What to do if you have an enlarged prostate

If you are a man and have been having more and more difficulty in urinating lately, there is a good chance that the problem may be due to an enlarged prostate gland  a condition known as benign prostatic hyperplasia (BPH).  It is a common problem many men face as they age.  Treatments are highly variable and depend on your particular symptoms, the size of the prostate, overall health, and your preference.

Some men find that lifestyle changes, along with medications, can provide effective relief.  Others may be helped by minimally invasive procedures or the long-term solution of surgical removal of the obstructing portion of the prostate gland.

As men age

The prostate gland produces most of the fluid that nourishes and transports sperm.  It’s located just below the bladder and surrounds the urethra, through which urine passes out of the body. After puberty, the prostate is about the size of a walnut.  As men age, the gland gradually increases in size (see illustration).

What causes this noncancerous (benign) prostate growth — which typically occurs in the gland’s central area — is uncertain.  Some believe it may be related to changes in the balance of sex hormones associated with aging.  Your risk of developing an enlarged prostate may be greater if your father or brother had similar problems, too. Symptoms of benign prostate growth generally don’t occur until later in life.  Overall, more than half of men in their 60s encounter symptoms related to prostate enlargement and most men in their 70s and 80s have symptoms as a result of it.

As the prostate gland’s central area enlarges, it can press in on the urethra, slowing and interfering with urine flow out of the body. Prostate size doesn’t necessarily predict symptoms’ occurrence.  Symptoms have more to do with how much prostate tissue has enlarged in the center area of the gland, where it creates resistance or obstructs urine flow.  That’s why some men with slightly enlarged prostates experience significant symptoms while others with very enlarged prostates encounter only minor urinary symptoms.  Some men’s symptoms may stabilize and even improve.

Signs and symptoms of prostate gland enlargement may include a weak urine stream, difficulty starting urination, stopping and starting while urinating, needing to urinate urgently, or straining to urinate.  You may urinate more often or find you’re getting up frequently during the night to go to the bathroom.  Over time, severe problems may develop, possibly including urinary tract infections, bladder stones, or — most seriously — obstruction of the kidneys and impaired kidney function.

Some men aren’t aware that they have prostate enlargement because they don’t experience symptoms or they view these symptoms as a normal part of aging.  However, these same men may suddenly find it’s impossible to urinate (acute urinary retention).  This may be triggered after taking a cold or allergy medication that has a decongestant or antihistamine in it.  These drugs can tighten muscles that control urine flow and generally should be avoided if you have an enlarged prostate.

Treatments

Treatments for BPH attempt to reduce troubling symptoms and restore normal function of your urinary tract.  For men who have a mildly enlarged prostate and no symptoms or very mild ones, treatment may not be immediately necessary.  Studies have found that as many as one-third of all mild cases clear up on their own without early treatment.

Medications are commonly used to treat and relieve mild and moderate symptoms due to enlarged prostate.  Drug therapies include:

• Alphablockers. These begin to work quickly by relaxing bladder neck muscles and muscle fibers in the prostate.  These drugs include terazosin, doxazosin, tamsulosin, alfuzosin, and silodosin.  They increase urinary flow and reduce the need to urinate as often.  Side effects may include lightheadedness when standing up too quickly (orthostatic hypotension), but this generally improves over time and may be avoided by taking the medication before bedtime.  While taking an alphablocker, you may experience a harmless condition called retrograde ejaculation — semen flows backward into the bladder rather than forward through the penis.

• Enzyme (5-alpha-reductase) inhibitors. These medications shrink prostate tissue by preventing hormonal changes related to prostate growth and generally work best for very enlarged prostates.  They include finasteride and dutasteride.  It may take months to notice optimal improvement.  In a small percentage of men, side effects may include impotence (erectile dysfunction), decreased sexual desire or retrograde ejaculation.  Talk with your doctor in more detail about risks and benefits to decide what’s best for you.

• Combined drug therapy. When an alphablocker or enzyme inhibitor alone isn’t enough, your doctor may recommend taking one of each at the same time or the combined medication tamsulosin and dutasteride.  Combination therapy can significantly reduce symptoms’ progression better than taking either drug alone. 

• Tadalafil (Cialis). This medication for erectile dysfunction was more recently approved for the treatment of symptoms of prostate enlargement.  However, it should not be taken in combination with alphablockers.

Surgery

If medication isn’t effective, if you have moderate to severe symptoms or your prostate is growing into the bladder, your doctor may recommend surgical treatment.  Some men prefer surgical treatment as a long-term solution instead of taking medication.  The main surgeries remove prostate tissue that otherwise blocks urine flow. The result is lasting relief from symptoms. But there may be side effects, which can vary depending on the procedure.  These may include retrograde ejaculation, loss of bladder control (incontinence), and impotence.  Talk with your doctor about specific risks in the context of your overall health with each treatment you are considering. 

Established surgical procedures to manage enlarged prostates include:

• Transurethral resection of the prostate (TURP). Your surgeon places a lighted scope into your urethra and uses specialized tools to open the channel through the prostate to relieve the obstruction.  TURP relieves symptoms quickly, and most men experience stronger urine flow soon after the procedure. A short hospital stay is often needed, and you can expect to have a urinary catheter for a few days.  Bleeding may be a risk, and you may have some blood in your urine until the prostate lining has healed over. Re-treatment is sometimes necessary in five to seven years.

If surgery is considered too risky and you have a small prostate but moderate-to-severe symptoms, an alternative to TURP is transurethral incision of the prostate (TUIP).  TUIP is a shorter procedure done in a similar fashion to TURP, but instead of removing prostate tissue, one or two small cuts are made in the prostate gland to open a wider channel at the bladder beck to improve urine flow rate.

• Open prostate removal (simple prostatectomy). This surgery is done in instances where the prostate gland is very large.  An incision is made in the lower abdomen — or small openings are made for laparascopic or robotic-assisted surgery — to reach the prostate and remove the interior portion of the gland.  A hospital stay of several days is likely, and a urinary catheter may be in place for as long as seven to 14 days.

Newer modern procedures

Minimally invasive therapies use various forms of heat or energy to shrink or remove excess prostate tissue around the urethra to enlarge the opening from the bladder. Blood loss is less likely during these procedures.  In some modern medical centers abroad, these are usually done on an outpatient basis using lasers.

Various types of lasers are used in different ways to destroy or remove overgrown prostate tissue.  Generally, the laser device is inserted through a narrow scope and into the urethra where it can be directed at prostate tissue.  Symptoms’ relief generally occurs right away, and the risk of side effects is lower than when TURP is done.  So far, there are only a few modern hospitals abroad which have lasers to perform this type of surgery or surgeons who have the specialized training.  But it certainly is part of a new wave of modern therapy for prostate problems that in the future, hopefully, will make the treatment of benign prostatic hyperplasia in older men, more precise and effective, and with less complications.