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Enlarged Prostate
(Benign Prostatic Hyperplasia - BPH)
Definition
Benign enlargement of the prostate gland, seen with increasing age
- By age 65 years, 50% of men will experience benign enlargement of the prostate and, at the age of 90, 90% of men have BPH
- An enlarged prostate alone does not always cause symptoms and the severity of the symptoms is not related to the size of the prostate
- 1 in 3 men will suffer prostatic symptoms during their life but only 1 in 10 will require surgical treatment
- Not all urinary symptoms in men are due to an enlarged prostate - incontinence, pain or blood in the urine may be due to other conditions
- Risk of prostate cancer is not increased by BPH
Causes/Risk Factors
- Very little is known about why the prostate gland enlarges with increasing age
- Hormone imbalance within the gland itself probably plays a part as well as certain genetic factors
- There is some evidence that hormones and certain growth factors may work together to cause the prostate gland to enlarge and there seems to be an inherited tendency in approximately 10% of men
Warning Signs/Symptoms
- difficulty starting or stopping urine flow
- a weak stream
- a feeling of incomplete bladder emptying
- increased urinary frequency
- urgency of urine passage by day or night
- a tendency to dribble at the end of voiding
Diagnosis
This will normally include some or all of the following:
- Full history together with a more detailed urological history.
- Symptom score
- Voiding dairy
- Physical examination including rectal examination to assess the size and texture of the prostate gland and examination of the abdomen to feel for an enlarged bladder.
- PSA (prostate-specific antigen) measurement. A raised PSA does mean the patient has prostate cancer. 50-60% of men with benign enlargement of the prostate have a raised PSA level but the only way to exclude prostate cancer is to be evaluated by a urologist for further tests and possibly a prostate biopsy.
- Urine tests to exclude infection.
- Voiding flow rate a measurement of how fast the patient urinates
- Bladder ultrasound scan to see how much urine is left in the bladder after the patient has voided (residual urine)
- Abdominal X-ray to look for stones
Treatment Options
No treatment is likely to clear all symptoms completely but they can be greatly improved so that the degree of "bother" is minimal. Symptoms can then be monitored regularly to see whether changes in treatment are needed
- 30-40% of men with prostatic symptoms do not experience worsening of their condition with time and may not require any treatment
- If treatment is indicated, this usually involves with drugs which relax the muscle in and around the prostate and/or drugs which shrink the glandular component of the prostate
- If symptoms are severe, if there is no response to medical treatment or if there are complications of prostatic enlargement, surgical treatment may be indicated
- The risk of acute, painful retention of urine is small (approximately 1 in 100) and it is not always preceded by prostatic symptoms; acute retention usually requires surgical treatment
General measures ("watchful waiting")
If treatment is not necessary initially, some simple measures can improve patient quality of life. These include
- limiting fluid intake when out of the house
- double voiding - emptying the bladder twice each time by returning to the toilet after a few minutes for another attempt at emptying
- reducing caffeine, alcohol & nicotine intake - they all cause increased urine production
- relaxation measures when standing to pass urine if slow stream
- "holding on" as long as possible to improve bladder capacity
Drugs
- Alpha-blockers (e.g. tamsulosin, terazosin, alfuzosin, doxazosin) will normally be the first type of medication to be prescribed. They relax the muscles in and around the prostate/bladder neck area to make the passage of urine easier. They may cause low blood pressure, a stuffy nose, skin rashes and impaired ejaculation.
- 5-alpha-reductase inhibitors (e.g. finasteride, dutasteride) shrink large prostate glands (>40 grams) and may be used together with alpha-blockers. They can cause ejaculatory problems, they take at least 6 months to have maximum effect and they do not work well if your prostate is small. They will also reduce the PSA level by up to 50%.
- Combination medication (both of the above) for larger prostates has been shown to be better than either type used alone, to reduce the risk of complications (especially retention) and to reduce the need for surgery.
- Herbal Remedies. Some herbal & plant extracts (e.g. saw palmetto) have been shown to be effective in relieving symptoms without the risk of side-effects. They probably work because the extracts contain plant hormones which mimic natural hormones alter the abnormal hormone balance within the prostate. These extracts are not usually available on prescription from your GP.
- Surgery (green light or conventional TURP) is usually recommended if symptoms are severe, medical treatment has failed or if there are complications (e.g. a large residual urine, retention of urine, infection, bladder stones).
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