Enlarged Prostate (BPH)

What is the prostate?

The prostate is an oval shaped organ that is located between the bladder and the penis.

The prostate surrounds the tube (the urethra) that carries urine and semen to the penis. A young man’s prostate is about the size of a walnut. However, with age, the prostate does grow in size. By the time many men reach 50 years of age, the prostate may be large enough to start causing many urinary symptoms.

What causes prostate enlargement?

The causes of prostate enlargement are still being explored. We do know that testosterone (male hormone) “feeds” the prostate and makes it grow larger. There may also be a genetic link to prostate enlargement, because prostate diseases tend to run in families.

What are the symptoms of prostate enlargement?

Not every man with an enlarged prostate has symptoms. But when symptoms do occur, they are related to the prostate obstructing the flow of urine through the urethra. Think of the prostate being a fist and the fist tightening as a person ages. This can lead to problems such as:

  • Difficulty in starting or stopping urination;
  • Dribbling of urine after urination is done;
  • A weak urine stream;
  • A frequent and urgent need to urinate, particularly at night;
  • Blood in the urine or ejaculate;
  • Pain in the area between the scrotum and the anus; and
  • A feeling that the bladder is not empty even after urinating
  • Urinating very small amount at a time.

Although these symptoms are usually due to an enlarged prostate, they may also be caused by other conditions. So men should always see a doctor if they notice changes in the how they urinate, or how often.

Complications of prostate enlargement

Left untreated, an enlarged prostate may lead to a number of complications, including:

  • Pain in the lower abdomen due to the retention of urine
  • Bladder infections due to urine sitting in the bladder too long which becomes infected with bacteria;
  • Bladder stones – stones that form as a result of urine particles crystallizing because of stale urine sitting too long.
  • Interrupted sleep because of the need to get up several times during the night to urinate;
  • A lower quality of life because of the inconvenience and embarrassment of problems with urination or problems with urinary accidents, wetting pants
  • Serious kidney problems if the flow of urine out of the bladder becomes blocked and causes a build-up of pressure all the way back to the kidneys, this may lead to kidney damage and sometimes kidney failure.
  • Urinary incontinence (urinary leaks and bed wetting) usually caused by the bladder being too full and spilling out urine
  • Inability to urinate requiring either a temporary or permanent penis tube (catheter) to help empty the bladder
  • The formation of bladder diverticula which are areas of stretched out bladder wall creating small pouches that do not empty urine very well
  • With progressive obstruction by the prostate, the bladder may become overworked, leading to symptoms of "overactive bladder" such as urgency and frequency
  • In severe cases with long term obstruction, the bladder may “give up” and the bladder muscle may no longer work well, resulting in need for a catheter tube to help drain the bladder

How common is prostate enlargement?

Prostate enlargement is the most common condition affecting the prostate. Prostate enlargement also is described by the medical term ‘BPH’, which is short for benign prostatic hyperplasia, or benign prostatic hypertrophy. This means that there is ‘benign’ (non-cancerous), and ‘hyperplasia’ or ‘hypertrophy’ means ‘enlargement'.

What things can make symptoms worse?

There are a number of things that can aggravate the symptoms of prostate enlargement, including:

  • Medicines used to treat depression or Parkinson's disease;
  • Some heart medications;
  • Some cough and cold medicines (like those containing antihistamines); and
  • Alcohol
  • Caffeine
  • Testosterone replacement treatments

Should I see a doctor?

You should see a doctor if you notice any of the above symptoms.

How is prostate enlargement diagnosed?

Your GP (or a specialist, such as a urologist) will take steps to diagnose the cause of your urinary symptoms. Your doctor may:

  • Ask about your personal, medical and family history;
  • Ask you to describe your symptoms and how much they interfere with your life;
  • Do a physical examination – this will usually include the doctor checking the size, shape and feel of the prostate by placing a lubricated gloved finger into the rectum (back passage);
  • Request urine or blood tests – a blood test can check levels of a particular protein. Levels of this protein (called PSA, or prostate specific antigen) can become high due to prostate problems such as an enlarged prostate or prostate cancer; or
  • Request an ultrasound scan of your prostate, bladder and kidneys. This may include a scan before and after emptying your bladder to see if significant urine remains after voiding.

What kind of tests may be done to check the prostate and my urinary functions?

There are some optional and mandatory testing that your doctor may do to check the prostate, bladder and the overall function of your urinary tract. You may click on the links to learn more about these tests in detail. These tests include:

  • Cystoscopy - a quick look inside the penis tube (urethra), inside the prostate and bladder with a flexible tube with a camera
  • UroFlow - with a full bladder, patient urinates into a special toilet that measures the speed and timing of urination
  • Bladder Scan or Bladder Ultrasound - use a small probe that is placed below the belly button to look with an ultrasound at the bladder and check how well you empty your bladder
  • Pressure Flow Test - with a full bladder, the patient urinates as a small pressure cuff around the penis inflates and deflates. This tests the pressure that the bladder is able to generate as you urinate.
  • Kidney Ultrasound - using a small probe against the side of your belly, we are able to look at the either the left or right kidneys to see if there is any urine backed up.
  • Prostate Ultrasound - using a small probe that is placed into the rectum (up the bottom), we are able to take pictures of the prostate and give the best measurement of the size and shape of the prostate.
  • Urodynamics - being the most complicated test, it is the most useful in showing us the exact functions of the bladder. It involves placing a very thin tube in the bladder, and another one in the rectum, we are able to find out the exact volume your bladder holds, and how the bladder muscle behaves (overactive, under-active or normal)
  • Urine Analysis - simple urine test that is done with both a litmus strip to check for any blood, protein, pH, concentration, and signs of infection in the urine as well as a microscopic examination to look for any bacteria, white and red blood cells
  • Urine Cytology - a specialized test done if there is suspicion of bladder cancer. It is simply a urine test done by a trained pathologist who looks for any suspicious/cancer cells that your urinary tract may shed into the urine
  • PSA (prostate specific antigen) - blood test that detects an enzyme that only the prostate makes and is used to screen for prostate cancer. Benign prostate tissue will also make PSA and thus also will be seen to rise in level as the prostate grows with age.
  • Digital rectal examination - the most notorious of exams, the doctor checking the size, shape and feel of the prostate by placing a lubricated gloved finger into the rectum (back passage)

Is it prostate enlargement or prostate cancer?

The symptoms of an enlarged prostate can be similar to the symptoms of prostate cancer. So if anything abnormal is found when checking your prostate, your doctor may request a biopsy of your prostate. The biopsy collects a small sample of cells from your prostate which are examined under a microscope to check for the presence of cancer cells.

How is prostate enlargement treated?

There are a number of treatments available for prostate enlargement. The most suitable treatment can depend on how severe the symptoms are:

For mild symptoms

  • No treatment may be required if the symptoms are not interfering with your enjoyment of life
  • Patients should still be monitored as about 60% of men see worsening of their symptoms over a 4-year period
  • Only 10 % of patients require surgical intervention
  • Worsening symptoms are typically seen in patients with
    • larger prostate size
    • higher PSA blood test levels
    • older age
    • lower urine flow rates

For moderate symptoms

There are medicines that are taken as tablets that can:

  • Make it easier to urinate – These medicines include PDE-5 inhibitor (Cialis) at low doses OR alpha-blocker drugs such as tamsulosin (Flomax), terazosin (Hytrin), alfuzosin (Uroxatra), or (silodosin) Rapaflo. These medicines work by relaxing the prostate and help it open up and improve urinary flow. They generally improve symptoms within several days to weeks.
  • Help to shrink the prostate – These medicines are called 5-alpha reductase inhibitors and include drugs such as finasteride (Proscar) and dutasteride (Avodart). They may take 3-6 months to improve symptoms, and are often combined with an alpha-blocker medicine.
  • Herbal medicines such as saw palmetto are commonly used but there is little mixed evidence of benefit.
  • Overactive bladder medicines - in cases where chronic urinary obstruction is increasing bladder sensitivity and leading to frequency and urgency, sometimes we use medicines to calm the bladder down. These drugs are only used in cases where patients are not retaining large volumes of urine.

For severe symptoms

  • In men with severe urinary symptoms, 40% require surgical treatment within 4 years
  • Surgery may be an option to remove part of the prostate or relieve pressure on the urethra. (see below)
  • In cases where surgery is too dangerous for a patient, patients are treated with a tube called a catheter that is either placed through the penis (Foley catheter) or below the belly button (suprapubic tube) to continuously drain the bladder. This tube is generally changed about once per month.
  • Patients who are willing and able, also have an option of using catheters to drain their bladders intermittently, meaning that the patient placed the catheter in their penis, drains the bladder and then immediately removes the tube.

Surgical treatment

There are several types of surgery available to treat prostate enlargement:

  • Aquablation® Robotic Prostate Therapy - Aquablation is the latest enlarged prostate surgical treatment that we would call the “one and done” of all the surgical treatment options. In short, it combines precision with efficiency and safety into a single robotic technology that rapidly, precisely and safely contours the prostate channel with a pressurized jet of water.
  • GreenLight Laser Vaporization of the prostate - while you’re asleep in the operating room, camera is used to look inside the prostate through the penis and a laser is used to heat up the prostate tissue and literally vaporize the prostate until a good open channel is created through the inner part of the prostate.
  • UroLift® – either done in the surgery center or office, the procedure is done by placing a small rigid camera in the penis and prostate and deploying clips on either side of the prostate so as to compress the obstructing parts of the prostate and open up the urinary channel.
  • Rezūm™ - an office procedure under a local anesthetic, where via a camera placed into the penis and prostate, steam is injected into the prostate and heats the prostate, which eventually makes the prostate shrink.
  • Transurethral resection of the prostate (TURP) – while you’re asleep in the operating room, camera is used to look inside the prostate through the penis and a metal loop at its end is used to slice off some of the enlarged prostate tissue to reduce pressure on the urethra. TURP has been a standard treatment of BPH for many years, however, it has been largely replaced by newer methods using a laser instead of a metal loop.
  • Transurethral incision of the prostate (TUIP) – This procedure also relieves the pressure on the urethra but without removing any of the prostate. It may be used in cases where the enlargement is not severe.
  • Microwave of the Prostate - this is an office procedure that involves placing a small catheter tube in the penis that contains a microwave antenna and heats the prostate over a short period. The heating of the prostate will eventually make the prostate smaller and improve urinary symptoms.
  • Robotic or Open Suprapubic prostatectomy – This is not a common treatment and is usually only done when the prostate is extremely enlarged and involves either the open or robotic/laparoscopic methods to remove the prostate via an incision in the belly and bladder and core out the inner part of the prostate. This is not the same operation that we do for prostate cancer, but is similar in the approach.

Surgery for an enlarged prostate usually provides significant relief from symptoms and an improvement in quality of life. However, some types of prostate surgery can result in complications which may include bleeding after surgery, infections, problems with sexual function, infertility or leakage of urine. Talk to your surgeon about the risks associated with surgery and click on the links to each procedure above to learn more.

What can I do to improve my symptoms?

Here are some things you may do to help relieve your symptoms, including:

  • Don’t let your bladder get too full – urinate as soon as the urge arises, and try to relax when urinating.
  • Double void – try emptying your bladder again after waiting a moment. Don’t strain or push, just relax your pelvic muscles.
  • Reduce your intake of drinks with caffeine – such as coffee, tea and cola – and alcohol that can irritate the bladder;
  • Restrict your intake of fluids before going to bed to reduce the need to get up during the night to urinate;
  • Check with your doctor about whether any medicines you are taking might make your symptoms worse and whether there are other alternatives;
  • Keep any other conditions such as diabetes and sleep apnea under control as they may also contribute to increased urination
  • Do pelvic floor muscle exercises (Kegels) to help stop urine leaking from the bladder (Broward Urology Center has a physiotherapist who can teach you the exercises);
  • Prevent constipation as large amounts of stool in the rectum can irritate the bladder as well as press on the prostate and make voiding more difficult;
  • When taking long flights and car trips, make frequent stops to urinate;
  • If you notice that your legs and ankles tend to be swollen by the end of the day, it is important to cut down your salt intake and also keep your legs elevated several hours before going to sleep as this will encourage your body to pee off the extra fluid prior to you actually laying down to sleep
  • Lose weight if necessary;
  • Quit smoking;
  • Be more active; and
  • Ask your doctor about natural or herbal supplements that may help relieve symptoms. Herbal extracts may include Saw palmetto, African plum tree or pumpkin seed. But be aware that these products are not as effective as prescription medicines, have not been tested in the same way and may interfere with other medicines you are taking.
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