Benign prostatic enlargement

An enlarged prostate means the gland has grown bigger. Prostate enlargement happens to almost all men as they get older. An enlarged prostate is often called benign prostatic hyperplasia (BPH).

Benign prostatic enlargement  is common.

By the age of 60, about half of men and by age 85, about 90% will have some signs of this condition.

About half of all people with BPH will develop symptoms that require treatment.

No,having BPH doesn’t increase your risk of developing prostate cancer. However, BPH and prostate cancer can at times have similar symptoms. If you have BPH, you may have undetected prostate cancer at the same time.

Men with the following factors are more likely to develop benign prostatic hyperplasia:

• age 40 years and older
• family history of benign prostatic hyperplasia
• medical conditions such as obesity, heart and circulatory disease, and type 2 diabetes
• lack of physical exercise
• erectile dysfunction

There is no sure way to prevent BPH.Losing weight and eating a well-balanced diet, rich in fruits and vegetables, may help. Too much body fat may increase hormone levels and other factors in the blood and stimulate the growth of prostate cells. Staying active also helps control weight and hormone levels.

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia may include

• urinary frequency
• urinary urgency
• trouble starting a urine stream
• a weak or an interrupted urine stream
• dribbling at the end of urination
• nocturia
• urinary retention
• urinary incontinence
• pain after ejaculation or during urination
• urine that has an unusual colour or smell

The complications of benign prostatic hyperplasia may include

• acute urinary retention
• chronic, or long lasting, urinary retention
• blood in the urine
• urinary tract infections (UTIs)
• bladder damage
• kidney damage
• bladder stones

The diagnosis in based on the :

• symptoms of BPH
• finding of an enlarged prostate on ultrasound examination.
• demonstration of a weak flow on uroflowmetry examination.This is a simple test in which the patient waits until his bladder is full and then passes urine in a specially designed cup that measures the flow of urine.

Sometimes other tears need to be done such as:

• PSA. When there is suspicion of prostate cancer, based on the clinical examination,your doctor may ask you to have a PSA test.
• Cystoscopy.This usually done when there is suspicion of a bladder abnormality, like a tumour, and to rule out a urethral stricture.
• CT or ultrasound scan of the kidneys.In cases where there are concerns about the anatomy of the kidneys and ureters a CT scan and when not available a ultrasound scan may be necessary.

There are a few things that you can do if you have symptoms related to BPH.This means of course that you have to see your Urologist first, who will make the correct diagnosis,will rule out any other conditions that cause them and give you specific advice as to what could be helpful for you.Some general measures are:

• Drink fewer fizzy drinks and less alcohol, caffeine and artificial sweeteners.
• Drinking less fluid in the evening

Try to avoid drinking fluids for 2 hours before going to bed.This may help reduce the episodes of waking up to pass urine during the night.

• Remember to empty your bladder

Remember to go to the toilet before long journeys or when you know you will not be            able to reach a toilet easily.

• Double voiding

Double voiding involves waiting a few minutes after you have finished peeing before trying to go again. It can help you empty your bladder properly. 

• Checking your medicines

Check with your doctor whether any medicines you take might be making your urinary symptoms worse.

• Eating more fibre

This can help you avoid constipation,which is a well known factor that worsens symptoms from your bladder.

Fruits, vegetables and healthy fats may benefit your prostate health. Consider following the Mediterranean diet or incorporating more of the following in your meals:

• Berries.
• Broccoli.
• Citrus.
• Nuts.
• Tomatoes.
• Turmeric.
  

A poor diet may worsen your BPH. If you have BPH, it’s a good idea to avoid processed foods, sugars and large amounts of carbohydrates as well as:

• Alcohol.
• Caffeine.
• Dairy.
• Red meat.
• Salt.

Yes,there are a few supplements that can be helpful in some patients.Unfortunately due to the great interest in this form of treatment there are numerous different formulations available, most of which are from unknown origin and composition.Before commencing any kind of those treatments the patient should asks the Urologist’s advice in order to choose one that has a chance to work. 

Unfortunately not all patients see a meaningful relief from their symptoms from conservative treatment. In this case the first line of treatment are medications that either relax the prostate or reduce its size. Sometimes a combination of those is given. They are usually quite effective and their result can last for a few years. In cases where other symptoms from the bladder are present, such as urgency and frequency in urinating, medications that relax the bladder can be used alone or in combination with the aforementioned tablets.

Patients who have developed complications from benign prostate enlargement like bladder stones, bladder diverticula, chronic retention,multiple episodes of significant bleeding from the prostate or kidney damage are unlikely to respond to medical treatment and delay in definite treatment can be quite dangerous.In those cases surgical treatment is usually the preferred approach as it relieves symptoms and prevents further damage to the bladder and kidneys.  

There are a few cases where medications will not work for the patient right from the beginning even if the patient has used them for a reasonable amount of time.Also after a few years of continuous treatment some patient may find that their symptoms worsen.In those cases the next step is usually surgery in the form of transurethral prostatectomy with plasma energy(TURIS), Rezum, laser enucleation of the prostate (HOLEP) or robotic simple prostatectomy.

In this case the patient should have a detailed discussion about which methods are indicated for that particular case and what are the expected results.All treatments can have very good results if they are applied based on the right indications and done by experienced Urologists.

In general,more aggressive treatments like robotic simple prostatectomy are indicated in cases with very large prostates and when other operations need to be done at the same time,like removal of a bladder diverticulum.

It is of utmost importance to choose an experienced Urologist that is able to perform all different types of surgery for benign prostate enlargement as this will allow you to choose what is truly suitable for you.Wrong indications and improperly performed surgery is the leading cause for failure of prostate operations and need for further treatment in the future.

As in any kind of surgery, techniques to cure symptoms from an enlarged prostate come with some risks.It is fundamental to discuss them with your Urologist and balance the benefit you will have against those.Complications include:

• Retrograde ejaculation

Retrograde ejaculation is the most common long-term complication of prostate surgery.This means that the patient will have a normal orgasm but there will be no ejaculation as the semen will flow back to the bladder.In cases where this is a major concern,techniques like Rezum are more acceptable.

• Urinary incontinence

Some degree of urinary incontinence, where you pee without meaning to, is quite common after this kind of surgery. It usually gets better in the weeks following surgery, but can rarely be a long-term problem.

• Erectile dysfunction

Up to 10% of men who have surgery for an enlarged prostate may have erectile dysfunction afterwards. This can be either temporary or permanent.

• Urethral strictures

Narrowing of the urethra can happen if the urethra is damaged during surgery and becomes scarred.

Symptoms of a urethra stricture may include:

• straining to pee
• spraying pee or a “split-stream”
• dribbling drops of pee once you have finished going to the toilet
• mild pain when peeing

There is always a certain risk for the prostate to grow again after surgery and this largely depends on the treatment used initially and if the operation was performed properly.More “radical” treatments like robotic simple prostatectomy, HOLEP and TURP tend to be less likely to allow the prostate to regrow.

This depends on the technique that will be used but generally, patients who have Rezum can go home on the same day and those who have HOLEP,TURIS or robotic simple prostatectomy should expect to stay for 1-2 nights.

The patient will need to see his Urologist 1-2 times after the operation just to make sure that everything works fine.When the operation is successful there is no need for long term follow up unless symptoms come back in the future.

Having an operation for benign prostatic enlargement does not mean that someone should stop checking the PSA.This test is done to detect prostate cancer when it’s still in its early stages and is not a marker for prostatic enlargement.

During surgery for benign prostatic enlargement the capsule of the prostate is left intact and this is exactly the part of the gland from which most cancers arise.

Usually the area of the operation takes about 3 weeks to heal,during which time it is necessary to avoid any strenuous physical activities.The patient will usually need to stay off work for a couple of weeks unless his work involves physical effort, in which case this period may need to be extended.