What is the Prostate?

The prostate is a male gland that surrounds the urethra (urinary channel) near the bladder. Its main role happens during the fertility years, since the prostate makes much of the fluid that comes out during ejaculation. It grows as men age and may start to cause partial or complete blockage of the urinary stream. This can cause a variety of symptoms (see below), ranging from obstructive (slow stream, incomplete bladder emptying) to irritative (urgency to void, voiding multiple times at night). The bladder, which works harder and harder to get the urine out, may start to become abnormal over time.

If you are worried about the condition of your prostate or have some uncomfortable symptoms, the urologists at the reconstructive urology clinic can help you determine the cause and suggest treatment options. Our urologists have particular expertise in the transurethral resection of the prostate and laser prostate treatments.

Enlarged Prostate or BPH

Also known as benign prostatic hypertrophy (BPH), prostate enlargement is NOT the same as prostate cancer, which is also common in men but usually does not cause urinary symptoms until it has been present for a long time. There is also a link between erectile dysfunction (ED) and BPH, although no one is entirely sure why that is. We know that if one is treated, the other often gets better also.

Benign prostatic hypertrophy (BPH) is growth of the prostate with normal aging and causes symptoms because the prostate blocks the flow of urine through the prostate as the urine exits the bladder. The name BPH indicates enlargement of the prostate, but men may suffer symptoms even with smaller prostates as they age.

Other terms that describe the same process include: lower urinary tract symptoms (LUTS), bladder outlet obstruction (BOO) and benign prostatic enlargement (BPE).

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Symptoms

Prostate enlargement symptoms may include:

  • Urinary frequency (day or night)
  • Urinary urgency (a stronger urge than usual to urinate); if this is very strong, the patient may even have incontinence.
  • Urinary hesitancy (difficulty initiating the urination) or straining to urinate
  • Incomplete bladder emptying: this may be just a feeling or it may be the case that the bladder is retaining too much urine
  • Weak or “stuttering” urinary stream

Diagnosis

There are many tools to evaluate how severe the problem is and how we may best fix it. Some common ones include:

  • Questionnaires, such as the international prostate symptom score (IPSS)
  • Ultrasound to determine whether the bladder is emptying
  • Rectal examination to evaluate the size and texture of the prostate
  • Blood tests including PSA (the level of a chemical made by the prostate)
  • Cystoscopy (looking inside urinary channel with a small camera)

Treatment of Enlarged Prostate

Treatment depends on a number of factors, including how severe the symptoms are, the size of the prostate, whether bladder is normal or abnormal, and others. If the patient is not very bothered by the symptoms, often they do not require any treatment other than a periodic visit to make sure things aren’t getting worse.

As men age and the prostate continues to enlarge, symptoms typically slowly progress, and men can develop retention of urine, bleeding, urinary infections, stones in the bladder and even kidney problems. Evaluation and management of these symptoms begin with an assessment of the urinary symptoms and quality of life. In the past treatment was often based on relieving serious problems, such as kidney failure, inability to urinate (retention), bleeding, recurrent infections and bladder stones. These are still indications for aggressive treatment but are less frequently encountered. In modern practice the level of bother from the symptoms most often drives treatment decision-making.

Medications

Medical therapy relies on three different types of medications used alone or in combination. Alpha blockers are medications that relax the prostate and bladder opening so the urine can flow more freely. These are typically well tolerated and offer quick improvement in symptoms. Five alpha reductase inhibitors shrink the prostate and work slowly over a four to six month period. These work best for patients with large prostates. Anticholinergic medications help treat bladder over activity and the frequency and urgency that many patients experience with prostate enlargement. These are often used when symptoms of frequency and urgency do not improve after other medical or surgical management and when PVR is reasonably low. Recently, the phosphdiesterase inhibiting drugs have been shown to improve symptom scores in men being treated for both erectile dysfunction and BPH. Exactly how these drugs improve LUTS is not currently known; but for patients with both problems, this is a new option for medical management.

Surgery

Surgical management relies on opening the urethra where it runs through the prostate. This can be done with a variety of different procedures including:

  • TUIP (transurethral incision of the prostate). Relaxing incisions are made in the prostate using a small scope; typically used for small prostates
  • TUMT (transurethral microwave therapy). Destroys prostate tissue with heat delivered by a catheter
  • Vaporization of the prostate. Using either laser energy or electrical energy to destroy tissue using a small scope under direct vision
  • TURP (transurethral resection of the prostate). Removal of prostatic tissue using electrical energy through a small scope
  • HoLEP (holmium laser enucleation of the prostate). Using a laser to carve out the prostate in larger portions and then remove them from the bladder with a morcellating device
  • Simple prostatectomy. Removing prostate tissue through an incision in the lower abdomen; typically used for very large prostates

The risks, benefits and indications for each of these procedures are slightly different, and your surgeon will discuss which is best for you. Often, surgeon experience with one technique will also help select the procedure with the lowest risk of complication and best outcome.

Complications From Surgery

In general risks for surgery for BPH include bleeding, urinary tract infection, abnormal healing with scar tissue formation in the urethra and bladder opening, erectile dysfunction, retrograde ejaculation (where semen flows backward into the bladder with orgasm) and incontinence (leaking urine without control).

Complications are not common and most surgeries work very well to increase the strength of men’s urinary flow and relieve the symptoms of frequency and urgency of urination.

Surgery is a very good option for men that do not tolerate medicines because of side effects or men for whom the medicines are not strong enough to relieve the symptoms of the problem.