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Enlarged prostate (benign prostatic hyperplasia)

It is normal for a man’s prostate gland to enlarge from age 40 years and sometimes this can cause a range of symptoms related to urination. More serious bladder and kidney problems may also develop. 

Enlarged prostate is known medically as benign prostatic hyperplasia or benign prostatic hypertrophy (BPH).  Up to 50% of New Zealand men have evidence of BPH by age 60 years and this increases to about 90% of men by age 85–90 years.
 
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). 
Prostate

Introduction

The prostate is a walnut-shaped gland located below the bladder. It is part of the reproductive system, and its main function is to produce the fluid that protects and enriches sperm.

Enlargement of the prostate can gradually cause the urethra (the tube that drains urine from the bladder) to narrow, obstructing the flow of urine. Resulting difficulties with urinating can cause problems with the bladder and kidneys.
 
Prostate gland enlargement is probably caused by hormonal changes associated with aging. A family history of BPH, type 2 diabetes, heart disease, and obesity are factors that increase the risk of developing BPH.
 
An enlarged prostate does not cause prostate cancer. However, prostate cancer can occur in men with an enlarged prostate. 

Signs and symptoms

An enlarged prostate 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.

The term LUTS (lower urinary tract symptoms) is commonly used to refer to the range of urinary symptoms associated with enlarged prostate.

Symptoms can vary 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 will aim to rule out other possible causes for the symptoms such as prostatitis (inflammation of the prostate) or prostate cancer. Diagnosis will likely include: 

  • Discussing the nature, duration, and severity of the current symptoms, the presence of any other medical conditions, and family history of prostate problems.
     
  • A physical examination during which 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 will be done to check kidney function and to check levels of 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.

  • Various urine tests can show infection or the presence of blood in the urine, strength and volume of flow and whether the bladder can be emptied completely.

  • A prostate biopsy or transrectal ultrasound may be used if blood tests indicate an elevated PSA level and the digital rectal examination indicates irregularities of the prostate. The biopsy may be advised in order to rule out prostate cancer. 

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. The choice of treatment depends mainly on the:

  • size of the prostate
  • person’s age
  • person’s overall health
  • severity of symptoms being experienced.
“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 considered if symptoms worsen.

Medical treatment

There are a number of medications that can be used to relieve symptoms of 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. 

Surgical treatment

Surgery will likely be recommended when symptoms become sufficiently severe to affect quality of life, and medication doesn’t provide relief. 

Various minimally invasive procedures have been developed in recent times but transurethral resection of the prostate (TURP) remains the most commonly used. Other similar procedures include laser resection and transurethral incision of the prostate (TUIP).
 
Transurethral Resection of the Prostate (TURP)
A TURP is performed by a urologist (urinary system specialist) and is usually performed under a general anaesthetic. The urologist inserts a resectoscope (a thin tube-like telescope with a light at its tip) through the urethra and up into the prostate gland. The urologist can view the prostate gland and bladder, either through the resectoscope or on a television monitor.
 
Enlarged prostate 1
Diagram courtesy of www.urolog.nl
 
A 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. 

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 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.  

Further information and support

For further information contact your doctor or practice nurse, or contact:
 
Prostate Cancer Foundation NZ
Freephone: 0800 4 PROSTATE (0800 477 678)
Email: info@prostate.org.nz
Website: www.prostate.org.nz 
 
The Prostate Cancer Foundation offers information and support about all prostate problems.

References

Deters, L.A. (2019). Benign prostatic hyperplasia (BPH) (Web Page). Medscape Drugs and Diseases. New York, NY: WebMD LLC. http://emedicine.medscape.com/article/437359-overview [Accessed: 02/04/20] 
Mayo Clinic (2019). Benign prostatic hyperplasia (BPH) (Web Page). Rochester, MN: Mayo Foundation for Medical Education and Research. https://www.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/symptoms-causes/syc-20370087 [Accessed: 02/04/20] 
O'Toole, M.T. (Ed) (2017). Benign prostatic hyperplasia (BPH). Mosby's Dictionary of Medicine, Nursing & Health Professionals (10th ed.) St. Louis, MI: Elsevier. 
Urology Health (2019). What is benign prostatic hyperplasia (BPH)? (Web Page). Linthicum, MD: Urology Care Foundation – Official Foundation of the American Urological Association. https://www.urologyhealth.org/urologic-conditions/benign-prostatic-hyperplasia-(bph) [Accessed: 02/04/20]
 
 
Last reviewed – April 2020
 
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