ENLARGED PROSTATE | CAUSES AND TREATMENTS
As men age, they have a greater chance of having an enlarged prostate, which can block the natural flow of urine. Read about causes and treatment options.
By the time you reach the age of 60, you have a 50/50 chance of having an enlarged prostate. When you blow out 85 candles on the birthday cake, the likelihood increases to 90%.
You might be wondering, "If it’s so common, what’s the big deal about having benign prostatic hyperplasia (BPH)?"
To begin with, a healthy prostate is important in supporting sperm nourishment and transport. When a man ejaculates, the prostate produces the semen that propels the sperm. In a post-pubescent male, the prostate is about the size of a walnut and stays that way until age 40. For a still unknown reason, the prostate experiences a second growth spurt and can grow to the size of an apricot or even a lemon.
When you take into account that the prostate gland is located just below the bladder at the site where the urethra connects, you can start to see how this can become a serious issue. The enlarged prostate begins to interfere with the urethra, the tube inside the penis that carries urine and semen out of the body. The pressure can block the natural flow of urine (and semen) causing irritation. If left untreated, this condition can lead to more serious problems.
There is not a consensus among physicians on exactly why the prostate begins to grow again, though it is widely speculated that an excess of certain hormones may be the catalyst. One study has shown a high correlation between DHT levels (dihydrotestosterone) in the blood and enlarged prostates. Conversely, men with low DHT levels do not experience enlarged prostates.
Estrogen has also been linked to prostate enlargement. As men age, less testosterone is found in the blood stream creating a larger proportion of estrogen. High levels of estrogen have been documented as a marker for this condition as well.
One important thing to note: just because you have a larger prostate does not necessarily mean you will suffer. As with real estate, it’s all about location, location, location. The position in relation to the urethra is more important than the actual size. What must be remembered is if you recognize any of the symptoms below, you need to ask for clinical testing to determine obstruction.
- A weak or interrupted urinary stream
- Sudden urgency to urinate
- Frequent urination
- Inability to completely empty the bladder during urination
- Trouble initiating urine flow even when bladder feels full
While these are most common, you may have an enlarged prostate and still not experience any of these. It's safe to say that after the age of 40, you will want to keep a dialogue with your physician about your prostate health as well as receiving full exams.
Important note: symptoms of bladder cancer, overactive bladder (OAB), and urinary retention may be similar to those associated with an enlarged prostate. It is important to have your primary care physician make a referral to a urologist if you fall into any of the following categories:
- Young patients
- Abnormal rectal exam, PSA, or urinalysis (see descriptions of these procedures below)
- History of extensive urethral instrumentation or stricture
- Poor response to medical therapy
As with all incontinence conditions, a thorough diagnosis must be developed before action can be taken. You may have heard of some of these exams. And if you haven’t, now is a good time to familiarize yourself with them. Not only is knowledge power, but it also eliminates surprises.
- Digital Rectal Exam. Due to the natural position of the prostate gland, an enlargement may be felt through the wall of the rectum. Your physician will insert a gloved finger into the rectum in order to assess the size and condition of the prostate gland.
- Urinalysis. With a urine sample, the laboratory can test for infections or other problems. This is a simple way to rule out bladder infection and bladder cancer, which can cause similar symptoms.
- Prostate Specific Antigen Test (PSA). Similar to a urinalysis, the PSA monitors the level of prostate-specific antigen in a patient's blood. Through a routine blood draw, this test can be used to check for prostate cancer and an enlarged prostate. Additionally, a man’s PSA may actually be an indicator of whether or not he is at risk for continued prostate enlargement.
- Urodynamic Tests. Urodynamics are a group of diagnostic tests done to evaluate the performance of the lower urinary tract. Measuring bladder pressure and urinary flow, these tests investigate problems such as urine control, urinary frequency or urgency, poor bladder emptying, and intermittent urination. A low flow and high pressure usually indicate obstruction to the urinary outlet.
- Cystoscopy. During cystoscopy, a small flexible fiberoptic camera is inserted into the urethra and bladder to evaluate the anatomy of the urethra, prostate, and bladder. To learn about screening for prostate cancer, check out the American Cancer Society's updated guidelines on prostate cancer screening.
Because those with BPH can experience symptoms from mild to severe, the treatment options featured here are organized from least invasive to more intense.
Men experiencing minimal symptoms of BPH may choose to practice what is called active surveillance. This means to simply monitor your condition and continue to meet with his physician regularly until changes warrant intervention.
- Transurethral Microwave Therapy. A controlled dose of microwave energy is delivered to the prostate, destroying excess prostate tissue that is causing blockage.
- Transurethral Needle Ablation. Low-level radio frequency energy is delivered to the prostate, destroying excess tissue.
- Laser Therapy. Removal of the prostate tissue to reduce overall size.
- Laser Vaporization. Uses higher energy laser vaporize the enlarged prostate obstruction and open the urethra.
- Transurethral resection of the prostate (TURP). In this surgery, the inner portion of the prostate is removed. Used 90% of the time, this is the most commonly used surgical procedure for BPH.
- Open prostatectomy (open surgery). The surgeon makes an incision and removes the enlarged tissue from the prostate.
- Laser surgery. Laser surgery uses laser energy to destroy prostate tissue and shrink the prostate.
- Transurethral incision of the prostate (TUIP). This surgery does not involve removing prostate tissue. A few small cuts are made in the prostate gland to reduce the prostate's pressure on the urethra, making urination easier.
There are two main classes of pharmaceuticals that work to alleviate enlarged prostate symptoms: alpha blockers and alpha reductase inhibitors
- Alpha Blockers. Alpha blockers relax the smooth muscle around the bladder neck and within the urethra.
- Inhibitors. Inhibitors stop the conversion of the male hormone testosterone to DHT to reduce the prostate's size, eliminating blockage.
Don’t be surprised if your physician prescribes a combination of the two medications, as they have been shown to work more effectively together than alone. The downside is that combination therapy may increase the likelihood of experiencing side effects from the medications. Be sure to work with your doctor to assess the benefits and costs (side effects) before starting on combination therapy.