QUESTION: I am 58 years old and recently went to my doctor because of some difficulty passing urine. He feels that I might have an enlarged prostate and has referred me to a urologist. What is likely to happen when I go for my clinic appointment? What does an enlargement of the prostate mean and what medical treatments are available to treat this condition? ANSWER: The prostate gland is just below the bladder and in front of the rectum. It surrounds the first inch of the urethra (the tube through which urine and sperm exit the body). Usually, the prostate gland starts to enlarge after middle age. When the prostate becomes enlarged, the condition is called benign prostatic hyperplasia (BPH). BPH affects 40 percent of men in their 50s and 90 percent of men in their 80s. If the enlarged gland begins to press on the urethra and to interfere with urination, then treatment may be needed. The main symptoms of BPH are: difficulty initiating a urine stream; a hesitant, interrupted and weak stream; and urgency and leaking or dribbling. Over time, as the urethra becomes narrower, the bladder wall may become thicker and the bladder itself may get smaller, causing more frequent urination; bladder irritability; a sudden, strong urge to urinate, especially at night; and urge incontinence (occurs when bladder muscles are too active). People with urge incontinence lose urine as soon as they feel a strong desire to go to the bathroom.
If a man suddenly becomes unable to pass any urine at all, this condition is called acute urinary retention. The size of the prostate does not always determine how severe the obstruction or the symptoms will be. Some men with greatly enlarged glands have little obstruction and few symptoms, while others whose glands are less enlarged may have more of a blockage and greater problems. To diagnose BPH, a full medical history will be taken when you attend the hospital. Specific questions relating to your urinary symptoms will be recorded in a special questionnaire called International Prostate Symptom Score (IPSS) which allows a more objective assessment of your urinary difficulties. A digital rectal examination will be performed by inserting a gloved finger into your rectum. This enables the doctor to assess the size of the prostate and also to determine whether there are any abnormal areas which would increase the suspicion of prostate cancer. Blood will be collected for a Prostate-Specific Antigen (PSA) blood test (which has been covered previously in this column). Higher than normal levels of prostate-specific antigen in the bloodstream may indicate BPH, prostate cancer or prostatitis (inflammation of the prostate). You may then be asked to pass your urine into a special receptacle so that the strength of the flow and the amount of urine passed can be measured.
After you have passed your urine, a simple scan of your lower abdomen will be done to determine whether you are actually emptying your bladder. A sample of urine will be analyzed to see if there is any evidence of infection or other conditions. Occasionally on your first visit an ultrasound of the kidneys will also be performed to see if there are any problems with the kidneys. Urodynamic studies (a test to measure the internal pressure and contractions of the bladder) may occasionally be indicated at a later date if your urologist feels that your symptoms are related to bladder problems rather than BPH. A direct inspection of your bladder may be indicated. This is done by inserting a thin tube containing a lens with a light system (cystoscope) into the urethra to allow direct visualisation of the urethra and bladder. The procedure, done under local or general anesthesia, can detect various problems and abnormalities, including BPH. Treatment decisions are based on each patient's condition and the benefits and drawbacks will be discussed with you. Several changes in diet and behavior may help some patients to avoid surgery. Examples include reducing fluid intake in the evening and eliminating bladder irritants from the diet (and these measures have been discussed in this column previously).
In patients who have moderate symptoms, drugs alone or in combination are often used to control BPH.
The main options are:
- Alpha-blockers can be used to make urination easier by relaxing the muscles where the bladder narrows toward the urethra.
- The use of 5-alpha reductase inhibitors to shrink the prostate gland may take up to six months to take effect and are more effective in men with large prostates.
- Anticholinergics may be useful in decreasing the urge to urinate and may help to increase the capacity of the bladder.
If medical therapy does not alleviate your symptoms then there is a variety of options available but the gold standard is a transurethral resection of the prostate gland (TURP). This surgery involves the "coring out" of the center of the prostate which is done using a telescope.
This entails a few days in hospital and will allow you to pass your urine with a greater flow.
Laser treatments are also very successful in treating BPH. Other less invasive techniques do not produce the same good results as a TURP.
The main side effect that is noticed by men after a TURP is a reduction in the volume of semen they ejaculate because surgery to the bladder neck may allow semen to flow backwards into the bladder.
Major complications are rare and problems such as impotence (erectile dysfunction) and incontinence are rare.
This weekly column is edited by Thomas Lynch, consultant urological surgeon, St James's Hospital, Dublin.