Prostate Enlargement/ BPH
Benign prostate hypertrophy (BPH) or prostate enlargement 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 lies above 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, and provides nourishment for the sperm.
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 is located under the bladder and surrounds the urethra. As it enlarges, it may compress the urethra leading to obstruction. The overall size of the prostate does not correlate to the degree of obstruction. More importantly, it is the degree of obstruction that is 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)
- Repeated 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 or bladder/prostate cancer. These tests also allow us to assess the severity of the problem to help direct the most appropriate treatment. This may include:
- A questionnaire about your symptoms (IPSS score) – you can use here this to check if your urine symptoms are significant
- A voiding diary to record your fluid intake and urine output
- A urine test to exclude infection
- PSA blood test to check for prostate cancer
- Blood test for kidney function
- A urine flow test and check for postvoid residual - to check the speed of your urine flow and how well your bladder empties
- An ultrasound of your prostate, bladder and kidneys
In some circumstances, we may recommend a look inside your prostate and bladder with a cystoscopy to make sure there is no other explanation for your symptoms.
What treatments are available for BPH?
If symptoms are mild and there are no complications, BPH can be managed with lifestyle advice. Otherwise, BPH may be treated with medications or surgery:
- Alpha blocker medication
- 5-alpha reductase inhibitors (5-ARI’s)
- Combination medical therapy
- Transurethral Resection of the Prostate (TURP)
- Greenlight Laser Prostatectomy
The two most common alpha blockers used to treat BPH are alfuzosin and tamsulosin. These have a quick acting effect on relaxing the smooth muscle around the prostate and bladder neck, easing the obstruction.
These medications may cause dizziness as a side effect by lowering your blood pressure. 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 stops the prostate from growing and even causes it to shrink. These medications take a long time to work, often as long as six months to a year 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 cause problems with erections. 5-ARIs 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 creating a larger channel out the prostate to relieve obstruction. They are performed under anaesthetic with a telescope through the urethra. This is required when:
- Symptoms are severe
- Medication fails to control symptoms
- Complications of BPH arise
Transurethral Resection of the Prostate (TURP)
TURP is the standard operation for BPH and has been in use for over 40 years. It uses an electrical wire loop to cut away the inside of the prostate into strips.
Greenlight Laser Prostatectomy
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 for small to medium sized prostates, or in patients who are on blood thinners.