BPH: The more scientific name is ‘Benign Prostatic Hyperplasia’ and not ‘Benign Prostatic Hypertrophy’!

The more scientific name for an enlarged prostate is BPH, or benign prostatic hyperplasia. “Benign” refers to the fact that the condition is not cancerous or malignant. “Prostatic” refers to the prostate gland. “Hyperplasia” is the growth of tissue through an increase in the number of cells. Men develop an enlarged prostate either because they experience an increase in the number of cells growing in the prostate, or there is a decrease in the number of cells that die.

Technically, BPH also is associated with two other prostate conditions, prostatitis and prostate cancer, since both diseases involve abnormal growth of the prostate. Sometimes you may see the term benign prostatic hypertrophy, which some doctors and laypeople use when referring to the same condition, but technically it is a misnomer. “Hypertrophy” means the growth of tissue through enlargement of existing cells

Structure of the prostate

The prostate is surrounded by connective tissue containing many muscle fibers; this capsule makes the prostate feel elastic to the touch. Scientists often split the prostate into four zones that encircle the urethra like layers of an onion. Here they are listed from outermost to innermost.

1. Anterior fibromuscular zone (stroma) — made of muscular and fibrous tissue. Part of the capsule.
2. Peripheral zone — mostly situated toward the back of the gland, this is where most of the glandular tissue is. Most prostate cancer starts in the peripheral zone (the back of the prostate), near the rectum. That’s why a digital rectal exam (DRE), in which a doctor examines the prostate by inserting a gloved finger in the rectum, is a common and useful screening test. Difficulty with urination is usually not a symptom of prostate cancer. In most cases, lower urinary tract symptoms are due to Benign Prostatic Hypertrophy, (BPH), which is a non-cancerous prostate condition that typically develops from the transition zone that surrounds the urethra, or urinary tube (closer to the middle of the prostate).
3. Central zone — surrounds the ejaculatory ducts and makes up around one-quarter of the prostate's total mass.
4. Transition zone — this is the smallest part of the prostate and surrounds the urethra; it is the only portion of the prostate that continues to grow throughout life.

Diseases affecting the prostate

As men age, the prostate can become enlarged. There are a number of ways in which the prostate can cause medical problems, including:

1. Prostate cancer — this is the most common form of cancer in males, affecting around 2 in 5 Ghanaian men during their lifetime by age 50 according to Ergote 2019 study in Brong Ahafo Men . Around 7 in 9 men die of prostate cancer according to Ghana Health Service figures in 2015. The Prostate Cancer UK also put it this way: ‘1 in 4 black men will be diagnosed with prostate cancer in their life time, 2013’
2. Enlarged prostate — also known as benign prostatic hypertrophy (BPH), this affects almost all men aged 50 or over. It makes it difficult to urinate and, in rare, serious cases, can prevent urination entirely. Most commonly, the enlargement occurs in the Transition zone
3. Prostatitis — an inflammation of the prostate; this is sometimes caused by an infection.

Benign Prostatic Hyperplasia (BPH)

The more scientific name for an enlarged prostate is BPH, or benign prostatic hyperplasia. “Benign” refers to the fact that the condition is not cancerous or malignant. “Prostatic” refers to the prostate gland. “Hyperplasia” is the growth of tissue through an increase in the number of cells. Men develop an enlarged prostate either because they experience an increase in the number of cells growing in the prostate, or there is a decrease in the number of cells that die.

Technically, BPH also is associated with two other prostate conditions, prostatitis and prostate cancer, since both diseases involve abnormal growth of the prostate.

Sometimes you may see the term benign prostatic hypertrophy, which some doctors and laypeople use when referring to the same condition, but technically it is a misnomer. “Hypertrophy” means the growth of tissue through enlargement of existing cells

showing the diagram of the Prostate

Who is at Risk of BPH?

Black men can expect to get an enlarged prostate as they gets older. The spurt in prostate growth typically begins around age 40, but the rate and extent of growth can vary considerably. While the normal size of the prostate is about 20 to 30 grams, it can increase to as much as 50 to 100 grams. As a trained and professional Medical Sonographer also with interest in urological ultrasound, I have seen prostate size practically more than 100grams without causing any urinary trouble to the patient. In a 2018 study by Egote al , the authors reported a patient with a prostatic hyperplasia weighing exactly 700 g which was successfully removed at the Brong Ahafo Regional Hospital theatre in Ghana by Pfannesteil Transvesical Simple Prostatectomy.

Obu (2014) research also revealed the prevalence of BPH using ultrasound detected enlarged prostate was 40.0%. It was also found that after age standardization, the prevalence of ultrasound detected enlarged prostate in Ghanaian men is higher with high prevalence of lower urinary tract symptoms (LUTS) and erectile dysfunction.

Interestingly enough, that doesn’t mean the larger prostate will cause discomfort or symptoms for all men. In fact, about one third of men experience symptoms by age 60, although that percentage can rise to as high as 90 percent by the age of 85. According to the National Association for Continence, about 19 million men have symptomatic enlarged prostate, and of that number 14 million are undiagnosed and 2 million have been diagnosed but are not receiving treatment

According to Yeboah 2016, benign prostatic hyperplasia (BPH) prevalence in Ghana is responsible for 60% acute retention of urine and 28.6% of haematuria. Worldwide prevalence of BPH varies from 20 – 62% in men over 50 years and this includes USA, UK, Japan and Ghana. Reports from South Africa indicate prevalence of over 50% in adult males of 60 years. Acheampong also in 2016 research revealed BPH prevalence rate of 71.4%.

On the economic Costs of BPH and Prostate cancer, Yeboah 2016, reports that, BPH in the USA national direct costs are estimated at U$4Billion and individual costs of US$1536 annually. In Ghana, individual costs for BPH medications range from US$300 – 550 per year and cost for simple prostatectomy/TURP is estimated at US$1100. For prostate cancer, individual direct costs from Europe range from 6,575 – 12,000 euros, £2818.00 UK and over U$12,000 – 20,000 in USA per annum. In Ghana, individual direct costs ranges, for radical prostatectomy and external beam radiotherapy US$1250 – 1500, for brachytherapy 9,000 Euros, for hormonal therapy US$1600 – 3200) per year and US$510 for orchidectomy.

BPH can co-exist with Prostate cancer also and reports from USA, UK and Japan and Ghana reveal moderate association of BPH and PC. The co-existence of PC in patients being treated for BPH is 3 – 20%(Yeboah 2016)

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BPH diagnoses and evaluation

Early diagnosis of BPH is important because if left untreated it can lead to urinary tract infections, bladder or kidney damage, bladder stones and incontinence. Distinguishing BPH from more serious diseases like prostate cancer is important.

Tests vary from patient to patient, but the following are the most common:

• Filling out a questionnaire: Your doctor is most interested in the severity and type of symptoms you have, and how much they bother you or impact your life. A simple questionnaire is a common starting point.
• Urine flow study: During this test, the patient voluntarily empties his bladder and the amount of flow is measured. A special device can help physicians detect reduced urine flow associated with BPH.
• Digital rectal examination (DRE): The physician inserts a gloved finger into the rectum (located next to the prostate) and feels the back of the prostate. Prostate cancers can sometimes be detected as lumps or bumps on the prostate here.
• Prostate-specific antigen (PSA) blood test: Elevated levels of PSA in the blood may sometimes be an indicator of prostate cancer.
• Cystoscopy: In this examination, the physician inserts a thin tube with a tiny camera on the end called a cystoscope through the opening of the urethra at the tip of the penis. The camera allows the physician to inspect the inside of the prostate, urethra channel and bladder.
• Transrectal ultrasound and Prostate Biopsy: There are two potential reasons for this exam: (1) If there is suspicion for prostate cancer, this test may be recommended. The physician uses an ultrasound probe to acquire images of the prostate and guides a biopsy needle into the prostate to remove small slivers of tissue for examination under a microscope. (2) Your doctor may simply want to know the exact size of your prostate to plan prostate surgery for BPH. In this case, only an ultrasound image will be obtained; no needles will be used.
• Transabdominal ultrasound: This exam may be performed to measure the size of the prostate and the amount of urine left in the bladder after urination.
• Prostate magnetic resonance imaging (MRI): MRI provides views of the entire prostate with excellent soft tissue contrast.

Prostate Cancer: The Ghana Case Study

Very often you find elderly male patients in Ghana above 40years complaining of a feeble urinary stream, hesitancy, dribbling, having to urinate frequently and urgently, feeling that they can't empty their bladder completely and loss of libido. These observations are usually on the increase whilst little or no effort is made to raise awareness for early detection and treatment. Eventually in Ghana, persons who retire with prostate problems spend a significant amount of their time and money on care that may be terminal or more expensive. Prostate cancer (especially in the early stages) is often asymptomatic.

The issue of prostate cancer in men in Ghana is not supposed to be toyed with. Lots of men of all categories of life are battling with this terrible disease. The situation has become one of the most challenging men's health conditions in Ghana where there are not enough prostate cancer screening centers in the various regions to help in the fight for early detection of prostate cancer.

40% of Men affected in Brong Ahafo Region

Prostate cancer is underestimated subject in Ghana; yet more men are battling with the disease. There is also more studies revealing the high incidence and death of the disease in Ghanaian men. For instance, one research studies, Egote et al 2019, aimed at reducing the paucity of data on prostate cancer by assessing the incidence, patterns and presentation in the Brong Ahafo Region of Ghana and also sought to provide region-specific hardcore data that will help to assess the issue and provide remedies.

The study authors, reviewed all prostate disease cases recorded from the year 2009 to 2014. They employed men from 40 years (based on previous studies) and above were eligible for screening. Diagnostic and screening tools for prostate cancer at the study site were family history, serum prostate specific antigen (PSA) test, digital rectal examination, urological ultrasound scan and histopathology (biopsy).

Age, PSA values and year of screening/diagnosis were also retrieved from their folders/archives for the purposes of the study. Histological findings and parameters considered in the study included diagnosis, carcinoma grading, perineural invasion (PNI)- and percentage of affected tissues (%TA).

The researchers revealed that, Prostate cancer constituted 236 cases (40.07%) of the 589 prostate diseases reviewed. The highest annual prevalence was recorded in 2014 with an incidence rate of 21.6% (51 cases). Interestingly enough, the ages of patients ranged from 46 to 101 years with a modal age range of 70 - 79 years and a mean ± SD of 71.7 ± 11.2. The mean PSA value recorded was 37.5 ng/ml (±68.9) with predominance in the 11 - 20.9 ng/ml (61 cases/patients) (27.9%) range. Moderately differentiated adenocarcinoma (intermediate grade) was the dominant grade of prostate cancer accounting for 61.4% (145 cases) of the 236 cases.

There was a significant correlation (p = 0.001) between grading of prostate cancer and perineural invasion. The study authors further revealed that, Only 21.2% graded cancer cases had perineural invasion with >50% affected tissues found in half of them.

The study authors concluded that, “there is a high incidence (40.07%) of prostate cancer in the Brong Ahafo Region of Ghana, presenting mostly with advanced prostatic carcinoma. Reported cases also show high %TA (Tissues Affected and PNI (Perineural invasion). Development and implementation of public health interventions are needed to address some of these issues”.

The study authors proposed development and implementation of public health interventions to address this. In 2015, during the John Dramani Mahama’s administration, I proposed fathers’ Day to be declare as National Day for Prostate Awareness; but it later turned into ‘Medical Politics’. I think, this is the right time for the current administration to consider the proposal for Fathers’ Day to be declare to raise awareness of prostate cancer. The current government also promised a special cancer policy in their 2016 Manifesto, yet nothing has been done!

Prostate Size in Ghanaian Men

All that is needed for a man to get prostate cancer is having the prostate gland. So without the prostate gland, there is no prostate cancer! We can’t also remove our prostate gland because, it is the priciest asset of a man and without it, and we are in doom as men!

In another 2018 study also by Egote al , the authors reported a patient with a prostatic hyperplasia weighing exactly 700 g which was successfully removed at the Brong Ahafo Regional Hospital theatre in Ghana by Pfannesteil Transvesical Simple Prostatectomy.

A prostatic hyperplasia of enormous size is very uncommon and to the best of their knowledge, only ten of such cases have been previously reported. Their case reported constitutes the eleventh heaviest prostate reported in medical literature and also forms the first case report of giant prostatic hyperplasia from Ghana.

Does Prostate size Matters?

I'm passing that message on and I hope others will too. It's a life saver. Let alone what it does! You see, Size definitely isn't everything where the prostate is concerned. This little gland, hidden from sight just below the bladder, is only about the size of a walnut. But when it goes rogue, a man's life can be over.

Also a large prostate does NOT always cause urinary problems. I think one of the areas conventional urological medicine is behind is assuming that a 60-year-old plus man with urinary problems has a big prostate. A big prostate is not always the problem. As someone with a background also in Medical Sonography graduated from Radford University with interest in Urological Ultrasound for almost ten years, I often see 100 to 150-gram prostates (normal is roughly 20 to 40grams) with little to no urinary symptoms and smaller prostates with lots of frequency, urgency and nighttime urination.

Benign Prostatic Hyperplasia (also known as BPH or enlarged prostate) is treated with 5-alpha-reductase inhibiting drugs like Finasteride (Proscar, the trade name) or Dutasteride (Avodart). These drugs can marginally make the prostate smaller but do NOT help with urination. 5-alpha reductase drugs can cause feminization, sexual dysfunction and may lead to advanced prostate cancer (Traish et al 2014, published in the Korean Journal of Urology, titled “The Dark Side of 5α-Reductase Inhibitors’ Therapy: Sexual Dysfunction, High Gleason Grade Prostate Cancer and Depression”

That’s bad news!

Trying to reduce the size of the prostate does not always mean urinary problems go away. The real problem is the area of the prostate called the transitional zone (TZ) that surrounds the urethra (the tube that brings out your urine in your body). The TZ squeezes the urethra for many reasons, including due to stress. That’s why some men with small prostate have urinary symptoms. Be aware of this fact: “A large prostate does not always cause urinary problems in men, and 5-alpha reductase inhibitors can cause more problems than fix them (Traish et al 2014)

Age as Risk factor for Prostate Diseases in Ghana

To assess the risk age for prostate diseases in Brong Ahafo Region, Egote al 2018 research further employed a selective prospective study to review prostate cases from 2009 to 2014. Subjects were selectively recruited for the study using the reference age of the study location (40 yrs) – men from 40 years and above were eligible for testing. They concluded that Ghanaian men between the ages of 50 and 89 are highly predisposed to prostate diseases compared to those <50 years and >89 years. “This observation may provide a rational for effective medical or preventive interventions especially among Ghanaian Adults”. They added.

Increased Risk in military occupations in Ghana

Adler et al 2019 study revealed that risk was increased among men in management and military occupations. Risks were also elevated for management and military-specific jobs based on 3-digit level Standard Occupational Classification definitions. Sensitivity analyses accounting for access to medical care did not show significant differences. The study authors aimed to evaluate the association between usual adult occupation and Prostate cancer risk in Ghanaian men, a population with historically low rates of Prostate cancer screening.

The study dubbed the Ghana Prostate Study, a case-control study of Prostate cancer that was conducted from 2004 to 2012 in 749 cases and 964 controls. In-person interviews were conducted to collect information from participants, including longest held job. Industrial hygienists classified job titles into occupational categories. Unconditional logistic regression was used to calculate ORs and 95% Cis(Odds ratios (ORs), confidence intervals(Cis)) for the association between longest held job and Prostate cancer risk (overall, aggressive (Gleason≥7)), controlling for potential confounders.

The study provides some evidence for increased risk of Prostate cancer among men in management and military occupations, which is consistent with the published literature. However, they concluded “Additional research is needed to clarify the drivers of the associations between these occupations and Prostate cancer risk”.

Prostate cancer also top in Men in Kumasi Municipality

Another 2019 recent study by Amoako et al, revealed that prostate cancer had the highest incidence of 10.5 per 100,000. The mean age of all cancer cases was 51.3 years (with a range of 1 to 99 years). The study authors reviewed data from the Kumasi Cancer Registry for the year 2015. Data collected included clinical and demographic information, laboratory reports and source of case information. Data was entered into the Canreg-5 software. Data was initially analysed using Canreg-5 to estimate the incidence and age standardised rates (ASR) for various tumours. Data was also exported to Microsoft Excel for further analysis using Epi Info version 7.1.4. Microsoft Excel was used to generate charts and graphs. Aggregated data for the years 2013 and 2014 were also analysed for trends in cancer incidence and ASR.

One interesting thing about this Kumasi’s study that focused on all cancers is that, the study authors also found that, lung and skin cancers are rare. Here is what they said “Our report indicates that breast cancer is the commonest female cancer in Ghana and is consistent with other evidence. The leading male cancer reported in this study is consistent with other local and international reports. Lung and skin cancers are rare in Kumasi”.

Disclaimer: As pertains to all my previous articles, they are for educational purposes and not to be use as substitute to medical advice.

Dr. Raphael Nyarkotey Obu, PhD, Is an honorary Professor of Naturopathic Medicine with research interest in Naturopathic & Holistic Urology, Vinnytsia State Pedagogical University, Ukraine. President of Nyarkotey College of Holistic Medicine- Formulated of FDA approved Men’s Formula for Prostate Health, Women’s Formula for wellness & Nyarkotey Tea for cardiovascular Health. 0241083423 or 0541234556