Trouble with water works (enlarged 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 publicity 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

Prostate

Benign prostate hyperplasia is a very common non cancerous 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.  It is more common with increasing age, such that by the age of 50 years  50% of men have BPH, 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.

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 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 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 impairment of 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 from 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 (L UTS), or water work troubles.  They all refer to these same symptom complex and most commonly are referred to as L UTS by urologists.

The main symptoms include:

Obstructive symptoms

  • Reduced flow
  • Longer time taken to empty bladder
  • Feeling of incomplete bladder emptying
  • Dribble of urine after finishing voiding
  • Straining to empty your bladder

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 2 hr 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, 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 will 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 ascertained 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 LUTS objectively and provide information on the impact your symptoms have on your quality of life
  • DRE: 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, this 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 of any abnormal cells in the urine)
  • Ultrasound (gives a rough guide to the size of the prostate 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 for an enlarged prostate gland is usually a possibility for men that have mild to moderate symptoms and are not particularly bothered.  Many men 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. 
Observation may entail follow up visits with your urologist to allow reassessment for signs of progression of the severity of symptoms.  At the end of the day, the aim of treating 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, works 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, notably, featuring a point for further evaluation with a prostate biopsy must also be reduced by a factor of 50%.  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 of this medication, although used in Australia is not widespread.  The side-effects or 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, a view 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/an enlarged prostate gland.  To date, the gold standard way of treating this condition is with a TURP (transurethral resection of prostate).  There are other newer modalities of achieving the same goal, which use a different energy sources to remove excess prostatic tissue, and thereby creating a larger channel and reduce the obstruction caused by an overgrown prostate client.  These newer modalities include laser therapy and also microwave Thermotherapy.