|Prostate Gland Enlargement
The prostate gland is located just below a male's bladder and surrounds the top portion of the tube that drains urine from the bladder (urethra). The gland's primary function is to produce most of the fluids in semen, the fluid that nourishes and transports sperm.
From birth to young adulthood, the prostate grows from about the size of a pea to about the size of a walnut. Most men experience a second period of prostate growth in their mid- to late 40s. At this time, cells in the central portion of the gland — where the prostate surrounds the urethra — begin to reproduce more rapidly, resulting in prostate gland enlargement. 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 prostate gland enlargement.
Prostate gland enlargement affects about half of men in their 60s and up to 90 percent of men in their 70s and 80s. The presence or absence of prostate gland enlargement is not related to the development of prostate cancer.
Treatment of prostate gland enlargement depends on your signs and symptoms and may include medications, surgery or nonsurgical therapies.
At birth, a boy's prostate gland is about the size of a pea. It grows slightly during childhood and then at puberty undergoes a rapid growth spurt. By the time a man reaches age 25, his prostate is fully developed and is about the size of a walnut.
The causes of noncancerous growth of tissue inside the prostate later in life are unclear. Researchers believe that with age, the prostate becomes more susceptible to the effects of male hormones, including testosterone.
Risk Factor :
The main risk factor for prostate gland enlargement is aging. Prostate gland enlargement rarely causes signs and symptoms in men younger than 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 are single men. There's no evidence that supports a link between sexual activity and prostate growth.
When to seek medical advice :
If you're experiencing urinary problems, seek medical advice. Your doctor can help determine whether you have prostate gland enlargement and whether your symptoms warrant further evaluation and treatment.
If you don't find your symptoms troublesome and they don't pose a health threat, you may not need treatment. That doesn't mean that it's all right to let urinary symptoms go without medical evaluation. Instead of an enlarged prostate gland, 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 neurological problem, inflammation of the prostate (prostatitis) or 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 (hematuria)
- Urinary tract infection
To diagnose prostate gland enlargement, your doctor will likely begin by asking you about your symptoms, when they developed and how often they occur. Your doctor will also want to know about other health problems, medications you're taking and whether there's a history of prostate problems in your family. Over-the-counter (OTC) drugs, such as aspirin, decongestants and antacids, are considered medications, so tell your doctor about those too. The history of when you start and stop medications also is important for your doctor to know.
In addition, your checkup may include :
- Digital rectal exam. To perform this exam, your doctor puts on an examination glove, applies a lubricant to one of his or her gloved fingers, and then 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 determine 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 conditions that can produce symptoms similar to those of prostate enlargement, such as prostatitis, cystitis and 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 prostatitis.
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 :
- Questionnaire. A short questionnaire, developed by the American Urological Association, asks you about specific urinary symptoms associated with prostate enlargement and how often they occur. In addition to helping determine the severity of prostate gland enlargement, this symptom 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. By charting the results of this test, your doctor can determine if your urinary flow patterns change 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 weakened 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 bladder, calcifications of your prostate, or a tumor in your prostate.
- Urodynamic studies. If your doctor suspects that your symptoms may be related to a bladder problem rather than prostate gland 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 your 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, and the presence of stones in your bladder. These disorders may cause your bladder to weaken.
- 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 your bladder.
If your signs and symptoms are mild and don't bother you, your doctor may suggest watchful waiting as an appropriate response 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 and kidney damage. However, these complications are uncommon.
Prostate gland 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.
Treatments for prostate gland enlargement don't reduce or increase the risk of prostate cancer. Even if you're being treated for an enlarged prostate gland, you still need to continue regular prostate exams to screen for cancer. Surgical treatment for prostate gland enlargement can identify cancer in its early stages.
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 and kidney damage, 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, other nonsurgical therapies and surgical procedures.
Medications are the most common method for controlling moderate symptoms of prostate enlargement. Doctors use a variety of medications to treat prostate gland enlargement :
Alpha blockers. These drugs were originally developed to treat high blood pressure. They relax the muscles at the neck of your bladder, making it easier to urinate. The Food and Drug Administration (FDA) has approved four alpha blockers for prostate enlargement: terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax) and alfuzosin (Uroxatral).
Alpha blockers are effective in many men who take them. The drugs work quickly. Within a day or two, most men notice an increase in urinary flow and a decrease in how often they need to urinate. You may need to take an alpha blocker indefinitely.
Doctors are uncertain about the long-term benefits and risks of alpha blockers. To reduce your risk of side effects, your doctor may start with a low dose of medication and gradually increase the dosage. Alpha blockers taken with drugs for impotence, such as sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis), may interact and cause low blood pressure. Discuss with your doctor the possible side effects of these medications before taking them.
Finasteride (Proscar, Propecia) and dutasteride (Avodart). These drugs relieve symptoms in a totally different manner than alpha blockers do. Instead of relaxing your muscles, they shrink 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.
Finasteride takes a longer time to work than does dutasteride. You may notice some improvement in urinary flow after three months, but for complete results generally it takes up to a year. A small percentage of men who take finasteride experience impotence, decreased libido and reduced semen release during ejaculation. But in most men, finasteride produces only slight side effects. The long-term effects of this drug are unknown.
Finasteride has been shown to prevent or delay the onset of prostate cancer in men 55 years and older. However, finasteride also has been shown to adversely affect sexual function and to slightly raise the risk of developing higher grade prostate cancer.
- Combination drug therapy. One study found that taking finasteride and the alpha blocker doxazosin together significantly reduced the risk of further prostate gland enlargement to the point where invasive surgery was not needed. This therapy also appears to decrease urination problems often caused by an enlarged prostate.
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. 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 are 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 three 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.
It may take several weeks before you begin to see a noticeable improvement in your symptoms. Those who seem to respond best over time are men whose initial symptoms are mild. The long-term effectiveness of the procedure is uncertain.
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.
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 your prostate gland, heating and destroying the tissue. As in TUMT, a special catheter is inserted through your urethra. The needles are inserted into your 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 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 (anticoagulant) medication. Its long-term benefits aren't yet known.
- Laser therapy. This procedure is performed similarly to other heat therapies, 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 of the prostate (VLAP), interstitial laser therapy, and photosensitive vaporization of the prostate (PVP).
TUEP is similar to electrovaporization. The difference is that your doctor destroys prostate tissue with laser energy instead of 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. 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 during urination for days to weeks.
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 three 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.
PVP is a newer form of laser treatment for prostate gland enlargement. This procedure and its results are similar to transurethral resection of the prostate (TURP), which is the most common surgical treatment for enlarged prostate. However, photosensitive vaporization uses laser energy — instead of the electrical current used by TURP — to destroy prostate tissue. In general, photosensitive vaporization is better for smaller prostates. PVP may also result in less bleeding and a shorter recovery time than with TURP.
A drawback of heat therapies is that no tissue is taken (biopsied) 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.
Prostatic stents. A prostatic stent is a tiny metal coil. During this procedure, the stent is inserted into your urethra to widen the urethra and keep it open. Tissue grows over the stent to hold it in place. This treatment produces little or no bleeding and doesn't require a catheter. It may be an option for men who are unwilling or unable to take medications or who are reluctant or unable to have surgery. 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 find that the stents don't improve their symptoms. Others experience irritation when urinating or have frequent urinary tract infections. These complications, along with the high cost and potential difficulties in removing the stents, have reduced the popularity of this treatment.
Surgical and other procedures
At one time surgery was the most common treatment for BPH. But because of increased use of medications and the development of other less invasive therapies, surgery is on the decline. Today it's used mainly for more severe signs and symptoms or if you have complicating factors, such as :
- Frequent 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 a serious lung, kidney, or heart condition, 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 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 two months.
The types of surgery for an enlarged prostate include :
Transurethral resection of the prostate (TURP). This is the most common surgery for an enlarged prostate. During the procedure, you're given a general anesthesia or anesthetized from the waist down with a spinal block. A surgeon threads a narrow instrument (resectoscope) into your urethra and uses small cutting tools to scrape away excess prostate tissue. You can expect to stay in the hospital for one to three days after surgery. During your recovery, you'll have a urinary catheter in place 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 some cases, you may be sent home from the hospital with a catheter that is later removed in your doctor's office.
In some cases, TURP can cause impotence and loss of bladder control. Generally, these conditions are only temporary. Pelvic floor muscle exercises (Kegels) often help restore bladder control. Normal sexual function often returns within a few weeks to months. However, it can take up to a 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 or bladder neck. This often can be remedied by stretching of the scar tissue, done on an outpatient basis. Some men who have TURP may need some sort of prostate surgery again because the prostate grew back or the scar tissue from a previous procedure needs to be removed.
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. During an open prostatectomy, only the inner portion of your prostate gland is removed, leaving the outer portion intact.
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 three to five days.