Enlarged Prostate

What is an enlarged prostate?

The prostate, a small gland that produces fluid for semen, is in an ideal position to cause trouble. The gland wraps snugly around the urethra, the tube that carries urine from the bladder. It's a tight squeeze -- and it only gets tighter as men grow older.

As men age, the prostate inevitably grows, putting more and more pressure on the urethra. For some men, this growth is too slow to ever cause any symptoms. But for most, it's only a matter of time before trouble sets in. According to the National Institutes of Health, more than half of all men in their 60s and 90 percent of men in their 80s have symptoms of an enlarged prostate, also called benign prostatic hyperplasia, benign prostatic hypertrophy, or simply BPH.

For most men, an enlarged prostate is little more than a nuisance. But in severe cases, it can completely block the flow of urine and create a medical emergency. Whether a man's condition is mild or extreme, he has many options for relief.

What are the symptoms of an enlarged prostate?

As the prostate begins to squeeze the urethra, emptying the bladder becomes more and more difficult. Common symptoms include the following:

  • Frequent urination, especially at night
  • A weak urine stream
  • topping and starting during urination
  • Leaking, dribbling
  • A feeling that the bladder is never completely empty

How is an enlarged prostate diagnosed?

If you're a man over 40 with the above symptoms, your doctor will immediately suspect an enlarged prostate. However, it's not the only possible diagnosis. The doctor will probably want to run a few other simple tests to rule out other conditions. A urine test can check for infection. A prostate-specific antigen (PSA) blood test combined with a digital rectal exam may help rule out prostate cancer. The digital rectal exam will also allow the doctor to feel the prostate and gauge its size. Be sure to discuss these tests with your doctor if he recommends them in order to weigh their potential benefits or risks.

In some cases severe symptoms appear even though the prostate is only slightly larger than normal. For this reason, your doctor may not notice any unusual swelling during the digital rectal exam. If there's doubt about the cause of symptoms, the doctor may take a closer look by inserting a cystoscope -- a narrow tube equipped with a tiny camera -- into the urethra. You may also be asked to urinate into a device that measures urine flow.

What can I do to ease my symptoms?

First things first: If you have symptoms of an enlarged prostate, you should see your doctor. Remember, there's a chance that your symptoms may signal something more serious. Once your doctor diagnoses your enlarged prostate, there are many things you can do to help yourself. If your symptoms are mild, these self-care steps, adapted from Mayo Clinic guidelines, may be the only treatment you need:

  • You can cut down on nighttime trips to the bathroom by avoiding drinking beverages after 7 pm.
  • Try to urinate when you first feel the urge. Every time you urinate, make an extra effort to empty the bladder completely.
  • Go easy on alcohol and caffeine, which increase the need to urinate.
  • Avoid over-the-counter cold remedies that contain antihistamines and decongestants. Antihistamines can impair the muscles that control the opening to the bladder and the bladder itself. Decongestants can tighten muscles around the bladder, making it difficult to empty. If the cold medication contains both, it may be nearly impossible to urinate.
  • Stay active. Regular exercise can help keep urine from pooling in your bladder.
  • Keep warm. When your body is cold, your bladder is more likely to retain extra urine.

What can my doctor do to treat my enlarged prostate?

In recent years, the Food and Drug Administration has approved several drugs for the treatment of enlarged prostates. One class of drugs, known as alpha-blockers, relaxes muscles at your bladder neck and makes it easier to urinate. Some of the drugs in this category include terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), and alfuzosin (Uroxatral). The FDA issued a warning in 2005 for alpha blockers because they may cause a pupil disorder that can complicate cataract surgery.

Another class of drugs enzyme (5-alpha-reductase) inhibitors works to ease BPH by shrinking the prostate. In February 2009, the American Society of Clinical Oncology and the American Urological Association announced joint prostate cancer guidelines recommending men and their doctors discuss taking 5-alpha-reductase inhibitors to reduce the risk of prostate cancer. Two of these drugs have been approved by the FDA: finasteride (Proscar) and dutasteride (Avodart). Because it inhibits the production of PSA, which in levels higher than 2.6 nanograms per milliliters of blood is associated with prostate cancer, researchers believe finasteride may also help prevent or delay that disease as well.

In a seven-year, double-blind study of almost 19,000 men reported in the New England Journal of Medicine, researchers found that finasteride reduced the risk of prostate cancer by about 25 percent. Not all of the results were positive, though. Although fewer men on finasteride developed prostate cancer than those on a placebo, those who did get the disease were more likely to develop more serious tumors, which tended to grow quickly. However, a follow-up study, published in the Journal of the National Cancer Institute, showed that finasteride did not cause tumors. In fact, researchers in the follow-up study discovered that finasteride increased the overall sensitivity of PSA testing to detect tumors, including high-grade ones.

Doctors caution that no medication is a sure cure. Although taking these drugs usually improves symptoms, they may not be enough to bring about a return to normal. For this reason, many men eventually need more serious treatment.

Surgery used to be the most common treatment for enlarged prostate, but its use is declining because of the availability of new medications and less invasive treatments. In the most common procedure, a surgeon inserts a special wire down the urethra and removes a small section of the prostate. This is called transurethral resection of the prostate or TURP. The procedure only takes about 90 minutes, but most patients have to recover in the hospital for several days. The operation carries a small risk of impotence and infection. Surgery tends to be used when other treatments fail, or when the patient has frequent complications, such as urine retention, urinary tract infections, or bladder stones.

If the prostate is extremely large, or if the bladder needs surgical repair, a surgeon may need to operate through an incision. This is a major operation, and surgeons will avoid it if possible.

Several alternatives to surgery have come along in the past 15 years. In a procedure called transurethral microwave thermotherapy (TUMT), a doctor inserts a tube into the urethra that emits carefully aimed microwaves to destroy a section of the prostate. TUMT is more effective than medications at improving urine flow, but less effective than surgery. Most men require a catheter for a few days after the procedure. A similar procedure, called transurethral needle ablation (TUNA), does the same job with radio waves. This procedure is also considered more effective than medications, but less effective than surgery. Both these treatments are best for men with mild to moderate obstructions. They don't work well for men with very large prostates. Neither of these procedures is known to cause impotence, but they may temporarily cause frequent or painful urination, or urinary tract infections.

Whatever treatment your doctor recommends, be sure to get a clear explanation of the risks, benefits, and goals of the treatment. With so many options available, you and your doctor should be able to find an approach that works for you.

References

American Society of Clinical Oncology. New ASCO/AUA guideline recommends men and their doctors discuss using 5-ARIs to reduce prostate cancer risk. February 2009. http://www.auanet.org/content/press/press_releases/article.cfm?articleNo=101

Kramer BS et al. Use of 5- -Reductase Inhibitors for Prostate Cancer Chemoprevention: American Society of Clinical Oncology/American Urological Association 2008 Clinical Practice Guideline. Journal of Clinical Oncology. Volume 27, Number 9. March 20, 2009.

"The Prostate-Specific Antigen (PSA) Test: Questions and Answers, National Cancer Institute, U.S. National Institutes of Health.

National Institutes of Health. Prostate enlargement: Benign prostatic hyperplasia. January 2000.

Mayo Clinic Health Letter. Enlarged prostate gland. April 2001. 19(4): 1-3.

American Academy of Family Physicians. Benign prostatic hyperplasia. 2000.

Blute, M.L. et al. Introduction [to benign prostatic hyperplasia overview issue]. Urology. December 2001. 58(6A): 1-4.

Thompson, IM, et al. The influence of finasteride on the development of prostate cancer. New England Journal of Medicine 2003;10.1056/NEJMoa030660

First Prostate Cancer Prevention Drug Found, But Not All Men Benefit: NCI Announces Results of Prostate Cancer Prevention Trial. National Cancer Institute. June 24, 2003. http://www.nci.nih.gov/newscenter/pressreleases/PCPTresults

Mayo Clinic. Enlarged Prostate (BPH). April 2007. http://www.mayoclinic.com/health/enlarged-prostate-bph/BP99999/PAGE=BP00009

Food and Drug Administration. 2005 Safety Alerts. http://www.fda.gov/medwatch/safety/2005/safety05.htm#Flomax

Thompson, IM et al. Effect of Finasteride on the Sensitivity of PSA for Detecting Prostate Cancer. Journal of the National Cancer Institute. Volume 98, Number 16. June 1, 2006. http://jnci.oxfordjournals.org/cgi/content/full/98/16/1128

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