BPH and the Bladder

The prostate is a walnut-sized and shaped organ that sits below the bladder, in front of the rectum, and straddles the urethra. It is a vital component of the male reproductive system and supplies an important fluid that both nourishes and facilitates the transport of sperm. When a man is in his teens and 20s, the prostate weighs about 20 grams. As most men age, their prostate tends to keep growing, and can double, triple or even further exceed its young adult size. When this growth doesn’t stop, men develop an enlarged prostate, also called prostatic hyperplasia, benign prostatic hyperplasia, or BPH. Whereas the prostate was the size of a walnut or apricot when a man was young, the prostate can grow to the size of a tennis ball or larger as a man grows older. Even though the prostate tissue continues to grow, it’s not considered prostate cancer and isn’t known to cause prostate cancer. It is simply the non-cancerous enlargement of the prostate gland that most men experience as they age. Benign prostatic hyperplasia can be brought on by factors such as hormonal changes, family history, medical conditions, age, and other factors. The exact cause is unknown, but these are the prime suspects. As the prostate continues to grow in size and/or a more impactful direction, BPH symptoms that present as lower urinary tract symptoms or LUTS can become more prevalent, and if they persist long enough without treatment, they can begin causing bladder issues.

BPH Symptoms and How They Can Affect the Bladder

Given the prostate’s proximity to the bladder and since the prostate surrounds the urethra (the tube that transports urine from the bladder), an enlarged prostate can have a significant impact on the bladder and its function if it becomes large enough or grows in an orientation that more directly affects the bladder. If the enlargement of prostate tissue becomes severe enough for long enough, it can cause LUTS so acute that bladder function is compromised and permanent bladder damage can occur. There are numerous ways in which the bladder can be affected by benign prostatic hyperplasia. They include:

1. Voiding/Obstructive and Storage/Irritative Urinary Symptoms:

Benign prostatic hyperplasia can cause the prostate to both press against the bladder and pinch the urethra, causing bladder overactivity and numerous lower urinary tract symptoms which can include¹:

• A Weak Urinary Stream (voiding/obstructive): Urinary flow may be weaker and slower due to the bladder and urethra being obstructed because of benign prostatic hyperplasia
• Terminal Dribbling (voiding/obstructive): After urination is complete, some dribbling may still occur. This is caused by the enlarged prostate acting as a bladder outlet obstruction or BOO when other urinary symptoms are present and not allowing the sphincter to perform correctly. If there is a good amount of leakage, it could be considered incontinence.²
• Straining to Urinate (voiding/obstructive): When obstruction by the prostate is significant, straining to urinate can become an issue.
• Incomplete Emptying (voiding/obstructive): When the bladder can’t fully empty its contents, residual urine can remain in the bladder or urinary tract. This is called urinary retention. In severe cases, benign prostatic hyperplasia can lead to overflow incontinence when the bladder can’t empty properly and urine leaks out intermittently. Men who experience incomplete emptying will often double void (make several back-to-back trips to the restroom) to try and empty the bladder fully.
• Difficulty Starting and Stopping Urination (voiding/obstructive): Starting the urine stream (hesitation) may become more difficult and the stream may intermittently start and stop; resulting in a non-continuous urine stream.
• Frequent Urination (storage/irritative): When prostate tissue continues growing further toward the bladder and urethra and they become partially blocked, the bladder may need to empty more often because it can’t hold as much urine. Most of the time this is more noticeable while sleeping since additional overnight trips to the bathroom (Nocturia) are usually needed as the prostate grows larger. Daytime increased frequency is also common, but it is easier to deal with versus nighttime frequency.
• Urgency (storage/irritative): There can be a sudden and urgent need to urinate when the prostate grows large enough that bladder overactivity sets in. These “have to go now” moments can impact lifestyles dramatically if experienced often. Environmental factors such as the sound of running water can trigger this urgency even more.
• Urge Incontinence (storage/irritative): A sudden and compelling urge to urinate, caused by BPH induced LUTS, can result in the involuntary leakage of urine.
• Nocturia (storage/irritative): Sleep interruption and deprivation due to frequent bathroom visits during the night can lead to daytime fatigue, mood swings, difficulty concentrating on tasks and a decrease in productivity.

2.Bladder Muscle Changes:

When the bladder isn’t able to fully empty for an extended period, the bladder’s muscle walls can begin to thicken and become more sensitive due to the increased effort required to push urine through the obstructed urethra. This structure and function change is called detrusor hypertrophy and can eventually lead to bladder instability and decreased bladder capacity.³ In severe cases, this issue can result in a decompensated bladder over time and lead to incontinence and the need to place a permanent catheter.

3.Urinary Tract or Bladder Infections:

Benign prostatic hyperplasia can increase the risk of urinary tract infections (UTIs)¹ or bladder infections since the urinary tract or bladder may not be able to fully expel all of the urine each time. This leftover urine presents a perfectly warm and moist setting for bacterial growth. UTIs are notorious for causing discomfort and antibiotics are necessary to fight the infection.

4. Bladder Diverticula:

Sometimes chronic bladder outlet obstruction (BOO) caused by BPH can lead to the development of diverticula (small pouches) on the bladder wall. These diverticula can capture and hold urine and increase the risk of a bladder infection or damage to the bladder.³

5. Bladder Stones:

Some men with BPH may develop bladder stones¹ due to stagnant urine solidifying in the bladder and forming uric acid concretions that can cause pain and other urinary symptoms. When the bladder can’t fully empty, urine can continue accumulating and can eventually harden into bladder stones.

6. Acute Urinary Retention (AUR):

In severe cases, benign prostatic hyperplasia can lead to AUR, a situation where a man suddenly can’t urinate at all. The urinary system becomes fully blocked and no urine can be released from the bladder. When this happens, it is a medical emergency that requires immediate attention. If catheterization is not available to release the backed-up urine, the bladder could burst and cause severe medical issues or even death.⁴

7. Kidney Damage:

Rarely, severe, and long-lasting benign prostatic hyperplasia can result in kidney damage if urine is allowed to consistently back up into the kidneys. This can lead to a kidney infection, kidney function impairment, or renal failure.⁵ Lower urinary tract symptoms and their complications brought on by benign prostatic hyperplasia can lead to bladder damage if BPH is not managed or treated properly. Men diagnosed with BPH need to consider medical evaluation and treatment options to prevent or treat potential BPH symptoms. Options for treating BPH and protecting the bladder include watchful waiting, medications, minimally invasive therapies, and surgery depending on the severity of BPH and the impact on bladder health and functionality. Regular checkups and follow-ups are vital for monitoring and managing any bladder issues that may arise due to BPH.   References:  

1. Mayo Clinic. Benign prostatic hyperplasia (BPH). https://www.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/symptoms-causes/syc-20370087
2. https://gpnotebook.com/simplepage.cfm?ID=1745223707#:~:text=Terminal%20dribbling%20occurs%20when%20the,accompanied%20by%20other%20urinary%20symptoms.
3. Zhang EY, Stein R, Chang S, Zheng Y, Zderic SA, Wein AJ, Chacko S. Smooth muscle hypertrophy following partial bladder outlet obstruction is associated with overexpression of non-muscle caldesmon. Am J Pathol. 2004 Feb;164(2):601-12. doi: 10.1016/S0002-9440(10)63149-5. PMID: 14742265; PMCID: PMC1602268.
4. Iscaife A, Dos Anjos G, Barbosa C Neto, Nahas WC, Srougi M, Antunes AA. The role of bladder diverticula in the prevalence of acute urinary retention in patients with BPH who are candidates to surgery. Int Braz J Urol. 2018 Jul-Aug;44(4):765-770. doi: 10.1590/S1677-5538.IBJU.2017.0605. PMID: 29617085; PMCID: PMC6092655.
5. Bengtsen, M. B., Heide-Jørgensen, U., Borre, M., Knudsen, J. S., & Nørgaard, M. (2023). Acute urinary retention in men: 21-year trends in incidence, subsequent benign prostatic hyperplasia-related treatment and mortality: A Danish population-based cohort study. The Prostate, 83(1), 87-96. https://doi.org/10.1002/pros.24440
6. https://www.healthline.com/health/BPH-renal-failure-know-your-risks#the-connection

Important Safety Information

All surgical treatments have inherent and associated side effects. Individual’s outcomes may depend on a number of factors, including but not limited to patient characteristics, disease characteristics and/or surgeon experience. The most common side effects are mild and transient and may include mild pain or difficulty when urinating, discomfort in the pelvis, blood in the urine, inability to empty the bladder or a frequent and/or urgent need to urinate, and bladder or urinary tract infection. Other risks include ejaculatory dysfunction and a low risk of injury to the urethra or rectum where the devices gain access to the body for treatment. Further, there may be other risks as in other urological surgery, such as anesthesia risk or the risk of infection, including the potential transmission of blood borne pathogens. For more information about potential side effects and risks associated with Aquablation therapy for Benign Prostatic Hyperplasia (BPH) treatment, speak with your urologist or surgeon. Prior to using our products, please review the Instructions for Use, Operator’s Manual or User Manual, as applicable, and any accompanying documentation for a complete listing of indications, contraindications, warnings, precautions and potential adverse events. No claim is made that the AquaBeam Robotic System will cure any medical condition, or entirely eliminate the diseased entity. Repeated treatment or alternative therapies may sometimes be required.

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