Benign Prostate Disease
Most men will have a degree of prostate enlargement as they get older. About half of the male population over 50 years of age will notice some alteration in their voiding pattern, and for about one third of them, it will be enough of a bother that they will want to do something about it. This is the process we know medically as Benign Prostatic Hypertrophy (BPH). It is not cancerous, but can have other effects on general health if not treated.
What is the Prostate?
The Prostate is the male gland which sits below the base of the bladder. The urethra, which the urine passes, runs through the prostate as shown in the diagram.
The main function of the prostate gland is to aid in the production of semen. It does not produce any hormones. The prostate makes about one third of the fluid that is ejaculated from the penis at time of orgasm. The prostate gland is of no particular function in the elderly.
In most men, beginning about the age of forty, there is a gradual enlargement of the prostate. This occurs to different degrees in different men. In some men the enlarging prostate squeezes on the channel carrying the urine to such an extent that it effects the passage of urine. In a few patients, the prostate gland shrinks and causes a contraction of the neck of the bladder.
Disease of the prostate refers to any medical problem affecting the prostate and includes:
- Benign Prostatic Hyperplasia or hypertrophy (BPH) – this is non-cancerous enlargement of the prostate
- Prostatitis – this is an inflamed prostate usually due to bacterial infection
- Prostate cancer – this is cancerous enlargement of the prostate within the prostate (localized) or outside the prostate (advanced). Refer to cancerous prostate section
Why does benign prostatic hyperplasia (BPH) need treatment?
Although many men have some symptoms of prostate disease, they are usually fairly minor and do not need active treatment. In approximately 25% of men the condition is serious enough to need treatment at some stage.
This is the commonest indication (reason) for treatment. These symptoms include:
- A weak and poor stream
- Difficulty in starting or stopping the flow of urine
- Going to the toilet frequently
- An urgent need to pass urine
- Losing control of urine
- Not emptying the bladder completely
- Having to get up at night to pass urine
- Straining to urinate
- Painful urination
- Pain in between the scrotum and penis
Lower urinary tract symptoms (LUTS)
Lower urinary tract symptoms (LUTS) refer to a range of urinary symptoms linked with benign prostatic hyperplasia (BPH). The symptoms may be mild, moderate or severe and it is matter for each individual to decide if his symptoms are bothersome enough to require treatment (refer to IPPS). IPPS is a short questionnaire that helps determine how severe a patient’s bladder symptoms are.
Although LUTS is often caused by BPH there are other reasons including prostate cancer, prostatitis, medications, neurological disease, spinal cord injury, strictures and infections.
The effect of the blockage of the urine by the enlarging prostate varies from person to person. In some patients quite marked damage to the kidneys or bladder can occur. Incomplete bladder emptying may then produce urinary infections, bladder stones, or marked over activity (sometimes producing incontinence) or underactivity (so that even after the operation the bladder doesn’t work properly). Of course, if these problems have occurred, or are likely to occur, treatment is needed, usually surgical.
At times a complete blockage (acute retention) of the urine occurs. This may occur with little warning, but usually the patient will have had prior symptoms as indicated above. When retention occurs a catheter is usually inserted. Experience shows that if retention has occurred, the best course is usually to proceed with an operation.
It is important you discuss your symptoms with us so that we can investigate the problem, make the right diagnosis and arrange the most appropriate treatment/management.
How is prostatic disease diagnosed?
- Description of symptoms
- Physical examination – a digital rectal examination (DRE) is the main test. This is where the doctor places a gloved finger in the back passage to check the size and shape the prostate and to feel for any other problems of the prostate.
- Blood test – Prostate Specific Antigen (PSA). PSA is a protein that is mainly made in the prostate and an elevated PSA may mean there is either an enlarged prostate, an infection or cancer.
- Other blood tests – urea and creatinine- check kidney function
- Urine tests – check for signs for infections or cancer
- Renal ultrasound – check the health of the kidneys and bladder
- Voiding flow rate and ultrasound residual -measures flow of urine and ultrasound residual checks what is left in the bladder following a void
- Urodynamics studies – pressure and flow relationship study – (refer to uodynamics studies section)
What are the treatment options?
- Surgery – Transurethral resection for the prostate (TURP), Greenlight Laser, Transurethral incision of the prostate (TUIP), Open or retropubic prostatectomy
A number of drugs are also used. The first group are alpha blockers and are derivatives of blood pressure medications. The original was prasozin (Minipress or Pressin). This is still used as it is cheap, but it does lower blood pressure significantly and that can be a real problem. More recently Flomaxtra (Tamsulosin) is prescribed as it appears to improve prostatic obstruction more, with less side-effects. Although fairly expensive for long term use, some patients are quite happily using it. This group of medications can alleviate symptoms but does not fix the underlying problem. They also tend to lose their effect over time.
The second main type of drug are 5-alpha reductase inhibitors which lower male hormone levels within the prostate (testosterone). The available drugs for this group in Australia are finasteride (Proscar) or dutasteriede (Avodart, Duodart). These medications actually shrink the prostate somewhat, but has not been particularly successful in improving the flow (about 15%). They work best with very large prostates, and are also useful in reducing the amount of bleeding from the prostate in various situations.
Herbal treatments have been popular in some countries. Some seem to work, apparently in the same general way as Proscar, but not nearly as effective. We do not prescribe these herbal treatments.
For Surgical treatment options refer to section on Transurethral Resection of the Prostate (TURP) or section on Greenlight.
Can Prostate Problems recur following treatment?
Occasionally they can. Symptoms may recur in the early postoperative phase if scar tissue develops and encircles the urethra or bladder neck. If a ‘Bladder Neck Stenosis’ develops, it requires another minor procedure to release it. The other type of scar tissue is known as ‘urethral stricture’ is generally fairly easy to treat, but may at times require further surgery.
The prostate can grow back to some extent. This usually takes many years if the operation was for a non-cancerous condition. You will probably be asked to come back to see your urologist once or twice after the operation, but if you have urinary problems develop after that, ask your local doctor to arrange another appointment.
Prostate Cancer or Prostate Enlargement?
This section has been about benign (i.e. non-cancerous) prostatic enlargement. Although a small proportion of men who have prostatic problems do have cancer in their prostate glands, we do not generally recommend a TURP to treat it. Treatment of prostate cancer is usually quite different to the treatment of benign prostate complaints.
During the routine tests you have prior to the operation the presence of a cancer would be changed. If you are worried about cancer do not hesitate to ask. We will not conceal anything from you.
Most patients will have a PSA test during pre-operative evaluation. This is a very sensitive test for prostate cancer, but unfortunately it only shows up positive in certain other conditions (including benign prostatic enlargement!).
Small areas of dormant prostate cancer are found in about 10% of older men. They do not usually require treatment if found by the pathologist. There are some cases where an active cancer does not show up on the tests prior to the operation, and is only found by the pathologist when he makes the routine check of the tissue we remove. If this happens you will be told of it and further tests and perhaps treatment begun.
Please contact the Practice Nurse if you have any questions or concerns.