Lakeview Health System
Enlarged Prostate

The prostate is normally a walnut-sized gland located just below the urinary bladder. Its primary function is the secretion of semen which functions to nourish and protect sperm. The prostate encircles the neck of the bladder, thus it can affect urine flow.  



Picture of the Prostate - Side View of the Prostate.
The prostate is a walnut-sized gland located between the bladder and the penis. The prostate is just in front of the rectum. The urethra runs through the center of the prostate, from the bladder to the penis, letting urine flow out of the body. The prostate secretes fluid that nourishes and protects sperm. During ejaculation, the prostate squeezes this fluid into the urethra, and it’s expelled with sperm as semen. The vasa deferentia (singular: vas deferens) bring sperm from the testes to the seminal vesicles. The seminal vesicles contribute fluid to semen during ejaculation.

EP is the nonmalignant enlargement of the prostate gland that typically begins in men over age 40. It has also been called Benign Prostate Hyperplasia (BPH). Prostatic growth and enlargement is a natural process that occurs in all  men as they age. It occurs to varying degrees; in some men growth can be excessive and can obstruct the flow of urine. For example, those with EP might find they have a decreased flow of urine or that they have to strain more than  previously to start their urinary stream. Also they might find that they have to get up once, twice, or even three times during the night to urinate. Occasionally EP causes urine to be retained in the bladder. When this happens, urine may back up into the kidneys, which can result in kidney failure, inability to empty the bladder (urinary retention), formation of stones within the bladder, or urinary tract infections (that are otherwise rare in men).

Signs and Symptoms

The symptoms caused by BPH can be obstructive and irritative. Obstructive symptoms result from the mechanical obstruction of the flow of urine caused by the prostate. As a man's bladder contracts to empty, it has to overcome the obstruction caused by the enlarged prostate. Obstructive symptoms include a weak or intermittent stream, hesitancy or needing to strain or bear down to empty. Irritative symptoms are often a combination of the mechanical obstruction and the effects of obstruction. Because the prostate is enlarged, the bladder must work harder to empty. In doing so it undergoes a series of changes that result in a "hypersensitive bladder". Irritative symptoms include more frequent and urgent urination, including leakage of urine and getting up at night to urinate. Untreated EP may worsen. Retained bladder urine may increase in volume, putting patients at increased risk of having stones, infections, or kidney failure. In the final stages of the disease, the patient is unable to empty his bladder at all and urinary retention ensues. This necessitates immediate medical intervention with the placement of a catheter either through the penis or lower abdominal wall into the bladder to facilitate drainage. Once at this stage, if ignored, the bladder can enter a final phase where the bladder fails to contract. This situation requires long-term drainage of the bladder with a catheter. In some cases this is continued until the bladder recovers and the obstruction is treated. If the bladder fails to recover, permanent drainage of the bladder with a catheter may be required.  

Diagnosis of EP

To diagnose EP a man should undergo a basic evaluation to make sure there is no other cause for the man's urinary symptoms (such as infection, prostate or bladder cancer).

There are some basic questions to assess how bothersome the urinary symptoms are-also called an AUA symptom score. Take the AUA symptom score to see if you may have enough symptoms to be of concern – add up all the points  –a total score over 8 usually should prompt an exam for EP.



A brief physical exam is also done, that  includes a DRE (digital exam) that estimates the size of the prostate and whether there is a hard mass or lump on the gland. A serum PSA (Prostate Specific Antigen) blood test should be done to assess the risk of cancer of the prostate. A urinalysis is  usually done to look for infection. 

Treatment Options

1.     Lifestyle Changes
2.     Medications
3.     Surgery


1. LIFESTYLE CHANGES
The first thing that should be done is to make some lifestyle changes. Limiting fluids a couple of hours before bed can cut down on getting up at night. Decreasing alcohol and caffeine may also help reduce urinary frequency. Some medications can contribute to urinary frequency, most notably diuretics prescribed  for high blood pressure or pedal edema (lower leg swelling). Ask your primary care doctor if these medications could be changed.           

2.  MEDICATIONS
Alpha Blockers (HYTRIN®, CARDURA®, FLOMAX® Uroxatral)
Originally used to treat high blood pressure, these medications relax smooth muscle around blood vessels and within the prostate and bladder, helping relieve some of the obstruction from the EP. They tend to work immediately. Side effects include orthostatic hypotension (fall in blood pressure upon standing, causing dizziness), fatigue, headaches and a stuffy nose. These are lifelong medications.

5ARI’s (Proscar, Avodart)
Finasteride (Proscar) or Dutasteride (Avodart) block the conversion of testosterone to dihydrotestosterone (DHT), the major male sex hormone found within cells of the prostate. By doing so, it may help to actually shrink the size of the prostate and, in some people, decrease BPH symptoms and increase urinary flow rates. These medications may be best suited for men with relatively large prostates (those greater than 30 cubic centimeters in size, with normal prostate size being 25 cubic centimeters). Side effects include erectile dysfunction and breast enlargement in about 5% of men. These side effects resolve with cessation of the drug. These medications lower the PSA blood test levels by ~50% - important to remember when screening for prostate cancer. These are lifelong medications. COMBINATION MEDICATION - Both alpha blockers and 5aRI’s can safely be  used together to treat EP. There is a medication (Jalyn) that is flomax and dutasteride combined into one tablet. Their effectiveness and side effects are additive from the individual medications. Phosphodiesterase inhibitors (daily Cialis). Daily Cialis (5mg) has been shown to help men with Erectile Dysfunction, and also may help reduce symptoms of EP. Side effects include flushing of the face, headache and sinus congestion. It should not be taken with Nitroglycerin or it could result in a very low blood pressure. It is not clear how the medication affects the prostate.

Herbals
Herbals have been used for EP. The most popular one used is Saw palmetto. Other herbals that are popular are beta sitosterol and Pygeum. While it is unclear what the best dose is and how these herbals work - they sometimes can give mild relief from EP. These must be taken lifelong to maintain their effects.  

3.  Surgery
TRANSURETHRAL RESECTION OF THE PROSTATE (TURP)
TURP- the gold standard  treatment for BP, involves removal of the core of the prostate using an instrument passed through the urethra. High frequency current flowing through a wire loop allows removal of "chips" of prostatic tissue and coagulation of blood vessels. The prostate tissue is removed through the cystoscope used to visually guide and monitor this process. Patients require an anesthetic and need to be hospitalized typically for 2-3 days, and wear a catheter for 3 or more days. Most patients (80% to 90%) experience dramatic improvement in their symptoms and urinary flow rates after TURP. Possible side effects include bleeding requiring transfusion, salt imbalances from fluid absorption, ED (less than 5%) and incontinence (1%).  

View a TURP procedure.

Open Prostactectomy 
Open prostatectomy is performed for those patients with very large prostates (greater than 100 grams) in whom transurethral surgery would be difficult to perform safely. In this procedure, an incision is made from the navel to the pubic bone. The bladder is opened; and prostatic tissue is removed through the bladder. A urethral catheter remains for approximately 7 days and patients stay in the hospital 5-7 days. It is a more invasive procedure and complications include bleeding and infection.

Minimally Invasive Surgery

Laser Prostatectomy 
Laser prostatectomy has the effectiveness of  a TURP with less side effects and a decreased risk of complications such as intraoperative bleeding and fluid absorption, retrograde ejaculation, impotence, and incontinence. Patients undergoing this procedure require an anesthetic at the hospital and usually go home the same day. The Green Light and Holmium Laser are the two most popular, each slightly different laser systems but about equally effective. Lasers seem to be as effective as TURP with less complications and the catheter is usually only needed for a day. The re-treatment rate for laser procedures may be greater than for TURP or open prostatectomy. Retrograde ejaculation occurs in about 1 in 3 men. View a laser prostatectomy.

Cooled thermotherapy

Cooled thermotherapy (microwave hyperthermia) uses microwave energy with frequencies between 915 and 2450 MHz to heat tissues through radiant heat transfer. Using a transurethral probe, microwave heat delivery is delivered to the prostatic tissue while the surrounding tissue is cooled by a special catheter. This procedure can be performed in the office with local anesthesia. Although it is safer than TURP, it is not as effective with a higher re-treatment rate. Side effects include bleeding, bladder spasms, and blood in the ejaculate.

Prostatic Stents
Prostatic stents are permanent, flexible, self-expanding devices placed in the inside of the prostate. Unfortunately their tendency to encrust and be uncomfortable has not made them a popular choice for most men.