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Prostate Enlargement

Introduction

Prostate enlargement, also known as benign prostatic hyperplasia (BPH), is a common condition that affects older men.

The prostate

The prostate is a small gland found only in men. It is located in the pelvis, between the penis and bladder, and surrounds the urethra (the tube that carries urine from the bladder to the penis).

The prostate is involved in the production of semen. The prostate produces a thick, white fluid that is made into a liquid by a protein called prostate-specific antigen (PSA). The liquid is then mixed with sperm, produced by the testicles, to create semen.

If the prostate becomes enlarged, it can place pressure on the bladder and urethra. This can affect urination (passing urine when going to the toilet) and may cause:

  • difficulty starting urination,
  • a frequent need to urinate, and
  • difficulty emptying the bladder fully.

These symptoms can range from mild to severe.

How common is prostate enlargement?

Prostate enlargement is a common condition that is associated with ageing. It is estimated that 60% of men who are 60 or over have some degree of prostate enlargement.

The cause of prostate enlargement is unknown, but most experts agree that it is linked to changes in hormone levels in a man’s body due to ageing.

Prostate enlargement and prostate cancer

Many men worry that having an enlarged prostate means that they have an increased risk of developing prostate cancer. This is not the case. Men with prostate enlargement do not have a higher risk of prostate cancer compared to men without an enlarged prostate. 

Outlook

Prostate enlargement is not usually a serious threat to a man’s health. The outlook for the condition normally depends on the pattern of associated symptoms. In some men, the symptoms are mild and do not require treatment. In others, symptoms can be very troublesome and have an adverse effect on their quality of life.

A number of treatments are available for prostate enlargement, including:

  • lifestyle changes, such as avoiding alcohol and caffeine,
  • medication, and
  • surgery.
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Symptoms

Symptoms of prostate enlargement 

The symptoms of prostate enlargement are caused by the enlarged prostate placing pressure on the bladder and urethra (the tube that carries urine from the bladder to the penis). This can cause a range of symptoms that affect normal urination.

Health professionals sometimes group the symptoms together under the general term lower urinary tract symptoms (LUTS).

Lower urinary tract symptoms include:

  • difficulty with beginning to urinate,
  • weak or intermittent (stopping and starting) flow of urine,
  • having to push or strain to pass urine,
  • a frequent need to urinate,
  • waking up frequently during the night to urinate (nocturia),
  • a sudden urge to urinate, which can result in incontinence if you cannot find a toilet quickly enough,
  • not being able to empty your bladder fully,
  • pain when urinating (dysuria), and
  • blood in your urine (hematuria).

When to seek medical advice

See your GP if you notice any problems with or changes to your usual pattern of urination. Even if the symptoms are mild, they could be caused by a condition that needs to be investigated

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Causes

Causes of prostate enlargement 

The exact cause of prostate enlargement is unknown, but research shows that hormones are probably involved in its development.

Hormones, such as testosterone, are powerful chemicals that have a wide range of effects on the body's cells.

As men get older, the amount of testosterone in their body increases. A leading theory is that the additional testosterone may interact with the tissue of the prostate, stimulating the growth of new cells and leading to enlargement of the prostate.

Risk factors

Research has shown that rates of prostate enlargement are higher among men with high blood pressure (hypertension) and diabetes.

However, diabetes and hypertension are also associated with ageing, so there may not be a direct connection between them and prostate enlargement.

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Diagnosis

The diagnosis of prostate enlargement has three stages:

  • determining whether your symptoms match the usual pattern of symptoms for people with prostate enlargement,
  • assessing the severity of your symptoms, and
  • ruling out other conditions that cause similar symptoms.

The third stage of diagnosis is particularly important because the symptoms of prostate enlargement are similar to those of prostate cancer. Therefore, healthcare professionals have to be completely sure that your symptoms are not caused by prostate cancer.

Checking and assessing symptoms

Healthcare professionals use a checklist to assess the symptoms of prostate enlargement. The checklist includes the questions below:

Over the past month:

  • How often have you had the sensation of not completely emptying your bladder after urinating?
  • How often have you had to urinate again less than two hours after finishing urinating?
  • How often have you found that you stopped and started again when urinating?
  • How often have you found it difficult to postpone urination?
  • How often have you had a weak stream of urine?
  • How often have you had to push or strain to begin urinating during the course of one night?

Each question has six possible answers that carry a score. Your scores are then used to assess the severity of your symptoms.

Ruling out other conditions

Urine tests

A urine test can be used to check if your symptoms are caused by an infection in your urinary system, such as a kidney or bladder infection.

Digital rectal examination

A digital rectal examination (DRE) can be used to rule out a diagnosis of prostate cancer. Prostate cancer can cause the prostate gland to become hard and bumpy.

A DRE can be carried out by your GP. During the procedure, your GP will insert a finger into your rectum (back passage). As the rectum is close to the prostate gland, your GP will be able to check whether the surface of the gland has changed. The procedure will feel a little uncomfortable but it is not usually painful.

Prostate cancer does not always cause changes to the gland so you will probably need additional tests to rule out prostate cancer.

Prostate-specific antigen (PSA) test

A blood test can be used to measure the amount of the prostate-specific antigen (PSA) protein that is produced by the prostate.

A raised PSA level indicates enlargement of the prostate and a significantly raised level may indicate prostate cancer. However, as with the DRE, a PSA test cannot give a definitive diagnosis of prostate cancer.

Transrectal ultrasound (TRUS)

A transrectal ultrasound (TRUS) is a type of ultrasound scanner that is specifically designed to study the prostate and surrounding area.

An ultrasound probe is placed into your rectum and uses soundwaves to build a detailed image of your prostate.

A TRUS measures the size of your prostate and can be used to either confirm or rule out a diagnosis of prostate cancer.

Intravenous urography (IVU)

An intravenous urography (IVU) is an X-ray that is used to study the urinary tract (kidneys, bladder and urethra).

An IVU can be used to check for obstructions in your urinary system that could be causing your symptoms, such as a kidney or bladder stone. An IVU can also detect damage to the urinary tract.

During an IVU, you will be injected with a harmless radioactive dye, which will appear on the X-rays. After 30 to 60 minutes, the dye should have passed into your urinary tract and a series of X-rays will be taken. In some cases, you may be asked to pass urine before the final X-ray is taken.

Voiding charts

A voiding chart is a urination diary, which you may be asked to keep for 24 hours. You will be asked to record how often you urinate, as well as details about how you urinate, for example whether your urination is intermittent (stopping and starting) or whether it is difficult to start urinating.

A voiding chart is a good way to find out more information about your symptoms and can be used to determine the type of treatment that would be most effective in controlling your symptoms.

Uroflowmetry

Uroflowmetry measures the pressure of your bladder and how well your bladder works when you urinate.

You will be given a local anaesthetic and a small flexible tube (catheter) will be inserted into your urethra and moved up into your bladder.

Water will then be injected through the catheter and into your bladder. A computer connected to the catheter measures the pressure inside your bladder and how well your bladder is working.

As with voiding charts, uroflowmetry is a good way of determining what type of treatment will help control your symptoms.

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Treatment

Your treatment plan

If you have an enlarged prostate, your recommended treatment plan will be determined by how severe your symptoms are.

Watchful waiting

If your symptoms are mild to moderate, a policy of watchful waiting will probably be recommended. This means that you will receive no immediate medical treatment but will be given regular check-ups to carefully monitor your prostate.

Lifestyle changes

As well as watchful waiting, you will probably be advised to make changes to your lifestyle to see if they improve your symptoms. You may be advised to:

  • Stop drinking any liquids for one to two hours before going to bed. This will help to improve symptoms of nocturia (waking up during the night to pass urine).
  • Stop drinking alcohol and caffeine, or limit your consumption of them. They can irritate your bladder and make your symptoms worse.
  • Exercise regularly. Research has shown that moderate exercise, such as walking for 30 to 60 minutes a day, can improve symptoms (although it is unclear exactly why this is).

Bladder training

Bladder training is an exercise programme to increase the time between urination and to increase the amount of urine your bladder can hold.

You will be given a target, such as waiting for at least two hours between each time you urinate. You will also be taught a number of exercises, such as breathing, relaxation and muscle exercises, to help take your mind off the need to urinate.

Over time, your target time will be increased and at the end of the programme you should be able to go five or six hours without urinating.

Bladder training should only be undertaken with proper medical supervision. This is because not doing the exercises properly could damage your bladder muscles.

Herbal remedies

There is some limited evidence to suggest that a herbal remedy called pygeum africanum can help improve mild to moderate symptoms of prostate enlargement. Pygeum africanum is taken from a plum tree found in Africa. It is not recommended for people with moderate to severe symptoms.

A similar claim was made about another herbal remedy called saw palmetto, which comes from the berries of a type of palm tree. However, recent research suggests that palmetto is not effective in treating the symptoms of prostate enlargement.

Herbal remedies are not licensed or controlled in the same rigorous way as conventional medicines. Therefore, if you decide to try a herbal remedy, make sure you buy it from a reputable supplier.

Herbal remedies are not suitable for everyone so speak to your GP before you take them.

Medication

Medication, in combination with the lifestyle changes above, is usually recommended to treat moderate to severe symptoms of prostate enlargement.

Finasteride

Finasteride is widely used to treat prostate enlargement. Finasteride is a type of medication known as a 5-alpha reductase inhibitor (5ARI). 5ARIs block the effects of testosterone on the prostate gland, which can reduce the size of the prostate and improve symptoms of prostate enlargement.

If you are prescribed finasteride, you may experience an immediate improvement in symptoms. However, you will need to take it for at least six months to get the maximum benefit.

If you are sexually active, use a condom as finasteride can have an adverse affect on your sperm. If you get a woman pregnant, there is a risk that the baby could develop birth defects that affect their genitalia.
 
Side effects of finasteride include:

  • impotence (inability to get an erection), and
  • a decrease in or an absence of sperm when you ejaculate.

In many cases, these side effects will improve as your body gets used to the medication.

Less common side effects include:

  • breast swelling or tenderness, and
  • pain in your testicles.

See your GP if these side effects are troubling you.

Research has shown that the long-term use of finasteride has both benefits and risks in relation to prostate cancer.

The benefit is that taking finasteride will lower your risk of getting prostate cancer. The risk is that if you do develop prostate cancer, it may be a more aggressive form of cancer.

Your GP can give you more information about the risks and benefits of finasteride.

Alpha blockers

Alpha blockers help relax the muscles of your bladder, making it easier to pass urine.

You may be given alpha blockers as your primary treatment or in combination with 5ARIs.

Tamsulosin is an alpha blocker that is widely used to treat prostate enlargement. Side effects of tamsulosin are uncommon and usually mild. They include:

  • dizziness,
  • headaches,
  • weakness, and
  • a decrease in or total lack of sperm when you ejaculate.

If you experience dizziness, avoid driving or operating heavy machinery until it has passed.

Surgery

Surgery is usually only recommended for moderate to severe symptoms of prostate enlargement that have failed to respond to medication.

Trans-urethral resection of the prostate (TURP)

Trans-urethral resection of the prostate (TURP) is a surgical procedure where excess prostate tissue is removed to reduce the pressure on your bladder.

During TURP, the surgeon will insert a small instrument, known as a resectoscope, into your urethra. Tiny blades attached to the resectoscope are used to slice away excess tissue.

TURP is not painful because it is performed either under general anaesthetic (where you are asleep) or an epidural (a type of local anaesthetic that means you cannot feel any pain in the bottom half of your body).

Most men are well enough to leave hospital two to three days after the operation.

A common complication of TURP is that you will no longer produce semen when you ejaculate. This is known as retrograde ejaculation. It is caused by damage to the bladder and results in sperm going into your bladder rather than out of your penis during ejaculation.

However, you will still experience the physical pleasure associated with ejaculation (the climax).

Less common complications of TURP include:

  • impotence (inability to get an erection), and
  • urinary incontinence (the unintentional passing of urine).

In most cases, these two complications are temporary and improve as your body recovers from the effects of the surgery.

Transurethral incision of the prostate (TUIP)

Transurethral incision of the prostate (TUIP) is an alternative to TURP for men who:

  • only have a moderately enlarged prostate, and/or
  • are in poor health and are not be suitable for TURP (TUIP generally involves less blood loss than TURP, so is a safer treatment option).

After TUIP, there is a lower risk of experiencing retrograde ejaculation, which may be an important consideration for some men, particularly if they wish to have children.

In some cases of retrograde ejaculation, it is possible to take a sample of sperm from your urine for use in fertility treatments, such as artificial insemination or IVF (in vitro fertilisation).

TUIP is carried out in a similar way to TURP, but rather than removing prostate tissue, two small cuts are made in the prostate. These cuts allow your urethra to be widened, making it easier for you to pass urine.

Open prostatectomy

During an open prostatectomy, an incision is made in your abdomen and the outer portion of your prostate is removed.

While open prostatectomy may be effective in treating your symptoms, it carries a high risk of complications. Therefore, it is usually only recommended for men who have a severely enlarged prostate.

Complications of an open prostatectomy include:

  • impotence, and
  • urinary incontinence.

If these complications develop following an open prostatectomy, there is a greater chance that they will become permanent than if they occur following TURP.

It may be possible to treat the symptoms of impotence with medication, such as sildenafil (Viagra).

Laser treatment

Laser treatment can be used in men who are not healthy enough to have surgery or who only have a moderately enlarged prostate.

During surgery, a very narrow cable will be placed in your urethra. A laser is beamed out of the cable to burn off excess tissue.

After surgery, you may need to use a catheter (a flexible tube that you place into your bladder) to remove urine from your bladder while your urethra recovers. Many men experience pain while urinating for several weeks after the operation.

As with other types of prostate surgery, laser surgery carries a risk of developing retrograde ejaculation.

As laser surgery is a new technique, its long-term effectiveness is unknown.

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Complications

Urinary tract infections

If you are unable to empty your bladder properly, there is a risk that bacteria in your urinary system will not get flushed out and will spread through the urine and cause a urinary tract infection (UTI).

Symptoms of UTI include:

  • cloudy, bloody or bad-smelling urine,
  • pain in your lower abdomen,
  • nausea,
  • vomiting,
  • shaking and chills, and
  • a high temperature (fever) of 38°C (100.4°F) or above.

UTIs can be treated with antibiotics. While a single UTI is not usually serious, repeated UTIs can damage your kidney and bladder. If you have a history of repeated UTIs, surgery may be required to treat the underlying symptoms of prostate enlargement.

Acute urinary retention (AUR)

Acute urinary retention (AUR) is the sudden inability to pass any urine. AUR should be treated as a medical emergency because, without prompt treatment, urine may be passed back up into the kidneys, which can damage them.

Symptoms of AUR include:

  • the sudden inability to pass urine,
  • severe pain in your lower abdomen, and
  • swelling of your bladder that is noticeable to the touch.

If you or someone you know experiences the symptoms of AUR, call 999 and ask for an ambulance.

AUR can be treated using a thin tube (catheter) to drain the urine out of your bladder. In very serious cases, surgery may be required to empty the bladder.

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Prevention

Diet

There is evidence to suggest that eating a diet high in protein and vegetables and low in red meat and fat may reduce your risk of developing an enlarged prostate.

Foods that are a good source of protein include:

  • eggs,
  • milk,
  • soya,
  • tofu,
  • fish,
  • cheese, and
  • chicken.

There is also some evidence to suggest that increased alcohol consumption reduces the risk of prostate enlargement. However, drinking more alcohol could increase your risk of developing a serious alcohol-related disease, such as liver cancer or cirrhosis.

The best way to get the preventative benefit from alcohol is not to exceed the daily limit for alcohol consumption. For men, the recommend daily limit is three to four units. A unit of alcohol is equal to about half a pint of normal strength lager, a small glass of wine or a single measure (25ml) of spirits.

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