The male reproductive system undergoes various changes as men age, and two common conditions that affect the prostate are Benign Prostatic Hyperplasia (BPH) and prostate cancer. While both involve the prostate gland, they differ significantly in terms of their nature, causes, and implications for health. It is crucial to distinguish between these two conditions to ensure accurate diagnosis and appropriate management. In this overview, I will delve into the fundamental differences between BPH and prostate cancer, shedding light on their distinct characteristics, risk factors, symptoms, and potential treatment options.

Understanding the differences between BPH and prostate cancer is crucial for informed decision-making regarding diagnosis and treatment. As these conditions share some common symptoms, consulting with a urologist is essential for accurate evaluation and personalized care.

What is the BPH and prostate cancer?

BPH (Benign Prostatic Hyperplasia): BPH is a non-cancerous condition characterized by the enlargement of the prostate gland, often causing urinary symptoms due to increased pressure on the urethra.

Prostate Cancer: Prostate cancer is a malignant disease where abnormal cells in the prostate gland multiply uncontrollably, potentially spreading to other tissues and organs. It is one of the most common cancers in men.

Incidence and prevalance

BPH (Benign Prostatic Hyperplasia):

• Incidence: BPH is highly prevalent among aging men, and its incidence increases with age. By the age of 60, more than half of men experience symptoms of BPH, rising to about 90% among those aged 85 and older.
  • Prevalence: BPH is a common condition, affecting millions of men worldwide. While not all cases require medical intervention, its prevalence underscores the importance of understanding and managing its symptoms.

Prostate Cancer:

• Incidence: Prostate cancer is the most common cancer among men, with incidence rates varying globally. Age is a significant factor, and the risk increases substantially after the age of 50. However, it can occur in younger men as well.
  • Prevalence: Prostate cancer has a high prevalence, and it is estimated that a considerable proportion of men will be diagnosed with this cancer during their lifetime. However, the majority of cases are slow-growing, and not all require aggressive treatment. Regular screening and early detection play a crucial role in managing the prevalence of prostate cancer.

Heredity

BPH (Benign Prostatic Hyperplasia):

• Heredity: There is some evidence suggesting a hereditary component in the development of BPH. Men with a family history of BPH may have a higher risk of experiencing this condition. However, the exact genetic factors contributing to BPH are still being researched.

Prostate Cancer:

• Heredity: Heredity plays a notable role in the risk of developing prostate cancer. Men with a family history of prostate cancer, especially in first-degree relatives (father, brother), have an increased likelihood of developing the disease. Certain genetic mutations and variations are associated with a higher prostate cancer risk, emphasizing the importance of familial factors in its etiology. Regular screenings are often recommended for individuals with a family history to ensure early detection and appropriate management.

BPH and Prostate Cancer Etiology

BPH (Benign Prostatic Hyperplasia): The exact cause of BPH is not fully understood, but it is believed to be influenced by hormonal changes associated with aging, particularly an increase in dihydrotestosterone (DHT). Genetic and familial factors may also contribute to the development of BPH. Additionally, inflammation and hormonal imbalances are considered potential contributors to the etiology of BPH.

Prostate Cancer: The etiology of prostate cancer is multifactorial. Genetic predisposition, family history, and race are significant factors. Mutations in specific genes, such as BRCA1 and BRCA2, are associated with an increased risk. Hormonal influences, especially testosterone and its derivatives, play a role in the development and progression of prostate cancer. Age is a crucial factor, with the risk increasing substantially after the age of 50. Dietary and lifestyle factors, including high-fat diets, may also contribute to the etiology of prostate cancer. Understanding these factors helps in risk assessment, prevention, and early detection strategies.

Mechanisms of prostate cancer and BPH

Mechanisms of Prostate Cancer:

• Genetic Mutations: Prostate cancer is associated with genetic alterations. Mutations in specific genes, such as BRCA1 and BRCA2, are linked to an increased risk of developing prostate cancer.
  • Androgen Hormones: Testosterone and its derivative, dihydrotestosterone (DHT), play a crucial role in the development and growth of the prostate. In some cases, an imbalance in androgen hormones can contribute to the initiation and progression of prostate cancer.
  • Inflammation: Chronic inflammation in the prostate may contribute to the development of prostate cancer. Inflammatory processes can lead to genetic mutations and promote the survival and growth of cancerous cells.
  • Age-Related Changes: The risk of prostate cancer increases with age, suggesting that age-related changes, possibly cumulative genetic mutations, hormonal changes, and environmental factors, contribute to its development.
  • Environmental and Lifestyle Factors: Diet, lifestyle choices, and environmental exposures may influence the risk of prostate cancer. High-fat diets, obesity, and exposure to certain environmental toxins may contribute to the development of prostate cancer.

Mechanisms of Benign Prostatic Hyperplasia (BPH):

Understanding these mechanisms is crucial for developing targeted interventions and treatments for both prostate cancer and BPH. Ongoing research continues to enhance our knowledge of these conditions at the molecular and cellular levels.

• Hormonal Changes: Aging is associated with changes in hormone levels, particularly an increase in DHT. Hormonal imbalances, especially involving androgens, contribute to the overgrowth of prostate cells in BPH.
  • Cellular Proliferation: BPH is characterized by an increase in the number of prostate cells, leading to the enlargement of the gland. The exact mechanisms triggering excessive cell proliferation are not fully understood but are believed to involve hormonal and growth factor signals.
  • Inflammatory Processes: Inflammation within the prostate may play a role in the development of BPH. Chronic inflammation can lead to cellular changes and the accumulation of growth-promoting factors.
  • Stromal and Epithelial Changes: Changes in the stromal and epithelial components of the prostate contribute to the development of BPH. These changes involve alterations in the balance between cell proliferation and cell death.
  • Genetic and Familial Factors: There is evidence suggesting a genetic predisposition to BPH. Familial factors and specific genetic variations may contribute to an individual’s susceptibility to developing an enlarged prostate.

Symptoms of BPH and prostate cancer

It’s important to note that both BPH and prostate cancer can share urinary symptoms. However, the key distinction lies in the nature of these conditions. While BPH is a non-cancerous enlargement of the prostate, prostate cancer involves the growth of malignant cells within the gland. If experiencing any of these symptoms, particularly in the case of prostate cancer, seeking prompt medical attention for evaluation and diagnosis is crucial. Regular screenings, especially for individuals at higher risk, can aid in the early detection of prostate cancer.

Symptoms of Benign Prostatic Hyperplasia (BPH):

• Urinary Frequency: Increased need to urinate, especially during the night.
  • Urgency: A sudden and compelling need to urinate.
  • Weak Urine Stream: Reduced force or caliber of the urine stream.
  • Difficulty Initiating Urination: Trouble starting the flow of urine.
  • Incomplete Emptying: Sensation that the bladder is not completely emptied after urination.
  • Intermittent Flow: Stopping and starting of the urine stream.
  • Straining During Urination: Exertion or difficulty in passing urine.
  • Dribbling at the End of Urination: Release of urine drops after completion of urination.
  • Bladder Incontinence: In some cases, BPH can lead to urinary incontinence.

Symptoms of Prostate Cancer:

• Asymptomatic in Early Stages: Prostate cancer may not cause noticeable symptoms in its early stages. Regular screenings are crucial for early detection.
  • Urinary Changes: Changes in urinary habits, such as increased frequency, urgency, difficulty starting or stopping urination, or a weak urine stream.
  • Blood in Urine or Semen: Hematuria (blood in the urine) or hematospermia (blood in the semen).
  • Erectile Dysfunction: Difficulty achieving or maintaining an erection.
  • Pelvic Discomfort: Discomfort or pain in the pelvic area, lower back, or hips.
  • Bone Pain: Advanced prostate cancer may spread to the bones, causing pain, especially in the spine, hips, and pelvis.
  • Weight Loss and Fatigue: Unexplained weight loss and persistent fatigue.
  • Leg Swelling: Swelling in the legs may occur if the cancer spreads to the lymph nodes.

Examination of BPH and prostate cancer

The examination of Benign Prostatic Hyperplasia (BPH) and Prostate Cancer involves assessing symptoms, conducting diagnostic tests like digital rectal exams and PSA tests, and often includes imaging studies such as ultrasound or MRI. BPH is a non-cancerous enlargement of the prostate gland, leading to urinary symptoms, while prostate cancer is the abnormal growth of cells in the prostate gland, potentially causing similar symptoms.

Differentiating between the two conditions is crucial for proper management and treatment. Treatment options range from watchful waiting to medication and surgical interventions, depending on the severity and type of condition diagnosed. Regular screenings and consultations with healthcare providers are essential for early detection and effective management of both BPH and prostate cancer.

Diagnosis of BPH and prostate cancer

Early detection and accurate diagnosis are critical for both BPH and prostate cancer. Patients with symptoms or those at higher risk should consult with a healthcare professional for a comprehensive evaluation and appropriate diagnostic tests. Regular screenings, especially for prostate cancer, are recommended for individuals with risk factors.

Diagnosis of Benign Prostatic Hyperplasia (BPH):

• Medical History and Physical Examination: A healthcare provider will discuss the patient’s symptoms, medical history, and perform a physical examination, including a digital rectal exam (DRE) to assess the size and condition of the prostate.
  • Urinary Flow Tests: Uroflowmetry measures the rate and amount of urine voided, helping evaluate the urinary flow and identify any obstruction.
  • Post-void Residual Measurement: This test measures the amount of urine left in the bladder after voiding to assess if there is incomplete emptying.
  • Prostate-Specific Antigen (PSA) Blood Test: Elevated PSA levels can be associated with BPH, though it is not a definitive diagnostic tool for BPH. Elevated PSA levels may prompt further investigation to rule out prostate cancer.
  • Transrectal Ultrasound (TRUS): TRUS uses sound waves to create an image of the prostate, providing information about its size and any abnormalities.
  • Cystoscopy: Cystoscopy involves inserting a thin, flexible tube with a camera through the urethra to visualize the interior of the bladder and urethra, helping identify any obstructions or abnormalities.

Diagnosis of Prostate Cancer:

• Digital Rectal Exam (DRE): A physical examination in which a healthcare provider assesses the size, shape, and consistency of the prostate by inserting a gloved, lubricated finger into the rectum.
  • Prostate-Specific Antigen (PSA) Blood Test: Elevated PSA levels may indicate the presence of prostate cancer, though it can also be elevated in conditions like BPH or prostatitis.
  • Prostate Biopsy: A definitive diagnosis of prostate cancer is often made through a biopsy, where a small tissue sample is taken from the prostate gland using a needle. The sample is then examined under a microscope for the presence of cancerous cells.
  • Imaging Studies: Imaging tests such as Magnetic Resonance Imaging (MRI), Computed Tomography (CT) scans, or bone scans may be performed to determine the extent of cancer, especially if there is suspicion of metastasis.
  • Transrectal Ultrasound (TRUS): TRUS may be used in conjunction with a biopsy to guide the needle to the specific area of concern within the prostate.
  • Gleason Score: The Gleason score, assigned after examining biopsy samples, helps grade the aggressiveness of the prostate cancer cells.

Laboratory tests

It’s important to note that a combination of tests is often employed to accurately diagnose and differentiate between BPH and prostate cancer. These tests, along with a thorough medical history and physical examination, aid healthcare professionals in determining the most appropriate course of action for each patient. Regular screenings are recommended, especially for individuals at higher risk of developing prostate cancer.

Laboratory Tests for Benign Prostatic Hyperplasia (BPH):

• Prostate-Specific Antigen (PSA) Blood Test: Although primarily used for prostate cancer, PSA levels can also be elevated in BPH. It is a useful marker to assess the health of the prostate and may prompt further investigation if elevated.

Laboratory Tests for Prostate Cancer: Prostate-Specific Antigen (PSA) Blood Test:

• PSA: Elevated levels of PSA may indicate the presence of prostate cancer, but it is not definitive. Other conditions such as BPH or prostatitis can also cause elevated PSA levels.
  • Prostate Biopsy: The definitive diagnosis of prostate cancer is made through a biopsy. During this procedure, a small tissue sample is taken from the prostate and examined under a microscope to identify cancerous cells.
  • Urine Tests: Urine tests may be conducted to check for the presence of blood or other markers that could indicate prostate cancer or other urinary conditions.

Additional Tests for Both BPH and Prostate Cancer:

Uroflowmetry: This test measures the rate and amount of urine voided, helping assess the urinary flow and identify any obstruction. It is commonly used for BPH.

Post-void Residual Measurement: Measures the amount of urine left in the bladder after voiding, helping to assess if there is incomplete emptying. It is used for both BPH and prostate cancer.

Imaging Studies:

Transrectal Ultrasound (TRUS):Uses sound waves to create an image of the prostate, providing information about its size and any abnormalities. It is commonly used for both BPH and prostate cancer.

Magnetic Resonance Imaging (MRI): Provides detailed images of the prostate and surrounding structures, helping to detect abnormalities and assess the extent of cancer. It is particularly useful for staging prostate cancer.

Cystoscopy: Involves inserting a thin, flexible tube with a camera through the urethra to visualize the interior of the bladder and urethra. It can help identify any obstructions or abnormalities and is used in both BPH and prostate cancer diagnostics.

BPH and Prostate Cancer Teatment

Treatment decisions for both BPH and prostate cancer depend on factors such as the severity of symptoms, cancer stage, age, overall health, and patient preferences. A thorough discussion with healthcare providers is essential to determine the most appropriate treatment plan tailored to individual needs and circumstances. Regular follow-ups and screenings are crucial for monitoring the effectiveness of treatments and managing potential side effects.

Treatment of Benign Prostatic Hyperplasia (BPH):

Watchful Waiting/Active Surveillance: Monitoring the condition without immediate intervention, especially for mild symptoms.

Lifestyle Modifications: Changes in diet and exercise to improve overall health and manage symptoms.

Medications:

Alpha-Blockers: Relax muscles near the prostate to improve urine flow.

5-Alpha Reductase Inhibitors: Reduce the size of the prostate by inhibiting the production of dihydrotestosterone (DHT).

Combination Therapy: A combination of alpha-blockers and 5-alpha reductase inhibitors may be prescribed.

Minimally Invasive Procedures:

Transurethral Resection of the Prostate (TURP): Surgical removal of excess prostate tissue through the urethra.

Transurethral Incision of the Prostate (TUIP): Small incisions to reduce pressure on the urethra.

Prostatic Urethral Lift (UroLift): A minimally invasive procedure that lifts and holds the enlarged prostate tissue, relieving pressure on the urethra.

Laser Therapy:

Laser Vaporization (GreenLight): Uses laser energy to remove excess prostate tissue.

Holmium Laser Enucleation of the Prostate (HoLEP): Removes prostate tissue using a laser.

Treatment of Prostate Cancer:

Active Surveillance: Monitoring the cancer without immediate treatment, particularly for slow-growing and low-risk tumors.

Surgery:

• Radical Prostatectomy: Surgical removal of the entire prostate gland.
  • Robot-Assisted Laparoscopic Prostatectomy: Minimally invasive surgery using robotic assistance.

Radiation Therapy:

• External Beam Radiation Therapy (EBRT): High-dose radiation directed at the prostate from outside the body.
  • Brachytherapy: Placement of radioactive seeds directly into the prostate.

Hormone Therapy: Reducing levels of male hormones (androgens) to slow the growth of prostate cancer cells.

Chemotherapy: Medications to kill or slow the growth of cancer cells, often used in advanced stages or when other treatments are ineffective.

Immunotherapy: Stimulating the immune system to target and destroy cancer cells.

Targeted Therapy: Drugs that target specific molecules involved in cancer growth, often used when other treatments have not been effective.

Cryotherapy: Freezing of prostate tissue to destroy cancer cells.

High-Intensity Focused Ultrasound (HIFU): Using ultrasound waves to heat and destroy cancer cells.

Chemical Ablation: Injecting medications directly into the prostate to destroy cancer cells.

Summary

BPH is a non-cancerous enlargement causing urinary symptoms, while prostate cancer involves the growth of malignant cells. Both conditions may share urinary symptoms, emphasizing the importance of accurate diagnosis through medical evaluation and tests. Regular screenings are crucial for early detection and appropriate management of prostate cancer.

In summary, understanding the distinctions between BPH and prostate cancer is vital for individuals, healthcare providers, and caregivers. Timely diagnosis and tailored treatment plans contribute to better outcomes for those affected by these prostate-related conditions.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKEY