Enlarged prostate (bph)
  • Feb 09, 2017

 

There are several effective treatments for prostate gland enlargement, including medications, minimally invasive therapies and surgery. To choose the best option, you and your doctor can consider the symptoms, the size of prostate, other health conditions you might have and your preferences.
Prostate gland produces the fluid which carries sperms during ejaculation. It sits behind the urinary bladder and surrounds the urethra through which urine passes out of the body. Prostate enlargement is a common condition as men get older with 60 % of men above 60 years having some degree of enlargement. Benign prostatic hyperplasia (BPH), can cause bothersome urinary symptoms. Untreated, prostate gland enlargement can block the flow of urine out of the bladder and cause bladder, urinary tract or kidney problems.

Symptoms

The severity of symptoms in people who have prostate gland enlargement varies, but symptoms tend to gradually worsen over time. Common signs and symptoms of BPH include:

  • Frequent or urgent need to urinate

  • Increased frequency of urination at night (nocturia)

  • Difficulty starting urination

  • Weak urine stream or a stream that stops and starts

  • Dribbling at the end of urination

  • Straining while urinating

  • Inability to completely empty the bladder

Less common signs and symptoms include:

  • Urinary tract infection

  • Urinary retention – sudden inability to urinate

  • Blood in the urine

 In some men, symptoms eventually stabilize and might even improve over time.
 The size of prostate doesn't necessarily mean that symptoms will be worse. Some men with only slightly enlarged prostates can have significant symptoms, while other men with very enlarged prostates can have only minor urinary symptoms.

Other Possible Causes of Urinary Symptoms

Conditions that can lead to symptoms similar to those caused by enlarged prostate include:

  • Urinary tract infection

  • Inflammation of the prostate (prostatitis)

  • Narrowing of the urethra (urethral stricture)

  • Scarring in the bladder neck as a result of previous surgery

  • Bladder or kidney stones

  • Problems with nerves that control the bladder

  • Cancer of the prostate or bladder

When to see a Doctor

If you're unable to pass any urine, seek immediate medical attention.
If you're having urinary problems, discuss them with your doctor. Even if you don't find urinary symptoms bothersome, it's important to identify or rule out any underlying causes. Untreated, urinary problems might lead to obstruction of the urinary tract.

Causes

It isn't entirely clear what causes the prostate to enlarge. However, it might be due to changes in the balance of sex hormones as men grow older.
Most men have continued prostate growth throughout life. In many men, this continued growth enlarges the prostate enough to cause urinary symptoms or to significantly block urine flow.
The prostate gland is located beneath the bladder. The tube that transports urine from the bladder out of penis (urethra) passes through the center of the prostate. When the prostate enlarges, it begins to block urine flow.

Risk Factors

Risk factors for prostate gland enlargement include:

  • Aging. Prostate gland enlargement rarely causes signs and symptoms in men younger than age 40. About one-third of men experience moderate to severe symptoms by age 60, and about half do so by age 80.

  • Family history. Having a blood relative, such as a father or brother, with prostate problems means you're more likely to have problems.

  • Ethnic background. Prostate enlargement is less common in Asian men than in white and black men.

  • Diabetes and heart disease. Studies show that diabetes, as well as heart disease and use of beta blockers, might increase the risk of BPH.

  • Lifestyle. Obesity increases the risk of BPH, while exercise can lower the risk.

Complications

Complications of enlarged prostate can include:

  • Urinary Retention - Sudden Inability to Urinate. It may require (catheter) insertion of a catheter into the bladder to drain the urine. Some men with an enlarged prostate may need surgery to relieve urinary retention.

  • Urinary Tract Infections (UTIs). Inability to fully empty the bladder can increase the risk of infection in the urinary tract. If UTIs occur frequently, there may be a need of surgery to remove part of the prostate.

  • Bladder stones. These are generally caused by an inability to completely empty the bladder. Bladder stones can cause infection, bladder irritation, blood in the urine and obstruction of urine flow.

  • Bladder damage. A bladder that hasn't emptied completely can stretch and weaken over time. As a result, the muscular wall of the bladder no longer contracts properly, making it harder to fully empty your bladder.

  • Kidney damage. Pressure in the bladder from urinary retention can directly damage the kidneys or allow bladder infections to reach the kidneys.

Most men with an enlarged prostate don't develop these complications. However, acute urinary retention and kidney damage can be serious health threats.

Preparing for Appointment with Urologist

What you must do

  • Make a list of your symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment.

  • Keep track of how often and when you urinate, whether you feel you're completely emptying your bladder, and how much liquid you drink.

  • Make a list of your key medical information, including other conditions you might have.

  • Make a list of all medications, vitamins or supplements that you're currently taking.

  • Write down questions to ask your doctor.

Questions to ask your Doctor

  • Is an enlarged prostate or something else likely causing my symptoms?

  • What kinds of tests do I need?

  • What are my treatment options?

  • How can I manage other health conditions along with an enlarged prostate?

  • Are there any restrictions on sexual activity?

Don't hesitate to ask other questions during your appointment.

What to expect from your Doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them might give you more time to address any concerns. You might be asked:

  • When did you first begin experiencing urinary symptoms? Have they been continuous or occasional? Have they gradually worsened over time, or did they come on suddenly?

  • How often do you urinate during the day, and how often do you need to get up at night to urinate?

  • Have you ever leaked urine? Do you have a frequent or urgent need to urinate?

  • Is it difficult for you to begin urinating? Do you start and stop when urinating, or feel like you have to strain to urinate? Does it ever feel like you haven't completely emptied your bladder?

  • Is there any burning when you urinate, pain in your bladder area or blood in your urine? Have you had urinary tract infections?

  • Do you have a family history of enlarged prostate, prostate cancer or kidney stones?

  • Have you ever had any trouble getting and maintaining an erection (erectile dysfunction), or other sexual problems?

  • Have you ever had surgery or another procedure that involved insertion of an instrument through the tip of your penis into your urethra?

  • Are you taking any blood thinners, such as aspirin, warfarin or clopidogrel?

  • How much caffeine do you consume? What is your fluid intake?

Tests and Diagnosis

After taking detailed history about the symptoms the will conduct a physical exam. This initial exam is likely to include:

  • Digital Rectal Exam. The doctor inserts a finger into the rectum to check the prostate for enlargement.

  • Urine Test. Analyzing a sample of urine can help rule out an infection or other conditions that can cause similar symptoms.

  • Blood Test. The results can indicate kidney problems.

  • Prostate-specific Antigen (PSA) blood test. PSA is a substance produced in your prostate. PSA levels increase in case of an enlarged prostate. However, elevated PSA levels can also be due to recent procedures, infection, surgery or prostate cancer.

  • Neurological exam. This brief evaluation of mental functioning and nervous system can help identify causes of urinary problems other than enlarged prostate.

After that, doctor might recommend additional tests to help confirm an enlarged prostate and to rule out other conditions. These additional tests might include:

  • Urinary Flow Test. You urinate into a receptacle attached to a machine that measures the strength and amount of urine flow. Test results help determine over time if the condition is getting better or worse.

  • Post Void Residual Volume Test. This test measures whether you can empty your bladder completely. The test can be done using ultrasound or by inserting a catheter into your bladder after you urinate to measure how much urine is left in your bladder.

  • 24-hour Voiding Diary. Recording the frequency and amount of urine might be especially helpful if more than one-third of your daily urinary output occurs at night.

If your condition is more complex, your doctor may recommend:

  • Transrectal Ultrasound. An ultrasound probe is inserted into rectum to measure and evaluate the prostate.

  • Prostate Biopsy. Transrectal ultrasound guides needles to take tissue samples (biopsies) of the prostate. Examining the tissue can help diagnose or rule out prostate cancer.

  • Urodynamic and Pressure Flow Studies. A catheter is threaded through urethra into the bladder. Water — or, less commonly, air — is slowly injected into the bladder to measure bladder pressure and determine how well bladder muscles are working.

  • Cystoscopy. A lighted, flexible cystoscope is inserted into urethra, allowing doctor to see inside urethra and bladder.

  • Intravenous Pyelogram or CT Urogram. A tracer is injected into a vein. X-rays or CT scans are then taken of kidneys, bladder and the tubes that connect kidneys to bladder (ureters). These tests can help detect urinary tract stones, tumors or blockages above the bladder.

Treatments and Drugs

A wide variety of treatments are available for enlarged prostate, including medication, minimally invasive therapies and surgery. The best treatment choice depends on several factors, including:

  • The size of prostate

  • Age

  • Overall health

  • The amount of discomfort or bother being experienced

If the symptoms are tolerable, you might decide to postpone treatment and simply monitor the symptoms. For some men, symptoms can ease without treatment.

Medication

Medication is the most common treatment for mild to moderate symptoms of prostate enlargement. The options include:

  • Alpha Blockers. These medications relax bladder neck muscles and muscle fibers in the prostate, making urination easier. Alpha blockers — which include alfuzosin (Alfoo), doxazosin (Duracard), tamsulosin (Urimax), and silodosin — usually work quickly in men with relatively small prostates. Side effects might include dizziness and a harmless condition in which semen goes back into the bladder instead of out the tip of the penis (retrograde ejaculation).

  • 5-Alpha Reductase Inhibitors. These medications shrink prostate by preventing hormonal changes that cause prostate growth. These medications — which include finasteride (Finax) and dutasteride (Dutas) — might take up to six months to be effective. Side effects include retrograde ejaculation.

  • Combination Drug Therapy. Your doctor might recommend taking an alpha blocker and a 5-alpha reductase inhibitor at the same time if either medication alone isn't effective.

  • Tadalafil (Cialis). Studies suggest this medication, which is often used to treat erectile dysfunction, can also treat prostate enlargement. However, this medication is not routinely used for BPH and is generally prescribed only to men who also experience erectile dysfunction.

Minimally Invasive or Surgical Therapy

Minimally invasive or surgical therapy might be recommended if:

  • Symptoms are moderate to severe

  • Medication hasn't relieved symptoms

  • In case of urinary tract obstruction, bladder stones, blood in urine or kidney problems

  • You prefer definitive treatment

Minimally invasive or surgical therapy might not be an option if you have:

  • An untreated urinary tract infection

  • Urethral stricture

  • A history of prostate radiation therapy or urinary tract surgery

  • A neurological disorder, such as Parkinson's disease or multiple sclerosis

Any type of prostate procedure can cause side effects. Depending on the procedure you choose, complications might include:

  • Semen flowing backward into the bladder instead of out through the penis during ejaculation

  • Temporary difficulty with urination

  • Urinary tract infection

  • Bleeding

  • Erectile dysfunction

  • Very rarely, loss of bladder control (incontinence)

There are several types of minimally invasive or surgical therapy.
Transurethral Resection of the Prostate (TURP)
A lighted scope is inserted into urethra, and the surgeon removes all but the outer part of the prostate. TURP generally relieves symptoms quickly, and most men have a stronger urine flow soon after the procedure. After TURP you might temporarily need a catheter to drain your bladder, and you'll be able to do only light activity until you've healed.
Transurethral Incision of the Prostate (TUIP)
A lighted scope is inserted into urethra, and the surgeon makes one or two small cuts in the prostate gland — making it easier for urine to pass through the urethra. This surgery might be an option in case of a small or moderately enlarged prostate gland, especially when associated with other health problems that make other surgeries too risky.
Transurethral Microwave Thermotherapy (TUMT)
Doctor inserts a special electrode through urethra into prostate area. Microwave energy from the electrode destroys the inner portion of the enlarged prostate gland, shrinking it and easing urine flow. This surgery is generally used only on small prostates in special circumstances because re-treatment might be necessary.
Transurethral Needle Ablation (TUNA)
In this outpatient procedure, a scope is passed into urethra, allowing the doctor to place needles into the prostate gland. Radio waves pass through the needles, heating and destroying excess prostate tissue that's blocking urine flow.
This procedure might be a good choice if you bleed easily or have certain other health problems. However, like TUMT, TUNA might only partially relieve your symptoms and it might take some time before you notice results.
Laser Therapy
A high-energy laser destroys or removes overgrown prostate tissue. Laser therapy generally relieves symptoms right away and has a lower risk of side effects than does nonlaser surgery. Laser therapy might be used in men who shouldn't have other prostate procedures because they take blood-thinning medications.
The options for laser therapy include:

  • Ablative procedures. These procedures vaporize obstructive prostate tissue to increase urine flow. Examples include photoselective vaporization of the prostate (PVP) and holmium laser ablation of the prostate (HoLAP). Ablative procedures can cause irritating urinary symptoms after surgery, so in rare situations another resection procedure might be needed at some point.

  • Enucleative procedures. Enucleative procedures, such as holmium laser enucleation of the prostate (HoLEP), generally remove all the prostate tissue blocking urine flow and prevent regrowth of tissue. The removed tissue can be examined for prostate cancer and other conditions. These procedures are similar to open prostatectomy.

Prostate Lift
In this experimental transurethral procedure, special tags are used to compress the sides of the prostate to increase the flow of urine. Long-term data on the effectiveness of this procedure aren't available.
Embolization
In this experimental procedure, the blood supply to or from the prostate is selectively blocked, causing the prostate to decrease in size. Long-term data on the effectiveness of this procedure aren't available.
Open or Robot-Assisted Prostatectomy
The surgeon makes an incision in lower abdomen to reach the prostate and remove tissue. Open prostatectomy is generally done in case of a very large prostate, bladder damage or other complicating factors. The surgery usually requires a short hospital stay and is associated with a higher risk of needing a blood transfusion.

Follow-up care

Follow-up care will depend on the specific technique used to treat the enlarged prostate.
Recommend limiting heavy lifting and excessive exercise for seven days in case of laser ablation, transurethral needle ablation or transurethral microwave therapy. In case of open or robot-assisted prostatectomy, might need to restrict activity for six weeks.
Whichever procedure you have, your doctor likely will suggest that you drink plenty of fluids afterward.

Lifestyle and Home Remedies

To help control the symptoms of an enlarged prostate, try to:

  • Limit beverages in the evening. Don't drink anything for an hour or two before bedtime to avoid middle-of-the-night trips to the toilet.

  • Limit caffeine and alcohol. They can increase urine production, irritate the bladder and worsen symptoms.

  • Limit decongestants or antihistamines. These drugs tighten the band of muscles around the urethra that control urine flow, making it harder to urinate.

  • Go when you first feel the urge. Waiting too long might overstretch the bladder muscle and cause damage.

  • Schedule bathroom visits. Try to urinate at regular times — such as every four to six hours during the day — to "retrain" the bladder. This can be especially useful if you have severe frequency and urgency.

  • Follow a healthy diet. Obesity is associated with enlarged prostate.

  • Stay active. Inactivity contributes to urine retention. Even a small amount of exercise can help reduce urinary problems caused by an enlarged prostate.

  • Urinate — and then urinate again a few moments later. This practice is known as double voiding.

  • Keep warm. Colder temperatures can cause urine retention and increase the urgency to urinate.

Alternative Medicine

  • Studies on herbal therapies as a treatment for enlarged prostate have had mixed results. One study found that saw palmetto extract was as effective as finasteride in relieving symptoms of BPH, although prostate volumes weren't reduced. But a subsequent placebo-controlled trial found no evidence that saw palmetto is better than a placebo.

  • Other herbal treatments — including beta-sitosterol extracts, pygeum and rye grass — have been suggested as helpful for reducing enlarged prostate symptoms. But the safety and efficacy of these treatments hasn't been proved.


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