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Review

Burden of Benign Prostatic Hyperplasia (BPH) in Low- and Middle-Income Countries in Sub-Saharan Africa (SSA)

by
Ayun Cassell
1,*,
Babacar Sine
2,
Mohamed Jalloh
2,3 and
Stavros Gravas
4
1
Division of Urology, Department of Surgery, John F Kennedy Medical Center, Monrovia 100010, Liberia
2
Service d’Urologie Centre de Santé de Ngor, Dakar P.O. Box 3001, Senegal
3
Service d’Urologie Hopital General Idrissa Pouye, Dakar P.O. Box 3270, Senegal
4
Medical School, University of Cyprus, 99138 Nicosia, Cyprus
*
Author to whom correspondence should be addressed.
Soc. Int. Urol. J. 2024, 5(5), 320-329; https://doi.org/10.3390/siuj5050051
Submission received: 4 August 2024 / Revised: 27 September 2024 / Accepted: 30 September 2024 / Published: 16 October 2024
Browse Figure
Review Reports Versions Notes

Abstract

:
Background: Benign prostatic hyperplasia (BPH) is the leading cause of lower urinary tract symptoms (LUTSs) in men, with a histological prevalence that increases significantly with age. While extensive research on BPH has been conducted in high-income countries (HICs), limited information exists regarding its burden in low- and middle-income countries (LMICs), especially in Sub-Saharan Africa (SSA). Understanding the prevalence, impact on quality of life, and management practices in these regions is crucial for developing effective healthcare policies and improving patient outcomes. Objectives: This scoping review aims to collate the existing literature on the burden of BPH in LMICs, focusing on prevalence rates, quality-of-life impact, and management practices. The goal is to provide a comprehensive overview that informs healthcare strategies in resource-constrained settings. Methods: A scoping review methodology was employed, following the framework proposed by Arksey and O’Malley. The review encompassed five stages: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting the results. A comprehensive search of electronic databases, including Google Scholar, PubMed, Scopus, and Embase, was conducted using specific search terms related to BPH and LMICs. The inclusion criteria were studies conducted in LMICs (limited to SSA); reporting on the prevalence, impact, or management of BPH; and published in English. Results: The review included studies that reported the wide-ranging prevalence rates of BPH in LMICs, highlighting significant regional variations. The impact of BPH on quality of life was profound, with many men experiencing significant bother and reduced daily functioning due to LUTSs. The management practices in these regions often differed from those in HICs, with limited access to pharmacological treatments and surgical interventions. The economic burden of BPH in LMICs was also notable, with many patients facing financial barriers to accessing effective care. Conclusions: BPH poses a significant health and economic burden in LMICs, particularly in SSA. The prevalence of the condition is high, and its impact on quality of life is substantial. There is an urgent need for improved diagnostic and management strategies tailored to the resources available in these settings. Policymakers should consider integrating BPH management into broader healthcare initiatives to enhance patient outcomes and reduce the overall burden of the disease.

1. Introduction

Benign prostatic hyperplasia (BPH) is the leading cause of lower urinary tract symptoms (LUTSs) in men. Histological studies indicate that BPH prevalence at autopsy rises with age, reaching up to 90% in men aged 81–90 years. The prevalence of LUTSs increases from 44% in men aged 40–59 years to 70% in men over 80 years [1]. The World Health Organization projected a 20% increase in cases of LUTSs and bladder outlet obstruction (BOO) in Africa by 2018, mainly due to an aging population [2].
BPH is diagnosed histologically, while prostate enlargement is clinically diagnosed. The severity of these conditions is assessed using the International Prostate Symptom Score (IPSS), where a score > 7 indicates symptoms and a QoL score > 3 indicates significant bother. An IPSS combined with a prostate size > 30 cm³ confirms the presence of LUTSs related to an enlarged prostate [3].
The effective management of bothersome LUTSs requires an understanding of the complex interactions between the bladder, bladder neck, prostate, urethra, and central nervous system and other systemic diseases [4]. Although medical therapy is commonly the first-line treatment for LUTSs/BPH, certain clinical scenarios necessitate surgical intervention as the initial treatment, provided there are no contraindicating medical conditions. Transurethral resection of the prostate (TURP) is considered the surgical “gold standard” for treating BPH. However, newer, minimally invasive interventions have been introduced, each with unique modes of action, acquisition costs, hospitalization durations, and complication rates [5].
Using international clinical data, a study showed an increase in absolute cases and the disability-adjusted life year (DALY) burden of BPH from 2000 to 2019, with stable age-standardized prevalence and DALY rates. Low- and middle-income countries had the most important variation in BPH prevalence and DALY burden, likely due to better diagnosis, health system adaptation, and rising risk factors like obesity and metabolic syndrome [6].
Men aged 65–74 years bear the greatest absolute burden of BPH globally, accounting for 42% of cases among men aged 40 and older. The highest age-specific prevalence is in men aged 75–79 years at 24,300 per 100,000, followed by those aged 80–84 years at 23,500 per 100,000 and those aged 70–74 years at 22,200 per 100,000 [7].
In 2019, there were 11.26 million new cases of BPH and 1.86 million years lived with disability (YLD) globally. While the age-standardized rates (ASRs) of incidence and YLD slightly decreased from 1990 to 2019, the absolute numbers increased significantly due to population growth and aging. The burden of BPH varied widely by region, socioeconomic status, and country [8].
The burden of BPH has grown significantly across different Socio-Demographic Index (SDI) categories. The incidence and YLD increased by over 100% in the low, low-middle, and middle quintiles, which is much higher than the increases observed in the high-middle and high quintiles [8]. In 2006, the UK spent GBP 44 million on primary care, GBP 69 million on drug treatment, and GBP 101 million on BPH complications [9]. By 2019, global medical service costs for BPH, based on US Medicare patterns, were estimated at USD 73.8 billion annually [1]. The actual cost of care for BPH in low- and middle-income countries, especially Sub-Saharan Africa (SSA), has not been estimated. It is expected that medical service costs will continue to rise in the region despite the low economic status.
Membership in the category of LMICs in Sub-Saharan Africa is based on the World Bank’s classification of income levels, which consist of Low-Income Countries (LICs) with a GNI per capita of USD 1045 or less and Lower-Middle-Income Countries with a GNI per capita between USD 1046 and USD 4095 [10].
The low- and middle-income countries in Sub-Saharan Africa include Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, the Republic of the Congo, the Democratic Republic of the Congo, Cote d’Ivoire, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, South Sudan, Sudan, Eswatini, Tanzania, The Gambia, Togo, Uganda, Zambia, and Zimbabwe [10].
While extensive research has been conducted in high-income countries (HICs), there is limited information regarding the burden of BPH in low- and middle-income countries (LMICs). This gap is particularly pronounced in Sub-Saharan Africa, where healthcare resources are often limited, and the ability to manage chronic conditions like BPH can be constrained. The demographic shift toward an aging population in Sub-Saharan Africa is expected to increase the incidence and prevalence of BPH and its associated complications. Despite this, there is a significant lack of region-specific data on the prevalence, impact on quality of life, and management practices of BPH.
This scoping review aims to collate the existing literature on the burden of BPH in Sub-Saharan Africa, focusing on the prevalence, impact on quality of life, and management practices. Understanding these aspects is crucial for informing healthcare policies and improving patient outcomes in resource-constrained settings.

2. Methods

A scoping review methodology was employed to systematically map the literature on BPH in LMICs. The review followed the framework proposed by Arksey and O’Malley [11], encompassing five stages: identifying the research objective, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting the results.

2.1. Search Strategy

A comprehensive search of electronic databases including Google Scholar, PubMed, Scopus, and Embase was conducted. The search terms included “Burden”, “Benign Prostatic Hyperplasia”, “BPH”, “prostate enlargement”, “lower urinary tract symptoms”, “prevalence”, “quality of life”, “management”, and “low- and middle-income countries” or “LMICs”.

2.2. Inclusion and Exclusion Criteria

The inclusion criteria were as follows:
  • Studies conducted in LMICs (limited to Sub-Saharan Africa) as defined by the World Bank.
  • Studies reporting on the prevalence, impact, or management of BPH.
  • Articles published in English.
The exclusion criteria were as follows:
  • Studies conducted in HICs.
  • Articles not focused on BPH.
  • Non-peer-reviewed articles, editorials, and opinion pieces.

2.3. Data Extraction and Analysis

Data were extracted using a standardized form capturing study characteristics, prevalence rates, impact on quality of life, and management practices. The results were analyzed descriptively to provide an overview of the burden of BPH in LMICs.

3. Results

A total of 41 abstracts were found after reviewing the literature. There were 19 studies on the burden of BPH in Sub-Saharan Africa that met the inclusion criteria for collation and analysis (Table 1).

3.1. Prevalence of BPH in LMICs

The prevalence of (BPH) in LMICs shows considerable variation, with rates reported between 10% and 69% among men aged 50 years and above (Table 1). This variation is largely due to differences in study methodologies, diagnostic criteria, and population demographics (Figure 1).
In a prospective study of male residents aged 40–70 in a suburb of Accra, the prevalence of LUTSs was found to be 42.3% using the International Prostate Symptom Score (IPSS) definition alone and 27.0% when combined with prostate volume measurements [3]. Notably, the prevalence of enlarged prostate was 41.98% in the LUTS-Negative (LN) group and 100% in the LUTS-Positive (LP) group. Quality of life was significantly better in the LN group compared to the LP group (p < 0.001).
A community-based survey of 615 men reported a 57.4% prevalence of LUTSs, with 28.5% having moderate-to-severe symptoms (average IPSS score of 12.3 ± 5.2) [12]. Over half (56.1%) of these men reported impaired quality of life. The prevalence of enlarged prostate was 68.3% by digital rectal examination (DRE) and 64.9% by ultrasound. Overall, BPH prevalence was 23.7%, increasing with age from 104 per 1000 men in their 50 s to 429 per 1000 men over 90. Similarly, in Ghana, the prevalence of DRE-detected BPH was 62.3%, with the highest rates in men aged 60–69 years at 68.3% and the lowest in men aged 50–59 years at 58.9% [13].
In Ethiopia, BPH was found to be highly prevalent among men, with identified risk factors including older age, positive family history, smoking, renal disease, and difficulties with sexual activities [14].
A review of 440 surgical patients in Malawi highlighted that BPH-related procedures, such as simple prostatectomy and transurethral resection of the prostate (TURP), were the second most common, accounting for 6.7% and 8.2% of cases, respectively [15].
An online survey of 114 urologists from 27 countries outside the USA and Europe revealed that BPH (15%) and urolithiasis (30%) were the most commonly treated conditions in LMICs. Patients in these regions were less likely to receive urgent treatment for kidney stones or obstructing prostates. Visiting urologists cited knowledge deficits and inadequate facilities as major challenges, while local LMIC urologists pointed to financial issues and limited access to diagnostics and support staff [16].

3.2. Cost Implications

The financial burden of BPH treatment is a significant barrier in LMICs. A cross-sectional survey of 473 men from a rural community in Uganda found that most respondents did not seek services because they felt unable to afford the associated costs, with many coming from lower-income families [17].
An interactive Markov model analyzed the cost-effectiveness of treating 2.9 million 50-year-old men in Nigeria with a fixed-dose combination of dutasteride and tamsulosin (FDCT) for BPH. The FDCT had an incremental cost-effectiveness ratio of USD 1481.92 per quality-adjusted life year (QALY) saved, indicating significant economic implications for universal provision in Nigeria [18].
A retrospective study of patients diagnosed with BPH between September 2017 and August 2019 found that 99% received pharmacological treatment, primarily alpha-blockers and 5-alpha-reductase inhibitors. The total annual direct cost of managing BPH at the healthcare facility was approximately NGN 4,966,080 (about USD 12,810) [19].
In Kenya, a survey of 387 men indicated that the cost of seeking BPH services significantly affected service uptake. Many men reported the services were expensive due to direct, indirect, and intangible costs. Most lacked medical insurance and came from lower-income levels, rendering costs a significant burden [20]. Another survey in Kenya highlighted that 83% of respondents faced financial constraints affecting access, and 87% experienced delays due to these constraints [21].

3.3. Impact on Quality of Life

BPH significantly impacts the quality of life of affected individuals in LMICs. The findings from the published literature in SSA showed that the IPSS score was used to assess the severity of symptoms and quality of life [12,13,14,15,16].
A study in Uganda found that the frequency and negative impact of LUTSs were high, aligning with WHO estimates, but the disease burden was greater than previously recognized. Patients often sought care only when symptoms became severe [22].
Prevalence rates for moderate and severe LUTSs were 40.5% and 20%, respectively, in men over 55 in Uganda, with these conditions associated with low scores on sexual satisfaction measures. It is estimated that 381,557 men in Uganda and 13,729,500 men in Sub-Saharan Africa over 55 have moderate LUTSs, while 188,423 in Uganda and 6,780,000 in Sub-Saharan Africa have severe LUTSs, with many experiencing compromised sexual function [23].
In Nigeria, around one-third of patients with BPH develop urinary tract infections, with Escherichia coli being the most common bacterial cause, and high sensitivity to Nitrofurantoin. The presence of an indwelling catheter was identified as the sole independent predictor of infection [24].
A cross-sectional study in Kenya used the Patient Health Questionnaire-9 and IPSS to assess depressive symptoms and LUTSs. The prevalence of depressive symptoms among patients with symptomatic benign prostatic enlargement (sBPE) was 42.9%, with the associated factors including comorbid conditions, medication side effects, reduced libido, alcohol use, disturbed sleep, and anxiety about the prostate condition [25].

3.4. Management Practices

The management of BPH in LMICs is challenged by limited healthcare resources, a lack of specialized healthcare providers, and inadequate diagnostic facilities [26]. Pharmacological treatments such as alpha-blockers and 5-alpha-reductase inhibitors are commonly used, but access to these medications is inconsistent. Surgical options, including TURP, are available in urban centers but often inaccessible to rural populations.
A scoping review of 21 studies from 10 low- to middle-income sub-Saharan countries revealed that, unlike the developed world, where minimally invasive procedures are preferred, open prostatectomy remains common in Africa for treating benign prostatic enlargement [27]. The cost of endoscopic setup and training in minimally invasive surgeries is a significant challenge [28].
The access to TURP for BPH in Ghana is currently low at 20.7%. With enhanced facilities, including the routine use of transrectal ultrasound (TRUS) for prostate size assessment and increased expertise in TURP, 67.4% of the patients currently offered open prostatectomy could benefit from TURP, particularly for prostate volumes of 75 mL or less [29].

4. Discussion

The burden of disease in adults in Sub-Saharan Africa is poorly understood due to limited data and weak disease surveillance. The prevalence of BPH in LMICs varies widely, influenced by differences in study methodologies, diagnostic criteria, and population demographics [30]. The region faces critical shortages of urologists and necessary medical equipment, with Nigeria, for instance, having only one urologist per 3.2 million people [16]. Training programs and healthcare funding are also limited, which hampers the effective management of BPH.
Moreover, the economic burden of BPH on patients and healthcare systems is substantial, with many individuals facing barriers to accessing effective treatment [31]. Studies indicate that the costs associated with BPH services significantly affect service uptake, particularly in rural areas [17]. That review also reveals that open prostatectomy remains common due to the lack of resources for minimally invasive procedures, which are preferred in developed countries.
International guidelines recommend open prostatectomy or endoscopic enucleation techniques for large prostates, but due to inadequate equipment and expertise, open prostatectomy remains the only viable option for most BPH patients in SSA [32]. The findings underscore the need for improved healthcare infrastructure, the training of healthcare providers, and access to diagnostic and treatment modalities.
The high prevalence of BPH in SSA can be attributed to several factors, including aging populations, lifestyle changes, and genetic predispositions. Despite the significant burden of BPH, the awareness and understanding of the condition among the general population and healthcare providers remain low. This lack of awareness often leads to delayed diagnosis and treatment, exacerbating the condition and reducing the quality of life for affected individuals.
The economic impact of BPH on individuals and healthcare systems in SSA is significant. This financial burden often forces patients to seek alternative treatments, such as herbal remedies, which may not be effective and could potentially worsen the condition. Many patients are unable to afford the high costs associated with BPH treatment, including medication, surgery, and follow-up care [31].
Cultural factors also play a significant role in the management of BPH. In many communities, there is a stigma associated with urological conditions, leading men to avoid seeking medical help until symptoms become severe [22]. This delay in seeking care results in more advanced disease stages at the time of diagnosis, which complicates treatment and management.
The healthcare systems in SSA are often under-resourced, with limited access to diagnostic tools such as ultrasound and PSA testing, which are crucial for the early detection of BPH. The scarcity of specialized healthcare professionals, such as urologists and radiologists, further exacerbates the problem. As a result, general practitioners who may lack specialized training in urology are often the first point of contact for patients with BPH, leading to suboptimal management of the condition [33].
A survey of 43 centers in Sub-Saharan Africa showed that only 1/3 of urologists in the survey were able to perform endoscopic procedures. Some of these centers lacked the endoscopic setup, rendering open prostatectomy the sole surgical management of BPH [34].
The cost of setup of endoscopic suites and the price of prostate surgery have been a setback for most hospitals, as well as patients needing the service. In the USA, the national direct costs associated with benign BPH are estimated to be approximately USD 4 billion. On an individual level, the annual cost for BPH in the USA is estimated to be USD 1536 [35].
In Ghana and Nigeria, the individual costs for BPH medications range from USD 300 to USD 550 per year. Additionally, the cost for a simple prostatectomy or TURP procedure is estimated to be USD 1100 [35,36].
Data emerging from Chad, Togo, and Senegal have shown that open prostatectomy is still widely practiced in regional hospitals [37,38,39]. Despite these challenges, some institutions in the region have been pioneering endourology, specifically the Hospital General Idrissa Pouye, formerly the Grand Yoff Hospital. Reports from Bouake, Ivory Coast, have shown a paradigm shift to endourology, with TURP being frequently performed for BPH requiring surgery [40]. Liberia currently has only three urologists, and endourology is also gradually evolving at the John F. Kennedy Medical Center.
Better access to drugs should be explored by policymakers recognizing the burden of BPH. While the use of minimally invasive surgery (e.g.,: TURP) is limited by access to equipment, simulation can be helpful in developing skills among practitioners and residents [33].
Efforts to address the burden of BPH in SSA must include strengthening healthcare infrastructure, increasing the availability of diagnostic and treatment facilities, and enhancing the training of healthcare professionals. Public health campaigns aimed at raising awareness about BPH and reducing the stigma associated with the condition are also crucial.
Research is needed to better understand the epidemiology of BPH in SSA and to develop context-specific guidelines for the management of the condition. Collaboration between governments, non-governmental organizations, and international health agencies is essential to mobilize resources and implement effective interventions.

5. Conclusions

BPH is a prevalent condition in SSA, with substantial implications for individuals and healthcare systems. Addressing the burden of BPH in these regions requires a multifaceted approach, including enhancing healthcare infrastructure, improving access to care, and conducting further research to inform evidence-based practices. Policymakers and healthcare providers must prioritize BPH as a public health issue to improve the quality of life for affected individuals.

Author Contributions

Conceptualization: A.C., M.J. and S.G.; methodology: A.C., M.J. and S.G.; validation: A.C., B.S. and M.J.; formal analysis: A.C., M.J. and S.G.; resources: M.J. and S.G.; data curation: A.C.; writing—original draft preparation: A.C., M.J., S.G. and B.S.; writing—review and editing: A.C., M.J., S.G. and B.S.; visualization: A.C.; supervision: M.J., S.G. and B.S. All authors have read and agreed to the published version of the manuscript.

Funding

This research has no external funding.

Acknowledgments

Special thanks to all the collaborators and authors of this manuscript.

Conflicts of Interest

The authors declare no conflicts of interest.

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Siuj 05 00051 g001
Figure 1. The map illustrates LMICs in Sub-Saharan Africa with studies highlighting the burden of BPH.
Figure 1. The map illustrates LMICs in Sub-Saharan Africa with studies highlighting the burden of BPH.
Siuj 05 00051 g001
Table 1. This table shows the demographics of studies on the burden of BPH in LMICs (Sub-Saharan region).
Table 1. This table shows the demographics of studies on the burden of BPH in LMICs (Sub-Saharan region).
StudyYear of PublicationCountryDesignGeneral Objective of BPH/LUTS StudySample Size (Subjects)
Asare et al. [3]2021Ghana Prospective cross-sectional study Prevalence of LUTSs111
Ojewola. et al. [12]2017NigeriaCross-sectional studyLUTSs/QOL615
Chokkalingam et al. [13]2012GhanaProspective cross-sectional studyPrevalence of LUTSs/BPH950
Gebre et al. [14]2021EthiopiaCross-sectional studyPrevalence of BPH143
Juvet et al. [15]2020MalawiRetrospective studyLUTSs/Management440
Metzler et al. [16]2020MultinationalSurveyPrevalence BPH114
Stothers et al. [17]2017UgandaCross-sectional studyCost burden of BPH473
Udeh et al. [18]2016NigeriaInteractive Markov modelCost burden of BPH2.9 million
Nneoma Igwe et al. [19]2021NigeriaRetrospective, descriptivePrevalence/Cost burden of BPH102
Vincent et al. [20]2021KenyaMixed methodCost burden of BPH387
Namusonge et al. [21]2021KenyaDescriptive surveyCost burden of BPH50
Stothers et al. [22]2016UgandaSurveyLUTSs/QOL238
Bajunirwi et al. [23] UgandaCross-sectional surveyPrevalence/QOL250
Tolani et al. [24]2020NigeriaCross-sectional studyPrevalence/QOL118
Abdalla et al. [25]2023KenyaCross-sectional studyQOL308
Jeje et al. [26]2016NigeriaReviewLUTSs/Management
Zubair et al. [27]2022MultinationalScoping reviewLUTSs/Management2999
Idowu et al. [28]2022NigeriaRetrospective studyLUTSs/Management151
Kyei et al. [29]2012GhanaProspective cohort studyLUTSs/Management114
BPH: benign prostatic hyperplasia; LUTSs: lower urinary tract symptoms; QOL: quality of life.
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MDPI and ACS Style

Cassell, A.; Sine, B.; Jalloh, M.; Gravas, S. Burden of Benign Prostatic Hyperplasia (BPH) in Low- and Middle-Income Countries in Sub-Saharan Africa (SSA). Soc. Int. Urol. J. 2024, 5, 320-329. https://doi.org/10.3390/siuj5050051

AMA Style

Cassell A, Sine B, Jalloh M, Gravas S. Burden of Benign Prostatic Hyperplasia (BPH) in Low- and Middle-Income Countries in Sub-Saharan Africa (SSA). Société Internationale d’Urologie Journal. 2024; 5(5):320-329. https://doi.org/10.3390/siuj5050051

Chicago/Turabian Style

Cassell, Ayun, Babacar Sine, Mohamed Jalloh, and Stavros Gravas. 2024. "Burden of Benign Prostatic Hyperplasia (BPH) in Low- and Middle-Income Countries in Sub-Saharan Africa (SSA)" Société Internationale d’Urologie Journal 5, no. 5: 320-329. https://doi.org/10.3390/siuj5050051

APA Style

Cassell, A., Sine, B., Jalloh, M., & Gravas, S. (2024). Burden of Benign Prostatic Hyperplasia (BPH) in Low- and Middle-Income Countries in Sub-Saharan Africa (SSA). Société Internationale d’Urologie Journal, 5(5), 320-329. https://doi.org/10.3390/siuj5050051

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