Enlarged Prostate – Symptoms, Causes and Surgery
The prostate is a small gland in the pelvis only found in men. It is located between the penis and bladder and surrounds the urethra (the tube that carries urine from the bladder to the penis). The prostate produces a liquid that is mixed with sperm, produced by the testicles, to create semen.
Enlargement of this gland leads to a condition called benign prostatic hyperplasia (BPH). It is a condition that affects older men. When sufficiently large, the prostate compresses the urethral canal to cause partial or sometimes complete obstruction of the urethra. This interferes with the normal flow of urine.
The symptoms of BPH are
- difficulty starting urination
- a frequent need to urinate
- difficulty fully emptying the bladder
- painful urination (dysuria)
- increased risk of urinary tract infections
- urinary retention.
In some men, the symptoms are mild and don’t require treatment. In others, the symptoms can be very troublesome and have a major impact on a person’s quality of life.
The risk of prostate cancer is no greater for men with an enlarged prostate than it is for men without an enlarged prostate.
Research suggests that hormones probably play an important role in this condition. It is believed that with increasing age, the levels of the hormone dihydrotestosterone (DHT) increases, which may stimulate the growth of the prostate.
Younger men produce high levels of testosterone and much smaller levels of estrogen. With increasing age, their levels of testosterone decrease, resulting in a higher proportion of estrogen in their body. It is thought that the relative increase in estrogen may stimulate prostate growth.
Risk factors are high BP and diabetes through no direct correlation has been found.
Your doctor will ask you about your symptoms that includes questions about urination such as:
- The sensation of not completely emptying your bladder after urinating
- Stopping and starting again when urinating
- Difficulty in postponing urination
- Having a weak stream of urine
- The need to push or strain to begin urinating
- Waking up at night frequently to urinate
It is important that prostate cancer is ruled out as the symptoms are similar.
Urine tests will be done to check whether your symptoms are caused by an infection in your urinary system.
A rectal examination will be done by your surgeon to check for prostate cancer that will cause the prostate gland to become hard and lumpy. As the rectum is close to the prostate internally, an examination through the rectum will be able to feel the surface of the gland. This is an examination that is not painful though it may be a little uncomfortable.
Prostate-specific antigen (PSA) test is a test to measure the amount of the PSA protein that’s produced by the prostate. High PSA levels indicate enlargement of the prostate, and very raised levels may indicate prostate cancer. However, a PSA test will not provide a definitive diagnosis of prostate cancer.
Transrectal ultrasound (TRUS):is a type of ultrasound scan specifically designed to study the prostate and the surrounding area. An ultrasound probe is placed into your rectum and image of your prostate can be obtained.
Computer tomographic (CT) urogram During a CT urogram, a radioactive dye will be injected, which as it gets excreted in the urine will be visible on X-rays. You may be asked to pass urine before the final X-ray is taken.
a CT program will show up blockages in your urinary system that could be causing your symptoms, such as a kidney stone or bladder stone. It can also be used to detect any damage in the urinary tract.
Uroflowmetry After local anesthesia, a catheter will be inserted through your urethra into your bladder. Water will then be injected through the catheter into your bladder. A computer connected to the catheter measures the pressure inside your bladder and can assess how well your bladder is working.
This will depend upon how severe the symptoms are. Treatment may involve lifestyle changes, medication or surgery.
If your symptoms are mild to moderate, you may not need any immediate medical treatment, but you will be advised regular check-ups to carefully monitor your prostate gland and will be asked to try lifestyle changes to see whether they improve your symptoms.
- Control the intake of fluids especially near bedtime to avoid waking up at night to pass urine.
- Limit your intake of alcohol and coffee or stop taking it.
- Exercise every day for 30 -60 minutes to improve symptoms though it is not clear why this is effective.
You’ll also be taught a number of exercises, such as breathing, relaxation and muscle exercises, to help take your mind off the need to urinate. Bladder training is a program that sets targets between urination to prolong the interval and increase the amount of urine your bladder can hold. Over time you will be able to go for longer without urinating.
Bladder training should only be carried out under medical supervision.
In combination with the lifestyle changes above, medication is usually recommended to treat moderate to severe symptoms of benign prostate enlargement.
Finasteride or dutasteride are widely used to treat benign prostate enlargement. They block the effects of a hormone called dihydrotestosterone (DHT) on the prostate gland, which can reduce the size of the prostate and improve associated symptoms. It is important to follow up regularly with your doctor while on the medication. Side effects are an effect on sperm quality and impotence. Alpha blockers help relax the muscles of your bladder, making it easier to pass urine. You may be prescribed alpha blockers as your primary treatment or in combination with finasteride. Side effects of alpha-blockers are the risk of causing low BP and fainting.
Surgery is usually only recommended for moderate to severe symptoms of benign prostate enlargement that have failed to respond to medication.
Transurethral resection of the prostate (TURP)
Transurethral resection of the prostate (TURP) is the most common surgery that is done to relieve moderate to severe urinary symptoms caused by an enlarged prostate. TURP is recommended if symptoms caused by benign prostatic hyperplasia (BPH) have not improved in response to medication and other treatment. Procedure
An instrument (a combined visual and surgical instrument called a resectoscope) is inserted through the tip of your penis and into the tube that carries urine from your bladder (urethra). The prostate is located around the urethra and using the resectoscope, the surgeon trims away the excess prostate tissue that is blocking the urine flow.
TURP usually requires hospitalization for 2-3 days and is done under general or spinal anesthesia.
After surgery, you may find it difficult to urinate normally at first because of your swollen urethra. A thin tube called a catheter will be inserted into your urethra and up into your bladder to allow urine to drain away. This will usually be removed 24 to 48 hours after surgery.
After the catheter is removed, you may experience urinary frequency; urgency and pain while urine passes through the surgical area. These symptoms improve over 1-4 weeks.
It is common to observe blood in the urine soon after the surgery. However, if you notice clots, then contact your doctor.
Certain risks which may be associated with surgery include blood clots, uncontrolled micturition, and problems with erection.
Transurethral incision of the prostate (TUIP)
Transurethral incision of the prostate (TUIP) is a surgical procedure where the urethra is widened, making it easier to pass urine. The surgeon will insert a resectoscope into your urethra. The resectoscope is used to make small incisions in the muscle where the prostate meets the bladder. This type of surgery relaxes the opening to the bladder, helping urine flow out easily. TUIP is carried out under spinal or general anesthesia.
After surgery, a catheter may be needed to empty your bladder. The catheter will be removed within a short time once you are able to urinate normally.
Insertion of prostatic urethral lift implants
The insertion of prostatic urethral lift implants is a new surgical procedure that can help relieve urinary symptoms.
The procedure involves inserting tiny implants through the urethra. The implants are then positioned to hold the enlarged prostate away from the urethra so it isn’t blocked.
Prostatic urethral lift implants are unlikely to provide permanent symptom relief in all cases. Since it’s a new procedure, the long-term outcomes are unknown.
Holmium laser enucleation of the prostate– a laser is used to remove excess prostate tissue using a similar route to a TURP.
KTP laser vaporization – a small tube known as a cystoscope is inserted into your urethra, which fires pulses of laser energy to burn away prostate tissue.
An open prostatectomy is a procedure that may be more effective than TURP if you have a severe benign prostate enlargement. However, it’s rarely used, even for larger prostates, because of the development of other techniques, such as holmium laser enucleation of the prostate.
During an open prostatectomy, an incision will be made in your abdomen and the outer portion of your prostate will be removed.
Following certain precautions can help you in a faster recovery.
- Avoid any kind of strenuous exercises for at least for 6 to 8 weeks post-surgery.
- Eat fiber-rich food and plenty of water to prevent constipation.
- Start on your pelvic floor exercises on the day you return home, these help in regaining the bladder control.
- Do not skip the dose of antibiotics.
- Include more calories in the diet if your appetite is poor.
- Avoid having sex for 6 weeks after the surgery.