Prostate Enlargement – Causes, Symptoms, Treatment

Prostate enlargement/Benign prostatic hyperplasia (BPH) is a commonest, urological,  nonmalignant overgrowth or hyperplasia of prostate tissue with abnormal stromal and epithelial cell proliferation in the prostate transition zone surrounding the urethra that affecting the aging male associated with unregulated proliferation of connective tissue, smooth muscle, and glandular epithelium within the prostatic transition zone.[rx] A glandular element composed of secretory ducts and acini, and a stromal element composed primarily of collagen and smooth muscle. During the development of the prostate, the epithelium and mesenchyme are under the control of testicular androgens and interact to form an organized secretory organ. In BPH, cellular proliferation leads to increased prostate volume and increased stromal smooth muscle tone. The first phase consists of an increase in BPH nodules in the periurethral zone and the second a significant increase in the size of glandular nodules.[rx]

ANATOMY

According to McNeal’s model of the prostate (7), four different anatomical zones may be distinguished that have anatomy-clinical correlation (Figure 2):

• The peripheral zone – is the area forming the posteroinferior aspect of the gland and represents 70% of the prostatic volume. It is the zone where the majority (60-70%) of prostate cancers form.
• The central zone – represents 25% of the prostate volume and contains the ejaculatory ducts. It is the zone that usually gives rise to inflammatory processes (eg prostatitis).
• The transitional zone – represents only 5% of the total prostatic volume. This is the zone where benign prostatic hypertrophy occurs and consists of two lateral lobes together with periurethral glands. Approximately 25% of prostatic adenocarcinomas also occur it this zone.
• The anterior zone – predominantly fibromuscular with no glandular structures.

The prostate weighs approximately 20g by the age of 20 and has the shape of an inverted cone, with the base at the bladder neck and the apex at the urogenital diaphragm. The prostatic urethra does not follow a straight line as it runs through the center of the prostate gland but it is actually bent anteriorly approximately 35 degrees at the verumontanum (where the ejaculatory ducts join the prostate).

Causes of Prostate Enlargement

The cause of benign prostatic hyperplasia is not well understood; however, it occurs mainly in older men. Benign prostatic hyperplasia does not develop in men whose testicles were removed before puberty. For this reason, some researchers believe factors related to aging and the testicles may cause benign prostatic hyperplasia.

• Produce Testosterone – Throughout their lives, men produce testosterone, a male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in their blood decreases, which leaves a higher proportion of estrogen. Scientific studies have suggested that benign prostatic hyperplasia may occur because the higher proportion of estrogen within the prostate increases the activity of substances that promote prostate cell growth.
• Dihydrotestosterone (DHT) – a male hormone that plays a role in prostate development and growth. Some research has indicated that even with a drop in blood testosterone levels, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage prostate cells to continue to grow. Scientists have noted that men who do not produce DHT do not develop benign prostatic hyperplasia.
• Metabolic syndrome – refers to conditions that include hypertension, glucose intolerance/insulin resistance, and dyslipidemia. Meta-analysis has demonstrated those with metabolic syndrome and obesity have significantly higher prostate volumes.[rx] Further studies looking at men with elevated levels of glycosylated hemoglobin (Hba1c) have demonstrated an increased risk of LUTS.[rx] Limitations of these studies are that there were no subsequent significant differences in IPSS, and the effect of diabetes on LUTS has been shown to be multifactorial in nature.[rx][rx] Further studies are therefore required to establish causation in these individuals.
• Obesity – has been shown to be associated with an increased risk of BPH in observational studies.[rx][rx] The exact cause is unclear but is likely multifactorial in nature as obesity makes up one aspect of metabolic syndrome. Proposed mechanisms include increased levels of systemic inflammation and increased levels of estrogens.[rx][rx]
• Genetic predisposition – to BPH has been demonstrated in cohort studies, first-degree relatives in one study demonstrated a four-fold increase in the risk of BPH compared to control.[rx] These findings have demonstrated consistency in twin studies looking at the disease severity of BPH, with higher rates of LUTS seen in monozygotic twins.[rx][rx]
• Diet – Studies indicate that dietary patterns may affect development of BPH, but further research is needed to clarify any important relationship.^[rx] Studies from China suggest that greater protein intake may be a factor in development of BPH. Men older than 60 in rural areas had very low rates of clinical BPH, while men living in cities and consuming more animal protein had a higher incidence.^[rx][rx] On the other hand, a study in Japanese-American men in Hawaii found a strong negative association with alcohol intake, but a weak positive association with beef intake.^[rx] In a large prospective cohort study in the US (the Health Professionals Follow-up Study), investigators reported modest associations between BPH (men with strong symptoms of BPH or surgically confirmed BPH) and total energy and protein, but not fat intake.^[rx]
• Degeneration – Benign prostatic hyperplasia is an age-related disease. Misrepair-accumulation aging theory^[rx][rx] suggests that the development of benign prostatic hyperplasia is a consequence of fibrosis and weakening of the muscular tissue in the prostate.^[rx] The muscular tissue is important in the functionality of the prostate and provides the force for excreting the fluid produced by prostatic glands. However, repeated contractions and dilations of myofibers will unavoidably cause injuries and broken myofibers. Myofibers have a low potential for regeneration; therefore, collagen fibers need to be used to replace the broken myofibers.

Symptoms of Prostate Enlargement

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia may include

• urinary frequency—urination eight or more times a day
• urinary urgency—the inability to delay urination
• trouble starting a urine stream
• a weak or an interrupted urine stream
• dribbling at the end of urination
• nocturia—frequent urination during periods of sleep
• urinary retention
• urinary incontinence—the accidental loss of urine
• pain after ejaculation or during urination
• urine that has an unusual color or smell
• a blocked urethra
• Weak urine stream
• Straining to urinate
• Wakening during the night to urinate (nocturia)
• Affected man’s perceived quality of life
• incomplete bladder emptying
• nocturia, which is the need to urinate two or more times per night
• dribbling at the end of your urinary stream
• incontinence, or leakage of urine
• the need to strain when urinating
• a weak urinary stream
• a sudden urge to urinate
• a slowed or delayed urinary stream
• painful urination
• blood in the urine
• a bladder that is overworked from trying to pass urine through the blockage
• The size of the prostate does not always determine the severity of the blockage or symptoms. Some men with greatly enlarged prostates have a little blockage and few symptoms, while other men who have minimally enlarged prostates have a greater blockage and more symptoms.
• Less than half of all men with benign prostatic hyperplasia have lower urinary tract symptoms.

Sometimes men may not know they have a blockage until they cannot urinate. This condition, called acute urinary retention, can result from taking over-the-counter cold or allergy medications that contain decongestants, such as pseudoephedrine and oxymetazoline. A potential side effect of these medications may prevent the bladder neck from relaxing and releasing urine. Medications that contain antihistamines, such as diphenhydramine, can weaken the contraction of bladder muscles and cause urinary retention, difficulty urinating, and painful urination. When men have partial urethra blockage, urinary retention also can occur as a result of alcohol consumption, cold temperatures, or a long period of inactivity.

Diagnosis of Prostate Enlargement

A health care provider diagnoses benign prostatic hyperplasia based on

Personal and Family History

Taking a personal and family medical history is one of the first things a health care provider may do to help diagnose benign prostatic hyperplasia. A health care provider may ask a man

• what symptoms are present
• when the symptoms began and how often they occur
• whether he has a history of recurrent UTIs
• what medications he takes, both prescription and over the counter
• how much liquid he typically drinks each day
• whether he consumes caffeine and alcohol
• about his general medical history, including any significant illnesses or surgeries

Physical Exam

A physical exam may help diagnose benign prostatic hyperplasia. During a physical exam, a health care provider most often

• examines a patient’s body, which can include checking for
• discharge from the urethra
• enlarged or tender lymph nodes in the groin
• a swollen or tender scrotum
• taps on specific areas of the patient’s body
• performs a digital rectal exam

A digital rectal exam, or rectal exam, is a physical exam of the prostate. To perform the exam, the health care provider asks the man to bend over a table or lie on his side while holding his knees close to his chest. The health care provider slides a gloved, lubricated finger into the rectum and feels the part of the prostate that lies next to the rectum. The man may feel slight, brief discomfort during the rectal exam. A health care provider most often performs a rectal exam during an office visit, and men do not require anesthesia. The exam helps the health care provider see if the prostate is enlarged or tender or has any abnormalities that require more testing.

In the elective setting, the examination should include abdominal examination (looking for a palpable bladder/loin pain) and examination of external genitalia (meatal stenosis or phimosis). The examination should then conclude with a digital rectal examination making a note in particular of the size, shape (how many lobes), and consistency (smooth/hard/nodular) of the prostate (BPH is characterized by a smoothly enlarged prostate).

Further bedside evaluation includes

• Urine dipstick (rule out other causes such as infection)
• Post-void residual volume (whether the bladder is emptied properly)
• IPSS (international prostate symptom score)
• Frequency-volume chart

Questionnaires

Both the American urological association symptom index and IPSS can be used to assess the impact of LUTS on quality of life.[rx] They are useful when quantifying the disease burden on the patient and can be used to stratify patients into disease categories for treatment.[rx] The IPSS stratifies patients into three groups on the basis of symptoms. They are mild (0-7), moderate (8-19), and severe (20-35). Those with more severe symptoms are less likely to benefit from conservative or medical measures.

Medical Tests

A health care provider may refer men to a urologist—a doctor who specializes in urinary problems and the male reproductive system—through the health care provider most often diagnoses benign prostatic hyperplasia on the basis of symptoms and a digital rectal exam. A urologist uses medical tests to help diagnose lower urinary tract problems related to benign prostatic hyperplasia and recommend treatment. Medical tests may include

• Urinalysis. Urinalysis involves testing a urine sample. The patient collects a urine sample in a special container in a health care provider’s office or a commercial facility. A health care provider tests the sample during an office visit or sends it to a lab for analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color to indicate signs of infection in urine.
• PSA blood test. A health care provider may draw blood for a PSA test during an office visit or in a commercial facility and send the sample to a lab for analysis. Prostate cells create a protein called PSA. Men who have prostate cancer may have a higher amount of PSA in their blood. However, a high PSA level does not necessarily indicate prostate cancer. In fact, benign prostatic hyperplasia, prostate infections, inflammation, aging, and normal fluctuations often cause high PSA levels. Much remains unknown about how to interpret a PSA blood test, the test’s ability to discriminate between cancer and prostate conditions such as benign prostatic hyperplasia, and the best course of action to take if the PSA level is high.
• Urinary rate recording –  is a non-invasive way to determine the intensity or strength of the urinary stream. As discussed above, a maximum urinary flow rate of greater than 15 mL/s is considered nearly in the normal range, whereas a maximum flow rate of less than 10 mL/s is highly suggestive of outlet obstruction.
• Measurement of postvoid residual urine – can be performed by transabdominal ultrasonography or in-and-out catheterization, the former being the preferred method. Postvoid residual urine values differ substantially over time within an individual and between individuals. They have not been shown to be reliable predictors of the natural history of the disease and/or the response to treatment. However, it is widely accepted that rising amounts of residual urine and decreasing voiding efficiency are associated with worsening of the condition and a greater likelihood of acute urinary retention with subsequent need for surgery.
• Urodynamic tests. Urodynamic tests include a variety of procedures that look at how well the bladder and urethra store and release urine. A health care provider performs urodynamic tests during an office visit or in an outpatient center or a hospital. Some urodynamic tests do not require anesthesia; others may require local anesthesia. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely and may include the following uroflowmetry, which measures how rapidly the bladder releases urine postvoid residual measurement, which evaluates how much urine remains in the bladder after urination reduced urine flow or residual urine in the bladder, which often suggests urine blockage due to benign prostatic hyperplasia.
• Prostate-Specific Antigen (PSA) – Prostate-specific antigen testing has been shown to predict prostate volume.[rx] Prostate-specific antigen (PSA) testing should be used with caution, however, and should not be done routinely in the investigation of BPH. Levels may be raised in a large range of conditions (large prostate, infection, catheterization, prostate cancer) and can cause undue anxiety or further unnecessary investigations for the patient. It is the author’s preference to conduct PSA testing in specific circumstances, i.e., where cancer is suspected (malignant feeling prostate, metastatic disease suspected) or a previous baseline established.
• Ultrasound – Ultrasound scans are used to look for evidence of hydronephrosis and are indicated in patients with high residual volumes or renal impairment. Other indications include suspicion of urinary tract stones or the investigation of haematuria.
• Flow Studies – Urine flow studies are used to determine the volume of urine passed over time. This can help establish whether there is objective evidence for obstruction to flow. Urodynamic studies are used to see how the bladder empties and fills. They can help further assess patients where the diagnosis is not certain or where a neurogenic/overactive bladder is suspected (i.e., neurological conditions that may affect the bladder, flow studies equivocal, diagnosis not clear).
• Invasive pressure-flow studies or formal urodynamic studies – are the best tests to determine whether a patient is obstructed at the level of the bladder neck. Appropriate nomograms have been established for normative values regarding the pressure-flow parameters, and it is commonly accepted that the best marker of obstruction is the pressure within the bladder generated by the detrusor muscle at the time of the maximum urinary flow rate.^17,18
• Cystoscopy – Cystoscopy is a procedure that uses a tubelike instrument, called a cystoscope, to look inside the urethra and bladder. A urologist inserts the cystoscope through the opening at the tip of the penis and into the lower urinary tract. A urologist performs cystoscopy during an office visit or in an outpatient center or a hospital. The urologist will give the patient local anesthesia; however, in some cases, the patient may require sedation and regional or general anesthesia. A urologist may use cystoscopy to look for blockage or stones in the urinary tract.
• Transrectal ultrasound – Transrectal ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. The health care provider can move the transducer to different angles to make it possible to examine different organs. A specially trained technician performs the procedure in a health care provider’s office, an outpatient center, or a hospital, and a radiologist—a doctor who specializes in medical imaging—interprets the images; the patient does not require anesthesia. Urologists most often use transrectal ultrasound to examine the prostate. In a transrectal ultrasound, the technician inserts a transducer slightly larger than a pen into the man’s rectum, next to the prostate. The ultrasound image shows the size of the prostate and any abnormalities, such as tumors. Transrectal ultrasound cannot reliably diagnose prostate cancer.
• Biopsy – The biopsy is a procedure that involves taking a small piece of prostate tissue for examination with a microscope. A urologist performs the biopsy in an outpatient center or a hospital. The urologist will give the patient light sedation and local anesthetic; however, in some cases, the patient will require general anesthesia. The urologist uses imaging techniques such as ultrasound, a computerized tomography scan, or magnetic resonance imaging to guide the biopsy needle into the prostate. A pathologist—a doctor who specializes in examining tissues to diagnose diseases—examines the prostate tissue in a lab. The test can show whether prostate cancer is present.

Treatment of Prostate Enlargement

• Active monitoring of symptoms (often called “watchful waiting”): If the symptoms are mild and there are no complications, it may be enough to change a few things in everyday life and go in for a check-up about once a year. This strategy helps in about 30 out of 100 men who seek medical help because of an enlarged prostate.
• Herbal medicine products: There are several over-the-counter herbal products for the relief of symptoms associated with a benign enlarged prostate. Most of these products haven’t been well studied. Others have been studied but weren’t found to reduce prostate symptoms. So the German Society of Urology doesn’t generally recommend them for the treatment of benign enlarged prostates.

Men may not need treatment for a mildly enlarged prostate unless their symptoms are bothersome and affecting their quality of life. In these cases, instead of treatment, a urologist may recommend regular checkups. If benign prostatic hyperplasia symptoms become bothersome or present a health risk, a urologist most often recommends treatment.

Medications

• Phytotherapy
• Monotherapy
• Alpha-blockers
• 5-alpha reductase inhibitors
• PDE5 Inhibitors
•  Combination therapy:
• Alpha-blocker + 5-alpha reductase inhibitor
•  PDE5 inhibitor + Alpha-blocker (experimental)

H. Alpha-blockers, 5-alpha reductase inhibitors, and now phosphodiesterase-5 inhibitors provide significant symptomatic improvement for BPH, particularly when used in combination. A health care provider or urologist may prescribe medications that stop the growth of or shrink the prostate or reduce symptoms associated with benign prostatic hyperplasia:

• alpha-blockers
• phosphodiesterase-5 inhibitors
• 5-alpha reductase inhibitors
• combination medications

Alpha-blockers

Alpha 1-adrenoreceptors are present on prostate stromal smooth muscle and bladder neck. Alpha 1-adrenoreceptor blockage results in stromal smooth muscle relaxation addressing the dynamic component of BPH and thus improving flow. Examples include selective Alpha-blockers such as Tamsulosin (400mcg once daily) and Alfuzosin (10mg once daily). These medications relax the smooth muscles of the prostate and bladder neck to improve urine flow and reduce bladder blockage:

• terazosin (Hytrin)
• doxazosin (Cardura)
• tamsulosin (Flomax)
• alfuzosin (Uroxatral)
• silodosin (Rapaflo)

Phosphodiesterase-5 inhibitors

Urologists prescribe these medications mainly for erectile dysfunction. Tadalafil (Cialis) belongs to this class of medications and can reduce lower urinary tract symptoms by relaxing smooth muscles in the lower urinary tract. Researchers are working to determine the role of erectile dysfunction drugs in the long-term treatment of benign prostatic hyperplasia. Alpha-reductase inhibitors such as finasteride (5mg once daily) and dutasteride block the conversion of testosterone to DHT.[rx]. This addresses the static component of BPH by causing shrinkage of the prostate and takes several weeks to show noticeable improvement, with six months needed for maximal effectiveness.[rx] As a result of treatment serum, PSA can be reduced by 50%, with prostate volume decreasing by up to 25%. This has been shown to alter the disease process and subsequent disease progression.[rx]

5-alpha reductase inhibitors

These medications block the production of DHT, which accumulates in the prostate and may cause prostate growth:

• finasteride (Proscar)
• dutasteride (Avodart)

These medications can prevent the progression of prostate growth or actually shrink the prostate in some men. Finasteride and dutasteride act more slowly than alpha-blockers and are useful for only moderately enlarged prostates.

Combination medications

Several studies, such as the Medical Therapy of Prostatic Symptoms (MTOPS) study, have shown that combining two classes of medications, instead of using just one, can more effectively improve symptoms, urinary flow, and quality of life. The combinations include

• Finasteride and doxazosin
• Dutasteride and tamsulosin (Jalyn), a combination of both medications that is available in a single tablet
• Alpha-blockers and antimuscarinics

A urologist may prescribe a combination of alpha-blockers and antimuscarinics for patients with overactive bladder symptoms. Overactive bladder is a condition in which the bladder muscles contract uncontrollably and cause urinary frequency, urinary urgency, and urinary incontinence. Antimuscarinics are a class of medications that relax the bladder muscles.

Antimuscarinics

Bladder detrusor instability can develop in patients with worsening bladder outlet obstruction. This can result in increased urgency (overactive bladder) and frequency. Muscarinic receptor antagonists can help with these symptoms by blocking muscarinic receptors on detrusor muscle. This reduces smooth muscle tone and can improve symptoms in those with overactivity. Examples include solifenacin, tolterodine, and oxybutynin. Those who fail antimuscarinic treatment may be considered for mirabegron use (a Beta-3 adrenoreceptor agonist), which causes detrusor relaxation.

In practice, the combination of an alpha-blocker and alpha-reductase inhibitor is often used to achieve improvements in voiding symptoms. This is backed by studies confirming the effectiveness of combination therapy over monotherapy.[rx][rx]

Additionally, central α-receptors and the effect of these agents on those receptors will likely play an additional role in the improvement of LUTS in men with BPH. Of the 3 α₁-adrenergic receptor subtypes, α_1A, α_1B, and α_1D, by far the most important in the prostate is the α_1A receptor, constituting approximately 80% according to immunohistochemistry and other analytical methods.^[rx,rx–rx]

Among the available α₁-adrenergic receptor blockers in the United States are the short-acting selective α₁ blocker prazosin, the long-acting selective α₁ blockers terazosin, doxazosin, alfuzosin, and the more subtype-selective α_1A-receptor blocker tamsulosin. Although there are subtle differences between these drugs in terms of their side-effect profiles, they are fundamentally all equally effective in alleviating bothersome LUTS and improving urinary flow rates . Both terazosin (available as 1, 2, 5, and 10 mg) and doxazosin (available as 1, 2, 4, and 8 mg) require titration owing to the first dose effect to reach the maximum recommended doses of 10 and 8 mg, respectively. Tamsulosin is available in 0.4-mg tablets and might be increased to 2 tablets daily or 0.8 mg. Alfuzosin is available only as a single, 10-mg slow-release formulation, and no dose titration is recommended.

Antibiotics

Antibiotics may be used if your prostate becomes chronically inflamed from bacterial prostatitis related to BPH. Treating bacterial prostatitis with antibiotics may improve your symptoms of BPH by reducing the inflammation. However, antibiotics won’t help prostatitis or inflammation that is not caused by bacteria.

Minimally Invasive Procedures

Researchers have developed a number of minimally invasive procedures that relieve benign prostatic hyperplasia symptoms when medications prove ineffective. These procedures include

• Minimally invasive procedures – can destroy enlarged prostate tissue or widen the urethra, which can help relieve the blockage and urinary retention caused by benign prostatic hyperplasia.
• Urologists perform minimally invasive procedures  – using the transurethral method, which involves inserting a catheter—a thin, flexible tube—or cystoscope through the urethra to reach the prostate. These procedures may require local, regional, or general anesthesia. Although destroying troublesome prostate tissue relieves many benign prostatic hyperplasia symptoms, tissue destruction does not cure benign prostatic hyperplasia. A urologist will decide which procedure to perform based on the man’s symptoms and overall health.
• Transurethral needle ablation – This procedure uses heat generated by radiofrequency energy to destroy prostate tissue. A urologist inserts a cystoscope through the urethra to the prostate. A urologist then inserts small needles through the end of the cystoscope into the prostate. The needles send radiofrequency energy that heats and destroys selected portions of prostate tissue. Shields protect the urethra from heat damage.
• Transurethral microwave thermotherapy – This procedure uses microwaves to destroy prostate tissue. A urologist inserts a catheter through the urethra to the prostate, and a device called an antenna sends microwaves through the catheter to heat selected portions of the prostate. The temperature becomes high enough inside the prostate to destroy enlarged tissue. A cooling system protects the urinary tract from heat damage during the procedure.
• High-intensity focused ultrasound – For this procedure, a urologist inserts a special ultrasound probe into the rectum, near the prostate. Ultrasound waves from the probe heat and destroy enlarged prostate tissue.
• Transurethral electrovaporization – For this procedure, a urologist inserts a tube-like instrument called a resectoscope through the urethra to reach the prostate. An electrode attached to the resectoscope moves across the surface of the prostate and transmits an electric current that vaporizes prostate tissue. The vaporizing effect penetrates below the surface area being treated and seals blood vessels, which reduces the risk of bleeding.
• Water-induced thermotherapy – This procedure uses heated water to destroy prostate tissue. A urologist inserts a catheter into the urethra so that a treatment balloon rests in the middle of the prostate. Heated water flows through the catheter into the treatment balloon, which heats and destroys the surrounding prostate tissue. The treatment balloon can target a specific region of the prostate while surrounding tissues in the urethra and bladder remain protected.
• Prostatic stent insertion – This procedure involves a urologist inserting a small device called a prostatic stent through the urethra to the area narrowed by the enlarged prostate. Once in place, the stent expands like a spring, and it pushes back the prostate tissue, widening the urethra. Prostatic stents may be temporary or permanent. Urologists generally use prostatic stents in men who may not tolerate or be suitable for other procedures.

Surgery

For long-term treatment of benign prostatic hyperplasia, a urologist may recommend removing enlarged prostate tissue or making cuts in the prostate to widen the urethra. Urologists recommend surgery when

• Medications and minimally invasive procedures are ineffective
• Symptoms are particularly bothersome or severe
• Complications arise

Although removing troublesome prostate tissue relieves many benign prostatic hyperplasia symptoms, tissue removal does not cure benign prostatic hyperplasia.

Surgery to remove enlarged prostate tissue includes

• Transurethral resection of the prostate (TURP)
• Laser surgery
• Open prostatectomy
• Transurethral incision of the prostate (TUIP)

A urologist performs these surgeries, except for open prostatectomy, using the transurethral method. Men who have these surgical procedures require local, regional, or general anesthesia and may need to stay in the hospital. The urologist may prescribe antibiotics before or soon after surgery to prevent infection. Some urologists prescribe antibiotics only when an infection occurs.

Immediately after benign prostatic hyperplasia surgery, a urologist may insert a special catheter, called a Foley catheter, through the opening of the penis to drain urine from the bladder into a drainage pouch.

• TURP – With TURP, a urologist inserts a resectoscope through the urethra to reach the prostate and cuts pieces of enlarged prostate tissue with a wire loop. Special fluid carries the tissue pieces into the bladder, and the urologist flushes them out at the end of the procedure. TURP is the most common surgery for benign prostatic hyperplasia and considered the gold standard for treating blockage of the urethra due to benign prostatic hyperplasia.
• Laser surgery – With this surgery, a urologist uses a high-energy laser to destroy prostate tissue. The urologist uses a cystoscope to pass a laser fiber through the urethra into the prostate. The laser destroys the enlarged tissue. The risk of bleeding is lower than in TURP and TUIP because the laser seals blood vessels as it cuts through the prostate tissue. However, laser surgery may not effectively treat greatly enlarged prostates.
• Open prostatectomy – In an open prostatectomy, a urologist makes an incision, or cut, through the skin to reach the prostate. The urologist can remove all or part of the prostate through the incision. This surgery is used most often when the prostate is greatly enlarged, complications occur, or the bladder is damaged and needs repair. Open prostatectomy requires general anesthesia, a longer hospital stay than other surgical procedures for benign prostatic hyperplasia, and a longer rehabilitation period. The three open prostatectomy procedures are retropubic prostatectomy, suprapubic prostatectomy, and perineal prostatectomy. The recovery period for open prostatectomy is different for each man who undergoes the procedure.
• TUIP – A TUIP is a surgical procedure to widen the urethra. During a TUIP, the urologist inserts a cystoscope and an instrument that uses an electric current or a laser beam through the urethra to reach the prostate. The urologist widens the urethra by making a few small cuts in the prostate and in the bladder neck. Some urologists believe that TUIP gives the same relief as TURP except with less risk of side effects. After surgery, the prostate, urethra, and surrounding tissues may be irritated and swollen, causing urinary retention. To prevent urinary retention, a urologist inserts a Foley catheter so urine can drain freely out of the bladder. A Foley catheter has a balloon on the end that the urologist inserts into the bladder. Once the balloon is inside the bladder, the urologist fills it with sterile water to keep the catheter in place. Men who undergo minimally invasive procedures may not need a Foley catheter. Bipolar diathermy has largely replaced monopolar diathermy techniques for TURP, with increased benefits such as resection in saline and reduced risk of “TUR syndrome.
• HOLEP – Previously, open prostatectomy allowed adenoma to be removed or enucleated off its capsule. This can now be achieved with laser enucleation, referred to as HoLEP (Holmium laser enucleation of the prostate). Meta-analysis has shown improved Qmax (flow rate), reduction in post-void residual, and IPSS compared to TURP. Benefits include a lower transfusion rate with no increase in complications compared to TURP. However, limitations include specialized equipment required making it less readily available.[rx]
• Urolift – Tissue-sparing approaches, such as Urolift, have also been developed. This can help minimize the risk of bleeding in co-morbid patients and the associated risks of more invasive surgery (such as anesthesia risk, prolonged surgery time, etc.). By compressing prostate lobes, the channel can be widened in the prostatic urethra, improving LUTS. Studies have shown benefits, including the possibility of day-case surgery, preserved sexual function, and improved symptom scores (IPSS), and flow rates (QMax).[rx]

The Foley catheter most often remains in place for several days. Sometimes, the Foley catheter causes recurring, painful, difficult-to-control bladder spasms the day after surgery. However, these spasms will eventually stop. A urologist may prescribe medications to relax bladder muscles and prevent bladder spasms. These medications include

• Oxybutynin chloride (Ditropan)
• Solifenacin (VESIcare)
• Darifenacin (Enablex)
• Tolterodine (Detrol)
• Hyoscyamine (Levsin)
• Propantheline bromide (Pro-Banthine)

Les Minimally invasive procedures

Some less invasive procedures are available according to patients’ preferences and co-morbidities. These are performed as outpatient procedures with local anesthesia.

• Prostatic artery embolization – an endovascular procedure performed in interventional radiology.^[rx] Through catheters, embolic agents are released in the main branches of the prostatic artery, in order to induce a decrease in the size of the prostate gland, thus reducing the urinary symptoms.^[rx]
• Water vapor thermal therapy – This is a newer office procedure for removing prostate tissue using steam aimed at preserving sexual function.
• Prostatic urethral lift (marketed as UroLift) – This intervention consists of a system of a device and an implant designed to pull the prostatic lobe away from the urethra.^[rx]
• Transurethral microwave thermotherapy (TUMT) – is an outpatient procedure that is less invasive compared to surgery and involves using microwaves (heat) to shrink prostate tissue that is enlarged.^[rx]
• Temporary implantable nitinol device (TIND and iTIND) – is a device that is placed in the urethra that, when released, is expanded, reshaping reshaping the urethra and the bladder neck.^[rx]
• Open or robot-assisted prostatectomy – The surgeon makes an incision in your lower abdomen to reach the prostate and remove tissue. Open prostatectomy is generally done if you have a very large prostate, bladder damage or other complicating factors. The surgery usually requires a short hospital stay and is associated with a higher risk of needing a blood transfusion.

Alternative medicine

While herbal remedies are commonly used, a 2016 review found the herbs studied to be no better than placebo.^[rx] Particularly, several systematic reviews found that Saw palmetto extract from Serenoa repens, while one of the most commonly used, is no better than placebo in both symptom relief and decreasing prostate size.^[rx][rx][rx] Other ineffective herbal medicines include beta-sitosterol^[rx] from Hypoxis rooperi (African star grass), pygeum (extracted from the bark of Prunus africana),^[rx] pumpkin seeds (Cucurbita pepo) and stinging nettle (Urtica dioica) root.^[rx] A systematic review of Chinese herbal medicines found that Chinese herbal medicine, either as monotherapy or an adjuvant therapy with Western medicine, was similar to either placebo or Western medicine in the treatment of BPH. Chinese herbal medicine was found to be superior to Western medicine in improving quality of life and reducing prostate volume.

Complications after surgery may include

• Problems urinating – Men may initially have painful urination or difficulty urinating. They may experience urinary frequency, urgency, or retention. These problems will gradually lessen and, after a couple of months, urination will be easier and less frequent.
• Urinary incontinence – As the bladder returns to normal, men may have some temporary problems controlling urination. However, long-term urinary incontinence rarely occurs. The longer urinary problems existed before surgery, the longer it takes for the bladder to regain its full function after surgery.
• Bleeding and blood clots – After benign prostatic hyperplasia surgery, the prostate or tissues around it may bleed. Blood or blood clots may appear in the urine. Some bleeding is normal and should clear up within several days. However, men should contact a health care provider right away if they experience pain or discomfort their urine contains large clots their urine is so red it is difficult to see through. Blood clots from benign prostatic hyperplasia surgery can pass into the bloodstream and lodge in other parts of the body most often the legs. Men should contact a health care provider right away if they experience swelling or discomfort in their legs.
• Infection – Use of a Foley catheter after benign prostatic hyperplasia surgery may increase the risk of a UTI. Anesthesia during surgery may cause urinary retention and also increase the risk of a UTI. In addition, the incision site of an open prostatectomy may become infected. A health care provider will prescribe antibiotics to treat infections.
• Scar tissue – In the year after the original surgery, scar tissue sometimes forms and requires surgical treatment. Scar tissue may form in the urethra and cause it to narrow. A urologist can solve this problem during an office visit by stretching the urethra. Rarely, the opening of the bladder becomes scarred and shrinks, causing a blockage. This problem may require a surgical procedure similar to TUIP.
• Sexual dysfunction – Some men may experience temporary problems with sexual function after benign prostatic hyperplasia surgery. The length of time for restored sexual function depends on the type of benign prostatic hyperplasia surgery performed and how long symptoms were present before surgery. Many men have found that concerns about sexual function can interfere with sex as much as benign prostatic hyperplasia surgery itself. Understanding the surgical procedure and talking about concerns with a health care provider before surgery often helps men regain sexual function earlier. Many men find it helpful to talk with a counselor during the adjustment period after surgery. Even though it can take a while for sexual function to fully return, with time, most men can enjoy sex again.
• Recurring problems – Men may require further treatment if prostate problems, including benign prostatic hyperplasia, return. Problems may arise when treatments for benign prostatic hyperplasia leave a good part of the prostate intact. About 10 percent of men treated with TURP or TUIP require additional surgery within 5 years. About 2 percent of men who have an open prostatectomy require additional surgery within 5 years.

Lifestyle Changes

A health care provider may recommend lifestyle changes for men whose symptoms are mild or slightly bothersome. Lifestyle changes can include

• reducing intake of liquids, particularly before going out in public or before periods of sleep
• avoiding or reducing intake of caffeinated beverages and alcohol
• avoiding or monitoring the use of medications such as decongestants, antihistamines, antidepressants, and diuretics
• training the bladder to hold more urine for longer periods
• exercising pelvic floor muscles
• preventing or treating constipation

Complications of Benign prostatic hyperplasia

The complications of benign prostatic hyperplasia treatment depend on the type of treatment.

Medications used to treat benign prostatic hyperplasia may have side effects that sometimes can be serious. Men who are prescribed medications to treat benign prostatic hyperplasia should discuss possible side effects with a health care provider before taking the medications. Men who experience the following side effects should contact a health care provider right away or get emergency medical care:

• hives
• rash
• itching
• shortness of breath
• rapid, pounding, or irregular heartbeat
• painful erection of the penis that lasts for hours
• swelling of the eyes, face, tongue, lips, throat, arms, hands, feet, ankles, or lower legs
• difficulty breathing or swallowing
• chest pain
• dizziness or fainting when standing up suddenly
• sudden decrease or loss of vision
• blurred vision
• sudden decrease or loss of hearing
• chest pain, dizziness, or nausea during sexual activity

These side effects are mostly related to phosphodiesterase-5 inhibitors. Side effects related to alpha blockers include

• dizziness or fainting when standing up suddenly
• decreased sexual drive
• problems with ejaculation

Minimally Invasive Procedures

Complications after minimally invasive procedures may include

• UTIs
• painful urination
• difficulty urinating
• an urgent or a frequent need to urinate
• urinary incontinence
• blood in the urine for several days after the procedure
• sexual dysfunction
• chronic prostatitis—long-lasting inflammation of the prostate
• recurring problems such as urinary retention and UTIs

Most of the complications of minimally invasive procedures go away within a few days or weeks. Minimally invasive procedures are less likely to have complications than surgery.

Points to Remember

• Common prostate problems include
  • prostatitis—inflammation, or swelling, of the prostate
  • benign prostatic hyperplasia (BPH)—an enlarged prostate due to something other than cancer
  • prostate cancer
• Prostatitis is the most common prostate problem in men younger than age 50.
• BPH is the most common prostate problem in men older than age 50.
• The symptoms of a prostate problem may include problems with urinating and bladder control.
• If you have chronic prostatitis, your symptoms may cause long-lasting pain and discomfort in
  • your penis or scrotum
  • the area between your scrotum and anus
  • your belly
  • your lower back
• If you have bacterial prostatitis, your symptoms may come on quickly, or they may come on slowly and last a long time.
• If you have BPH, you may need to wake up often to urinate when you sleep.
• If you can’t urinate at all, you should get medical help right away.
• Your doctor will know if you have a prostate problem based on the following:
  • your medical and family history
  • a physical exam, including a digital rectal exam of your prostate
  • tests on your urine, blood, and lower urinary tract
  • ultrasound
  • prostate biopsy
• Treatment depends on the type of prostate problem you have.
• If you have chronic prostatitis, your doctor will try treatments to lessen pain, discomfort, and inflammation.
• If you have bacterial prostatitis, your doctor will give you an antibiotic, a medicine that kills bacteria.

References

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