Enlarged Prostate (BPH)
The prostate is a walnut-sized gland that forms part of the male reproductive system. The gland is made of two lobes, or regions, enclosed by an outer layer of tissue. The prostate is located in front of the rectum and just below the bladder, where urine is stored. The prostate also surrounds the urethra, the canal through which urine passes out of the body.
The prostate serves many functions, however its main role is to supply fluid and nutrients to the sperm during and after ejaculation. This fluid, which helps make up semen, energizes the sperm and makes the vaginal canal less acidic.
BPH: A Common Part of Aging
It is common for the prostate gland to become enlarged as a man ages. Doctors call the condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy.
As a man matures, the prostate goes through two main periods of growth. The first occurs early in puberty, when the prostate doubles in size. At around age 25, the gland begins to grow again. This second growth phase often results, years later, in BPH.
Though the prostate continues to grow during most of a man's life, the enlargement doesn't usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and as many as 90 percent in their seventies and eighties have some symptoms of BPH.
As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself. Urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH.
Many people feel uncomfortable talking about the prostate, since the gland plays a role in both sex and urination. Still, prostate enlargement is as common a part of aging as gray hair. As life expectancy rises, so does the occurrence of BPH. In the United States in 2000, there were 4.5 million visits to a physician for BPH.
Why BPH Occurs
The cause of BPH is not well understood. No definite information on risk factors exists. For centuries, it has been known that BPH occurs mainly in older men and that it doesn't develop in men whose testes were removed before puberty. For this reason, some researchers believe that factors related to aging and the testes may spur the development of BPH.
Throughout their lives, men produce both testosterone, an important male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen. Studies done with animals have suggested that BPH may occur because the higher amount of estrogen within the gland increases the activity of substances that promote cell growth.
Symptoms of BPH
Many symptoms of BPH stem from obstruction of the urethra and gradual loss of bladder function, which results in incomplete emptying of the bladder. The symptoms of BPH vary, but the most common ones involve changes or problems with urination, such as
- a hesitant, interrupted, weak stream
- urgency and leaking or dribbling
- more frequent urination, especially at night
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, have more blockage and greater problems.
Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to urinate at all. This condition, called acute urinary retention, may be triggered by taking over-the-counter cold or allergy medicines. Such medicines contain a decongestant drug, known as a sympathomimetic. A potential side effect of this drug may be to prevent the bladder opening from relaxing and allowing urine to empty. When partial obstruction is present, urinary retention also can be brought on by alcohol, cold temperatures, or a long period of immobility.
It is important to tell your doctor about urinary problems such as those described above. In 8 out of 10 cases, these symptoms suggest BPH, but they also can signal other, more serious conditions that require prompt treatment. These conditions, including prostate cancer, can be ruled out only by a doctor's exam.
Severe BPH can cause serious problems over time. Urine retention and strain on the bladder can lead to urinary tract infections, bladder or kidney damage, bladder stones, and incontinence. If the bladder is permanently damaged, treatment for BPH may be ineffective. When BPH is found in its earlier stages, there is a lower risk of developing such complications.
Diagnosis of BPH
You may first notice symptoms of BPH yourself, or your doctor may find that your prostate is enlarged during a routine checkup. When BPH is suspected, you may be referred to a urologist like your UANT physician, a doctor who specializes in problems of the urinary tract and the male reproductive system. Several tests help the doctor identify the problem and decide whether surgery is needed. The tests vary from patient to patient, but the following are the most common.
Digital Rectal Exam (DRE) -This exam is usually the first test done. The doctor inserts a gloved finger into the rectum and feels the part of the prostate next to the rectum. This exam gives the doctor a general idea of the size and condition of the gland in addition to feeling any nodules or bumps that may be suspicious for prostate cancer.
Prostate Specific Antigen (PSA) Blood Test -To rule out cancer as a cause of urinary symptoms, your doctor may recommend a PSA blood test. PSA, a protein produced by prostate cells, is frequently present at elevated levels in the blood of men who have prostate cancer. The U.S. Food and Drug Administration has approved a PSA test for use in conjunction with a digital rectal exam to help detect prostate cancer in men age 50 or older and for monitoring prostate cancer patients after treatment. However, much remains unknown about the interpretation of PSA levels, the test's ability to discriminate cancer from benign prostate conditions, and the best course of action following a finding of elevated PSA. While the normal range should be less than 4.0, younger men should have a PSA that is less than 2.5.
Trans-Rectal Ultrasound - If there is a suspicion of prostate cancer; your UANT physician may recommend a test with transrectal ultrasound. In this procedure, a probe inserted in the rectum directs sound waves at the prostate. The echo patterns of the sound waves form an image of the prostate gland on a display screen. If biopsies are taken, the prostate is injected with numbing medication first and the biopsies are taken after the medication has taken effect, thus causing minimal discomfort.
Urine Flow Study -Sometimes your UANT physician will ask a patient to urinate into a special device that measures how quickly the urine is flowing. A reduced flow often suggests BPH.
Cystoscopy - In this exam, your UANT physician inserts a small tube through the opening of the urethra in the penis. This procedure is done after a solution numbs the inside of the penis so all sensation is lost. The tube, called a cystoscope, contains a lens and a light system, which helps him see the inside of the urethra and the bladder. This test allows visualization of the prostate in the urine channel to determine the size of the gland and identify the location and degree of the obstruction.
Treatment of BPH
Since BPH may cause urinary tract infections, your UANT physician will want to clear up any infection with antibiotics before treating the BPH itself. Although the need for treatment is not usually urgent, he generally advises going ahead with treatment once the problems become bothersome or present a health risk.
The following section describes the types of treatment that are most commonly used for BPH.
Over the years, researchers have tried to find a way to shrink or at least stop the growth of the prostate without using surgery. The Food and Drug Administration (FDA) has approved four drugs to relieve common symptoms associated with an enlarged prostate, these are better known as alpha blockers and these include Hytin, Cardura, Flomax and Uroxatral. In addition, many patients need a second drug to shrink the prostate further and stop the progression of BPH. These drugs are known as 5-alpha reductase inhibitors and include Proscar and Avodart. You will need to discuss which drugs are appropriate for your condition with your UANT physician.
Minimally Invasive Therapy
Because drug treatment is not effective in all cases, researchers in recent years have developed a number of procedures that relieve BPH symptoms but are less invasive than conventional surgery.
Transurethral microwave procedures -a device that uses microwaves to heat and destroy excess prostate tissue. In the procedure called transurethral microwave thermotherapy (TUMT), the Prostatron sends computer-regulated microwaves through a catheter to heat selected portions of the prostate to at least 111 degrees Fahrenheit. A cooling system protects the urinary tract during the procedure. The procedure takes about 1 hour and can be performed on an outpatient basis without general anesthesia. Neither procedure has been reported to lead to impotence or incontinence. Patients usually require a catheter for several days after the procedure and improvement in the urinary stream may take several months.
Transurethral needle ablation (TUNA) - The TUNA System delivers low-level radiofrequency energy through twin needles to burn away a well-defined region of the enlarged prostate. Shields protect the urethra from heat damage. The TUNA System improves urine flow and relieves symptoms with fewer side effects when compared with transurethral resection of the prostate (TURP). No incontinence or impotence has been observed.
Prolieve Thermotherapy Balloon Dilatation - The Prolieve thermodilatation system is the most recent advance in minimally invasive therapy for BPH and the enlarged prostate. A small catheter is inserted into the urethra (urine channel) similar to traditional microwave thermotherapy; however the catheter has a balloon which dilates the inside of the prostate area of the urine channel. By compressing the urine channel, there is less discomfort for the patient. With the balloon dilated, the catheter sends out computer-regulated microwaves to heat up the middle portion of the prostate. Patients tolerate this procedure very well in the office and most patients leave the office without a catheter but with immediate relief of symptoms.
Surgical Treatment of BPH
Most doctors recommend removal of the enlarged part of the prostate as the best long-term solution for patients with BPH. With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed; the rest of the inside tissue and the outside capsule are left intact. Surgery usually relieves the obstruction and incomplete emptying caused by BPH. The following section describes the types of surgery that are used.
TURP (transurethral resection of the prostate) is used for 90 percent of all prostate surgeries done for BPH. With TURP, an instrument called a resectoscope is inserted through the penis. The resectoscope, which is about 12 inches long and 1/2 inch in diameter, contains a light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels.
During the 60-minute operation, the surgeon uses the resectoscope's wire loop to remove the obstructing tissue one piece at a time. The pieces of tissue are carried by the fluid into the bladder and then flushed out at the end of the operation. Transurethral procedures are less traumatic than open forms of surgery and require a shorter recovery period.
Open surgery - In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. The location of the enlargement within the gland and the patient's general health help the surgeon decide which of the three open procedures to use. With all the open procedures, anesthesia is given and an incision is made. Once the surgeon reaches the prostate capsule, he scoops out the enlarged tissue from inside the gland.
Laser surgery - your UANT physician specializes in laser surgery and prostate laser surgery in particular. A variety of lasers are available to vaporize the prostate, however the goal is to vaporize the obstructing prostate tissue with minimal blood loss. One of the main problems with the traditional TURP was the associated bleeding during and after the procedure. The current lasers decrease the risk of blood loss significantly. The laser energy destroys the prostate tissue. Like TURP, laser surgery requires anesthesia, however some of the advantages of laser surgery include minimal blood loss, no hospital stay, and routinely patients do not require a catheter immediately after the procedure. Laser surgery also allows for a quicker recovery time. At this time, your UANT physician routinely performs laser surgery for prostate obstruction and only rarely performs the traditional TURP procedure.
Your Recovery after Surgery in the Hospital
If you undergo Laser surgery or Prolieve thermodilatation, chances are you will not need a urinary catheter after the procedure. In the event you do require a catheter, please see below.
At the end of surgery, a special catheter is inserted through the opening of the penis to drain urine from the bladder into a collection bag. Called a Foley catheter, this device has a water-filled balloon on the end that is placed in the bladder, which keeps it in place.
This catheter is usually left in place for several days. Sometimes, the catheter causes recurring painful bladder spasms after the procedure.
If spasms do become a problem, your UANT physician can prescribe medication to stop the spasms. These are usually pills to place under the tongue, but occasionally oral medication is given that lasts for 24 hours.
You may also be given other medications after the procedure. Routinely antibiotics are given before and after the procedure in addition to ant-inflammatory medication to decrease the pain after the procedure. Discuss this with your UANT physician before the procedure.
After surgery, you will probably notice some blood in your urine as the wound starts to heal. Some bleeding is normal, and it should clear up, and intermittent bleeding over the first several weeks is not unusual. If you notice bright red blood that does not clear up with increasing fluid intake, call your UANT physician. During your recovery, it is important to drink a lot of water (up to 8 cups a day) to help flush out the bladder and speed up the healing process.
Do's and Don'ts
Take it easy the first few weeks after you get home. You may not have any pain, but you still have an incision in the urinary tract that is healing-even with transurethral surgery, where the incision can't be seen. Since many people try to do too much at the beginning and then have a setback, it is a good idea to talk to your UANT physician before resuming your normal routine. During this initial period of recovery at home, avoid any straining or heavy lifting that could tear the incision. Here are some guidelines:
- Continue drinking a lot of water to flush the bladder.
- Avoid straining when moving your bowels.
- Eat a balanced diet to prevent constipation. If constipation occurs, try an over-the-counter laxative first and if this is not helpful, call the Doctor's office.
- Don't do any heavy lifting.