A non-cancerous condition that affects many men past 50 years of age, enlarged prostate makes urinating more difficult by narrowing the urethra, a tube running from the bladder through the prostate gland. It can be effectively treated by surgery and, today, by certain drugs.
Description
The common term for enlarged prostate is BPH, which stands for benign (non-cancerous) prostatic hyperplasia or hypertrophy. Hyperplasia means that the prostate cells are dividing too rapidly, increasing the total number of cells, and, therefore, the size of the organ itself. Hypertrophy simply means "enlargement." BPH is part of the aging process. The actual changes in the prostate may start as early as the 30s but take place very gradually, so that significant enlargement and symptoms usually do not appear until after age 50. Past this age the chances of the prostate enlarging and causing urinary symptoms become progressively greater. More than 40% of men in their 70s have an enlarged prostate. Symptoms generally appear between ages 55–75. About 10% of all men eventually will require treatment for BPH.
BPH has been viewed as a rare condition in African, Chinese and other Asian peoples for reasons that are not clear.
Causes and symptoms
The cause of BPH is a mystery, but age-related changes in the levels of hormones circulating in the blood may be a factor. Whatever the cause, an enlarging prostate gradually narrows the urethra and obstructs the flow of urine. Even though the muscle in the bladder wall becomes stronger in an attempt to push urine through the smaller urethra, in time, the bladder fails to empty completely at each urination. The urine that collects in the bladder can become infected and lead to stone formation. The kidneys themselves may be damaged by infection or by urine constantly "backing up."
When the enlarging prostate gland narrows the urethra, a man will have increasing trouble starting the urine stream. Because some urine remains behind in the bladder, he will have to urinate more often, perhaps two or three times at night (nocturia). The need to urinate can become very urgent and, in time, urine may dribble out to stain a man's clothing. Other symptoms of BPH are a weak and sometimes a split stream and general aching or pain in the perineum (the area between the scrotum and anus). Some men may have considerable enlargement of the prostate before even mild symptoms develop.
If a man must strain hard to force out the urine, small veins in the bladder wall and urethra may rupture,
causing blood to appear in the urine. If the urinary stream becomes totally blocked, the urine collecting in the bladder may cause severe discomfort, a condition called acute urinary retention. Urine that stagnates in the bladder can easily become infected. A burning feeling during urination and fever are clues that infection may have developed. Finally, if urine backs up long enough it may increase pressure in the kidneys, though this rarely causes permanent kidney damage.
Diagnosis
When a man's symptoms point to BPH, the first thing the physician will want to do is a digital rectal examination, inserting a finger into the anus to feel whether—and how much—the prostate is enlarged. A smooth prostate surface suggests BPH, whereas a distinct lump in the gland might mean prostate cancer. The next step is a blood test for a substance called prostate-specific antigen or PSA. Between 30–50% of men with BPH have an elevated PSA level. This does not mean cancer by any means, but other measures are needed to make sure that the prostate enlargement is in fact benign. An ultrasound exam of the prostate, which is entirely safe and delivers no radiation, can show whether it is enlarged and may show that cancer is present.
If digital or ultrasound examination of the prostate raises the suspicion of cancer, most urologists will recommend that a prostatic tissue biopsy be performed. This is usually done using a lance-like instrument that is inserted into the rectum. It pierces the rectal wall and, guided by the physcian's finger, obtains six to eight pieces of prostatic tissue that are sent to the laboratory for microscopic examination. If cancer is present, the prognosis and treatment are changed accordingly.
A catheter placed through the urethra and into the bladder can show how much urine remains in the bladder after the patient urinates—a measure of how severe the obstruction is. Another and very simple test for obstruction is to have the man urinate into a uroflowmeter, which measures the rate of urine flow. A very certain—though invasive—way of confirming obstruction from an enlarged prostate is to pass a special viewing instrument called a cystoscope into the bladder, but this is not often necessary.
It is routine to check a urine sample for an increased number of white blood cells, which may mean there is infection of the bladder or kidneys. The same sample may be cultured to show what type of bacterium is causing the infection, and which antibiotics will work best. The state of the kidneys may be checked in two ways: imaging by either ultrasound or injecting a dye (the intravenous venous urogram, or pyelogram); or a blood test for creatinine, which collects in the blood when the kidneys cannot eliminate it.
Drugs
A class of drugs called alpha-adrenergic blockers, which includes phenoxybenzamine and doxazosin, relax the muscle tissue surrounding the bladder outlet and lining the wall of the urethra to permit urine to flow more freely. These drugs improve obstructive symptoms, but do not keep the prostate from enlarging. Other drugs (finasteride is a good example) do shrink the prostate and may delay the need for surgery. Symptoms may not, however, improve until the drug has been used for three months or longer. Antibiotic drugs are given promptly whenever infection is diagnosed. Some medications, including anti-histamines and some decongestants, can make the symptoms of BPH suddenly worse and even cause acute urinary retention, and therefore should be avoided.
Intermediate treatments
When drugs have failed to control symptoms of BPH but the physician does not believe that conventional surgery is yet needed, a procedure called transurethral needle ablation may be tried. In the office and using local anesthesia, a needle is inserted into the prostate and radiofrequency energy is applied to destroy the tissue that is obstructing urine flow. Another new approach is microwave hyperthermia, using a device called the Prostatron to deliver microwave energy to the prostate through a catheter. This procedure is done at an outpatient surgery center.
Surgery
For many years the standard operation for BPH has been transurethral resection (TUR) of the prostate. Under general or spinal anesthesia, a cystoscope is passed through the urethra and prostate tissue surrounding the urethra is removed using either a cutting instrument or a heated wire loop. The small pieces of prostate tissue are washed out through the scope. No incision is needed for TUR. There normally is some blood in the urine for a few days following the procedure. In a few men—less than 5% of all those having TUR—urine will continue to escape unintentionally. Other uncommon complications include a temporary rise in blood pressure with mental confusion, which is treated by giving salt solution. Impotence—the inability to achieve lasting penile erections—does occur, but probably in fewer than 10% of patients. A narrowing or stricture rarely develops in the urethra, but this can be treated fairly easily.
Alternatives to TUR, some only recently introduced, include:
Laser ablation of the prostate. Laser energy is applied to the prostate through a special fiber passed through a cystoscope. The procedure is done in an operating room, and several patients have retained urine postoperatively.
Transurethral incision of the prostate. Less invasive than standard TUR, an incision is made through the prostate to open up the part of the urethra passing through it. This may work well in men whose prostate is not grossly enlarged.
Transurethral vaporization. A small roller ball is used to break up and vaporize the obstructing prostatic tissue, rather than cutting it away as in standard TUR. This is equally successful but patients usually can leave the hospital within 24 hours, and there is less blood loss.
If the prostate is greatly enlarged—as is the case in about 5–10% of those diagnosed, an incision is made to perform an open prostatectomy, removing the entire gland under direct vision.
Alternative treatment
An extract of the saw palmetto (Serenoa repens or S. serrulata) has been shown to stop or decrease the hyperplasia of the prostate. Symptoms of BPH will improve after taking the herb for one to two months, but continued use is recommended.
Prognosis
In a man without symptoms whose prostate is enlarged, it is hard to predict when urinary symptoms will develop and how rapidly they will progress. For this reasons some specialists (urologists) advise a period of "watchful waiting." When BPH is treated by conventional TUR, there is a small risk of complications but, in the great majority of men, urinary symptoms will be relieved and their quality of life will be much enhanced. In the future, it is possible that the less invasive forms of surgical treatment will be increasingly used to achieve results as good as those of the standard operation. It also is possible that new medications will be developed that shrink the prostate and eliminate obstructive symptoms so that surgery can be avoided altogether.
Prevention
Whether or not BPH is caused by hormonal changes in aging men, there is no known way of preventing it. Once it does develop and symptoms are present that interfere seriously with the patient's life, timely medical or surgical treatment will reliably prevent symptoms from getting worse. Also, if the condition is treated before the prostate has become grossly enlarged, the risk of complications is minimal. One of the potentially most serious complications of BPH, urinary infection (and possible infection of the kidneys), can be prevented by using a catheter to drain excess urine out of the bladder so that it does not collect, stagnate, and become infected.
BOOKS
Rous, Stephen N. The Prostate Book: Sound Advice on Symptoms and Treatment. 2nd ed. New York: W. W. Norton, 1995.
Selmans, Sandra. Prostate: Questions You Have… Answers You Need. Allentown, PA: People's Medical Society, 1996.
Walsh, Patrick C., and Janet F. Worthington. The Prostate: A Guide for Men and the Women Who Love Them. New York: Warner Books, 1997.
ORGANIZATIONS
Prostate Health Council. American Foundation for Urologi Disease. 1128 N. Charles St., Baltimore, MD 21201.(800) 242-AFUD.
David A. Cramer, MD
KEY TERMS
Catheter—A rubber or plastic tube placed through the urethra into the bladder to remove excess urine when the flow of urine is cut off, or to prevent urinary infection.
Creatinine—One of the "waste" substances normally excreted by the kidneys into the urine. When urine flow is slowed, creatinine may collect in the blood and cause toxic effects.
Hyperplasia—A condition where cells, such as those making up the prostate gland, rapidly divide abnormally and cause the organ to become enlarged.
Urethra—In males, the tube that conducts urine from the bladder through the penis to the outside of the body. When narrowed by an enlarging prostate, symptoms of BPH develop.
Urinary retention—The result of progressive obstruction of the urethra by an enlarging prostate, causing urine to remain in the bladder even after urination.
