It is normal for a man’s prostate gland to enlarge from age 40 years; this is known as benign prostatic hyperplasia or benign prostatic hypertrophy (BPH). This enlargement can cause a range of symptoms related to urination. More serious bladder and kidney problems may also develop.
Various effective treatment options exist to address enlarged prostate, including medical and surgical options. The most common prostate surgery is transurethral resection of the prostate (TURP).
Causes
The prostate is a walnut-shaped gland located below the outlet of the bladder. Its main function is to produce a fluid which protects and enriches sperm.As men age, it is normal for the prostate gland to gradually enlarge. This usually begins about the age of 40 years and is thought to be caused by hormonal changes. This enlargement can cause difficulties with urinating and can lead to problems with the bladder and kidneys. The enlargement can come about as a result of hyperplasia (an increase in cell numbers) and hypertrophy (an increase in cell size).
An enlarged prostate does not cause prostate cancer. However, prostate cancer can occur in men with an enlarged prostate.
Signs and symptoms
As the prostate gland enlarges it narrows the urethra (the tube that drains urine from the bladder) and can obstruct the flow of urine. This can lead to difficulties with urinating such as:
- Increased frequency – having to urinate more often
- Urinary urgency – having a sudden need to urinate
- Nocturia – having to get up frequently in the night to urinate
- Difficulty with getting the urine stream started (hesitancy)
- Poor flow of urine - weak flow or stop/start stream
- Dribbling of urine – particularly at the end of urination
- Incomplete emptying of the bladder.
Symptoms can fluctuate in nature and severity. Some men may have no symptoms at all, while for others, symptoms may be very problematic. An enlarged prostate, if severe, can also lead to:
- Back up of urine into the kidneys
- Enlargement and thickening of the bladder
- Bladder stones
- Urinary tract infections (UTIs)
- Bleeding from the urethra
- An inability to urinate at all.
Any of these situations can cause damage to the bladder, urethra and kidneys. If there is burning, bleeding or pain while urinating, medical attention should be sought promptly. Being unable to urinate at all is a medical emergency and requires immediate medical attention.
Diagnosis
If symptoms of enlarged prostate are present a doctor should be consulted so an accurate diagnosis can be made and treatment recommended. It is important to rule out other possible causes for the symptoms such as prostatitis (inflammation of the prostate) or prostate cancer. In order to diagnose the condition the doctor will undertake the following:
Medical history
Including the nature, duration and severity of the current symptoms, the presence of any other medical conditions, and family history of prostate problems.
Including the nature, duration and severity of the current symptoms, the presence of any other medical conditions, and family history of prostate problems.
Physical examination
During a physical examination the doctor will feel the abdomen for signs of an enlarged bladder and perform a digital rectal examination (DRE) to check for enlargement or irregularity of the prostate gland.
During a physical examination the doctor will feel the abdomen for signs of an enlarged bladder and perform a digital rectal examination (DRE) to check for enlargement or irregularity of the prostate gland.
Blood tests
These will be performed to check kidney function and to check the PSA (prostate specific antigen). PSA is a protein released into the blood by the prostate gland. Higher than normal levels can indicate an enlarged prostate, prostate inflammation (prostatitis) or prostate cancer. The PSA level tends to be significantly elevated in prostate cancer, but not always.
These will be performed to check kidney function and to check the PSA (prostate specific antigen). PSA is a protein released into the blood by the prostate gland. Higher than normal levels can indicate an enlarged prostate, prostate inflammation (prostatitis) or prostate cancer. The PSA level tends to be significantly elevated in prostate cancer, but not always.
Urine tests
This can show infection or the presence of blood in the urine. Other urine tests can measure strength and volume of flow and whether the bladder can be emptied completely.
This can show infection or the presence of blood in the urine. Other urine tests can measure strength and volume of flow and whether the bladder can be emptied completely.
If blood tests indicate an elevated PSA and the digital rectal examination indicates irregularities of the prostate, a biopsy of the prostate gland may be advised in order to rule out prostate cancer. An ultrasound scan of the prostate and urinary tract may also be recommended in some cases.
Treatment
Treatment is only required if an enlarged prostate is causing symptoms. Traditionally, three main treatment approaches have been taken - “wait and watch”, medical treatment, and surgical treatment.
“Wait and watch” (ie: no treatment)
This approach may be advised if the symptoms are mild and not adversely affecting quality of life. The condition is regularly monitored and treatment will be advised if symptoms worsen.
Medical treatment
There are a number of medications that can be used to treat enlarged prostate. Some medications work by relaxing the muscle inside the prostate, making it easier for the urethra to open, while others have the effect of shrinking the prostate. Medications commonly used in New Zealand to treat enlarged prostate include terazosin, doxazosin and finasteride.
Surgical treatment
Up to 25% of men with enlarged prostate will require surgical treatment, usually because they are experiencing severe symptoms that are negatively affecting their quality of life. Some less invasive procedures have been developed in recent times but, because the longer-term outcomes of these newer treatments are not yet known, transurethral resection of the prostate (TURP) remains the most commonly performed procedure.
Transurethral Resection of the Prostate (TURP)
This approach may be advised if the symptoms are mild and not adversely affecting quality of life. The condition is regularly monitored and treatment will be advised if symptoms worsen.
Medical treatment
There are a number of medications that can be used to treat enlarged prostate. Some medications work by relaxing the muscle inside the prostate, making it easier for the urethra to open, while others have the effect of shrinking the prostate. Medications commonly used in New Zealand to treat enlarged prostate include terazosin, doxazosin and finasteride.
Surgical treatment
Up to 25% of men with enlarged prostate will require surgical treatment, usually because they are experiencing severe symptoms that are negatively affecting their quality of life. Some less invasive procedures have been developed in recent times but, because the longer-term outcomes of these newer treatments are not yet known, transurethral resection of the prostate (TURP) remains the most commonly performed procedure.
Transurethral Resection of the Prostate (TURP)
A TURP is performed by a specialist urologist (urinary system specialist) and is usually performed under a general anaesthetic.
The specialist inserts a resectoscope (a thin tube-like telescope with a light at its tip) through the urethra and up into the prostate gland. The specialist can view the prostate gland and bladder, either through the resectoscope or on a television monitor.
The specialist inserts a resectoscope (a thin tube-like telescope with a light at its tip) through the urethra and up into the prostate gland. The specialist can view the prostate gland and bladder, either through the resectoscope or on a television monitor.
Diagram courtesy of www.urolog.nl
A special heated wire loop is inserted through the resectoscope and is used to cut away excess prostate tissue a sliver at a time. The wire also seals blood vessels to help minimise bleeding.
A hospital stay of between one and five days may be required after a TURP. Prior to going home the specialist will recommend recovery and activity guidelines and it is important to follow these carefully.
A hospital stay of between one and five days may be required after a TURP. Prior to going home the specialist will recommend recovery and activity guidelines and it is important to follow these carefully.
Laser resection
A variation on the TURP technique is laser resection of the prostate. This is performed in a similar way to a TURP, except that a laser beam is used to cut away the prostate tissue rather than a heated wire loop. This technique tends to produce less bleeding than a TURP and recovery time tends to be quicker.
Transurethral incision of the prostate (TUIP)
TUIP is similar to TURP except that no prostate tissue is removed. Instead, one to three cuts, or incisions, are made into the prostate near the neck of the bladder. This releases the 'ring' of enlarged tissue, creating a larger opening around the urinary tract and hence allowing urine to flow more freely.
Open prostatectomy
This surgery involves removing part, or all of the prostate gland via an incision in the lower abdomen or the perineum (the area between the scrotum and anus). It is also performed by a specialist urologist and it may be recommended in cases where the prostate gland is significantly enlarged. It is usually performed under a general anaesthetic. A hospital stay of up to five days is common after open prostatectomy. Again, the specialist will recommend recovery and activity guidelines.
This surgery involves removing part, or all of the prostate gland via an incision in the lower abdomen or the perineum (the area between the scrotum and anus). It is also performed by a specialist urologist and it may be recommended in cases where the prostate gland is significantly enlarged. It is usually performed under a general anaesthetic. A hospital stay of up to five days is common after open prostatectomy. Again, the specialist will recommend recovery and activity guidelines.
Other procedures
Some additional minimally invasive treatments are becoming available in Australasia. These include microwave therapy (TUMT trans-urethral microwave therapy) and treatments done under anaesthetic such as TUNA (trans-urethral needle ablation) both of which heat the prostate and can relieve symptoms without the need for drugs.
Further information and support
For further information contact your doctor of practice nurse, or contact:
The Prostate Cancer Foundation of New Zealand
Freephone: 0800 4 PROSTATE OR 0800 477 678
Freephone: 0800 4 PROSTATE OR 0800 477 678
Email: info@prostate.org.nz
Website: www.prostate.org.nz
Website: www.prostate.org.nz
The Prostate Cancer Foundation offers information and support about all prostate problems.
References
Deters, L.A. (2016). Benign prostatic hypertrophy (Web Page). Medscape Drugs and Diseases. New York, NY: WebMD LLC. http://emedicine.medscape.com/article/437359-overview [Accessed: 07/07/17]
Andrology Australia (2016). Prostate enlargement (BPH) (Web Page). Melbourne, VIC: Andrology Australia. https://www.andrologyaustralia.org/prostate-problems/prostate-enlargement-or-bph/ [Accessed: 07/07/17]
Mayo Clinic (2016). Benign prostatic hyperplasia (BPH) (Web Page). Rochester, NY: Mayo Foundation for Medical Education and Research. http://www.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/basics/definition/con-20030812 [Accessed: 07/07/17]
O'Toole, M.T. (Ed) (2013). Benign prostatic hyperplasia (BPH). Mosby's Dictionary of Medicine, Nursing & Health Professionals (9th ed.) St. Louis, MI: Elsevier Mosby.
Andrology Australia (2016). Prostate enlargement (BPH) (Web Page). Melbourne, VIC: Andrology Australia. https://www.andrologyaustralia.org/prostate-problems/prostate-enlargement-or-bph/ [Accessed: 07/07/17]
Mayo Clinic (2016). Benign prostatic hyperplasia (BPH) (Web Page). Rochester, NY: Mayo Foundation for Medical Education and Research. http://www.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/basics/definition/con-20030812 [Accessed: 07/07/17]
O'Toole, M.T. (Ed) (2013). Benign prostatic hyperplasia (BPH). Mosby's Dictionary of Medicine, Nursing & Health Professionals (9th ed.) St. Louis, MI: Elsevier Mosby.
Last reviewed – June 2017