The prostate is a gland about the size of a walnut that is only present in men. It is located just below the bladder and surrounds the urethra, the tube through which urine flows from the bladder and out through the penis. One of the main functions of the prostate gland is to produce prostatic fluid, one of the components of semen. A man’s prostate gland usually starts to enlarge after he reaches 40 years of age. This condition is called benign prostatic hyperplasia (BPH). It is not cancer, and it does not raise your risk for prostate cancer.
Benign Prostatic Hyperplasia (BPH) is mistaken to be simply a case of too many prostate cells. In reality, there is no cure for BPH and once prostate growth starts, it often continues, unless medical therapy is started. Prostate grows in two different ways. In the first type of growth, cells multiply around the urethra and squeeze it, much like you can squeeze a straw. The second type of growth is the middle-lobe prostate growth, in which cells grow into the urethra and the bladder outlet area. This type of growth typically requires surgery.
Causes of Enlarged Prostate
The actual cause of prostate enlargement is unknown. It is believed that factors linked to aging and the testicles themselves may play a role in the growth of the gland. Men who have had their testicles removed at a young age (for example, as a result of testicular cancer) do not develop BPH.
Throughout their lives, men produce both testosterone, an important male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen. Studies done on animals have suggested that BPH may occur because the higher amount of estrogen within the gland increases the activity of substances that promote cell growth.
Another theory focuses on dihydrotestosterone (DHT), a substance derived from testosterone in the prostate, which may help control its growth. Most animals lose their ability to produce DHT as they age. However, some research has indicated that even with a drop in the blood’s testosterone level, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage the growth of cells. Scientists have also noted that men who do not produce DHT do not develop BPH.
Signs & Symptoms
Many men with an enlarged prostate have no symptoms. Common symptoms may include the following:
- Blood in the urine (i.e. haematuria), caused by straining to void.
- Dribbling after voiding.
- Feeling that the bladder has not emptied completely after urination.
- Frequent urination, particularly at night (i.e. nocturia).
- Hesitant, interrupted or weak urine stream caused by decreased force.
- Leakage of urine (i.e. overflow incontinence).
- Pushing or straining to begin urination.
- Recurrent, sudden, urgent need to urinate.
In severe cases of BPH, another symptom i.e. Acute Urinary Retention (inability to urinate), can result. Acute Urinary Retention causes severe pain and discomfort. Catheterization may be necessary to drain urine from the bladder to obtain relief.
A physical examination and evaluation of symptoms provide the basis for a diagnosis of Benign Prostatic Hyperplasia. The physical examination includes a digital rectal examination (DRE), and symptom evaluation is obtained from the results of the AUA Symptom Index.
- Digital Rectal Examination (DRE)
DRE typically takes less than a minute to perform. The doctor inserts a lubricated, gloved finger into the patient’s rectum to feel the surface of the prostate gland through the rectal wall to assess its size, shape, and consistency. Healthy prostate tissue is soft, like the fleshy tissue of the hand where the thumb joins the palm. Malignant tissue is firm, hard, and often asymmetrical or stony, like the bridge of the nose. If the examination reveals the presence of unhealthy tissue, additional tests are performed to determine the nature of the abnormality.
- AUA Symptom Index
The AUA (American Urological Association) Symptom Index is a questionnaire designed to determine the seriousness of a man’s urinary problems and to help diagnose BPH. The patient answers seven questions related to common symptoms of benign prostatic hyperplasia. How frequently the patient experiences each symptom is rated on a scale of 1 to 5. These numbers added together provide a score that is used to evaluate the condition. An AUA score of 0 to 7 means the condition is mild; 8 to 19, moderate; and 20 to 35, severe.
- PSA Test
Blood test to check the levels of prostate specific antigen (PSA) in a patient who may have benign prostatic hyperplasia helps the Doctor to eliminate a diagnosis of prostate cancer.
- Uroflowmetry Test
This is a simple test performed which records urine flow to determine how quickly and completely the bladder can be emptied. With a full bladder, the patient urinates into a device that measures the amount of urine, the time it takes for urination, and the rate of urine flow. Patients with stress or urge incontinence usually have a normal or increased urinary flow rate, unless there is an obstruction in the urinary tract. A reduced flow rate may indicate BPH.
- Post-Void Residual (PVR)
This test measures the amount of urine that remains in the bladder after urination. The patient is asked to urinate immediately prior to the test and the residual urine is determined by ultrasound. PVR, less than 50 ml. generally indicates adequate bladder emptying and measurements of 100 to 200 ml. or higher often indicate blockage.
Treatment for Enlarged Prostate
Men who have BPH with symptoms usually need some kind of treatment at some time. However, a number of researchers have questioned the need for early treatment when the gland is just mildly enlarged. The results of their studies indicate that early treatment may not be needed because the symptoms of BPH clear up without treatment in as many as one-third of all mild cases. Instead of immediate treatment, they suggest regular checkups to watch for early problems. If the condition begins to pose a danger to the patient’s health or causes a major inconvenience to him, treatment is usually recommended.
Since BPH can cause urinary tract infections, a doctor will usually clear up any infection with antibiotics before treating the BPH itself. Although the need for treatment is not usually urgent, doctors generally advise going ahead with treatment once the problems become bothersome or present a health risk.
- Self-Care at Home
Some precautions can help to avoid worsening of symptoms of prostate enlargement and complications. Do not delay to urinate once you experience an urge. Urinate as soon as you feel the urge, and empty the bladder completely. Avoid alcohol and caffeine, especially after dinner. Don’t drink a lot of fluid all at once. Spread out fluids throughout the day. Avoid drinking fluids within 2 hours of bedtime. Keep warm and exercise regularly. Cold weather and lack of physical activity may worsen symptoms.
- Drug Treatment
There are two main classes of prescription medicines that are used to treat BPH: alpha-blockers and 5-alpha-reductase inhibitors. Alpha-blockers relax muscle fibres that control the tension in the prostate gland. They can reduce the pressure on the urethra and increase the flow of urine. They do not cure BPH but may help to alleviate some of the symptoms.
Though alpha-blockers are likely to help, they don’t work for everyone. If your symptoms don’t improve within a couple of months, your doctor may suggest trying an alternative treatment. There are several different alpha-blockers that may be prescribed for BPH. Some of these drugs can also be used to treat high blood pressure.
5-alpha-reductase inhibitors block production of a hormone called dihydrotestosterone (DHT). This can reduce the size of the prostate by up to 30 percent. Finasteride (Proscar) and dutasteride (Avodart) are examples of 5-alpha-reductase inhibitors. 5-alpha-reductase inhibitors are able to reverse BPH to some extent and so may delay your need for surgery.
- Surgery for Enlarged Prostate
There are a number of surgical options for BPH. Generally, surgery is considered for men who don’t get relief from symptoms using drug treatments.
Transurethral resection of the prostate (TURP) is the most common operation for BPH. Your surgeon inserts a thin, tube-like telescope (a resectoscope) into the urethra. The resectoscope includes a camera and specially adapted surgical instruments. This allows the surgeon to see the prostate clearly. A wire loop attachment that carries an electric current is used to “chip away” at the prostate. For further information, please see separate Bupa health factsheet, TURP.
Transurethral incision of the prostate (TUIP) may be appropriate for men who have a less enlarged prostate. It is a quicker operation than TURP and instead of “chipping away” a portion of the prostate, small cuts are made in the bladder neck and the prostate to improve the flow of urine.
Open prostatectomy is only recommended for men whose prostate is very large. It is a major operation carried out under general anaesthesia and may require up to a week in hospital. An incision is made in the lower abdomen in order to remove part of the prostate.
Holmium Laser Enucleation of Prostate (HOLEP)
It is the latest modality used in the management of Enlarged Prostate. In this procedure, a 550 Micron Fibre attached to a 100-Watts Holmium Laser machine is used to remove obstructive prostatic tissue and seal blood vessels. The enucleated gland is then pushed into the bladder, which is later sucked out with the help of an equipment called Morcellator. The whole procedure takes around 45-90 minutes, depending on the size of the gland. This procedure is nearly bloodless as the laser beam when cuts the gland also seals the blood vessels. In most of the cases there is no need for blood transfusion. At the end of surgery, a catheter is inserted to keep the bladder in place. It continuously drains the urine into a sterile collection bag. The catheter is usually kept for 24 to 48 hrs and the patient is discharged without catheter after giving a catheter free trial.
Advantages of Holmium Laser Enucleation of Prostate (HOLEP)
|Size of Prostate||200 gms||Not >80 gms|
|Patients on anticoagulants||Can be done||Contraindicated|
|Irrigation||Not needed||Usually required|
|Blood Transfusion||1 in 10000||10-15 in 100|
|Recovery||Very soon||Few weeks|
|Hospital stay||36-48 hrs.||4-7 days|
|Risk of Stricture, Bladder||Insignificant||High Risk|