An enlarged prostate is a non-cancerous condition in which the narrowing of the urethra makes the elimination of urine more difficult. It most often occurs in men over age 50.
A non-cancerous condition that affects many men past 50 years of age, enlarged prostate makes eliminating urine more difficult by narrowing the urethra, a tube running from the bladder through the prostate gland. It can effectively be treated by surgery and, today, by certain drugs.
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 often 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 the ages of 55 and 75. About 10% of all men eventually will require treatment for BPH.
BPH has been viewed as a rare condition in blacks, but this finding may partly be due to the fact that black patients may have less access to medical care. The condition also seems to be uncommon in the Chinese and other Asian peoples, for reasons that are not clear.
Causes & 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—to his embarrassment. 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
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.
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 (PSA). Between 30–50% of men with BPH have an elevated PSA level. In fact, recent studies indicate that the PSA level can be used as a predictor of a man's long-term risk of developing BPH. A high BPH level does not indicate cancer by any means, but other measures are needed to make sure that the prostate enlargement is benign.
An ultrasound examination 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 physician's finger, obtains six to eight pieces of prostatic tissue that are sent to the laboratory for microscopic examination.
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 that 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 urogram, or pyelogram); or a blood test for creatinine, which collects in the blood when the kidneys cannot.
An extract of the saw palmetto (Serenoa repens or S. serrulata) has been shown to stop or decrease the hyperplasia of the prostate. The herb is believed to inhibit the enzyme that converts one type of testosterone to another (significant in both prostate enlargement and prostate cancer), offering the same positive effects as the prescription drug Poscar (finasteride) without the negative side effects. Symptoms of BPH will improve after taking the herb for one to two months, but continued use is recommended.
Zinc has also been found effective in shrinking an enlarged prostate. A 15–30 mg zinc supplement, or inclusion of pumpkin or sunflower seeds in the daily diet can produce the desired effect. Prevention of prostate inflammation and swelling is thought to be aided by an increase in essential fatty acids. One source of these fatty acids is flaxseed oil, available in capsule or liquid form at most health food stores.
The increase in circulation to the groin achieved by certain yoga poses and exercises can also ease prostate problems. The knee squeeze and the seated sun poses should become a part of the daily routine. The stomach lock exercise, performed in a supine position, involves taking a deep breath and then breathing out slowly as the buttocks, groin, and stomach muscles are pulled in. Experts believe this exercise can both prevent prostate problems and treat flare ups; however, this exercise is not recommended for those with hypertension, heart disease, hiatal hernia, or ulcers.
Imagery that involves picturing the prostate shrinking to normal size and sensing an even flow of urine, practiced twice a day, can be helpful. A reflexology session to relax the entire body, with special attention to the prostate and endocrine reflexes in the hands and feet, may help the body heal itself.
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
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, or TUNA, may be tried. The patient is given local anesthesia, and a needle is inserted into the prostate and radio frequency energy is applied to destroy the tissue that is obstructing urine flow. TUNA was approved for patients in the United States by the FDA in 1996. 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.
Another treatment option for BPH involves the placement of a spiral stent, which is a small spring-shaped device placed in the urethra itself. When the stent is expanded, it pushes back the tissue and enlarges the urethra. Stents can be placed under a local anesthetic; they can be used as a stand-alone treatment or in combination with surgery to speed recovery. Stents are often recommended for patients who cannot take medications for BPH and are also poor candidates for more invasive surgery. The first stents used to treat BPH were made of stainless steel, but newer stents made of a biodegradable plastic material are now available. These stents break up into small fragments after two to three months and are eliminated from the body. They appear to offer a safe way to improve the patient's urinary drainage after surgery without the need for a special procedure to remove the stent several months later.
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.
Studies of men who undergo transurethral resection after acute urinary retention indicate that the general public is still not well informed about BPH. A majority of the men who were diagnosed with acute urinary retention said that they had had their symptoms for over a year. When asked why they did not seek treatment earlier, 35% said they were afraid of surgery, but 41% thought their symptoms were only a normal part of aging.
In several studies, 160 mg dose of saw palmetto given twice daily for 45 days achieved positive results in approximately 80% of the patients studied. That percentage increased when results were obtained after 90 days. When BPH is treated by conventional TUR, there is a 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.
Whether or not BPH is caused by hormonal changes in aging men, there is no known way of preventing the condition as of 2002. 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 is urinary infection (and possible infection of the kidneys), which 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.
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American Urological Association. 1120 North Charles Street, Baltimore, MD 21201. (410) 727-1100. <www.auanet.org>.
Prostate Health Council. American Foundation for Urologic Disease. 1128 N. Charles Street, Baltimore, MD 21201. (800) 242-AFUD.
Kathleen D. Wright
Rebecca J. Frey, PhD