It is common for the prostate gland to become enlarged as a man ages. Doctors call this condition benign prostatic hyperplasia (BPH), benign prostatic hypertrophy or benign prostatic enlargement.
As a man matures, the prostate goes through two main periods of growth. The first occurs early in puberty, when the prostate doubles in size. At around age 25, the gland begins to grow again. This second growth phase often results, years later, in BPH.
Though the prostate continues to grow during most of a man’s life, the enlargement doesn’t usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and as many as 90% in their seventies and eighties have some BPH related symptoms.
As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself, so some of the urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH.
Many people feel uncomfortable talking about the prostate, since the gland plays a role in both sex and urination. Still, prostate enlargement is as common a part of ageing as gray hair. As life expectancy rises, so does the occurrence of BPH.
Many symptoms of BPH stem from obstruction of the urethra and gradual loss of bladder function, which results in incomplete emptying of the bladder. The symptoms of BPH vary, but the most common ones involve changes or problems with urination, such as:
- ‘Obstructive’ bladder symptoms include having to wait to get started, a poor urinary flow and needing to strain to pass urine. In some patients, the back-pressure caused by the obstruction separates nerve endings from the bladder muscle fibres they are travelling towards, causing the bladder to behave in a reflex manner rather like a baby’s bladder does.
- The ‘irritative’ symptoms caused by an unstable bladder include frequency (going often), urgency (going in a hurry) and urge incontinence (leaking if you can’t get to a toilet in time).
Other BPH symptoms include:
- stagnation of urine – which can lead to urinary infection (pain on and frequency of passing urine)
- stone formation (recurrent urinary infections and frequency)
- the symptoms of kidney failure.
Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to urinate at all. This condition, called acute urinary retention and needs to be treated immediately.
It is important to tell your doctor about urinary problems such as those described above. In eight out of ten cases, these symptoms suggest BPH, but they also can signal other, more serious conditions that require prompt treatment. These conditions, including prostate cancer, can be ruled out only by a doctor’s examination.
Severe BPH can cause serious problems over time and therefore should be investigated and treated at the time of noticing the symptoms. Urine retention and strain on the bladder can lead to urinary tract infections, bladder or kidney damage, bladder stones and incontinence—the inability to control urination. If the bladder is permanently damaged, treatment for BPH may be ineffective. When BPH is found in its earlier stages, there is a lower risk of developing such complications.
The key diagnostic tests for patients with prostrate enlargement are:
Digital Rectal Examination (DRE)
This examination is usually the first test done. The doctor inserts a gloved finger into the rectum and feels the part of the prostate next to the rectum. This examination gives the doctor a general idea of the size and condition of the gland.
Prostate-Specific Antigen (PSA) blood test
Prostate Specific Antigen (PSA) is a protein produced by prostate cells which is often higher in the blood of men who have prostate cancer and is detected by performing a blood test. However, an elevated level of PSA does not necessarily mean you have cancer. PSA test is used in conjunction with Digital Rectal Examination (DRE) of the prostate to help detect prostate cancer in men and for monitoring men with prostate cancer after treatment. However, much remains unknown about how to interpret the PSA test, its ability to discriminate between cancer and benign prostate conditions and the best course of action if the PSA is high.
Dynamic urine flow study and bladder ultrasound
Your doctor may ask you to urinate into a special device that measures how quickly the urine is flowing. A reduced flow often suggests BPH. It is always advisable to try to attend your urologist with a relatively full bladder as this test is often required. An ultrasound scan of your bladder will follow the urine flow test to see if your bladder is still retaining significant volumes of urine.
Urodynamics testing may be indicated if you have a problem with frequent voiding, an urgent or difficult-to-control desire to void, urine leakage or reduced urine flow. This is the “gold standard” assessment of lower urinary tract symptoms and helps your specialist see measure how much urine your bladder can hold, how the pressure changes inside your bladder with increasing volume and how these factors relate to your urge to urinate.
Whilst you lie on a couch, a small catheter (tube) is gently passed through the penis and into the bladder; another is passed into the rectum to record pressure there as well. As the test progresses, your bladder is slowly filled with sterile water and you will be asked about bladder sensation and any desire to pass water.
Once your bladder is full, you will be asked to pass urine; the catheters remain in place to measure the pressure in your bladder as you pass urine. This pressure-flow study can identify bladder outflow obstruction and show whether you have prostate enlargement or stricture (tightening) in the urethra.
We can tell you the results of the tests immediately afterwards and decide on a treatment plan.
Cystoscopy or telescopic inspection of the bladder is usually performed in patients with ‘irritative’ bladder symptoms to exclude physical bladder irritants, such as a stone or bladder cancer, which are unusual. It can be performed awake using a local anaesthetic gel and using a flexible telescope. This procedure is well tolerated by most patients, however, on some occasions a general anaesthetic may be required. Post procedure, there might be transient blood in the urine and a stinging sensation as the local anaesthetic jelly wears off.
Alternative treatments for BPH:
Nutrition and the use of supplements and herbs can be used to modify the metabolism of testosterone and oestrogen and so reduce prostate size and hopefully symptoms.
Eat less dairy products, refined food, fried foods, hydrogenated oils, alcohol and caffeine.
Eat more fruit, vegetables, whole grains, soy, beans, seeds, nuts, olive oil and cold-water fish (salmon, tuna, sardines, halibut and mackerel).
Zinc – 30–50 mg daily. Zinc competes with copper for absorption; therefore, when supplementing long term with zinc, copper should also be supplemented. There are supplements available that contain both zinc and copper.
Saw palmetto – reduces the size of the prostate via its oestrogenic effect and so relieves symptoms of BPH. Recommended dosage is 320 mg of extract a day.
Medical treatments for BPH:
Over the years, researchers have tried to find a way to shrink or at least stop the growth of the prostate without using surgery. There are currently two classes of medical therapy available to relieve common symptoms associated with an enlarged prostate.
Finasteride (Proscar) and dutasteride (Avodart), inhibit production of the hormone DHT, which is involved with prostate enlargement. The use of either of these drugs can either prevent progression of growth of the prostate or actually shrink the prostate in some men.
The other class of drugs are called alpha blockers. These include Tamsulosin (Flomax) and Alfuzosin (Xatral). These drugs act by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and to reduce bladder outlet obstruction.
The Medical Therapy of Prostatic Symptoms (MTOPS) Trial, supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), recently found that using Finasteride and Doxazosin together is more effective than using either drug alone to relieve symptoms and prevent BPH progression. The two-drug regimen reduced the risk of BPH progression by 67%, compared with 39% for Doxazosin alone and 34 percent for Finasteride alone.
Most doctors recommend removal of the enlarged part of the prostate as the best long-term solution for patients with BPH. With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed; the rest of the inside tissue and the outside capsule are left intact. Surgery usually relieves the obstruction and incomplete emptying caused by BPH. The following section describes the types of surgery that are used.
Transurethral resection of the prostate (TURP)
This involves coring out the central part of the prostate (rather like one might core out the centre of an apple) to physically enlarge the channel one passes urine through. It was the first ‘keyhole’ operation and remains the standard to which other operations for BPH are compared. It is performed under general or spinal anaesthetic, usually lasts 45 minutes and involves no incisions on the outside. It is performed using an electrical loop inserted into the urethra via a telescope. It cuts tissue and seals blood vessels as it removes the prostate in slivers. These are washed out at the end of the operation and a catheter is inserted for two days, through which irrigation fluid flows into the bladder to rinse any blood in it.
In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. General anaesthesia is given and an incision is made. Once the surgeon reaches the prostate capsule, he or she scoops out the enlarged tissue from inside the gland.
Newer procedures that use laser technology can be performed on an outpatient basis.
GreenLightTM photoselective vaporisation of the prostate (PVP)
PVP uses a high-energy laser to vaporize prostate tissue and seal the treated area. Its advantages over TURP are less bleeding and a much shorter catheterisation time and hospital stay. The procedure is performed via a telescope inserted into the urethra under spinal or general anaesthetic and usually lasts 30-60 minutes.
Holmium Enucleation of Enlarged Prostate (HoLEP)
Uses Holmium laser technology to enucleate the enlarged adenomatous prostate. The procedure is also performed via a telescope inserted into the urethra under spinal or general anaesthetic and usually lasts 30-60 minutes.