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Prostate gland enlargement - Benign prostatic hyperplasia (BPH)
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Prostate gland enlargement - Benign prostatic hyperplasia (BPH)

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MEN'S HEALTH

Prostate

The prostate is a sex gland in men. It is about the size of a walnut, and surrounds the neck of the bladder and urethra - the tube that carries urine from the bladder. It is partly muscular and partly glandular, with ducts opening into the prostatic portion of the urethra. It is made up of three lobes: a center lobe with one lobe on each side.  The gland's primary function is to produce most of the fluids in semen, the fluid that nourishes and transports sperm.

Treatment

Treatment for an enlarged prostate is determined by your signs and symptoms and their severity. If you have significant problems, such as urinary bleeding, persistent urinary tract infections, bladder and kidney damage, your doctor generally will recommend treatment. If your prostate is enlarged but you experience little or no discomfort, treatment often isn't necessary.

A wide variety of treatments are available to ease the signs and symptoms of an enlarged prostate. They include medications, other nonsurgical therapies and surgical procedures.

Medications

Medications are the most common method for controlling moderate symptoms of prostate enlargement. Doctors use a variety of medications to treat prostate gland enlargement:

  • Alpha blockers. These drugs were originally developed to treat high blood pressure. They relax the muscles at the neck of your bladder, making it easier to urinate. The Food and Drug Administration has approved four alpha blockers for prostate enlargement: terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax) and alfuzosin (Uroxatral).

  • Alpha blockers are effective in about two-thirds of men who take them. The drugs work quickly. Within a day or two, most men notice an increase in urinary flow and a decrease in how often they need to urinate. You may need to take an alpha blocker indefinitely.

  • Doctors are uncertain about the long-term benefits and risks of alpha blockers. To reduce your risk of side effects, your doctor may start with a low dose of medication and gradually increase the dosage. Alpha blockers taken with drugs for impotence, such as sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis), may interact and cause low blood pressure. Discuss with your doctor the possible side effects of these medications before taking them.

  • Finasteride (Proscar, Propecia). This drug relieves symptoms in a totally different manner than alpha blockers do. Instead of relaxing your muscles, it shrinks your prostate gland. For some men with large prostates, the drug may produce a noticeable improvement in symptoms. It's generally not effective, though, if you have only a moderately enlarged or normal-sized prostate.

  • A few of men who take finasteride experience side effects, such as impotence and decreased sex drive. But in most men, the drug produces only slight side effects. Finasteride also takes a long time to work. You may notice some improvement in urinary flow after three months, but it generally takes up to a year for complete results. The long-term effects of this drug are unknown.

  • Finasteride has two other drawbacks. It's more expensive than alpha blockers, and although it generally lowers your baseline PSA level, finasteride doesn't affect or change your risk of prostate cancer. This can interfere with the effectiveness of the PSA screening test for prostate cancer. Be sure to tell your doctor if you are taking finasteride or have taken it in the past.

  • Combination drug therapy. A study published in the Dec. 18, 2003, issue of the New England Journal of Medicine found that taking doxazosin and finasteride together significantly reduced the risk of further prostate gland enlargement to the point where invasive surgery was not needed. This therapy also appears to decrease urination problems often caused by an enlarged prostate.

Nonsurgical therapies

Several nonsurgical treatment methods are available to reduce the size of the prostate. These therapies focus on enlarging the urethra, making it easier for you to urinate.

Heat therapy

Heat therapy uses heat energy delivered through the urethra to destroy excessive prostate tissue. It fills the gap between medications and invasive surgery. It's more effective than medications for moderate to severe symptoms, and it doesn't produce as many side effects as surgery.

Heat therapy is often performed on an outpatient basis. But depending on the procedure, your doctor and how quickly you're able to urinate on your own, you may need to stay in the hospital overnight. Heat therapy ordinarily requires only a few days' recovery time. An exception is laser therapy. Some older laser procedures require that you wear a catheter for up to three weeks. Newer techniques often require use of a catheter for only 24 hours.

Several types of heat therapy are available. These may include:

Microwave therapy

Transurethral microwave therapy (TUMT) uses computer-controlled heat in the form of microwave energy to safely destroy the inner portion of the enlarged gland.

The size and shape of an enlarged prostate is critical to the success of microwave therapy. If your prostate is very large or growing in an unusual shape into your bladder, this treatment generally isn't effective.

During the procedure a machine emits microwave energy through a urinary catheter. The catheter includes a tiny internal microwave antenna to deliver a dose of microwave energy that heats the enlarged cells and destroys them. Cool water circulates around the tip and sides of the antenna during the procedure to protect the urethra from the heat.

A local anesthetic helps control pain. You may feel some heat in the prostate and bladder area. You may also have a strong desire to urinate and may experience bladder spasms. These responses usually disappear after the treatment is finished. You can go home when you're urinating satisfactorily, usually the same day.

It may take several weeks before you begin to see a noticeable improvement in your symptoms. Those who seem to respond best over time are men whose initial symptoms are mild. The long-term effectiveness of the procedure is uncertain.

It's normal to have urgent, frequent urination and small amounts of blood in your urine during recovery. There may be changes in the amount of semen you ejaculate. However, unlike more invasive surgery, TUMT generally doesn't produce impotence, incontinence or retrograde ejaculation. With retrograde ejaculation, semen flows backward into the bladder during ejaculation instead of out through the penis and can result in infertility. TUMT isn't recommended if you have a pacemaker or any metal implants.

Radiofrequency therapy

Transurethral needle ablation (TUNA) works by sending radio waves through needles that are inserted into your prostate gland, heating and destroying the tissue. As in TUMT, a special catheter is inserted through your urethra. The needles are inserted into your prostate by maneuvering the catheter.

TUNA typically is less effective than traditional surgery in reducing symptoms and improving urine flow. Its long-term effectiveness also isn't known. Another drawback of the procedure is that it doesn't work as well in men with very large prostates. Side effects may include urine retention, blood in your urine, painful urination and a small risk of retrograde ejaculation.

Electrovaporization

Transurethral electrovaporization of the prostate (TVP) involves a special metal instrument that emits a high-frequency electrical current to cut and vaporize excess tissue while sealing off the remaining tissue to prevent bleeding. This procedure is especially useful for men at higher risk of complications, including those who take a blood-thinning (anticoagulant) medication. As with other, newer treatments, its long-term benefits aren't yet known.

Laser therapy

This procedure is performed similarly to other heat therapies, except it uses a laser instead of microwave energy, radio waves or electrical current to produce heat. It generally doesn't cause impotence or prolonged incontinence. However, some laser procedures require lengthy use of a catheter. Laser therapy includes transurethral evaporation of the prostate (TUEP), noncontact visual laser ablation of the prostate (VLAP) and interstitial laser therapy.

TUEP is similar to electrovaporization. The difference is that your doctor destroys prostate tissue with laser energy instead of electrical current. The procedure is generally safe and causes limited bleeding. It's often effective, with noticeable improvement in urine flow soon after the procedure.

VLAP involves applying enough laser energy to dry up and destroy excess prostate cells. Because of swelling and prolonged sloughing off of the dead tissue, you're likely to retain urine for several days and will need to wear a catheter. You may also experience a burning sensation during urination for days to weeks.

Interstitial laser therapy directs laser energy inside the prostate growths rather than at the urethral surface. It safely and moderately increases the urinary flow rate and reduces the volume of the prostate. It also seems to work well among men with large prostates. Because of substantial tissue inflammation after treatment, you may need to use a catheter for up to three weeks. Uncomplicated urinary tract infections also are common. Interstitial laser therapy is a good option if you can't have surgery because of other health complications. It doesn't cause any blood loss and uses a combination of local anesthesia and intravenous sedation to control pain during the procedure.

A drawback of heat therapies is that no tissue is taken (biopsied) from your prostate gland. During surgical treatments for an enlarged prostate, a small sample of your prostate generally is taken by your doctor and examined by a pathologist for possible cancer.

An enlarged prostate (left) can be treated with minimally invasive therapies that use heat produced by an energy source, such as a laser, to destroy prostate tissue (right)....

Prostatic stents

A prostatic stent is a tiny metal coil. During this procedure, it is inserted into your urethra to widen the urethra and keep it open. Tissue grows over the stent to hold it in place. This treatment produces little or no bleeding and doesn't require a catheter. It may be an option for men who are unwilling or unable to take medications or who are reluctant or unable to have surgery. Stents often aren't ideal for older men who have difficulty wearing or maintaining them, or who are unable to tolerate the procedure.

Some men find that the stents don't improve their symptoms. Others experience irritation when urinating or have frequent urinary tract infections. These complications, along with the high cost and potential difficulties in removing the stents, have reduced the popularity of this treatment.

Surgical and other procedures

At one time surgery was the most common treatment for benign prostatic hyperplasia (BPH). But because of increased use of medications and the development of other less invasive therapies, surgery is on the decline. Today it's used mainly for more severe signs and symptoms or if you have complicating factors, such as:

  • Frequent urinary tract infections

  • Kidney damage from urinary retention

  • Bleeding through the urethra

  • Stones in the bladder

Surgery is the most effective of all therapies for relieving symptoms of an enlarged prostate. It's the "gold standard" by which all other treatments are judged, and many doctors have extensive experience with it. However, it's also the most likely to produce side effects. Fortunately, most men experience few problems. Among those with certain health conditions, such as uncontrolled diabetes, cirrhosis of the liver, a major psychiatric disorder, or a serious lung, kidney or heart condition, surgery isn't usually recommended unless absolutely necessary.

Surgery for an enlarged prostate requires a hospital stay. If you have surgery, you may need to take up to a month off from work. You'll also need to avoid heavy lifting, jarring to your lower pelvic area or straining of your lower abdominal muscles for up to two months.

The types of surgery for an enlarged prostate include:

Transurethral resection of the prostate (TURP)

This is the most common surgery for an enlarged prostate. During the procedure, you're given a general anesthesia or anesthetized from the waist down with a spinal block. A surgeon threads a narrow instrument (resectoscope) into your urethra and uses small cutting tools to scrape away excess prostate tissue. You can expect to stay in the hospital for one to three days after surgery. During your recovery, you'll have a urinary catheter in place for a few days.

TURP is effective and relieves symptoms quickly. Most men experience a stronger urine flow within a few days. You can expect some blood or small blood clots to appear in your urine afterward. Before you leave the hospital, you should be able to urinate on your own. At first you may feel some pain or a sense of urgency when urine passes over the surgical area. This discomfort should gradually improve. In some cases, you may be sent home from the hospital with a catheter that is later removed in your doctor's office.

In some cases, TURP can cause impotence and loss of bladder control. Generally, these conditions are only temporary. Pelvic floor muscle exercises (Kegel exercises) often help restore bladder control. Normal sexual function often returns within a few weeks to months. However, it can take up to one year to make a full recovery from these side effects.

Another more common side effect of surgery is retrograde ejaculation. TURP may also produce scarring and narrowing in the urethra or bladder neck. This often can be remedied by stretching of the scar tissue done on an outpatient basis. Some men who have TURP may need some sort of prostate surgery again because the prostate grew back or the scar tissue from a previous procedure needs to be removed.

Transurethral incision of the prostate (TUIP)

This surgery is an option if you have only a moderately enlarged or small prostate gland. It's also an option for men who aren't good candidates for more invasive surgery for health reasons or because they don't want to risk sterility.

Like TURP, TUIP involves special instruments that are inserted through the urethra. But instead of removing prostate tissue, the surgeon makes one or two small cuts in the prostate gland. The cuts help enlarge the opening of the urethra, making it easier to urinate.

The procedure produces less risk of complications than other kinds of surgery. It doesn't require an overnight hospital stay, but it's less effective and often needs to be repeated. Some men experience only a small improvement in urinary flow.

Open prostatectomy

This type of surgery is generally performed only if you have an excessively large prostate, bladder damage or other complicating factors, such as bladder stones or urethral strictures. It's called open because the surgeon makes an incision in your lower abdomen to reach the prostate rather than going up through the urethra. During an open prostatectomy, only the inner portion of your prostate gland is removed, leaving the outer portion intact.

Open prostatectomy is the safest and most effective therapy for men with extreme prostate enlargement. But it poses the greatest risk of side effects. Complications of the procedure are similar to those of TURP, and their effects may be more severe. The procedure usually requires a hospital stay of three to five days.

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