Prostate Problems

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Prostate Problems

Benign Prostatic Hyperplasia (BPH)

The prostate gland is present only in males. Enlargement of the prostate gland causes problems in urination in elderly male. (usually over the age of 60 years). With increase in life expectancy, the incidence of benign prostatic hyperplasia (also called BPH) has also increased.

What is the prostate gland? What is its function?

The prostate gland is a small organ about the size of a walnut and is part of the male reproductive system.

The prostate gland is situated just underneath the bladder and in front of the rectum. It surrounds the initial portion of the urethra (the tube that carries urine from the bladder). In other words, the initial portion of the urethra (about 3 cm. long) runs through the prostate.

The prostate is a male reproductive organ. It secretes fluid that nourishes and carries sperm into the urethra during ejaculation.

What is benign prostatic hyperplasia (BPH)?

“Benign prostatic” means the prostatic problem is not caused by cancer and “hyperplasia” means enlargement.

Benign prostatic hyperplasia or benign prostatic hypertrophy (BPH) is a non-cancerous prostatic enlargement that occurs in almost all men as they get older. As men age, the prostate gland slowly grows bigger (or enlarges). An enlarged prostate compresses the urethra, blocks the urine stream and causes problems in urination. Because of narrowing of the urethra, flow of urine becomes slower and less forceful.

Benign Prostatic Hyperplasia is a disease of elderly males.

Symptoms of BPH

The symptoms of BPH usually begin after age 50. More than half of men in their 60s and up to 90% of men in their 70s and 80s have symptoms of BPH. Most symptoms of BPH start gradually and worsen over the years. The most common symptoms of BPH are:

  • Frequent urination, especially at night. This is usually a very early symptom.
  • Slow or weak stream of urine.
  • Difficulty or straining in starting the urine flow, even when the bladder feels full.
  • Urge to urinate immediately is the most bothersome symptom.
  • Straining to urinate ,Interrupted urine flow.
  • Leaking or dribbling at the end of urination. Drops of urine are expelled even after urination causing wetting of underclothes.
  • Incomplete emptying of bladder.

BPH causes weak stream of urine and frequent urination, especially at night.

Complications of BPH

Severe BPH can cause serious problems over a time in a few patients, if left untreated. Common complications of BPH are:

Acute urinary retention:

Untreated severe BPH over time can cause sudden, complete and often painful blockage of urine flow. Such patients require insertion of a tube called a catheter to drain urine from the bladder.

Chronic urinary retention:

Partial blockage of urine flow for a prolonged period can cause chronic urinary retention. Chronic urinary retention is painless and is characterized by an increased residual urine volume. The amount of urine which remains in bladder after normal urination is called residual urine. Its usual presentation is incomplete bladder emptying or frequent voiding of small amount of urine (overflow of urine).

Damage to bladder and kidney:

Chronic urinary retention causes stretching of the muscular wall of the bladder. In the long term the bladder becomes weak and no longer contracts properly.

Large residual urine volume leads to increased pressure in the bladder. High bladder pressure may lead to a back pressure of urine through the ureters and into the kidneys. Resultant fullness of the ureters and the kidneys eventually may lead to kidney failure.

Urinary tract infection and bladder stones:

Inability to completely empty the bladder increases the risk of urinary tract infection and formation of bladder stones.

Remember, BPH does not increase the risk for prostate cancer.

Digital rectal examination and sonography are two most important tests for the diagnosis of BPH.

Diagnosis of BPH

When history and symptoms suggest BPH, the following tests are performed to confirm or rule out the presence of an enlarged prostate.

Digital rectal examination (DRE) : In this examination, a lubricated, gloved finger is gently inserted into the patient’s rectum to feel the surface of the prostate gland through the rectal wall. This examination gives the doctor an idea of the size and condition of the prostate gland.

In BPH, on DRE, the prostate is enlarged, smooth, and firm in consistency. Hard, nodular and irregular feel of the prostate on DRE suggests cancer or calcification of prostate gland.

Ultrasound and post-void residual volume test

An ultrasound can estimate the size of the prostate and detect other problems such as malignancy, dilatation of the ureter and the presence of a kidney abscess.

Ultrasound imaging is also used to determine the quantity of urine left in the bladder after urination. Post-void residual urine volume less than 50 ml indicates adequate bladder emptying. Post-void residual urine volume of 100 to 200 ml or higher is considered to be significant and further evaluation is needed.

Prostate symptom score or index

The International Prostate Symptom Score (IPSS) or AUA (American Urological Association) symptom index helps in the diagnosis of BPH. In this diagnostic modality, patients are asked about the presence or absence of common symptoms of benign prostatic hyperplasia. The answers are then scored and, on the basis of the calculated prostate symptoms score, the severity of the urinary problem is judged.

Laboratory tests

Laboratory tests do not help diagnosing of BPH. But they help in the diagnosis of associated complications and excluding problems with similar presentation. Urine is tested for infection and blood is tested for kidney function.

Prostate Specific Antigen (PSA) is a screening blood test for cancer of the prostate.

Other investigations

Different investigationsperformed to diagnose or exclude the diagnosis of BPH are uroflowmetry, urodynamic studies, cystoscopy, prostate biopsy, intravenous pyelogram or CT urogram and retrograde pyelography.

Can a person with symptoms of BPH have prostate cancer? How is prostate cancer diagnosed?

Yes. Many symptoms of prostate cancer and BPH are similar, so on the basis of clinical symptoms it is not possible to differentiate between the two conditions. But remember, BPH is not related to prostate cancer. Three most important tests which can establish the diagnosis of prostate cancer are digital rectal examination (DRE), blood test for prostate- specific antigen (PSA) and prostate biopsy.

Blood PSA test is an important screening test for the diagnosis of cancer of the prostate.

Treatment of BPH

Factors determining treatment options of BPH are severity of symptoms, the extent to which daily life is affected due to symptoms, and the presence of associated medical conditions. Goals of treatment of BPH are to reduce symptoms, improve quality of life, reduce post void residual urine volume and prevent complications of BPH.

Three different treatment options of BPH are:

  • Watchful waiting and lifestyle changes (no treatment)
  • Medical Treatment
  • Surgical Treatment

Many symptoms of prostate cancer and BPH are similar. Thorough investigation is required for accurate diagnosis.

A. Watchful waiting and lifestyle changes (no treatment)

“Wait and watch” without any treatment is the preferred approach for men with mild symptoms or symptoms that don’t bother them. But watchful waiting does not mean to simply wait and do nothing to reduce symptoms of BPH. During watchful waiting, the person should make

changes in life style to reduce symptoms of BPH and also have regular yearly checkups to see if the symptoms are improving or getting worse.

  • Make simple changes in the habits of urination and in consumption of liquids.
  • Empty bladder regularly. Do not hold back urine for long. Urinate as soon as the urge arises.
  • Double void. This means urine is passed twice in succession. First empty the bladder normally in a relaxed way, wait for a few moments, and try to void again. Do not strain or push to empty.
  • Avoid drinking alcohol and caffeine containing beverages in the evening. Both can affect the muscle tone of the bladder, and both stimulate the kidneys to produce urine, leading to night-time urination.
  • Avoid excessive intake of fluid (take less than 3 liters of fluid per day). Instead of consuming a lot of fluid all at once, spread out intake of fluids over the day.
  • Reduce fluid intake few hours before bedtime or going out.
  • DO NOT take over-the-counter cold and sinus medications that contain decongestants or antihistamines. These medications can worsen symptoms or cause urinary retention.
  • Change the timing of medications which increases volume of urine (e.g. diuretics).
  • Keep warm and exercise regularly. Cold weather and lack of physical activity may worsen symptoms.
  • Learn and perform pelvic strengthening exercises as they are useful to prevent urine leakage. Pelvic exercises strengthen the muscles of the pelvic floor which support the bladder and help in closing the sphincter. The exercises consist of repeatedly tightening and releasing the pelvic muscles.
  • Bladder training focused on timed and complete voiding. Try to urinate at regular times.
  • Treatment of constipation.
  • Reduce stress. Nervousness and tension can lead to more frequent urination.

BPH with mild symptoms can be managed with watchful waiting and lifestyle changes and without medical treatment.

B. Medical Treatment

Medications are the most common and preferred way to control mild to moderate symptoms of BPH. Medications significantly reduce major symptoms in about two-thirds of treated men. There are two classes of drugs, alpha-blockers and anti-androgens (5-alpha-reductase inhibitors), for an enlarged prostate.

Conservative medical treatment is preferred for mild to moderate symptoms of BPH. Surgery is best avoided.

C. Surgical Treatment