Topic Overview
What is benign prostatic hyperplasia (BPH)?
Benign prostatic hyperplasia
(BPH) is an enlarged
prostate gland
. The prostate gland surrounds the
urethra, the tube that carries urine from the
bladder out of the body. As the prostate gets bigger,
it may squeeze or partly block the urethra. This often causes problems
with urinating.
BPH occurs in almost all men as they age. BPH is not
cancer. An enlarged prostate can be a nuisance. But it is usually not a serious
problem. About half of all men older than 75 have some symptoms.
Benign prostatic hyperplasia is also known as benign prostatic
hypertrophy.
What causes BPH?
Benign prostatic hyperplasia is probably a normal part of the aging
process in men, caused by changes in hormone balance and in cell growth.
What are the symptoms?
BPH causes
urinary problems such as:
- Trouble getting a urine stream started and
completely stopped (dribbling).
- Often feeling like you need to
urinate. This feeling may even wake you up at night.
- A weak urine
stream.
- A sense that your bladder is not completely empty after
you urinate.
In a small number of cases, BPH may cause the bladder to be
blocked, making it impossible or extremely hard to urinate. This problem may
cause backed-up urine (urinary retention), leading to
bladder infections or
stones, or kidney damage.
BPH does not
cause prostate cancer and does not affect a man's ability to father children.
It does not cause
erection problems.
How is BPH diagnosed?
Your doctor can diagnose BPH by asking
questions about your symptoms and past health and by doing a physical exam.
Tests may include a urine test (urinalysis) and a
digital rectal exam, which lets your doctor feel the
size of your prostate. In some cases, a prostate-specific antigen (PSA) test is
done to help rule out prostate cancer. (Prostate cancer and BPH are not
related, but they can cause some of the same symptoms.)
Your
doctor may ask you how often you have symptoms of BPH, how severe they are, and
how much they affect your life. If your symptoms are mild to moderate and do
not bother you much, home treatment may be all that you need to help keep them
under control. Your doctor may want to see you regularly to check on your
symptoms and make sure other problems haven't come up.
You can
use this tool to help you think about how bothersome your symptoms are:
-
Interactive Tool: How Bad Are Your Urinary Symptoms From Benign Prostatic Hyperplasia (BPH)?
How is it treated?
As
a rule, you don't need treatment for BPH unless the symptoms bother you or you
have other problems such as backed-up urine, bladder infections, or bladder
stones.
Although home treatment cannot stop your prostate from
getting larger, it can help reduce or control your symptoms. Here are some
things you can do that may help reduce your symptoms:
- Practice "double voiding." Urinate as much as
you can, relax for a few moments, and then urinate again.
- Avoid
caffeine and alcohol. They make your body try to get rid of water and can make
you urinate more often.
- If possible, avoid medicines that can make
urination difficult, such as
over-the-counter antihistamines, decongestants
(including nasal sprays), and allergy pills. Check with your doctor or
pharmacist about the medicines you take.
If home treatment does not help, BPH can be treated with
medicine. Medicine can reduce the symptoms, but it rarely gets rid of them. If
you stop taking medicine, symptoms return.
If your symptoms are
severe, your doctor may suggest surgery to remove part of your prostate. But
few men have symptoms or other problems severe enough to need surgery.
Can BPH be prevented?
You cannot prevent BPH or
the urination problems it may cause. Some people believe that regular
ejaculations will help prevent prostate enlargement. But there is no scientific
proof that ejaculation helps.
Frequently Asked Questions
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Learning about benign prostatic hyperplasia (BPH):
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Being diagnosed:
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Getting treatment:
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Living with BPH:
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Cause
Benign prostatic hyperplasia (BPH) is probably a normal part of the aging process in men. It is caused by changes in hormone balance and cell-growth factors. Genetics may also
play a role. This is especially true for severe BPH
requiring surgery in men younger than 60.
Men who are older than
50 have a higher chance of developing BPH. But why some men have more severe
symptoms than others is not known.
Symptoms
Many men with
benign prostatic hyperplasia (BPH) have no symptoms.
When symptoms (known as lower urinary tract symptoms, or LUTS) occur, they may
range from mild and barely noticeable to serious and disruptive. The amount of
prostate enlargement is not always related to the severity of the symptoms.
Some men with only slight enlargement have serious symptoms. And some men with
a great deal of enlargement have few symptoms.
Your symptoms may
become worse during cold weather or as a result of physical or emotional
stress.
Some medicines can make your symptoms worse. These
include over-the-counter cold medicines such as diphenhydramine
(Benadryl, for example), pseudoephedrine (such as Sudafed),
oxymetazoline spray (such as Afrin), and prescription medicines such as
antidepressants, water pills (diuretics), testosterone (gels, implants, or
injections), and pain medicines (narcotics).
The symptoms of BPH
may involve problems emptying the
bladder or problems with bladder storage.
Symptoms related to bladder emptying include:
- Difficulty starting a urine stream (hesitancy
and straining).
- Decreased strength of the urine stream (weak
flow).
- Dribbling after urination.
- Feeling that the
bladder is not completely empty.
- An urge to urinate again soon
after urinating.
- Pain during urination (dysuria).
Symptoms related to bladder storage include:
- Waking at night to urinate
(nocturia).
- Frequent urination.
- A sudden,
uncontrollable urge to urinate.
These symptoms are not always related to prostate
enlargement and can be caused by other conditions. BPH symptoms are often
balanced between the two types of symptoms. If symptoms come on rapidly, or if
you have more of one type of symptom than the other type, you may have another
condition. Other conditions that may cause similar symptoms include
urinary tract infections,
prostatitis
,
prostate cancer,
diabetes,
heart failure
, and neurologic diseases.
You can use the
Interactive Tool: How Bad Are Your Urinary Symptoms From BPH? to evaluate how bad your symptoms are and, later, to judge how well
your treatment is working.
What Happens
The prostate gland grows as
men age, with the fastest growth occurring at middle age. By age 50, 5 out of
10 men have an enlarged prostate. By age 80, up to 9 out of 10 men have an
enlarged prostate. Having an enlarged prostate does
not always cause symptoms.
As the prostate enlarges, the
urethra (the tube that carries urine from the
bladder out of the body) may become narrowed or
partially blocked. The narrowed or blocked urethra is what causes the symptoms
of
benign prostatic hyperplasia (BPH). By age 55, over 2
out of 10 men have some symptoms. By age 75, 5 out of 10 men complain of a
decrease in the force of their urine streams.
1
In rare cases, severe obstruction of the urine flow occurs and may lead
to complications, including complete or partial blockage
of the
urethra,
urinary tract infection (UTI),
bladder stones
, or visible blood in the urine.
Every man's experience with BPH is different. Symptoms may be stable, may
come and go, or may become more bothersome over time. Some men find the
symptoms to be mild and do not require treatment with medicines. Other men find
the symptoms bothersome and choose treatment with medicine or, less commonly,
surgery.
BPH does not cause
prostate cancer. But prostate cancer may cause
symptoms similar to those of BPH. It is important to have your symptoms checked
by a doctor to be certain they are not caused by prostate
cancer.
What Increases Your Risk
Men who are older than 50
have a higher risk for
benign prostatic hyperplasia (BPH).
The
hormone
testosterone
, which is produced mainly by the
testicles, is needed in order for BPH to develop.
Men who have their testicles removed before puberty never develop BPH. Men who
have their testicles removed after puberty (but before they have symptoms of
BPH) rarely develop BPH.
A family history of BPH may increase your
risk for needing treatment for this condition, especially if a relative
needed treatment before age 60.
A
vasectomy
does not increase your risk of BPH.
When To Call a Doctor
Call your doctor immediately if:
- You are completely unable to
urinate.
- Urination is painful and you have a fever over
100°F (37.8°C), chills, or body
aches.
- You have pain in the lower back, just below your rib cage
(flank pain), that is not related to an injury or
physical effort.
- There is blood or pus in your urine or
semen.
Call your doctor if you have painful urination and any of
the following signs of a possible
urinary tract infection or prostate infection that
last longer than 24 hours:
- A burning sensation while
urinating
- Painful ejaculation
- Problems controlling your
urination during the day or at night
Call your doctor if you have urination problems that have
developed over a few weeks or a few months and are frequent.
Watchful waiting
If urinary symptoms are minor or they don't bother you too much, and you do not have prostate cancer or a prostate infection, it may
be appropriate to try watchful waiting or home treatment. Call a doctor if your symptoms
change or get worse or if you change your mind about treatment.
Who to see
Mild and moderate urinary symptoms that are caused by
BPH can be evaluated and treated by any of the following health
professionals:
If the symptoms are severe or if surgical treatment is
being considered, you probably need to see a urologist.
To prepare for your appointment, see the topic Making the Most of Your Appointment.
Exams and Tests
Your doctor will first want to make
sure that your urination problem is caused by
benign prostatic hyperplasia (BPH) and not by
something else. This can usually be determined from your
medical history, a physical exam that focuses on the
urinary tract, a urinalysis, and a blood test. A neurological exam should also
be done to determine whether your symptoms are related to a problem with the
nerves to the bladder. A questionnaire such as the
American Urological Association (AUA) symptom index
may be used to evaluate how bothersome your symptoms are. It is not used to
diagnose BPH.
Tests that are often done
Tests that are used as needed
If your symptoms are
moderate to severe, additional tests, called urodynamic studies, may be
done.
- A
blood creatinine test checks how well your kidneys are
working.
-
Post-void residual urine test (PVR)
measures the amount of urine left in the bladder after urination. This test is
done using
ultrasound
or a small tube (catheter) put into the
bladder through the
urethra
.
- Pressure flow studies measure
pressure in the bladder while urinating. They may help distinguish between
urinary symptoms caused by obstruction, such as BPH, and those caused by a
problem affecting the bladder muscles or nerves.
-
Cystometrogram measures the bladder's pressure,
compliance, and capacity during urinary storage. This may include a
uroflowmetry test, which measures how fast the urine
flows out of the bladder.
Tests that may be done
The following tests may be
done if you have
complications of BPH or if there is a need to look for
other causes of the symptoms.
-
Ultrasound
uses sound waves to check the size and structure of the kidneys, bladder, and
prostate. A small device called a transducer is inserted into the rectum
(transrectal ultrasound) to evaluate the prostate.
-
Cystoscopy allows the doctor to look inside the
urethra and
bladder. This may allow the doctor to find out how much an enlarged prostate is blocking the urethra.
-
Intravenous pyelogram (IVP) uses X-rays
to show the function of the kidneys and the flow of urine from the kidneys to
the bladder.
- Spiral (helical)
computed tomography (CT) scan uses X-rays to make
detailed pictures of structures inside the body. These scanners can check for
an enlarged
prostate gland
, blockage, and urine flow from the kidneys.
Treatment Overview
Benign prostatic hyperplasia (BPH) cannot be cured, so treatment focuses on reducing your
symptoms. Treatment is based on how severe your symptoms are, how much they
bother you, and whether you have
complications.
Deciding how to treat BPH
is greatly influenced by how bothersome your symptoms are. The
American Urological Association (AUA) symptom index is
an interactive questionnaire that can help you tell how bad your symptoms are
and measure how well your treatment is working. This questionnaire ranks the
severity of your symptoms on a numerical scale. The higher the number, the more
you are bothered by your symptoms. The more your symptoms bother you, the more aggressive you may want to be in
your treatment.
Initial treatment
The American Urological Association (AUA) makes the following treatment
recommendations for
benign prostatic hyperplasia (BPH) based on how bad your symptoms are.
2
- Symptoms that are mild or that do not bother
you (AUA score of 0 to 7) may be best treated by watchful waiting. This means
you may make small changes to your lifestyle to control your symptoms. You
do not take medicines or have surgery. You have regular checkups to be sure
your symptoms are not getting worse.
- The treatment of moderate to
severe symptoms (AUA score of 8 or more) depends on how much you are bothered
by them. If the symptoms are not greatly affecting your quality of life, you
may choose watchful waiting or treatment with medicine. If the symptoms are
bothersome or you want more aggressive treatment, you may be offered surgery or
less invasive therapies, such as transurethral microwave therapy (
TUMT
) or transurethral needle ablation (
TUNA
).
- Complications of BPH, such as ongoing
inability to urinate, urinary tract infections, bladder stones, kidney damage, or ongoing blood in your
urine, should be treated with surgery. You may also want surgery if your symptoms have not been helped with other treatments.
There are some things you can do that may help reduce how
much BPH affects your quality of life.
- Do not try to rush your urination. Try to
relax while using the bathroom.
- Spread
your fluid intake throughout the day. Limit fluid intake in the evening if
you often wake up at night to urinate.
- If possible, avoid
medicines that make your symptoms worse.
-
Enlarged Prostate: Should I Take Medicine?
Ongoing treatment
If
your symptoms of
benign prostatic hyperplasia (BPH) remain mild and not
bothersome, watchful waiting may be your best treatment. With this treatment,
you may make small changes to your lifestyle to control your symptoms. You
do not take medicines or have surgery. You have regular checkups to be
sure your symptoms are not getting worse.
If symptoms get worse or become bothersome, or if you
develop
complications, you can consider medicine or
surgery.
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Enlarged Prostate: Should I Take Medicine?
-
Enlarged Prostate: Should I Have Surgery?
Treatment if the condition gets worse
If any of the following occur, you will probably need
surgery for
benign prostatic hyperplasia (BPH):
- You cannot urinate.
- Your BPH is causing repeated
urinary tract infections,
bladder stones
, or bladder damage.
- You
have blood in your urine that is not getting better and is causing other problems such as clots that make it hard to urinate.
- You have
kidney damage.
- You continue to have symptoms that bother you, even with medicine or other treatments.
-
Enlarged Prostate: Should I Have Surgery?
What to think about
Unless surgery is required
because of a
complication, choosing a treatment is largely up to
you and your doctor. If complications arise, surgery may be needed.
The extent to which treatment improves your symptoms depends partly on
how bad your symptoms are and how much you are bothered by them. If you are not
bothered by your symptoms before treatment, you are less likely to notice much
improvement after treatment.
Surgery offers the best chance for
improving the symptoms but also has the risk of causing other problems.
Prevention
The urination problems caused by
benign prostatic hyperplasia (BPH) cannot be
prevented. Some people believe that regular ejaculations will help prevent
prostate enlargement. But there is no scientific proof that ejaculation
helps.
Home Treatment
If your urination problem caused by
benign prostatic hyperplasia (BPH) is mild to moderate
and does not bother you, home treatment may be all you need to help keep your
symptoms from interfering with your daily activities. Your doctor may want to
see you regularly to check on your symptoms.
The following tips
may help minimize your symptoms:
- Practice "double voiding." Urinate as much as
possible, relax for a few moments, and then urinate again.
- Relax
before you urinate. Worrying about your symptoms can make them worse.
- Take plenty of time to urinate.
- Urinate while sitting
down instead of standing.
- While you are waiting, think of other
things or read.
- Turn on a faucet or picture running water in your
mind. This may help get your urine flowing.
- Do not limit your fluid
intake to avoid urinating. You could become
dehydrated, which can cause other problems.
- Drink fluids throughout the day.
- If you
often wake up because you need to urinate, limit your fluid intake in the
evening. And empty your bladder before bedtime.
- Avoid caffeine and alcohol. These substances make your body try
to get rid of water. They can make you urinate more often.
- If
possible,
avoid medicines that can make urination difficult,
such as nonprescription antihistamines, decongestants (including nasal sprays),
and allergy pills. Check with your doctor or pharmacist about all of the
medicines you take.
You may want to try an
herbal therapy for BPH, such as saw palmetto or
beta-sitosterol. Before you start an herbal therapy, talk to your doctor about
whether it might be helpful.
Medications
Medicines are sometimes used to help
relieve bothersome, moderate to severe urination problems caused by
benign prostatic hyperplasia (BPH). If you stop using
medicine, the symptoms will usually return.
The
American Urological Association (AUA) symptom index is
an interactive questionnaire that can help you determine how bad your urinary
symptoms are and check how well your treatment is working. But the most
important thing in deciding whether to use medicines is not your AUA score but
how much the symptoms bother you and affect your quality of life. A high score
on the AUA does not necessarily mean you need medicines.
In general, the side
effects of the most commonly used medicines are minor. And the side effects stop
when you stop taking the medicine.
-
Enlarged Prostate: Should I Take Medicine?
Medication choices
-
Alpha-blockers, such as terazosin (Hytrin), relieve symptoms within a few weeks but do not stop the
process of prostate enlargement.
-
5-alpha reductase inhibitors, such as dutasteride (Avodart) or finasteride (Proscar), may
reduce the size of an enlarged prostate but may take 6 months or more to show
any effect on symptoms.
- Using a combination of an alpha-blocker
with a 5-alpha reductase inhibitor long-term may help your symptoms more than either
medicine alone.
3
-
Phosphodiesterase-5 (PDE-5) inhibitors, such as tadalafil (Cialis), may help reduce BPH symptoms whether or not you have erection problems. PDE-5 inhibitors are well known medicines for erection problems.
4
What to think about
Alpha-blockers
and 5-alpha
reductase inhibitors affect different prostate tissues. How much your symptoms
improve may depend on which tissue is contributing most to your symptoms. None
of these medicines work for everyone.
Medicines used to treat urinary incontinence and overactive bladder may help BPH symptoms, too. And men with BPH can have multiple urinary problems.
Surgery
If you have difficulty urinating because of
benign prostatic hyperplasia (BPH), you probably will
not need surgery unless you:
- Cannot urinate.
- Have a partial blockage in your
urethra
that is causing repeated
urinary tract infections,
bladder stones
, or bladder damage.
- Have blood in your urine that is not getting better and is causing other problems such as clots that make it hard to urinate.
- Have kidney
damage.
If you have no complications but have symptoms that bother
you or if other treatment has not worked, you may choose to have surgery. In
this case, think about:
- How bad your symptoms are.
- How much you expect the surgery to improve your
symptoms.
- How you feel
about the risk of developing a
complication because of the surgery.
For more information on this decision, see:
-
Enlarged Prostate: Should I Have Surgery?
Surgery choices
Surgery that does not require an incision through the
skin is usually used. The surgical instruments are passed up the urinary
opening in the penis to the location of the prostate. This is described as a
transurethral surgery of the prostate.
Transurethral resection of the prostate (TURP) is the
surgery for benign prostatic hyperplasia that has been studied the most. It is
the surgery that is used the most to treat symptoms of BPH. All other surgeries
are compared to TURP. In TURP, part of the prostate is removed.
Some of the other surgeries that have been studied and compared to TURP
include:
In most cases, these treatments have been studied for
only a few years, so their long-term effectiveness is not yet known. There are
also some other surgeries.
The oldest surgical method to treat BPH is an
open prostatectomy, in which an incision is made
through the skin to reach the prostate. Doctors use this method less often now,
but it is still preferred if the prostate is very large.
What to think about
Surgery is the most reliable way
to relieve symptoms. But surgery may not relieve all your symptoms. And it puts
you at risk for certain
surgical complications, including
erection problems
(erectile dysfunction). Other
complications include the inability to control the release of urine (urinary
incontinence) and ejaculation of semen into the bladder instead of out through
the penis (retrograde ejaculation). The complication depends on which type of
surgery is used.
Men who have severe symptoms often notice great
improvement in the quality of life following surgery. Men whose symptoms are
mild may find that surgery does not greatly improve quality of life, and they
may want to think carefully before deciding to have surgery to treat
BPH.
If you have decided to have surgery, or if there are clear
medical reasons to have surgery, the best surgical option depends on the size
and shape of your prostate and the experience of the surgeon.
- Transurethral resection of the prostate
(TURP) is the most common surgery for
BPH.
- Other types of surgery have fewer risks and a shorter recovery period than TURP. But they may not work as well to stop symptoms. And you may need more treatment or surgery in the future.
Other Treatment
Some men use herbal therapy for
difficulty urinating caused by
benign prostatic hyperplasia (BPH). Herbal therapy includes treatments such as saw
palmetto or beta-sitosterol. Talk with your doctor about how
herbal therapy may be used along with medical treatment for BPH.
Balloon dilation is no longer used to
treat prostate enlargement, because it was found to be ineffective.
Other Places To Get Help
Organizations
|
AUA Foundation: The Official Foundation of the American Urological
Association
|
| 1000 Corporate Boulevard |
| Linthicum, MD 21090 |
| Phone: | 1-800-828-7866 |
| Phone: | (410) 689-3700 |
| Fax: | (410) 689-3998 |
| Email: | auafoundation@auafoundation.org |
| Web Address: | www.urologyhealth.org |
| |
|
UrologyHealth.org is a website written by urologists
for patients. Visitors can find specific topics by using the "search"
option. The website provides information about adult and
pediatric urologic topics, including kidney, bladder, and prostate conditions.
You can find a urologist, sign up for a free quarterly newsletter, or click on
the Urology A–Z page to find materials about urologic problems.
|
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|
National Institute on Aging
|
| Building 31, Room 5C27 |
| 31 Center Drive, MSC 2292 |
| Bethesda, MD 20892 |
| Phone: | 1-800-222-2225 |
| Phone: | (301) 496-1752 |
| TDD: | 1-800-222-4225 (TTY) |
| Email: | niaic@nia.nih.gov |
| Web Address: | www.nia.nih.gov |
| |
|
The National Institute on Aging (NIA), one of the
centers of the U.S. National Institutes of Health, leads a broad scientific
effort to understand the nature of aging and to extend the healthy, active
years of life. The NIA funds research and provides information about health and
research advances to the public and interested groups.
|
|
|
National Kidney and Urologic Diseases Information
Clearinghouse
|
| 3 Information Way |
| Bethesda, MD 20892-3580 |
| Phone: | 1-800-891-5390 |
| TDD: | 1-866-569-1162 |
| Fax: | (703) 738-4929 |
| Email: | nkudic@info.niddk.nih.gov |
| Web Address: | www.kidney.niddk.nih.gov |
| |
|
The National Kidney and Urologic Diseases Information
Clearinghouse (NKUDIC) provides information about diseases of the
kidneys and urologic system to people with these problems and to
their families, to health professionals, and to the public. NKUDIC answers
inquiries; develops, reviews, and distributes publications; and works closely
with professional and patient groups and government agencies to
coordinate resources about kidney and urologic diseases. NKUDIC, a federal agency, is a service of the National
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). NIDDK is part
of the National Institutes of Health under the U.S. Department of Health and
Human Services.
|
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References
Citations
-
Presti JC, et al. (2008). Benign prostatic hyperplasia
(BPH) section of Neoplasms of the prostate gland. In EA Tanagho, JW McAninch,
eds., Smith’s General Urology, 17th ed., pp. 348–355.
New York: McGraw-Hill.
-
AUA Practice Guidelines Committee (2010). AUA guideline on management of benign prostatic hyperplasia. Chapter 1: Guideline on the management of benign prostatic hyperplasia (BPH). Available online: http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=bph.
-
Roehrborn CG, et al. (2008). The effects of
dutasteride, tamsulosin and combination therapy on lower urinary tract symptoms
in men with benign prostatic hyperplasia and prostatic enlargement: 2-year
results from the CombAT study. Journal of Urology,
179(2): 616–621.
-
Liu L, et al. (2011). Phosphodiesterase-5 inhibitors for lower urinary tract symptoms secondary to benign prostatic hyperplasia: A systematic review and meta-analysis. Urology, 77(1): 123–130.
Other Works Consulted
- Aho TF, Gilling PJ (2003). Laser therapy for benign
prostatic hyperplasia: A review of recent developments. Current Opinion in Urology, 13(1): 39–44.
-
Helfand M, et al. (2007). Benign prostatic hyperplasia (BPH). Management in primary care—Screening and therapy. Department of Veterans Affairs Health Services Research and Development Service. Available online: http://www.hsrd.research.va.gov/publications/esp/BPH-2007.pdf.
- Murray MT, Pizzorno JE (2006). Serenoa repens (saw
palmetto). In JE Pizzorno Jr, MT Murray, eds., Textbook of Natural Medicine, 3rd ed., vol.1, pp. 1245–1250. St. Louis: Churchill
Livingstone Elsevier.
- Saw palmetto (2009). In A DerMarderosian et al., eds.,
Review of Natural Products. St. Louis: Wolters Kluwer
Health.
- Soliman SA, et al. (2007). Rotoresection versus
transurethral resection of the prostate: Short-term evaluation of a prospective
randomized study. Journal of Urology, 177(3):
1036–1039.
- Wilt TJ, N'Dow J (2008). Benign prostatic hyperplasia. Part 1—Diagnosis. BMJ, 336(7636): 146–149.
Credits
|
By
| Healthwise Staff |
|
Primary Medical Reviewer
| E. Gregory Thompson, MD - Internal Medicine |
|
Specialist Medical Reviewer
| J. Curtis Nickel, MD, FRCSC - Urology |
|
Last Revised
| March 5, 2012 |
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