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Enlarged prostate

Definition

The prostate is a male reproductive gland that produces the fluid that carries sperm during ejaculation. It surrounds the urethra, the tube through which urine passes out of the body.

An enlarged prostate means the gland has grown bigger. Prostate enlargement happens to almost all men as they get older. As the gland grows, it can press on the urethra and cause urination and bladder problems.

An enlarged prostate is often called benign prostatic hyperplasia (BPH) or benign prostatic hypertrophy. It is not cancer, and it does not raise your risk for prostate cancer.

Alternative Names

BPH; Benign prostatic hypertrophy (hyperplasia); Prostate - enlarged

Causes

The actual cause of prostate enlargement is unknown. Factors linked to aging and the testicles themselves may play a role in the growth of the gland. Men who have had their testicles removed at a young age (for example, as a result of testicular cancer) do not develop BPH.

Similarly, if the testicles are removed after a man develops BPH, the prostate begins to shrink in size.

Some facts about prostate enlargement:

• The likelihood of developing an enlarged prostate increases with age.
• BPH is so common that it has been said all men will have an enlarged prostate if they live long enough.
• A small amount of prostate enlargement is present in many men over age 40 and more than 90% of men over age 80.
• No risk factors have been identified other than having normally functioning testicles.

Symptoms

Less than half of all men with BPH have symptoms of the disease, which include:

• Dribbling at the end of urinating
• Inability to urinate (urinary retention)
• Incomplete emptying of your bladder
• Incontinence
• Needing to urinate two or more times per night
• Pain with urination or bloody urine (these may indicate infection)
• Slowed or delayed start of the urinary stream
• Straining to urinate
• Strong and sudden urge to urinate
• Weak urine stream

Exams and Tests

After taking a complete medical history, your doctor will perform a digital rectal exam to feel the prostate gland. The following tests may also be performed:

• Urine flow rate
• Post-void residual urine test to see how much urine is left in your bladder after urination
• Pressure flow studies to measure the pressure in the bladder as you urinate
• Urinalysis to check for blood or infection
• Urine culture to check for infection
• Prostate-specific antigen (PSA) blood test to screen for prostate cancer
• Cystoscopy

In addition, you may be asked to complete a form to evaluate the severity of your symptoms and their impact on your daily life. Your score may be compared to past records to determine if the condition is getting worse.

Treatment

The choice of a treatment is based on the severity of your symptoms, the extent to which they affect your daily life, and the presence of any other medical conditions. Treatment options include "watchful waiting," lifestyle changes, medication, or surgery.

If you are over 60, you are more likely to have symptoms. But many men with an enlarged prostate have only minor symptoms. Self-care steps are often enough to make you feel better.

If you have BPH, you should have a yearly exam to monitor the progression of your symptoms and determine if any changes in treatment are necessary.

SELF-CARE

For mild symptoms:

• Urinate when you first get the urge. Also, go to the bathroom when you have the chance, even if you don't feel a need to urinate.
• Avoid alcohol and caffeine, especially after dinner.
• Don't drink a lot of fluid all at once. Spread out fluids throughout the day. Avoid drinking fluids within 2 hours of bedtime.
• Try NOT to take over-the-counter cold and sinus medications that contain decongestants or antihistamines. These medications can increase BPH symptoms.
• Keep warm and exercise regularly. Cold weather and lack of physical activity may worsen symptoms.
• Learn and perform Kegel exercises (pelvic strengthening exercises).
• Reduce stress. Nervousness and tension can lead to more frequent urination.

MEDICATIONS

• Alpha 1-blockers (doxazosin, prazosin, tamsulosin, terazosin, and afluzosin) are a class of medications also used to treat high blood pressure. These medications relax the muscles of the bladder neck and prostate. This allows easier urination. Most people treated with alpha 1-blocker medication find that it helps their symptoms.
• Finasteride and dutasteride lower levels of hormones produced by the prostate, reduce the size of the prostate gland, increase urine flow rate, and decrease symptoms of BPH. It may take 3 to 6 months before you notice much improvement in your symptoms. Potential side effects related to the use of finasteride and dutasteride include decreased sex drive and impotence.
• Antibiotics may be prescribed to treat chronic prostatitis (inflammation of the prostate), which may accompany BPH. Some men note relief of their BPH symptoms after a course of antibiotics.

SAW PALMETTO

Many herbs have been tried for treating an enlarged prostate. Saw palmetto has been used by millions of men to ease BPH symptoms and is often recommended as an alternative to medication. Some studies have shown that it helps with symptoms, but there is evidence that this popular herb is no better than a dummy pill in relieving the signs and symptoms of BPH. Further studies are needed. If you use saw palmetto and think it works, ask your doctor if you should still take it.

SURGERY

Prostate surgery may be recommended if you have:

• Incontinence
• Recurrent blood in the urine
• Inability to fully empty the bladder (urinary retention)
• Recurrent urinary tract infections
• Kidney failure
• Bladder stones

The choice of a specific surgical procedure is usually based on the severity of your symptoms and the size and shape of your prostate gland.

• Transurethral resection of the prostate (TURP): This is the most common and most proven surgical treatment for BPH. TURP is performed by inserting a scope through the penis and removing the prostate piece by piece.
• Transurethral incision of the prostate (TUIP): This procedure is similar to TURP, but is usually performed in men who have a smaller prostate. It is usually performed without the need for a hospital stay. Like TURP, a scope is inserted through the penis until the prostate is reached. Then, rather than removing the prostate, a small incision is made in the prostate tissue to enlarge the opening of the urethra and bladder outlet.
• Simple prostatectomy: An open prostatectomy is usually performed using general or spinal anesthesia. An incision is made through the abdomen or perineum (the area behind the scrotum). Only the inner part of the prostate gland is removed. The outer portion is left behind. This is a lengthy procedure, and it usually requires a hospital stay of 5 to 10 days.

Most men who have prostate surgery have improvement in urine flow rates and symptoms. See prostate removal for a description of complications.

Other, less invasive procedures are available. These use different forms of heat to destroy prostate tissue, including:

• Radiofrequency energy -- transurethral needle ablation (TUNA)
• Microwave energy -- transurethral microwave thermotherapy (TUMT)
• Electrical current -- transurethral electrovaporization (TUVP)
• Hot water -- water-induced thermotherapy (WIT)
• Laser -- interstitial laser coagulation (ILC) and holmium laser enucleation of the prostate (HoLEP)

None of these techniques have been proven to be better than TURP. Patients who receive these less-invasive procedures are more likely to need surgery again after 5 or 10 years. However, these procedures may be a choice for:

• Younger men (many of the less-invasive procedures carry a lower risk for impotence and incontinence than TURP, although the risk with TURP is not very high)
• Elderly patients
• Patients with severe medical conditions, including uncontrolled diabetes, cirrhosis, alcoholism, psychosis, and serious lung, kidney, or heart disease
• Men who are taking blood-thinning drugs

Robot-guided prostatectomy is another newer technique. However, the technology is not widely available, and surgeon experience should be taken into consideration. In addition, there are no long-term studies of this surgery.

Another form of treatment is prostatic stents.

For more information, see prostate surgery.

Support Groups

See: BPH support groups

Possible Complications

Men who have had long-standing BPH with a gradual increase in symptoms may develop:

• Sudden inability to urinate
• Urinary tract infections
• Urinary stones
• Damage to the kidneys
• Blood in the urine

Even after surgical treatment, a recurrence of BPH may develop over time.

When to Contact a Medical Professional

Call your doctor right away if you have:

• Less urine than usual
• Fever or chills
• Back, side, or abdominal pain
• Blood or pus in your urine

Also call your doctor if:

• Your bladder does not feel completely empty after you urinate
• You take medications that may cause urinary problems, like diuretics, antihistamines, antidepressants, or sedatives. Do NOT stop or adjust your medications on your own without talking to your doctor
• You have taken self-care measures for 2 months without relief

References

Bent S, Kane C, Shinohara K, et. al. Saw palmetto for benign prostatic hyperplasia. NEJM. 2006; 354:557-566.

Abrams P, Chapple C, Khoury S, Roehrborn C, de la Rosette J; International Scientific Committee. Evaluation and treatment of lower urinary tract symptoms in older men. J Urol. 2009;181:1779-1787.

Kirby R, Lepor H. Evaluation and Nonsurgical Management of Benign Prostatic Hyperplasia. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 87.

Lourenco T, Pickard R, Vale L, Grant A, Fraser C, MacLennan G, et al. Minimally invasive treatments for benign prostatic enlargement: systematic review of randomised clinical trials. BMJ. 2008 Oct 9;337:a1662.doi:10.1136/bmj.a1662.

Roehrborn CG, McConnell JD. Benign Prostatic Hyperplasia: Etiology, Pathophysiology, Epidemiology, and Natural History. Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 86.

Rich KT, Safranek S. PPIN's clinical inquiries. Medical treatment of benign prostatic hyperplasia. Am Fam Physician. 2008;77:665-666.

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