Benign prostate enlargement (BPH) is a normal part of the ageing process in men. This can cause bothersome urinary symptoms and may lead to complications with time. Fortunately there are many ways this can be treated.
What is a prostate?
A prostate is a walnut sized gland that sits in front of the bladder and surrounds the urethra, the tube you pass urine from. The prostate makes ejaculatory fluid, the milky white fluid that makes up most of the ejaculate. This provides nourishment for the sperm and a mechanism for their delivery into the vagina during intercourse.
Why do prostates enlarge with age?
The prostate tissue is very responsive to testosterone, the male hormone made in the testes. Testosterone stimulates the prostate glands to grow – as men usually don’t stop making testosterone as they get older, their prostates may continue to grow in size.
Why does an enlarged prostate affect urination?
The prostate sits in front of the bladder and surrounds the urethra. As it enlarges, it may put pressure on these areas leading to obstruction. The overall size of the prostate does not correlate to the degree of obstruction, the more important cause is the location of the abnormal enlargement within the prostate. If the enlarged area is at a strategic point such the bladder neck it is much more likely to cause symptoms. This explains why a man with a smaller prostate may have worse symptoms than a man with a much larger prostate.
What symptoms does BPH cause?
BPH may cause a variety of urinary symptoms:
- Weak urine stream
- Intermittent urine stream
- Feeling of incomplete emptying
- Frequent voiding
- A sudden urge to void
- Waking at night to void repeatedly
What complications may occur if BPH is left untreated?
Most men with BPH have minor symptoms and do not have complications. In some men with severe obstruction, the following complications may occur:
- Urinary retention (a painful condition where you can’t void at all)
- Recurrent urinary infection (UTI)
- Pressure related damage to the bladder
- Bladder stones
- Haematuria (blood in the urine)
- Kidney failure from chronic backpressure
How is BPH diagnosed?
We perform a few different tests to confirm BPH is responsible for your urinary symptoms rather than another cause such as infection of prostate cancer. These tests also allow us to asses the severity of the problem to help direct the most appropriate treatment. This may include:
- A questionnaire about your symptoms (IPSS score)
- A fluid intake and output diary
- A urine test to exclude infection
- A blood test to check your PSA level and kidney function
- A urine flow test
- An ultrasound of your prostate, bladder and kidneys
In some circumstances, we may recommend a look inside your prostate and bladder with a cystoscopyto make sure there is no other explanation for your symptoms.
What treatments are available for BPH?
No treatment is necessary if the symptoms are mild and there are no complications. Otherwise, BPH may be treated with medications or surgery:
- Alpha blocker medication
- 5-alpha reductase inhibitors (5-ARI’s)
- Combination medical therapy
- Greenlight Laser Prostatectomy
- Holmium Laser Enucleation of the Prostate (HoLEP)
- Transurethral Resection of the Prostate (TURP)
The two most common alpha blockers used to treat BPH are prozosin and tamsulosin. These have an immediate effect in relaxing the smooth muscle around the prostate, easing the obstruction. These medications may cause dizziness as a side effect by lowering your blood pressure. Tamsulosin is a more selective medication and causes less dizziness than prazosin. Both medications may cause retrograde ejaculation, which results in a dry ejaculation at orgasm. This is harmless and means the medication is working effectively.
5-alpha reductase inhibitors (5-ARI’s)
Finasteride and Dutasteride are the two most widely used 5-ARI’s. They work by preventing the prostate converting testosterone into dihydro-testosterone, the active form of testosterone in the prostate. This essentially stops the prostate from growing and even causes it to shrink. These medications take a long time to work, it is often as long as six months until symptoms improve, so you need to be patient. They work best when combined with alpha blockers, which cause immediate relief. There are few side effects with 5-ARI’s, but they may reduce your libido and occasionally cause problems with erections. They are also used to treat baldness, so you may notice a few more hairs on your head.
Surgery for BPH
There are several methods for shelling out or “re-boring” the prostate. They are performed under anaesthetic with a telescope through the penis. They create a large channel inside your prostate to relieve obstruction. This is required when:
- Symptoms are severe
- Medication fails to control symptoms
- Complications of BPH arise
This technique uses a green coloured laser to vaporise the inside of the prostate, creating a channel to improve urine flow. it is best suited to small to medium sized prostates.
This technique uses a high powered holmium laser to cut out, or enucleate the internal lobes of the prostate. It is best suited to very large prostates.
Transurethral Resection of the Prostate (TURP)
TURP is the traditional operation for BPH and has been in use for over 40 years. It uses an electric knife to cut away the inside of the prostate into strips. It is prone to more bleeding than either of the laser techniques and is limited to prostates around 100g in size.