Trouble with water works (englarged prostate)?

As men get older it is much more common to have difficulty passing urine. Many men are concerned about the possibility of prostate cancer especially with the increase awareness of this condition in the media. Difficulty with voiding (or passing urine) is very common in men as they get older and in fact increases in frequency with age.

Benign prostatic hyperplasia/enlarged prostate gland

Benign prostate hyperplasia (BPH) or an enlarged prostate is a very common non cancerous (benign prostate disease) condition affecting the prostate gland. As men, increase in age, there is an accompanying increase in proliferation or growth of various components of the prostate gland. In essence, as a man grows older, there is an increase in the number of prostate cell found within the gland. It is more common with increasing age, such that by the age of 50 years, 50% of men have BPH or an enlarged prostate, approximately 65% of men between the ages of 60 and 70 are affected by the condition and by a 80 years approximately 80% of men are affected by this condition.

Normal sized prostate gland

Normal prostate

Enlarged BPH prostate gland

Enlarged prostate / BPH

The diagrams above of male anatomy show the prostate gland location under the bladder and the compression of the urethra or outlet pipe of the bladder with age.

Despite having an enlarged prostate, or BPH not all men will be bothered by symptoms. Moreover, symptoms can vary in severity ranging from a very mild and causing minimal bother with minimal impact on quality of life to very severe symptoms that can, in extreme circumstances result in complications including recurrent urinary tract infections, haematuria (or blood in the urine), the formation of bladder stones, and an inability to void at all (known as urinary retention).

What causes BPH?

The exact mechanism for development of an enlarged prostate/ BPH remains unclear, however, there are certain factors that are obviously involved. Firstly, it is clear that a normal level of testosterone (the male hormone), which is produced mainly from the testes, is essential to the development of BPH. We know that individuals that have impaied testosterone production do not develop increased prostatic growth later in life. Also, it is clear from treatments that impair testosterone production (commonly used in advanced prostate cancer) that there can be a significant reduction in prostate size with these agents. The active form or metabolite of testosterone is called dihydrotestosterone (DHT). There are medications available that prevent the formation of this metabolite and can be used to reduce the size of the prostate by approximately 20 to 30%. From these facts it is clear that testosterone is integral to the development of BPH.

What are the common symptoms of BPH / enlarged prostate?

BPH affects the part of the prostate that is adjacent to the urethra (the outlet pipe of the bladder), and as a result it is very common for lower urinary tract symptoms (LUTS) to develop. These symptoms have been referred to in various ways: you may have heard of the terms prostatism, Lower urinary tract symptoms (LUTS), or water work troubles. They all refer to the same symptom complex and most commonly are referred to as LUTS by urologists. We divide urinary symptoms into two main groups.

The main symptoms include:

  • Reduced flow
  • Longer time taken to empty bladder
  • Feeling of incomplete bladder emptying
  • Dribble of urine after finishing voiding (post micturition dribble)
  • Straining to empty your bladder (stranguria)

Irritative symptoms:

  • Urgency: a feeling of needing to pass urine immediately for fear of leaking urine (being incontinent)
  • Frequency: voiding more than once in a two hour period
  • Nocturia: getting up multiple times a night to pass urine

All or just some of these symptoms maybe present and it is possible that one in particular may predominate. With increase in the severity of these symptoms there is obviously a serious impact on the quality of a man’s life. In fact, it is not uncommon for men with very bad symptoms to know the whereabouts of all public toilets in his local area through frequent use and also to try to prevent a mishap.

These symptoms, most commonly, are due to benign (not cancerous) enlargement of the prostate gland. In simple terms, the prostate, which is located directly under the bladder, grows as men get older resulting in restriction of urine flow through the outlet pipe of the bladder (urethra) and hence the symptoms.

Symptoms, due to an enlarged prostate / BPH, may initially be obstructive and progress to become more irritative in nature as changes within the bladder wall develop due to the long standing blockage. There are, however, no hard and fast rules with prostate enlargement / BPH. On occasions symptoms improve naturally without any treatment, others remain unchanged, whilst in some men may progress and become more severe. It is difficult to determine who will progress and, who is less likely to develop more severe symptoms.

There are, however, certain factors, that increase a man’s likelihood of progression to more severe symptoms of BPH. These include:

  • PSA greater than 1.4 ng/ml
  • Prostate volume greater than 40 cc
  • Post void residual greater than 150 mils
  • Age > 60 years

These factors will be assessed during your evaluation process. This will help both you and your urologist to make decisions for your treatment plan of your BPH.

What are the complications of BPH (enlarged prostate)?

Besides the troublesome symptoms, BPH can result in:

  • Retention: an inability to pass urine
  • Urinary tract infections (UTI)
  • Heamaturia (blood in the urine)
  • The formation of stones in the bladder
  • Kidney failure (this is very uncommon)

How can BPH be treated?

Before starting treatment for BPH, several tests will be performed to help determine that there are no other conditions contributing to your symptoms. These tests usually include:

  • IPSS: This is a questionnaire that allows a urologist to assess your urinary symptoms/ LUTS objectively and provide information on the impact your symptoms have on your quality of life.
  • DRE or Digital Rectal Examination is a finger examination of the prostate gland.
  • Flow rate assesses how quickly urine is passed to help ascertain the presence of a blockage.
  • Blood tests – including a PSA – will, however, depend on the age of the man in question and his consent to undergo the test.
  • Urine tests (MSU & cytology): this excludes infection and aims to identify the presence or absence of any abnormal cells in the urine
  • Ultrasound: An ultrasound gives a rough guide to the size of the prostate, how well the bladder empties and allows the kidney, bladder and connecting piping (ureters) to be looked at.
  • Cystoscopy: If irritative symptoms predominate a telescopic camera test to evaluate the lining of the bladder may also be required.

If these tests confirm the presence of an enlarged prostate gland (and exclude other conditions) then treatment can be discussed. Options include

  • Observation
  • Natural therapies
  • Medications
  • Surgery

Observation

Observation for an enlarged prostate gland is usually a possibility for men that have mild to moderate symptoms and are not particularly bothered by their symptoms. Many men that I see day to day are relieved to know that they do not have prostate cancer, and once this has been excluded they are quite happy to live with their symptoms as they currently stand.

Observation may entail follow up visits with your urologist to allow reassessment for signs of progression and to assess the severity of symptoms. At the end of the day, the aim of treating an enlarged prostate/BPH is to alleviate symptoms and to improve the quality of a man’s life. Symptoms should only be treated if they are causing a man particular bother.

Natural therapies

Natural therapies have been used extensively to treat men with enlarged prostate glands. The most common natural remedy used for this purpose is Saw Palmetto. There are conflicting reports in the medical literature regarding the efficacy of saw palmetto for treating BPH. Some studies report that symptoms can be mildly improved with the use of this agent. A recent trial, however, has concluded that there was no improvement in symptoms amongst those men that used saw palmetto for treating BPH. The therapy, itself, has very few side-effects, which in part is why this treatment option remains popular today. Saw Palmetto is available without prescription.

Medications

There exist two common types of medication that can be used to treat men with LUTS/enlarged prostate glands. These include alpha blockers, or medication called five alpha reductase inhibitors. Alpha blockers work by relaxing the smooth-muscle in the prostate and the outlet pipe as it passes through the prostate gland. The net result is an improvement in urinary flow and a reduction in symptoms experienced by men. Alpha blockers tend to be the first port of call when choosing medical therapy to treat BPH. Alpha blockers can also relax the smooth-muscle in blood vessels. This has the potential to lower blood pressure and can make some men feel lightheaded and dizzy. Different alpha blockers affect blood vessels to a different extent. As a result, some alpha blocker medications are more prone to lowering a patient’s blood pressure than others. An alpha blocker, which is particularly specific for the renal tract is a more appropriate selection.

5 alpha reductase inhibitors, work by inhibiting the conversion of testosterone (male hormone) to its active form or metabolite DHT. The net result is a reduction in size of the prostate. It is also important to note that this type of medication has the ability to reduce a man’s psa value by approximately 50% after six months of use. This obviously has significant implications for a man who is undergoing serial psa testing for screening of prostate cancer. In essence the PSA must be doubled to obtain the true PSA value. Five alpha reductase inhibitors have been shown to reduce the relative risk of disease progression of BPH when combined with alpha blockers. However, the absolute reduction in risk of disease progression is not as significant. As a result, this medication although used in Australia is not widespread. The side-effects of this type of medication include sexual side effects. These include a reduction in the libido, ejaculatory disorders, and impotence.

Surgery for BPH / enlarged prostate

There are absolute and relative indications for proceeding on to surgical treatment for BPH. The absolute indications are where there have been complications from the disease. These include acute urinary retention, the formation of bladder stones, development of a bladder diverticulum (this is an acquired pocket that develops in the bladder lining as a result of long standing obstruction), recurrent urinary tract infections, and persistent prostatic bleeding that has been shown to originate purely from the prostate.

There are several different ways to surgically treat a man with BPH / enlarged prostate gland. To date, the most common way to perform this surgery has been with a TURP (transurethral resection of prostate). Although effective at improving urinary symptoms the draw-back to this operation is that there are significant potential side effects including bleeding (which can require blood transfusion), prolonged period of catheterisation and lengthy hospital stay and up to an 18% risk or erectile dysfunction.

There are other newer state of the art modalities which achieve the same goal, but use a different energy sources to remove the overgrown prostatic tissue, and thereby creating a larger channel and reduce the obstruction caused by an overgrown prostate. These newer modalities include GreenLight Laser prostatectomy