Enlarged Prostate (Benign Prostatic Hyperplasia)

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The prostate is a small gland, walnut-shaped and is part of the male reproductive system. Production of prostate fluid is its primary function. This fluid is crucial to fertility as it nourishes and transports sperm. 

The prostate gland is located below the bladder. The water pipe (urethra) passes through the prostate and carries urine from the bladder or, during orgasm, carries semen. 

The rectum forms the last part of the large bowel and lies behind the prostate gland.

The prostate gland has a role in hormone production. It changes testosterone into a biologically active form called dihydrotestosterone (DHT) which is ten times more potent.

When a doctor performs a digital rectal examination and finds an enlarged prostate, this is referred benign prostate enlargement (BPE).

Benign prostatic hyperplasia is a diagnosis made only after prostate tissue is analysed, for example, after shaving of the prostate (TURP) or prostate biopsy. Often the term is confused with benign prostatic hypertrophy, but this is an old error in the medical literature.

Benign prostatic hyperplasia or benign prostatic enlargement is not cancer and does not increase the risk of prostate cancer.

It's a common finding in men over 50 and tends to progress with ageing.

In some men, the prostate grows only mildly; in others, larger than expected, the prostate becomes huge in some.  

The exact cause is not known.

Hormonal changes may be implicated. There are two main theories;

• Theory 1. As some men get older, dihydrotestosterone (DHT) increases and encourages the growth of the prostate. It is interesting to note that dihydrotestosterone levels are the same in men with and without enlarged prostate.
  
• Theory 2. Alteration of the balance between testosterone and oestrogen as men age. The testosterone levels are lower, and there is a higher level of oestrogen. This change may drive prostate growth.

The prostate starts growing from the age of around 30 years. Interestingly at that age, testosterone levels start declining at a rate of 0.7% per year.

It is rare to experience BPH symptoms before the age of 40 years. Some men start noticing minor urinary changes in the 40-year age group.

Benign prostatic hyperplasia is more common as men age, as shown below;

• 50% of men between the ages of 51 and 60-year group
• 70% of men between the ages of 60 to 69-year group
• 80% of men over the age of 70 to 79-year group
• 90% of men over the age of 80 years
  
• 
  

In some men, their prostate remains small. In others, it can grow up to various sizes.

A normal prostate is walnut size and would be around 25 ml.

An enlarged prostate means;

• small prostate 30 ml to 40 ml 
• medium prostate 40 ml to 80 ml  
• large prostate 40ml to 100 ml 
• extra large prostate greater than 150ml 
  

Changes in urinary voiding habits can be found in small or enlarged prostates.

Knowledge of the size of the prostate helps in treatment decision-making.

There is no physical way you can check yourself.

Traditionally, after a digital rectal exam, the urologist or family doctor can know how large the prostate is. This is not reliable.

Accurate prostate size is measured by imaging in the form of ultrasound, magnetic resonance imaging (MRI) or CT scan.

• older age (starts showing from the 40-year mark onwards)
• family history of BPH
• Erectile dysfunction
• Certain medical diseases (diabetes, obesity, heart issues)
• lack of mobility (poor physical fitness)
  

There can be various lower urinary tract symptoms, including the following:

• Difficulty starting voiding
• Poor urine flow
• Need to strain to pass urine
• Start and stop urine flow
• Incomplete emptying of the bladder (urinary retention)
• Dribbling after emptying the bladder
• Frequent urination (need to pass urine often)
• Sudden inability to hold urine (need to go)
• Waking up at night to empty, disturbing sleep (nocturia)
• Urinary Incontinence
• Urinary tract infections
• Bladder Stones

An enlarged prostate is part of the ageing process in men. It is not cancer.

A person experiencing symptoms of BPH should seek urgent medical attention, if:

• unable to urinate.
• pain when passing urine and experiencing high temperature, fever or chills and rigors (signs of urinary tract infections)
• Lower back pain at the loin area, without a history of injury
• blood in the urine

Bleeding from the prostate is a common finding. An enlarged prostate increases the blood vessels in the bladder neck area. Prostate cell growth requires nutrients and oxygen only possible through forming new blood vessels that are friable. With minimal strain, they bleed easily.

Your NHS consultant or private urologist will see this on a flexible cystoscopy (a camera test that passes through the water pipe and a visual assessment of the bladder, inner prostate and urethra is done).

Finasteride 5 mg daily for a year is a common medication prescribed to suppress these bleeds caused by BPH.

An enlarged prostate causes issues with the way you void.

The majority of early prostate cancer does not cause any symptoms. In late stages, it can lead to frequent urination, a weak flow, stop and start type of flow, waking up at night to void and the need to strain to empty the bladder—the urge to urinate frequently at night.

If you have trouble with water habits, you should visit your family doctor for a PSA blood test and a rectal exam to help determine a benign enlarged prostate gland from prostate cancer.

The urologist will take a patient’s medical history and ask about their daily fluid intake, caffeinated beverages, fizzy drinks, juices, and alcohol, and what medications they are on that can affect urination.

Your healthcare provider will ask you to fill out an international prostate symptom score questionnaire (IPPS) to understand the severity of your lower urinary tract symptoms.

What is an international prostate symptom score questionnaire (IPPS)?

Recognised in 1993 by World Health Organisation, IPPS is an eight question-questionnaire (one of which is a quality of life assessment) to rapidly diagnose, monitor and tailor the management of benign prostatic hyperplasia symptoms.

What is a normal IPPS?

The score can fall into one of the following groups;

• 0 to 7 mild group symptoms
• 8 to 19 moderate group symptoms
• 20 to 35 group severe symptoms

The physical exam will include the abdomen and pelvic area, genital area and a digital rectal exam (the doctor will insert a finger into the rectum) to feel the prostate to check for size, symmetry, consistency, firmness and other abnormalities.

1. blood tests
2. urine tests
3. urine flow studies
4. flexible cystoscopy

Prostate-specific antigen (PSA)

Prostate specific antigen (PSA) is a protein produced by the prostate.

Slight traces of PSA are commonly found in men.

Various reasons lead to an increased PSA blood level, such as

• enlarged prostate
• incomplete emptying of the bladder,
• prostate cancer
• prostatitis
• recent ejaculation
• urinary tract infections
• urinary catheter

A kidney function is to identify any kidney diseases.

Urinary retention (acute urinary retention or acute on chronic urinary retention) resulting from blockage by benign prostate hyperplasia (BPH) can result in kidney dysfunction.

If your kidney function is abnormal, your doctor will order an ultrasound of your kidneys.

What is normal kidney function?

A GFR of 60 or above is in the normal range as recommended by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

What is an abnormal kidney function?

A GFR of 59 and below can reflect kidney disease.

GFR of 15 or lower ma kidney failure

A urinalysis will be ordered to check for signs of a urinary tract infection, blood in the urine (haematuria), and other parameters. If there are signs of urinary tract infection, urine for culture will be ordered.

You will be asked to perform a flow test to measure the rate of urine flow and an ultrasound test to measure the amount of urine that remains in the bladder after you finish voiding.

Will a flow test hurt?

No. This is a simple, non-invasive test. No risks are involved.

How is a urine flow test done?

You will be asked to come to the appointment with a comfortable near-full bladder. When you need to empty your bladder, you will be asked to do so in a unique toilet connected to a machine that measures the strength of your flow and volume.

After, you will have the lower part of your tummy scanned with a portable ultrasound to check how well you have emptied your bladder.

How long does a urine flow test take

One has to allow two to four hours to perform this test as often you will be asked to do at least two.

A camera test called flexible cystoscopy under local anaesthesia to examine the urethra and bladder.

There is no solid research that proves particular food effectiveness or food role in prevention; however, the most common natural food allegedly quoted that may counteract prostate enlargement are;

• Beta-sitosterol food sources (avocados, pecans, soybeans)
• Zinc Food sources (sesame seeds, pumpkin seeds)
• Vitamin C food sources (Bell peppers, kale, cauliflower)
• Lycopene food sources (tomatoes, watermelon, grapefruit, papaya)
• Tofu

1. switch to decaffeinated drinks (both tea and coffee), and avoid fizzy drinks, spices, sweeteners, and juices. All of these are irritants to the inner lining of the bladder.
2. Stop smoking. The chemicals present keep encouraging lower urinary tract storage issues
3. Stop drinking alcohol or lower your alcohol intake.
4. Your last drink before sleep should be at least three hours. Do not drink during the night. It is normal to start waking up once a night to empty at fifty and twice above the age of sixty.
5. Loss of excessive weight.
6. Regular exercise.
7. Avoid constipation.

Medical treatment must be explored if the bothersome symptoms do not improve.

·        Alpha-blockers (tamsulosin/alfuzosin/ doxazosin).

These medications relax the muscles in the bladder, bladder, neck and urethra and help to improve urine flow. Healthcare providers can prescribe them to treat high blood pressure and treat chronic prostatitis. They are once-daily medications. The common side effects are dizziness (postural hypotension) which happens in around 10% of men. 5% to 10 % of men may experience erectile dysfunction, including dry orgasms.

·        5-Alpha reductase inhibitors (finasteride/dutasteride)  

These medications reduce to some extent the size of the very large prostate glands and a certain degree, in some cases, stop it from growing larger. They take a long time to start being effective, typically 9 to 12 months. If you check your blood test PSA and are on one of these medications, you need to double it to get the actual result. 1% of men may complain of breast tenderness and enlargement, which needs to be stopped. In around 5% of men, it can cause erectile dysfunction.

·        Phosphodiesterase inhibitors (Cialis)

These drugs are mainly prescribed for erectile issues. However, they were found to improve urinary problems by relaxing muscles in the lower urinary tract. There are various medications, commonly Cialis, on a daily dose is prescribed. Common side effects include headaches, flushing, indigestion, nasal congestion, flu-like symptoms, vision issues, back pain and muscle pain.

·        Anticholinergics (solifenacin/ oxybutynin/ trospium)

They relax the bladder muscles reducing bladder spasms. They address mainly overactive bladder symptoms. The most common side effects are dry mouth, constipation, frontal facial fullness, tiredness and impaired memory.

·        combination of medications.

The above medications are initially prescribed as a stand-alone; however, if BPH symptoms do not improve or bothersome symptoms worsen, a combination of drugs can be tried before considering surgical management.

The procedure is performed under general anaesthetic or spinal anaesthesia.

·        Transurethral Resection of the Prostate (TURP). 

TURP has been practised for decades and is the most proven surgical treatment. The outcomes from the transurethral resection surgery are considered the reference standard to which other surgical treatments are compared.

A unique instrument is passed through the water pipe, and the prostate and bladder are assessed. Electricity passes through a loop that heats it, and excess prostate tissue is shaved. A catheter is placed, which is removed in 24 hours. An overnight stay is required.

TURP-specific complications;

o   Dry orgasm (retrograde ejaculation happens in 70% of men).

o   Erectile Dysfunction (happens in 10% of men)

o   Urinary tract infections.

o   leakage of urine (incontinence)

o   Narrowing of the urethra due to scarring (happens in 10% of men)

o   Regrowth of the prostate (happens in 12.5%)

·        Bladder neck Incision (BNI). 

The bladder neck is the entry to the bladder. In some men, this may be tight, or its position may be higher than usual. This would obstruct the flow of urine. A unique instrument is passed through the water pipe. The bladder neck is identified, and two cuts are done to release the tightness. A catheter is passed and removed the day after.

BNI-specific complications;

o   Dry orgasm (happens in 70% of men).

o   Urinary tract infections.

o   Narrowing of the urethra due to scarring (happens in 10% of men)

o   May need further treatment to improve urine flow.

·        Laser Prostate Surgery.

Ideal for large prostate glands or extra large prostate glands.

o   greenlight laser, otherwise known as photoselective vaporisation (PVP) – destroy prostate tissue by vaporisation. There is no tissue to be sent to the pathology lab.

o   holmium laser enucleation (HoLEP) uses a laser to core out the prostate from its capsule.

The advantages over the TURP procedure are:

o   reduced blood loss

o   prostates larger than 80g can be done

o   the blood thinning drugs men can take due to medical conditions do not need to be stopped avoiding certain risks.

·        Prostatic Urethral Lift (UroLift) 

This is a minimally invasive new prostate surgery treatment. A unique instrument is passed through the urethra, and four clips are deployed, compressing each side of the enlarged prostate tissue and widening the urethra. Urine passes better as there is a broader channel. There is no heat, no cutting or excess prostate tissue ablation.

Men can leave the hospital within a few hours and return to regular activity as soon as they feel confident. Erectile function is preserved.

The most common side effects may include blood in the urine, minimal urination discomfort, and urinary urgency. These generally resolve within four weeks after the benign prostatic hyperplasia treatment.

It is a relatively new treatment for enlarged prostate, and long-term data are still awaited. The 

durability of this surgical procedure has been shown to last a minimum of 4 years. Other benign prostatic hyperplasia treatments can still be explored.

·        REZUM

REZUM is a minimally invasive procedure that uses steam to destroy excess prostate tissue. The process takes around 7 minutes and can be performed as day surgery. A urinary catheter is typically needed for up to 14 days.

It is ideal for men with prostate gland volume greater than 30mls but less than 80mls.

Men can leave the hospital within a few hours and return to regular activity as soon as they feel confident.

Rezūm Water Vapor Therapy’s specific risks include the following:

o   frequent and painful urination

o   urinary tract infections (UTIs), prostatitis, epididymitis

o   inability to ejaculate or painful ejaculation

o   urinary incontinence

o   urinary retention

o   scarring and narrowing of the urethra

o   worsening erectile dysfunction

o   pelvic or genital pain/discomfort

It is a relatively new treatment for enlarged prostate, and long-term data are still awaited.

·        Aquablation

Using AquaBeam Robotic System, under general anaesthesia, images of the prostate enlargement are acquired with an ultrasound. This will guide the robotically controlled water jet to destroy prostate tissue with detailed precision. The operation takes around 45 minutes. You will be asked to stay overnight in the hospital and need a catheter for the first 24 hours. This technique can do gigantic prostate glands.

This lowers post-operative pain and shortens recovery, compared to traditional benign prostatic hyperplasia treatment.

At five years, this treatment option has shown to be durable for men with benign prostatic obstruction.

The main advantage over other treatments is the low risk of dry orgasms (10%)

·        Simple Open Prostatectomy 

The advent of better minimally surgical interventions to treat men with lower urinary tract symptoms due to very enlarged prostate means traditional open surgery is not the first prostate treatment option.

Open surgery means a more extended hospital stay, longer duration of urinary catheter and increased blood loss.

·        Prostatic Arterial Embolisation (PAE)

A needle puncture is done in the groin. A radiological catheter is advanced through the artery until the artery that supplies the prostate gland is reached. Tiny particles are released that block the prostatic artery, obstructing blood flow. This is done under local anaesthesia. It usually takes 2 hours, and patients can go home the same day.

Over a few weeks, this will shrink the prostatic tissue. There are no side effects on sexual function.

This benign prostatic hyperplasia treatment is indicated for men with slowly worsening symptoms despite medical therapy who are not fit based on their medical history or physical status for the above-mentioned surgical approaches.

Specific side effects from prostatic arterial embolisation are temporary blood in urine, rectal bleeding, and acute urinary retention.

Written by Mr E Calleja

NHS Consultant, Private Urologist, Robotic Surgery