The prostate gland is located just below a man’s bladder and surrounds the top portion of the urethra, the tube that drains urine from the bladder. The primary function of the prostate is to produce most of the fluids in semen, the fluid that nourishes and transports sperm.
Most men experience a second period of prostate growth when they reach their middle to late 40s. At that time, cells in the central portion of the gland — where the prostate surrounds the urethra — begin to reproduce more rapidly. As tissues in the area enlarge, they often compress the urethra and partially block urine flow. Benign prostatic hyperplasia (BPH) is the medical term for this condition.
Prostate enlargement adversely affects about half the men in their 60s and close to 80 percent of men in their 80s. The presence or absence of prostate gland enlargement is not related to the development of prostate cancer.
Prostate enlargement varies in severity from man to man and doesn’t always pose a problem. Only about half the men with prostate enlargement experience signs and symptoms that become noticeable or bothersome enough for them to seek medical treatment. These signs and symptoms may include:
Weak urine stream
Difficulty starting urination
Stopping and starting again while urinating
Dribbling at the end of urination
Frequent need to urinate
Increased frequency of urination at night (nocturia)
Urgent need to urinate
Not being able to completely empty the bladder
Blood in the urine
Urinary tract infection
The causes of prostate enlargement are unclear. Researchers believe that as the prostate gland ages, it becomes more susceptible to the effects of male hormones, including testosterone.
The main risk factor for prostate enlargement is aging. Prostate enlargement rarely causes signs and symptoms in men under age 40, but approximately half the men in their 60s experience some signs and symptoms. In addition to age, other risk factors include:
Heredity. A family history of prostate enlargement can increase the odds of
developing problems from prostate enlargement.
National origin. Prostate enlargement is more common in American and European
men than in Asian men.
Marital status. For unknown reasons, married men are more likely to experience
prostate enlargement than single men.
If you’re experiencing urinary problems, tell your doctor. He or she can help determine whether you have prostate enlargement and whether your symptoms warrant evaluation and treatment.
If you don’t find your symptoms troublesome and they don’t pose a health threat, treatment may be unnecessary. That doesn’t mean that it’s all right to let urinary symptoms go without medical evaluation. Instead of prostate enlargement, your symptoms could be early warnings of a more serious condition, including a bladder stone, a bladder infection, side effects of medication, heart failure, diabetes, a neurologic problem, prostatitis or prostate cancer.
To diagnose a case of prostate enlargement, your doctor will likely begin by asking you what your symptoms are, when they developed and how often they occur. He or she will also want to know about other health problems you have, medications you are taking and whether there's a history of prostate problems in your family.
In addition, your checkup may include:
Digital rectal exam. To perform this exam, your doctor puts on an examination
glove and applies a lubricant to one finger. You're then asked to bend over
while your doctor gently inserts the lubricated finger into your rectum. Because
the prostate gland is located adjacent to the rectum, your doctor can feel the
back wall of the gland. This allows your doctor to see whether your prostate
is enlarged and to help rule out prostate cancer.
Urine test. Having a sample of your urine analyzed in the laboratory can help
your doctor rule out an infection or other condition that can produce symptoms
similar to those of prostate enlargement, such as prostatitis, cystitis or kidney
disease.
Prostate-specific antigen (PSA) blood test. Prostate-specific antigen is naturally
produced in your prostate gland to help liquefy semen. A small amount circulates
in your blood. Higher-than-normal levels in your blood can indicate BPH, prostate
cancer or prostate inflammation.
If the results of these tests suggest prostate enlargement, your doctor may
want to perform additional exams. The following can help confirm the diagnosis
of prostate enlargement and determine its severity:
AUA symptom index. This short questionnaire, developed by the American Urological
Association (AUA), asks you about specific urinary symptoms associated with
prostate enlargement and how often they occur. In addition to helping determine
the severity of prostate enlargement, this index is helpful in monitoring the
progression of the condition over time.
Urinary flow test. This test measures the strength and amount of your urine
flow. A peak flow rate of more than 15 milliliters per second (mL/sec) is normal
or signifies only mild disease. A rate of 10 to 15 mL/sec is often associated
with moderate symptoms. Anything less than 10 mL/sec usually indicates serious
prostate enlargement. By charting the results of this test, your doctor can
determine if your urinary flow patterns are changing over time and at what rate.
Keep in mind that your peak flow rate normally decreases as you age. Restricted
urine flow can also be a sign of other problems, such as a weak bladder muscle.
Postvoid residual volume test. This test measures whether you can empty your
bladder. The test is done one of two ways: by inserting a thin, soft tube (catheter)
into your urethra and up into your bladder or by using ultrasound imaging to
see inside your bladder. The ultrasound method is more common and less uncomfortable,
but often less accurate. Because the results of this test can vary, you may
need to have it done more than once to get an accurate reading.
Ultrasound. Imaging through ultrasound is used to estimate the size of your
prostate gland. In addition, it can help detect problems such as an obstruction
of your kidney, stones in your kidneys or prostate, or a tumor in the prostate.
Urodynamic studies. If your doctor suspects that your symptoms may be related
to a bladder problem rather than prostate enlargement, he or she may recommend
a series of tests to measure bladder pressure and function. These tests are
done by threading a small catheter through the urethra and into the bladder.
Water is gently injected into your bladder to measure internal bladder pressure
and to determine how effectively your bladder contracts. Bladder pressure is
measured during bladder filling and urination.
Cystoscopy. This procedure involves the use of a thin tube containing a lens
with a light system (cystoscope) that's gently inserted into the urethra under
local anesthesia. It allows your doctor to see inside the urethra and bladder.
The procedure can detect problems including enlargement of the prostate, compression
of the urethra due to enlarged prostate, obstruction of the urethra or bladder
neck, an anatomical abnormality, or the development of stones in your bladder.
Intravenous pyelogram. An intravenous pyelogram is an X-ray image of the urinary
tract used to help detect an obstruction or abnormality. Dye is injected into
a vein, and an X-ray is taken of your kidneys, bladder and tubes that attach
your kidneys to your bladder (ureters). The dye makes it possible to identify
urinary stones, tumors or a blockage above the bladder.
If your signs and symptoms are mild and don’t bother you, your doctor may suggest watchful waiting as an appropriate way to respond to an enlarged prostate. Your doctor will periodically evaluate your condition to see if it improves, stays the same or worsens.
The risk you take in following this approach is that your condition could worsen
over time and other problems could develop, such as infection, bleeding or kidney
damage. However, these complications are uncommon.
Prostate enlargement becomes a serious health threat only if it interferes with your ability to empty your bladder. A bladder that’s continuously full can interfere with your sleep, cause recurrent bladder infection or result in kidney damage. If you’re unable to pass urine at all, seek immediate medical attention.
In about half the men with enlarged prostate, signs and symptoms stay the same or improve over time. Among the other half, signs and symptoms gradually worsen.
Treatments for prostate enlargement don’t reduce or increase the risk of prostate cancer, with the exception of complete prostate removal. So even if you’re being treated for prostate enlargement, you still need to continue regular prostate exams to screen for cancer. Surgical treatment for prostate enlargement can identify cancer in its early stages. Unsuspected cancer is found during surgery in about 5 percent of men.
Treatment for an enlarged prostate is determined by your signs and symptoms and their severity. If you have significant problems such as urinary bleeding, persistent urinary tract infections, bladder or kidney damage, or other symptoms that cause you considerable discomfort, your doctor generally will recommend treatment. If your prostate is enlarged but you experience little or no discomfort, treatment often isn't necessary.
A wide variety of treatments are available to ease the signs and symptoms of an enlarged prostate. They include medications, nonsurgical therapies and surgical procedures.
Alpha blockers. These drugs were originally developed to treat high blood pressure,
but they're also beneficial for other conditions, including an enlarged prostate.
They relax the muscles at the neck of your bladder, making it easier to urinate.
The Food and Drug Administration has approved three types of alpha blockers
for prostate enlargement: terazosin (Hytrin), doxazosin (Cardura) and tamsulosin
(Flomax).
Alpha blockers are effective in about 75 percent of men who take them. The drugs
also work quickly. Within just 1 or 2 days, most men notice an increase in urinary
flow and a decrease in how often they need to urinate.
Although doctors are uncertain about the long-term benefits and risks of alpha blockers, the drugs appear to be safe. Side effects can include headaches, dizziness, lightheadedness or tiredness, but these are generally reversible. For this reason it's best to take the medication before bedtime. Some men also report low blood pressure when standing and trouble with erectile dysfunction (impotence). To reduce your risk of these side effects, your doctor may start you with a low dose of medication and gradually increase the dosage. You may need to take this medication indefinitely.
Tamsulosin, the newest of the three drugs, may cause less dizziness. You also don't need to gradually increase its dosage. As result, its benefits tend to be more noticeable and occur more quickly. Abnormal ejaculation can occur in men who take tamsulosin. But adjusting the dosage may remedy the problem.
Finasteride (Proscar, Propecia). This drug relieves symptoms in a totally different
manner than alpha blockers do. Instead of relaxing your muscles, it shrinks
your prostate gland. For some men with large prostates, the drug may produce
a noticeable improvement in symptoms. It's generally not effective, though,
if you have only a moderately enlarged or normal-sized prostate. Obstruction
can occur if this drug is taken for a prostate that is only moderately enlarged
and located in the area immediately surrounding the urethra.
A small percentage of men who take finasteride experience impotence, decreased
libido and reduced semen release during ejaculation. But in most men it produces
only slight side effects. Finasteride also takes a long time to work. You may
notice some improvement in urinary flow after 3 months, but it generally takes
up to a year for complete results, and its long-term effects are unknown.
Finasteride has two other drawbacks. It's more expensive than alpha blockers, and although it generally lowers your baseline PSA level, finasteride doesn't affect or change your risk of prostate cancer. This can interfere with the effectiveness of the PSA screening test for prostate cancer. Be sure to tell your doctor if you are currently taking or have taken finasteride.
Nonsurgical therapies
Several nonsurgical treatment methods are available to reduce the size of the
prostate. These therapies focus on enlarging the urethra, making it easier for
you to urinate.
Heat therapy uses heat energy delivered through the urethra to destroy excessive prostate tissue. It fills the gap between medications and invasive surgery. It's more effective than medications for moderate to severe symptoms, and it doesn't produce as many side effects as surgery.
Heat therapy is often performed on an outpatient basis. But depending on the procedure, your doctor and how quickly you're able to urinate on your own, you may need to stay in the hospital overnight. Heat therapy ordinarily requires only a few days’ recovery time. An exception is laser therapy. Some older laser procedures require that you wear a catheter for up to 3 weeks. Newer techniques often require use of a catheter for only 24 hours.
Several types of heat therapy are available. These may include:
Microwave therapy. Transurethral microwave therapy (TUMT) uses computer-controlled
heat in the form of microwave energy to safely destroy the inner portion of
the enlarged gland.
The size and shape of an enlarged prostate is critical to the success of microwave
therapy. If your prostate is very large or growing in an unusual shape into
your bladder, this treatment generally isn't effective.
During the procedure a machine emits microwave energy through a urinary catheter. The catheter includes a tiny internal microwave antenna to deliver a dose of microwave energy that heats the enlarged cells and destroys them. Cool water circulates around the tip and sides of the antenna during the procedure to protect the urethra from the heat.
A local anesthetic helps control pain. You may feel some heat in the prostate and bladder area. You may also have a strong desire to urinate and may experience bladder spasms. These responses usually disappear after the treatment is finished. You can go home when you're urinating satisfactorily — usually the same day of your treatment. Most men need to wear a urinary catheter for a few days following treatment.
It may take several weeks before you begin to see a noticeable improvement in your symptoms. The long-term effectiveness of the procedure is also uncertain. One study found that 60 percent to 70 percent of men respond well to TUMT initially, but only about 25 percent of those men were satisfied with the results 4 years later. Those who seem to respond best over time are men whose initial symptoms are mild.
It's normal to have urgent, frequent urination and small amounts of blood in your urine during recovery. There may be changes in the amount of semen you ejaculate. However, unlike more invasive surgery, TUMT generally doesn't produce impotence, incontinence or retrograde ejaculation. With retrograde ejaculation, semen flows backward into the bladder during ejaculation instead of out through the penis and can result in infertility .www.thermatrx.com
TUMT isn't recommended if you have a pacemaker or any metal implants.
Radiofrequency therapy. Transurethral needle ablation (TUNA) works by
sending radio waves through needles that are inserted into the prostate gland,
heating and destroying the tissue. As in TUMT, a special catheter is inserted
through your urethra. The needles are inserted into the prostate by maneuvering
the catheter.
TUNA typically is less effective than traditional surgery in reducing symptoms
and improving urine flow. Its long-term effectiveness also isn't known. Another
drawback of the procedure is that it doesn't work as well in men with very large
prostates. Side effects may include urine retention, blood in your urine, painful
urination and a small risk of retrograde ejaculation.
Electrovaporization. Transurethral electrovaporization of the prostate
(TVP) involves a special metal instrument that emits a high-frequency electrical
current to cut and vaporize excess tissue while sealing off the remaining tissue
to prevent bleeding. This procedure is especially useful for men at higher risk
of complications, including those who take a blood-thinning medication. As with
other, newer treatments, its long-term benefits aren't yet known.
Laser therapy. This procedure is performed similarly to other thermotherapies,
except it uses a laser instead of microwave energy, radio waves or electrical
current to produce heat. It generally doesn't cause impotence or prolonged incontinence.
However, some laser procedures require lengthy use of a catheter. Laser therapy
includes transurethral evaporation of the prostate (TUEP), noncontact visual
laser ablation (VLAP) and interstitial laser therapy.
TUEP is similar to electrovaporization. The difference is that your doctor uses
laser energy to destroy prostate tissue instead of using electrical current.
The procedure is generally safe and causes limited bleeding. It's often effective,
with noticeable improvement in urine flow soon after the procedure.
VLAP involves applying enough laser energy to dry up and destroy excess prostate cells, which you eventually eliminate over several weeks to months. One major drawback lessens its appeal. Because of swelling and prolonged sloughing off of the dead tissue, you're likely to retain urine for several days and will need to wear a catheter. You may also experience a burning sensation for days to weeks during urination.
Interstitial laser therapy directs laser energy inside the prostate growths rather than at the urethral surface. It safely and moderately increases the urinary flow rate and reduces the volume of the prostate. It also seems to work well among men with large prostates. Because of substantial tissue inflammation after treatment, you may need to use a catheter for up to 3 weeks. Uncomplicated urinary tract infections also are common. Interstitial laser therapy is a good option if you can't have surgery because of other health complications. It doesn't cause any blood loss and uses a combination of local anesthesia and intravenous sedation to control pain during the procedure.(www.allaboutBPH.com )
A significant drawback of these therapies is that no tissue is taken (biopsy) from your prostate gland. During surgical treatments for an enlarged prostate, a small sample of your prostate generally is taken by your doctor and examined by a pathologist for possible cancer.
Surgical and other proceduresFrequent urinary tract infections
Kidney damage from urinary retention
Bleeding through the urethra
Stones in the bladder
Surgery is the most effective of all therapies for relieving symptoms of an
enlarged prostate. It's the "gold standard" by which all other treatments
are judged, and many doctors have extensive experience with it. However, it's
also the most likely to produce side effects. Fortunately, most men experience
few problems. Among those with certain health conditions, such as uncontrolled
diabetes, cirrhosis of the liver, a major psychiatric disorder, or serious lung,
kidney or heart conditions, surgery isn’t usually recommended unless absolutely
necessary.
Surgery for an enlarged prostate requires a hospital stay. If you have surgery, you may need to take up to a month off from work. You'll also need to avoid heavy lifting, jarring to your lower pelvic area or straining of your lower abdominal muscles for up to 2 months.
Three types of surgery exist for an enlarged prostate. These include:
Transurethral resection of the prostate (TURP). This is the most common surgery
for an enlarged prostate. During the procedure, you're placed under general
anesthesia or anesthetized from the waist down with a spinal block. A surgeon
threads a narrow instrument (resectoscope) into the urethra and uses small cutting
tools to scrape away excess prostate tissue. You can expect to stay in the hospital
for 1 to 3 days following surgery. During recovery you'll have a urinary catheter
for a few days.
TURP is effective and relieves symptoms quickly. Most men experience a stronger
urine flow within a few days. You can expect some blood or small blood clots
to appear in your urine afterward. Before you leave the hospital, you should
be able to urinate on your own. At first you may feel some pain or a sense of
urgency when urine passes over the surgical area. This discomfort should gradually
improve.
In a few cases, TURP can cause impotence and loss of bladder control. Generally, these conditions are only temporary. Pelvic floor muscle exercises (Kegel exercises) will often help restore bladder control. Normal sexual function often returns within a few weeks to months. However, it can take up to 1 year to make a full recovery from these side effects.
Another more common side effect of surgery is retrograde ejaculation. TURP may also produce scarring and narrowing in the urethra. This often can be remedied by a simple stretching of the scar tissue done on an outpatient basis. Up to 10 percent of men who have TURP need surgery again because the prostate may grow back.
Transurethral incision of the prostate (TUIP). This surgery is an option if
you have only a moderately enlarged or small prostate gland. It's also an option
for men who aren't good candidates for more invasive surgery for health reasons
or because they don't want to risk sterility.
Like TURP, TUIP involves special instruments that are inserted through the urethra.
But instead of removing prostate tissue, the surgeon makes one or two small
cuts in the prostate gland. The cuts help enlarge the opening of the urethra,
making it easier to urinate.
The procedure produces less risk of complications than other kinds of surgery. It doesn't require an overnight hospital stay, but it's less effective and often needs to be repeated. Some men experience only a small improvement in urinary flow.
Open prostatectomy. This type of surgery is generally performed only if you
have an excessively large prostate, bladder damage or other complicating factors,
such as bladder stones or urethral strictures. It's called open because the
surgeon makes an incision in your lower abdomen to reach the prostate rather
than going up through the urethra.
Open prostatectomy is the safest and most effective therapy for men with extreme
prostate enlargement. But it poses the greatest risk of side effects. Complications
of the procedure are similar to those of TURP, and their effects may be more
severe. The procedure usually requires a hospital stay of 3 to 5 days.
The most common type of open prostatectomy is radical prostatectomy to remove cancerous tissue. It involves removing the entire prostate gland. During an open prostatectomy for the treatment of an enlarged prostate, only the inner portion of the gland is removed, leaving the outer portion intact.
For men who are unwilling or unable to take medications or who are reluctant or unable to have surgery, other nonsurgical options do exist. These may include:
Balloon dilation. With the use of a catheter, your doctor positions a tiny
deflated balloon in the part of your urethra that lies within your prostate
gland. The balloon is then inflated to stretch the urethra and compress prostate
tissue. Because improvement lasts only a short time, the use of this procedure
has declined and has often proved to be ineffective.
Prostatic stents. A tiny metal coil is inserted into your urethra to widen the
urethra and keep it open. Tissue grows over the stent to hold it in place.
One advantage of the procedure is that it takes only 10 to 15 minutes. It also
produces little or no bleeding and doesn't require a catheter. In early trials,
though, nearly a third of the men with stents had them removed because of poor
placement or complications. Stents often aren't ideal for older men who have
difficulty wearing or maintaining them, or who are unable to tolerate the procedure.
Some men found that the stents didn't improve their symptoms. Others experienced irritation when urinating or had frequent urinary tract infections. These complications, along with the high cost and potential difficulties in removing the stents, have reduced their popularity.
Some simple lifestyle changes can often help control the symptoms of an enlarged prostate and prevent your condition from worsening. Consider these steps:
Limit beverages in the evening. Stop drinking water and other beverages after
7 p.m. to reduce your need to go to the bathroom at night. In particular, beverages
that contain caffeine will increase urine production, cause bladder irritation
and aggravate your symptoms.
Empty your bladder. Try to urinate all that you can each time you go to the
bathroom. For some men, sitting on the toilet is more effective than standing.
Limit alcohol. Alcohol increases urine production and irritates your bladder.
Be careful with over-the-counter decongestants. They can cause the band of muscles
that control urine flow from your urethra (urethral sphincter) to tighten, making
urination more difficult.
Keep active. Inactivity causes you to retain urine. A recent study shows that
even a small amount of exercise can reduce urinary problems caused by an enlarged
prostate.
Stay warm. Cold weather can lead to urine retention and increase your urgency
to urinate.
Health food stores carry a number of herbs that are marketed to treat prostate enlargement. But only saw palmetto has been studied in large, long-term trials and proved to show some effectiveness. However, scientific data is still lacking.
Saw palmetto is thought to work by preventing testosterone from breaking down into another form of the hormone associated with prostate tissue growth. In 1998, researchers with the Department of Veterans Affairs reviewed more than a dozen studies involving saw palmetto and concluded that the herb appears to be as effective as the medication finasteride — and appears to produce fewer side effects. The researchers recommended additional studies to determine the appropriate daily dosage of the supplement and its long-term effectiveness. Other studies have produced similar results.
Saw palmetto works slowly. Most men begin to see an improvement in their urinary
symptoms within 1 to 3 months. If after 3 months you haven’t noticed any
benefit from the product, then it may not work for you. It appears safe to take
saw palmetto indefinitely, but possible effects from long-term use are unknown.
One drawback of this herb, and many other such herbal products, is that it may suppress your baseline PSA level. This action can interfere with the effectiveness of the PSA test for prostate cancer. That’s why if you take saw palmetto or another herbal medicine, it’s important to tell your doctor before having a PSA test. ( www.prostate.com )