe from front to back. Doing so after urinating and after a bowel movement helps prevent bacteria in the anal region from spreading to the vagina and urethra.
- Empty your bladder soon after intercourse. Also, drink a full glass of water to help flush bacteria.
- Avoid potentially irritating feminine products. Using deodorant sprays or other feminine products, such as douches and powders, in the genital area can irritate the urethra.
- Change your birth control method. Diaphragms, or unlubricated or spermicide-treated condoms, can all contribute to bacterial growth.
Urethral Stricture
The urethra is a thin tube through which the bladder empties urine out of the body. The female urethra is much shorter and wider than in males. Male urethra is about 15-20 cms long and transports sperms along with urine through the penis outside. When a scar from swelling, injury or infection causes urethral narrowing, it is called a urethral stricture.
Clinical relevance of Male and Female Urethra
The long and curved course of male urethra makes urinary catheterization (the process of inserting a tube through the urethra and into the bladder, typically performed in situations where urine output needs to be monitored (such as sepsis), or when the patient is unable to pass urine (urinary retention)) a complex procedure. In male urethra, there are two angles to consider during catheterization, the infrapubic prepubicangles and the prepubic angle can be diminished by holding the penis upwards during urinary catheterisation.
Due to the short length of the urethra, women are more susceptible to infections of the urinary tract. This usually manifests as cystitis, an infection of the bladder.
What are the causes of Urethral Stricture?
Men are more likely to have a urethral stricture because of their longer urethra. They are rare in women and in infants.
Common causes are:
- trauma to the urethra due to fall onto scrotum or perineum
- infection such as a sexually transmitted disease (Gonorrhea and Chlamydia are common causes)
- damage from surgical tools during catheterization, prostate surgery, kidney stone removal
In many cases, no cause can be found.
What are the common symptoms of Urethral Stricture?
The urethra is like a garden hose. When there is a kink or narrowing along the hose, no matter how short or long, the flow is reduced. Urethral stricture most commonly leads to slow or decreased urine stream. Problems with urinating, UTIs, and swelling or infections of the prostate may occur. Severe blockage that lasts a long time can damage the kidneys.
Other symptoms are:
- bloody or dark urine
- blood in semen
- urine stream spraying
- pain with urinating
- abdominal pain
- urethral leaking
- loss of bladder control
What are the common diagnostic tests?
The commonly utilized tests are:
- physical exam
- uroflowmetry- a test to measure the rate of urine flow during urination.
- urethroscopy and cystoscopy (to see the inside of the urethra till the bladder)
- retrograde urethrogram- an X-ray test where contrast dye (fluid that can be seen in X-rays) is inserted through tip of penis into urethra to confirm urethral strictures and identify how many strictures there are, and their position, length and severity.
What are the available treatment options?
The treatment options depend on the extent and severity of stricture. Treatments include:
- dilation – enlarging the stricture with gradual stretching
- urethrotomy – cutting the stricture with a laser or knife through a scope
- open surgery – surgical removal of the stricture with reconnection and reconstruction, possibly with grafts (urethroplasty)
There are no available drugs to help treat strictures.
Without treatment, one will continue to have problems with voiding. Urinary and/or testicular infections and stones could develop. Urine retention may occur, which could lead to an enlarged bladder and kidney problems.
What are the suggested measures for Prevention?
- Avoid injury to the urethra and pelvis.
- Be careful with self-catheterization
- Use lubricating jelly liberally
- Use the smallest possible catheter needed for the shortest time
- Avoid sexually transmitted infections.
- Infection can be prevented with condom use, or by avoiding sex with infected partners.
- If a problem occurs, take the right antibiotics early. Urethral strictures are not contagious, but sexually transmitted infections are.
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