Enlarged Prostate

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What Is an Enlarged Prostate (Benign Prostatic Hyperplasia)?

A man's prostate gland usually starts to enlarge after he reaches 40 years of age. This condition is called benign prostatic hyperplasia (BPH). This is considered a natural process of aging, and attempts to stop or reverse it so far have been unsuccessful.

The prostate gland serves a fertility function as it secretes the seminal fluid that helps to nourish and transport the sperm that comes from the testicles. The fluid is then stored in the seminal vesicles. The gland itself surrounds the urethra, which is the tube that carries urine from the bladder out through the tip of the penis (see multimedia file 1). As the prostate grows larger, it may press on the urethra. This narrowing of the urethra can cause some men with prostate enlargement to have trouble with urination. Prostate enlargement may be the most common health problem in men older than 60 years of age.

What Causes an Enlarged Prostate?

The prostate gland, which is normally about the size and shape of a walnut, wraps around the urethra between the pubic bone and the rectum, below the bladder. In the early stage of prostate enlargement, the bladder muscle becomes thicker and forces urine through the narrowed urethra by contracting more powerfully. As a result, the bladder muscle may become more sensitive, causing a need to urinate more often and more suddenly.

The prostate grows larger due to an increase in the number of cells (hyperplasia). However, the precise reason for this increase is unknown. A variety of factors may be involved, including androgens (male hormones), estrogens, and growth factors and other cell signaling pathways (cell-to-cell communication).

As the prostate grows larger and the urethra is squeezed more tightly, the bladder might not be able to fully compensate for the problem and completely empty. In some cases, blockage from prostate enlargement may result in stagnation and backing up of urine, which in turn may cause repeated urinary tract infections, bladder stones, bladder diverticulae (outpouchings or pockets inside the bladder), and gradually result in bladder or kidney damage. It may also cause a sudden inability to urinate (acute urinary retention) -- a painful medical emergency that requires urgent drainage.

What Are Enlarged Prostate Symptoms and Signs?

Many men with an enlarged prostate have no symptoms or signs. If symptoms are present, they commonly include

  • a weak stream of urine;
  • difficulty starting urination;
  • dribbling of urine, especially after urinating;
  • a sense of not fully emptying the bladder;
  • leaking of urine;
  • more frequent urination and a strong and sudden desire to urinate, especially at night; and
  • blood in the urine.

When Should Someone Call the Doctor About an Enlarged Prostate?

Urinary symptoms related to enlarging prostate initially affect the quality of life, and if no complications exist, as mentioned above (urinary infections, bladder stones, bleeding), the decision to treat is optional and is left to the patient. This means that if you don't feel bothered enough to take a medicine or undergo a procedure for it, you'll need to follow up with your doctor to ensure the symptoms are stable, and the bladder empties well. This can be assessed by prostate symptom questionnaires and a measure of the strength of the urinary stream (flow test) and residual urine in the bladder. If complications develop, however, or if the bladder starts holding increasing amounts of residual urine after urination, treatment should be started.

If you experience bladder pain or burning with urination, blood in the urine associated with fever/chills or nausea/vomiting, or if the prostate enlargement condition worsens and symptoms such as blood in the urine or lower back pain are present, consult a doctor immediately. If you cannot reach your doctor when these symptoms are present, seek evaluation at a hospital's emergency department.

For acute symptoms such as acute urinary retention (you feel uncomfortably full but cannot urinate), you should immediately go to the closest emergency medical facility for bladder drainage, usually with a catheter, which is a tube inserted into the bladder.

Men over 50 years of age should have their prostate checked annually by their physician even if they have no symptoms.

Enlarged Prostate Symptom

Inability to Urinate

The two essential causes of urinary retention are (1) blockage of the urethra and (2) disruption of the delicate and complex system of nerves that connects the urinary tract with the brain and the nervous system (as described earlier).

Common causes

  • Blockage (obstruction): The most common cause of blockage of the urethra in men is enlargement of the prostate. In males, the prostate gland partially surrounds the urethra. If the prostate becomes enlarged, which is common in older men, it presses on the urethra and can block it. The most common cause of prostate enlargement is benign prostatic hypertrophy (often called BPH). Other causes of prostate enlargement include prostate cancer and prostate infection (prostatitis). Causes of blockage of the urethra that can occur in both sexes include scar tissue, injury (as in a car wreck or bad fall), blood clots, infection, tumors in the pelvic region, and stones (rare).

What Tests Do Doctors Use to Diagnose Benign Prostatic Hyperplasia?

  • A physical exam is required to see if other medical problems may be causing your symptoms. The doctor will conduct a digital rectal exam to examine the prostate gland. He or she can feel the prostate by inserting a gloved, lubricated finger into the rectum. This procedure allows your doctor to roughly estimate the size and consistency of the prostate. Most importantly, it allows the doctor to feel for lumps or hard areas that could indicate the presence of prostate cancer.
  • Your doctor may check your urine (urinalysis) for blood or signs of infection. Your blood may be tested for kidney problems (a serum creatinine level) or sent for a prostate-specific antigen (PSA) level, a screening test for prostate cancer.
  • Some men are referred to a specialist (urologist) for further tests. Urologists specialize in diseases of the male and female urinary tracts and of the male genital tract. Before you are treated for benign prostate enlargement, it is important to rule out other possible causes of an enlarged prostate, such as cancer.

What Are Treatment Options for an Enlarged Prostate?

Once the diagnosis of prostate enlargement is made, your doctor may not recommend immediate treatment if symptoms are mild. Likely, one or more exams will be conducted per year to be sure that you are not developing any complications from prostate enlargement. Should your symptoms become more severe, both medical and surgical treatments are available.

Are There Home Remedies for an Enlarged Prostate?

Some precautions can help to avoid worsening of symptoms of prostate enlargement and complications.

Do not delay urination once you experience an urge. Urinate as soon as you feel the urge, and empty the bladder completely.

What Is the Medical Treatment for an Enlarged Prostate?

Watchful waiting: This conservative and often wise program of care is used because, for many men, symptoms can lessen without treatment. On the other hand, medications should be started early for moderate symptoms. Also, if there are complications or if symptoms are severe, your doctor may recommend surgery. For most men, the decision to treat the symptoms of an enlarged prostate is based on the patient's desire to improve his quality of life.

What Types of Medications Treat Benign Prostatic Hyperplasia?

Several types of medications have been approved for treatment of urinary symptoms secondary to prostate enlargement. Men with severe symptoms may require treatment with a combination of these medications. Your doctor will determine the optimal combination for your condition:

Is Surgery an Effective Treatment for an Enlarged Prostate?

  • A common operation for treatment of prostate enlargement is transurethral resection of the prostate (TURP) and is considered the gold standard. In this procedure, the doctor scrapes away the innermost core of the prostate through a small instrument inserted through the urethra. The surgery reduces pressure on the urethra and generally gives relief from symptoms.
  • A more limited operation called transurethral incision of the prostate (TUIP) may be an option for some men. In this operation, instead of removing prostate tissue, the doctor passes an instrument through the urethra to make one or two small cuts in the prostate. These cuts reduce the prostate's pressure on the urethra, making urination easier.
  • Several newer treatments that may be performed in the office with local anesthetic alone or supplemented by sedation have been introduced and may be effective for men with an enlarged prostate. These include a treatment known as Rezum therapy, which consists of injecting a water steam into the prostate under local anesthetic; the Urolift procedure, which consists of placing small suture implants to hold the prostate tissue apart from around the urethra; transurethral microwave thermotherapy (TUMT), transurethral radiofrequency needle ablation of the prostate (TUNA), and interstitial laser coagulation (ILC). The general principle of all these treatments is similar. In each case, the prostate tissue is heated to a level that will lead to death of portions of the prostate tissue, thus shrinking away and removing some of the obstruction.
  • The Rezum and Urolift procedures have the advantage of preserving ejaculatory function, which can be affected by almost all other prostate procedures. These can also be done in the office without the need for anesthesia.
  • Another popular new treatment is photovaporization of the prostate (PVP) or laser ablation of the prostate, in which a laser is used to directly remove or vaporize prostate tissue in a similar fashion to what is accomplished with a TURP (see above) with much less bleeding. The advantage of this technique compared with TUMT, TUNA, or ILC is that it offers immediate removal of tissue with rapid improvement in symptoms. Conversely, these other three treatments lead to delayed tissue loss and are not associated with immediate improvement of urinary symptoms in most cases.
  • Other new surgical alternatives are being evaluated by the FDA for approval in the U.S. (like the AquaBeam ablation procedure, which also preserves ejaculatory function). Ask your doctor about the potential risks and benefits of medication and surgery. An operation for an enlarged prostate does not eliminate the risk of developing prostate cancer.
  • Holmium laser enucleation of the prostate (HoLEP) is a procedure that is offered in specialized centers and allows larger prostates to be enucleated (shelled out).
  • Sometimes for very large prostates, a procedure called simple prostatectomy is indicated, which is traditionally done by open surgery. A minimally invasive procedure can be done in specialized centers where the enlarged part of the prostate (referred to as the adenoma) is removed laparoscopically or with a surgical robot through keyhole incisions instead of the open surgical incision.

Enlarged Prostate Follow-up

Once your doctor has given you a medical plan, you should stick to it and follow up as recommended. Sometimes men need follow-up with a urologist.

Is It Possible to Prevent an Enlarged Prostate?

There is no known way to prevent prostate enlargement. It is a common part of aging.

  • Men can reduce the need to urinate frequently during the night by not drinking liquids after 6 p.m.
  • Caffeinated beverages, alcohol, and spicy foods can be bladder irritants and make urinary symptoms worse.
  • Drinking more fluid, up to eight glasses of water per day, may help prevent infection. However, for men already suffering with increased urinary frequency, this may only exacerbate the problem. In most cases, drinking a normal amount of fluid based on thirst is all that is necessary.
  • There is evidence that cranberry juice may be helpful in the prevention of urinary tract infections in those who are prone to developing these.
  • Finasteride or dutasteride (see above) are prescription medications that can slow down the process of prostatic enlargement and reduce the risk of urinary retention, complications, and the future need for surgery related to benign prostatic enlargement.

What Is the Prognosis of an Enlarged Prostate?

Your condition may improve, remain the same, or become worse. Serious urinary problems from prostate enlargement affect one in 10 older men. If the bladder is permanently damaged from prostate enlargement, treatment may not be as effective.

Prostate enlargement is not cancer, nor does it seem to increase your chances of developing prostate cancer. You can, however, have both prostate enlargement and prostate cancer at the same time.

Enlarged Prostate (BPH) Pictures

Male urinary system and prostate: The prostate makes some of the milky fluid (semen) that carries sperm. The gland is the size of a walnut and is found just below the bladder, which stores urine. The prostate wraps around a tube (the urethra) that carries urine from the bladder out through the tip of the penis. During a man's orgasm (sexual climax), muscles squeeze the prostate's fluid into the urethra. Sperm, which are made in the testicles, also go into the urethra during orgasm. The milky fluid carries the sperm through the penis during orgasm.
Male urinary system and prostate: The prostate makes some of the milky fluid (semen) that carries sperm. The gland is the size of a walnut and is found just below the bladder, which stores urine. The prostate wraps around a tube (the urethra) that carries urine from the bladder out through the tip of the penis. During a man's orgasm (sexual climax), muscles squeeze the prostate's fluid into the urethra. Sperm, which are made in the testicles, also go into the urethra during orgasm. The milky fluid carries the sperm through the penis during orgasm.

Normal prostate and enlarged prostate (prostate with benign prostatic hyperplasia [BPH]
Normal prostate and enlarged prostate (prostate with benign prostatic hyperplasia [BPH]

Reviewed on 9/11/2017

REFERENCE:

Deters, L. A., et al. "Benign Prostatic Hypertrophy." Medscape.com. Oct. 12, 2015.

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