Enlarged Prostate

What is an enlarged prostate?

An enlarged prostate is a prostate gland that is bigger than normal. The prostate is part of a man's reproductive system. It is, on average, a little bigger than a walnut. It is located between the base of the bladder and the beginning of the penis. It surrounds the upper part of the urethra. (The urethra carries urine from the bladder out through the penis.) The prostate makes the fluid that nourishes and carries sperm. When the prostate gets bigger, it may put pressure on the urethra and cause problems with urination.

Other names for this condition are benign prostatic hyperplasia (BPH), benign prostatic hypertrophy, and enlarged prostate.

BPH is a common health problem for men over age 60.

What is the cause?

A man’s prostate gland starts to get bigger at puberty, but it usually does not start to get big enough to cause problems until around the age of 50. Enlargement of the prostate can make the passageway through the urethra smaller. The bladder muscle forces urine through the narrowed urethra by squeezing more strongly. This can make the bladder muscle thicker and more sensitive. The change in the muscle can cause urination problems, such as a need to urinate more often. As the prostate grows even bigger, the urethra may be squeezed more tightly. This can cause a blockage (obstruction) and may make it hard for the bladder to empty completely.

What makes the prostate get bigger is not known.

What are the symptoms?

Many men with enlarged prostates have no symptoms. If you have symptoms, they may include:

• a weak stream of urine
• stopping and starting of the stream of urine
• leaking of urine
• dribbling of urine, especially after urinating
• a feeling that the bladder is not empty
• trouble starting to urinate
• urinating more often, especially at night
• a strong and sudden desire to urinate
• blood in the urine

BPH may cause urinary tract infections. If you have an infection, you may have burning or pain during urination.

BPH may also cause a sudden inability to urinate. This is called acute urinary retention and is a medical emergency.

How is it diagnosed?

Your healthcare provider will ask about your medical history and symptoms. Your provider will examine you to check for other medical problems that might cause your symptoms.

You will have a rectal exam. Your provider can feel the prostate by putting a gloved, lubricated finger into the rectum. The exam allows your provider to estimate the size and condition of the prostate.

You may have urine tests to check for blood or signs of infection. You may have blood tests to check for kidney problems or prostate-specific antigen (PSA).

Your provider may refer you to a urologist for more tests. Urologists specialize in diseases of the urinary tract and the male genital tract. Before you are treated for BPH, it is important to rule out other diagnoses, such as cancer. Other tests you might have are:

• Rectal ultrasound and prostate biopsy: A probe put into the rectum sends sound waves at the prostate to create a picture of the prostate gland. Your provider may use a needle, guided by the ultrasound images, to collect a few pieces of prostate tissue to check for cancer.
• A test to measure how fast urine flows when you urinate and the amount of urine left in the bladder after you urinate.
• Cystoscopy: For this test your provider uses a slim, flexible, lighted tube inserted through the urethra to look at the bladder and prostate. (You are given a solution to numb the inside of the penis so that you will have little discomfort during the test.)

Sometimes tests called a urodynamic study may be done to see how well your bladder and sphincter muscles work when you urinate. The tests can show how well the bladder and urethra are doing their job of storing and releasing urine.

How is it treated?

If you have BPH but no symptoms, or your symptoms are mild, you may not need any treatment. Your provider may advise you to have regular exams to be sure that you are not developing more serious problems. This is called watchful waiting. Your symptoms may get better without treatment.

If your symptoms become bothersome or there is a risk that your kidneys will be affected, your provider may recommend treatment. BPH may be treated with medicines or various procedures.

These medicines may be used for treatment of BPH:

• Finasteride (Proscar) and dutasteride (Avodart) can stop the prostate from getting larger. These drugs may even cause the prostate to get smaller. As a result, your symptoms may get better. These drugs do not work for everyone.
• Alpha blockers, such as terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), and alfuzosin (Uroxatral), relax the muscles in the prostate. These medicines can often lessen symptoms.

Drug treatment does not always work. Different procedures may be done to relieve BPH symptoms.

• Transurethral microwave thermotherapy (TUMT) uses microwaves to heat and destroy excess prostate tissue. The procedure takes about 1 hour and can be done without general anesthesia. TUMT does not appear to cause erectile dysfunction (impotence, or ED) or loss of bladder control (incontinence). Microwave therapy does not cure BPH, but it lessens symptoms, such as having to urinate too often. It does not always correct the problem of incomplete emptying of the bladder.
• Transurethral needle ablation (TUNA) delivers low-level radio waves through needles to burn away part of the enlarged prostate. This procedure improves urine flow and relieves symptoms. It does not appear to cause incontinence or ED.
• Surgical removal of the enlarged part of the prostate is often the best long-term solution for BPH.
  • Removal of the prostate or part of it reduces pressure on the urethra and generally gives relief from symptoms. The common surgical procedure for BPH is transurethral resection of the prostate (TURP). For this procedure the surgeon removes just the part of the prostate that is pressing on the urethra. The surgeon uses a small scope and wire loop inserted through the penis to do this.
  • In some cases a procedure called transurethral incision of the prostate (TUIP) may be done instead of TURP. Instead of removing prostate tissue, the surgeon passes a cutting tool through the penis. The tool is used to make a few small cuts in the prostate and in the part of the urethra that joins the bladder. The cuts reduce the prostate's pressure on the urethra, making it easier to urinate.
  • Another surgical procedure uses a laser to destroy prostate tissue that is causing blockage. This procedure is called laser prostatectomy, or laser TURP Your healthcare provider passes the laser fiber through the urethra into the prostate using a cystoscope. The laser delivers several bursts of energy. The laser energy destroys prostate tissue and relieves the obstruction. An advantage of laser surgery is that it causes less blood loss than other surgical procedures. Recovery from the procedure is also faster. But laser surgery may not work if you have a very large prostate. Also, how long the effect of this treatment will last is not known.
  • Sometimes open surgery is needed. The surgery is called open prostatectomy. It means that prostate tissue is removed through a cut (incision) made in your lower abdomen. Open surgery is often done when the gland is quite large, when the bladder has been damaged and needs to be repaired, or when there are other problems.

You will be given an anesthetic for all surgical procedures so that you do not have pain during the surgery.

Ask your provider about the potential risks and benefits of medicine, surgery, and other possible treatments.

How long will the effects last?

Serious urinary problems from BPH affect 1 in 10 older men. Without treatment your symptoms may get better, stay the same, or get worse. BPH may hurt the bladder or kidneys over time. If the bladder is damaged by BPH, treatment for BPH may not be as effective.

TURP, TUIP, and simple open prostatectomy give immediate relief of obstruction and the urine starts flowing better right away. Other symptoms such as frequent urination and night-time urination may take longer to get better. Many men notice that their bladder symptoms are better within 2 to 3 weeks after these procedures. Laser TURP and procedures that use heat (thermotherapy), such as TUNA or TUMT, rely on sloughing off tissue, which usually takes a few weeks, so symptoms usually take longer to improve.

With treatment, the improvement in symptoms tends to last a long time. You will not feel the need to urinate as often and you will have few or no urination “emergencies.”

Sometimes the symptoms come back. If they do, you may need to have the procedure again after several years. This happens more often after thermotherapy than after TURP or open prostatectomy.

BPH is not cancer and it does not seem to increase the chances of getting prostate cancer. You can, however, have both BPH and prostate cancer at the same time.

How can I help take care of myself?

If you have symptoms of BPH, it is important to get checked by your healthcare provider because prostate cancer causes similar symptoms.

Follow the treatment prescribed by your healthcare provider.

What can I do to help prevent BPH?

Doctors don’t know how to prevent BPH. It is a common part of aging.