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BPH (Prostate Gland Enlargement)

BPH

What is the prostate gland?

The prostate gland is only found in men. It lies just beneath the bladder. The urethra (the tube which passes urine from the bladder) runs through the middle of the prostate. The prostate's main function is to produce fluid which protects and enriches sperm. The prostate gets bigger (enlarges) gradually after the age of about 50.

What are the symptoms of prostate enlargement?

As the prostate enlarges it may cause narrowing of the first part of the urethra. This may partially obstruct the flow of urine. This can lead to obstructive symptoms such as:

  • Poor stream. The flow of urine is weaker, and it takes longer to empty your bladder.
  • Hesitancy. You may have to wait at the toilet for a while before urine starts to flow.
  • Dribbling. Towards the end of passing urine, the flow becomes a slow dribble.
  • Poor emptying. You may have a feeling of not quite emptying your bladder.

The enlarged prostate may also make the bladder irritable, which may cause:

  • Frequency (passing urine more often than normal). This can be most irritating if it happens at night. Getting up several times a night is a common symptom and is called nocturia.
  • Urgency. This means you have to get to the toilet quickly when you need to go.

An enlarged prostate does not always cause symptoms. Only a quarter to a half of men with an enlarged prostate will have symptoms. Also, the severity of the symptoms is not always related to the size of the prostate.

What are the possible complications?

Serious complications are unlikely to occur in most men with an enlarged prostate. Complications that sometimes occur include:

1.In some cases, a total blockage of urine occurs so you will no longer be able to pass urine. This is called urinary retention.
2. In some cases, only some of the urine in the bladder is emptied when you pass urine. Some urine remains in the bladder at all times. This may cause recurring urine infections, or incontinence.
3. The risk of prostate cancer is not increased. Men with a benign prostate enlargement are no more or less likely to develop prostate cancer than those without benign prostate enlargement.

Do I need any tests?

Benign prostatic enlargement is usually diagnosed based on the typical symptoms as described earlier. Tests are not always needed to confirm the diagnosis. The following tests may be done:

  • A doctor may examine your prostate to see how big it is. This is done by inserting a gloved finger through the anus into the rectum to feel the back of the prostate gland.
  • Urine and blood tests may be done to check the function of your kidneys, to exclude a urine infection and to check there is no blood in the urine.
  • Cystoscopy (a look inside the bladder with a special telescope);
  • A urine flow test to assess how bad the obstruction has become;
  • An ultrasound scan to see whether much urine remains in the bladder after you pass urine.
  • Voiding diary. You may be asked to complete a diary over a week or so. This will have information about the number of times during the day and night you void (pass urine), the amount passed, and also the number and types of drinks you have had.
  • A prostate specific antigen (PSA) blood test may be offered, although this test is not done routinely.

Is treatment always necessary?

No. In most cases, an enlarged prostate does not do any damage or cause complications. Whether treatment is needed usually depends on how much botheration the symptoms cause.

What are the treatment options for prostate enlargement?

No treatment is likely to clear all symptoms totally, although symptoms can usually be greatly improved with treatment.

General measures

  • Try to anticipate times when urinary frequency and urgency are likely to be most inconvenient, and reduce the amount that you drink beforehand. For example, when you go out, don't drink much for 2-3 hours before you go out.
  • After you have finished passing urine, go back to the toilet again after a few minutes to try to pass some more. (This is called double micturition.) This aims to make sure the bladder is emptied completely.
  • Consider reducing or stopping caffeine and alcohol.
  • If hesitancy is a problem - try to relax when standing to pass urine.
  • If urgency is a problem - try some distraction techniques such as breathing exercises and mental tricks to take your mind off the bladder.
  • If frequency is a problem - try retraining the bladder by holding on for as long as you can each time before passing urine. The bladder muscle can be trained to expand more in this way.
  • If you are a smoker then stopping smoking may significantly improve your symptoms, as nicotine irritates the bladder.

Medicines

There are two groups of medicines that may help: alpha-blockers and 5-alpha reductase inhibitors.

Alpha-blocker medicines. These medicines work by relaxing the smooth muscle of the prostate and bladder neck. This can improve the flow of urine. There are several different types and brands of alpha-blockers which include: prazosin, indoramin, tamsulosin, alfuzosin, doxazosin and terazosin. Some improvement usually occurs within a few days, but the full effect may take up to six weeks.

5-alpha reductase inhibitor medicines. These are alternatives to alpha-blockers. There are two: finasteride and dutasteride. These work by blocking the conversion of the hormone testosterone to dihydrotestosterone in the prostate. A reduced amount of dihydrotestosterone in the prostate causes it to shrink. It can take up to six months for you to notice any effect from these medicines, as it takes time for the prostate gradually to shrink.

Surgery

Removal of part of the prostate is an option if symptoms are very bothersome, or if medicines do not help. In these operations, only the central part of the prostate is removed (creating a wide channel for urine to flow through), leaving the outer part behind.

Transurethral resection of the prostate (TURP). This is the most common operation carried out for an enlarged prostate. Under anesthetic, either spinal or general, a rigid cystoscope is inserted through the urethra into the bladder. A semicircular loop of wire has an electrical current passed through it. It is this loop that sticks out from the end of the cystoscope and cuts out small chips of prostate that are then washed out at the end of the operation. 80-90% of men after this operation will have retrograde ejaculation, which is when semen goes backwards into the bladder at climax producing a 'dry' orgasm. Impotence and incontinence are rare complications.

Laser prostatectomy. This is the application of laser to achieve the same goal as either TURP or open prostatectomy. It has the advantage of fewer side-effects, a shorter period of having a catheter in, and a shorter stay in hospital. There are two types of lasers: green light which vaporizes the prostate tissue to create a cavity, and holmium or thulium lasers that can very effectively core out large lobes of prostate which, in turn, are chopped into small pieces in order to be removed from the bladder.


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