Benign Prostatic Hyperplasia (BPH)

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 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.¹

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), a blood test (serum creatinine), 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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	Interactive Tool: How Bad Are Your Urinary Symptoms From Benign Prostatic Hyperplasia (BPH)?

Cause

Benign prostatic hyperplasia (BPH) is probably a normal part of the aging process in men, caused by changes in hormone balance and cell-growth factors. Genetics may also play a role.² 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 hydrochloride (Benadryl, for example), pseudoephedrine hydrochloride (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.³ 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 develops 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 of developing benign prostatic hyperplasia (BPH).

The hormone testosterone, which is produced mainly by the testicles, is necessary 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 requiring treatment for this condition, especially if a relative required treatment before age 60.

A vasectomy does not increase your risk of BPH.

When To Call a Doctor

Call your doctor immediatelyif:

• 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 and not bothersome, 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 you develop any of the symptoms of benign prostatic hyperplasia (BPH) or if your symptoms change or get worse.

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:

• Nurse practitioner
• Physician assistant
• Family medicine doctor
• Internist
• Urologist

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

• A digital rectal exam checks the size and firmness of the prostate. The size of the prostate does not always determine the severity of the symptoms. A man with only a small degree of prostate enlargement may have more severe symptoms than a man with more enlargement.
• A urinalysis and urine culture check for a urinary tract infection that might be the cause of the symptoms.
• A blood creatinine checks how well your kidneys are working.
• A prostate-specific antigen (PSA) test helps check for prostate cancer, which can cause the same symptoms as BPH.

Tests that are used as needed

If your symptoms are moderate to severe, additional tests, called urodynamic studies, may be done.

• 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 see the extent of blockage of the urethra caused by an enlarged prostate and estimate its severity.
• 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.

Early Detection

There is no routine screening test for prostate enlargement. But it may be detected during other screening tests that are regularly done to check for prostate or rectal cancer, such as the digital rectal exam and prostate-specific antigen (PSA) test.

• Many doctors recommend yearly digital rectal exams and PSA tests for all men over age 50 to check for prostate cancer. But some doctors don't recommend this type of regular screening, saying there is no proof that such routine testing results in more successful treatment of prostate cancer.
• The best screening method and schedule for you may depend on other risk factors you have. Talk with your doctor about this.

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 and 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 the severity of your symptoms.⁴

• 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, but you do not take medicines or have surgery. You have regular checkups to be certain 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).
• Severe symptoms, such as ongoing inability to urinate, bladder stones, kidney damage, or ongoing blood in your urine, should be treated with surgery.

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.
• Consider trying an herbal therapy for BPH, such as saw palmetto or beta-sitosterol. Talk with your doctor before starting any herbal therapy.

Should I use medication or watchful waiting to treat benign prostatic hyperplasia?

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, but you do not take medications or have surgery. You have regular checkups to be certain your symptoms are not getting worse.

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 frequently awaken at night to urinate.
• If possible, avoid medications that make your symptoms worse.
• You may want to try an herbal therapy for BPH, such as saw palmetto or beta-sitosterol. Talk with your doctor before starting any herbal therapy.

If symptoms get worse or become bothersome, or if you develop complications, you should consider medication or surgery.

Should I use medication or watchful waiting to treat benign prostatic hyperplasia?

Should I have surgery or use medication to treat benign prostatic hyperplasia?

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. About half of men who cannot urinate need catheterization. Half of these men will be able to urinate again after catheterization. Those who do not improve may need surgery.
• Your BPH is causing repeated urinary tract infections, bladder stones, or bladder damage.
• You have blood in your urine that is not getting better.
• You have kidney damage.

Should I have surgery or use medication to treat benign prostatic hyperplasia?

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 necessary.

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. For more information, see the Surgery section of this topic.

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 and 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.

Call your doctor 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 your lower back, just below your rib cage, that is not related to an injury or physical activity.
• There is blood or pus in your urine or semen.
• Your symptoms are getting worse.

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 factor 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.

The side effects of the most commonly used medicines are generally minor, and they stop when you stop taking the medicine.

Should I use medication or watchful waiting to treat benign prostatic hyperplasia?

Medication Choices

• Alpha-blockers, including doxazosin (Cardura) and 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 may help your symptoms more than either medicine alone.^{5, 6}

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 will work for everyone.

Alpha-blockers may help symptoms caused by a blockage at the opening to the bladder. With this type of obstruction, you may have difficulty starting urination and have a weak urine stream. Alpha-blockers relax the smooth muscle tissue in the prostate and the opening to the bladder. This muscle tissue must relax to allow urine to flow.

5-alpha reductase inhibitors can reduce the size of your prostate and can slow the rate of enlargement. Men with smaller prostates see less benefit than those with larger prostates. Men who have only slightly enlarged prostates usually find alpha-blockers more helpful.

5-alpha reductase inhibitors may cause you to have less desire to have sex (decreased libido).

Surgery

If you have difficulty urinating because of benign prostatic hyperplasia (BPH), you probably will not need surgery unless you:

• Cannot urinate. About half of the men who cannot urinate need catheterization. In catheterization, a tube is passed up the penis into the bladder and urine is drained. Half of these men will be able to urinate again after catheterization. Those who do not improve may need surgery.
• 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.
• 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, consider:

• How much you expect the surgery to improve your symptoms.
• How severe your symptoms are.
• How you feel about the risk of developing a complication because of the surgery.

For more information on this decision, see:

Should I have surgery or use medication to treat benign prostatic hyperplasia?

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:

• Transurethral incision of the prostate (TUIP), in which incisions are made in the prostate that cause it to press less on the urethra.
• Laser therapy (transurethral laser coagulation and transurethral laser vaporization), in which a laser is used to make incisions in or remove a portion of the prostate.
• Transurethral microwave therapy (TUMT), in which microwave energy is used to destroy a portion of the prostate through heating.
• Transurethral needle ablation (TUNA), in which a heated needle is used to destroy a portion of the prostate.

In most cases, these treatments have been studied for only a few years, so their long-term effectiveness is not yet known. There are some other surgeries that are used in rare cases.

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.
• Transurethral incision of the prostate (TUIP) is most effective for men with smaller prostates. It has fewer risks and a shorter recovery period than TURP, and it appears to be nearly as effective in relieving symptoms.

Other Treatment

Herbal therapy for difficulty urinating caused by benign prostatic hyperplasia (BPH), such as saw palmetto or beta-sitosterol, may be helpful. Talk with your doctor about how herbal therapy may be used in addition to medical treatment for BPH.

For information on transurethral treatment options, see the Surgery section of this topic.

Balloon dilation is no longer used to treat prostate enlargement because it was found to be ineffective.

Other Places To Get Help

Organization

References

Citations

1. 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. 348-370. New York: McGraw-Hill.

2. Roehrborn CG, McConnell JD (2007). Benign prostatic hyperplasia: Etiology, pathophysiology, epidemiology, and natural history. In AJ Wein, ed., Campbell-Walsh Urology, 9th ed., vol. 3, pp. 2727-2765. Philadelphia: Saunders Elsevier.

3. Paterson R, Goldenberg L (2001). Benign prostatic hyperplasia. In J Teichman, ed., 20 Common Problems in Urology, part 2, pp. 185-198. New York: McGraw-Hill.

4. AUA Practice Guidelines Committee (2003). AUA guideline on management of benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. Journal of Urology, 170(2, Part 1): 530-547.

5. McConnell JD, et al. (2003). The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. New England Journal of Medicine, 349(25): 2387-2398.

6. 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.

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.

• ALLHAT Collaborative Research Group (2000). Major cardiovascular events in hypertensive patients randomized to doxazosin vs. chlorthalidone. JAMA, 283(15): 1967-1975.

• Dambro MR (2006). Prostatic hyperplasia, benign (BPH). In Griffith's 5-Minute Clinical Consult 2006. Philadelphia: Lippincott Williams and Wilkins.

• 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 (2004). 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.

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