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What is an enlarged prostate (benign prostate hyperplasia)?

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The prostate is a gland the size of a chestnut. It is only present in men, and it is situated under the bladder surrounding the urethra, the passageway which takes the urine to the outside. The gland produces seminal fluid which is mixed with sperm to make semen which the man ejaculates.

With age, the gland may begin to grow. This growth happens to most men. The growth may eventually cause problems with urination because the gland pinches off the urethra as it increases its size. The growth in itself is harmless and consequently the condition is called benign prostate hyperplasia (BPH). This occurs most often in men above the age of 60. Up to 30 per cent of men in their 70s have BPH which causes them symptoms.

What kinds of problems can an enlarged prostate cause?

The enlargement of the prostate gland stretches and distorts the urethra and therefore obstructs the urine flow. Symptoms include:

  • A weak or interrupted urinary stream. Several attempts to empty the bladder may be necessary
  • Difficulty starting the urine flow even when the bladder feels full
  • A feeling the bladder is not completely empty
  • A need to urinate often during the day as well as during the night. Increased need to urinate in the night is usually a very early symptom
  • A need to urinate right away. Some men may experience involuntary discharge of urine
  • Dribbling of urine after urination
  • Burning sensation or pain during urination
  • Repeated bladder infections (cystitis)

Different men get different symptoms. The symptoms may also vary with each individual throughout the course of the disease. It is important to emphasize that the above symptoms do not necessarily prove that the prostate is enlarged . Other diseases may cause similar symptoms. Men with problems urinating should always see their doctor.

How does the doctor diagnose and an enlarged prostate?

Patients will be asked about their symptoms and may also be asked to fill out a symptom questionnaire to let the doctor know the nature of the symptoms and how troublesome they are. They may also be asked to record their drinking and urination over a period of three days.  By carrying out a rectal examination, the doctor can feel through the rectum wall whether or not the prostate is enlarged. Usually, the patient’s urine will be examined, and may be sent for culture, when it will also be tested for sensitivity to antibiotics. Kidney function will also be examined by a blood test.

If there is a need for further tests, they will usually be carried out by a specialist. He or she will be able to check for specific urinary functions like the flow rate of the urine and whether the bladder is emptied on urination. X-rays including ultrasound examinations and blood tests may be necessary. Many hospitals  and a number of general practices have specialized prostate clinics where a full prostate check is carried out.

How does the doctor treat an enlarged prostate?

There are a variety of treatment strategies for this condition. Treatment is only necessary if the symptoms are bothersome or complications are present. Each treatment has advantages and disadvantages. The patient and his doctor will have to decide which is most appropriate.

Wait and see (watchful waiting):

  • If there are only a few minor symptoms it might be best to wait and see how it develops.
  • A doctor should be consulted regularly to avoid complications setting in.

Medical treatment

  • Alpha blockers. These drugs help to relax muscle fibres within the prostate thereby reducing the obstruction to the flow.  They do not reduce the size of the prostate. Examples include Terazosin, Alfuzosin and Tamsulosin. Patients occasionally experience side-effects such as dizziness, headache, drowsiness and retrograde ejaculation.
  • 5-alpha-reductase-inhibitors like finasteride inhibit the growth of prostate and decrease the size of the gland.

Research studies have shown that both types of drug treatment are effective at improving urinary symptoms in men with BPH.

What kind of surgery is available for an enlarged prostate?

An operation on the prostate will involve the removal of parts of the enlarged tissue. The most common operation is an endoscopic surgical procedure where parts of the enlarged tissue are peeled off. This is called transurethral resection (TUR). If the prostate is only slightly enlarged, it may be enough to make a little cut in the prostate, without removing tissue, to reduce the constriction of the urethra. his is called transurethral incision (TUI).

If the prostate is considerably enlarged it may be necessary to make an incision in the lower abdomen and to carry out an open operation. But this procedure is only carried out rarely.

Surgery carries more risk than medical treatment and there are possible complications including retrograde ejaculation. In retrograde ejaculation, the sperm enters the bladder during ejaculation instead of being expelled through the penis. Later it is flushed out with urine. Studies estimate that 74 per cent of men will experience retrograde ejaculation after transurethral resection of the prostate (TURP).

Surgery has also been linked with side effects of erectile dysfunction (in 14 per cent of men after TURP) and urinary incontinence (five per cent). But studies are inconclusive as to whether the same rates of these problems would have occurred anyway in men not undergoing surgery. The  benefits of surgery are long lasting but because only part of the prostate is removed, some men may eventually need another operation.

  • Microwave thermotherapy: In this treatment, the prostate tissue is heated to around 45° C by means of microwaves. This reduces the size of the prostate by causing cells in the center of the prostate to die. This treatment is carried out through the urethra.
  • Electrovaporisation: In this procedure, part of the prostate tissue is removed by evaporation by means of electrical current. The treatment is performed with an endoscope.
  • Laser-resection: Another endoscopic treatment, in which part of the prostate tissue is removed with laser energy. For this treatment, inserting a tube made of metal or plastic – which remains in place where the prostate gland obstructs the urethra, creates a passage. This procedure is used only on rare occasions, for those patients who are unable to be considered for other forms of treatment.

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