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Prostate Enlargement Benign Prostatic Hyperplasia Fact Book
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prostrate, postate, prostat
The Prostate Gland
The prostate is a walnut-sized gland that forms part of the male
reproductive system. The gland is made of two lobes, or regions, enclosed
by an outer layer of tissue. As the diagrams show, the prostate is located
in front of the rectum and just below the bladder, where urine is stored.
The prostate also surrounds the urethra, the canal through which urine
passes out of the body.
Scientists do not know all the prostate's functions. One of its main
roles, though, is to squeeze fluid into the urethra as sperm move through
during sexual climax. This fluid, which helps make up semen, energizes the
sperm and makes the vaginal canal less acidic.
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BPH: A Common Part of Aging
It is common for the prostate gland to become enlarged as a man ages.
Doctors call the condition benign prostatic hyperplasia (BPH), or benign
prostatic hypertrophy.
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Normal urine
flow. |
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Urine flow with
BPH. |
As a man matures, the prostate goes through two main periods of growth.
The first occurs early in puberty, when the prostate doubles in size. At
around age 25, the gland begins to grow again. This second growth phase
often results, years later, in BPH.
Though the prostate continues to grow during most of a man's life, the
enlargement doesn't usually cause problems until late in life. BPH rarely
causes symptoms before age 40, but more than half of men in their sixties
and as many as 90 percent in their seventies and eighties have some
symptoms of BPH.
As the prostate enlarges, the layer of tissue surrounding it stops it
from expanding, causing the gland to press against the urethra like a
clamp on a garden hose. The bladder wall becomes thicker and irritable.
The bladder begins to contract even when it contains small amounts of
urine, causing more frequent urination. Eventually, the bladder weakens
and loses the ability to empty itself. Urine remains in the bladder. The
narrowing of the urethra and partial emptying of the bladder cause many of
the problems associated with BPH.
Many people feel uncomfortable talking about the prostate, since the
gland plays a role in both sex and urination. Still, prostate enlargement
is as common a part of aging as gray hair. As life expectancy rises, so
does the occurrence of BPH. In the United States alone, 375,000 hospital
stays each year involve a diagnosis of BPH.
It is not clear whether certain groups face a greater risk of getting
BPH. Studies done over the years suggest that BPH occurs more often among
married men than single men and is more common in the United States and
Europe than in other parts of the world. However, these findings have been
debated, and no definite information on risk factors exists.
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Why BPH Occurs
The cause of BPH is not well understood. For centuries, it has been
known that BPH occurs mainly in older men and that it doesn't develop in
men whose testes were removed before puberty. For this reason, some
researchers believe that factors related to aging and the testes may spur
the development of BPH.
Throughout their lives, men produce both testosterone, an important
male hormone, and small amounts of estrogen, a female hormone. As men age,
the amount of active testosterone in the blood decreases, leaving a higher
proportion of estrogen. Studies done with animals have suggested that BPH
may occur because the higher amount of estrogen within the gland increases
the activity of substances that promote cell growth.
Another theory focuses on dihydrotestosterone (DHT), a substance
derived from testosterone in the prostate, which may help control its
growth. Most animals lose their ability to produce DHT as they age.
However, some research has indicated that even with a drop in the blood's
testosterone level, older men continue to produce and accumulate high
levels of DHT in the prostate. This accumulation of DHT may encourage the
growth of cells. Scientists have also noted that men who do not produce
DHT do not develop BPH.
Some researchers suggest that BPH may develop as a result of
"instructions" given to cells early in life. According to this theory, BPH
occurs because cells in one section of the gland follow these instructions
and "reawaken" later in life. These "reawakened" cells then deliver
signals to other cells in the gland, instructing them to grow or making
them more sensitive to hormones that influence growth.
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Symptoms
Many symptoms of BPH stem from obstruction of the urethra and gradual
loss of bladder function, which results in incomplete emptying of the
bladder. The symptoms of BPH vary, but the most common ones involve
changes or problems with urination, such as
- a hesitant, interrupted, weak stream
- urgency and leaking or dribbling
- more frequent urination, especially at night
The size of the prostate does not always determine how severe the
obstruction or the symptoms will be. Some men with greatly enlarged glands
have little obstruction and few symptoms while others, whose glands are
less enlarged, have more blockage and greater problems.
Sometimes a man may not know he has any obstruction until he suddenly
finds himself unable to urinate at all. This condition, called acute
urinary retention, may be triggered by taking over-the-counter cold or
allergy medicines. Such medicines contain a decongestant drug, known as a
sympathomimetic. A potential side effect of this drug may be to prevent
the bladder opening from relaxing and allowing urine to empty. When
partial obstruction is present, urinary retention also can be brought on
by alcohol, cold temperatures, or a long period of immobility.
It is important to tell your doctor about urinary problems such as
those described above. In 8 out of 10 cases, these symptoms suggest BPH,
but they also can signal other, more serious conditions that require
prompt treatment. These conditions, including prostate cancer, can be
ruled out only by a doctor's exam.
Severe BPH can cause serious problems over time. Urine retention and
strain on the bladder can lead to urinary tract infections, bladder or
kidney damage, bladder stones, and incontinence. If the bladder is
permanently damaged, treatment for BPH may be ineffective. When BPH is
found in its earlier stages, there is a lower risk of developing such
complications.
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Diagnosis
You may first notice symptoms of BPH yourself, or your doctor may find
that your prostate is enlarged during a routine checkup. When BPH is
suspected, you may be referred to a urologist, a doctor who specializes in
problems of the urinary tract and the male reproductive system. Several
tests help the doctor identify the problem and decide whether surgery is
needed. The tests vary from patient to patient, but the following are the
most common.
Digital Rectal Exam (DRE)
This exam is usually the first test done. The doctor inserts a gloved
finger into the rectum and feels the part of the prostate next to the
rectum. This exam gives the doctor a general idea of the size and
condition of the gland.
Prostate Specific Antigen (PSA) Blood Test
In order to rule out cancer as a cause of urinary symptoms, your doctor
may recommend a PSA blood test. PSA, a protein produced by prostate cells,
is frequently present at elevated levels in the blood of men who have
prostate cancer. The U.S. Food and Drug Administration has approved a PSA
test for use in conjunction with a digital rectal exam to help detect
prostate cancer in men age 50 or older and for monitoring prostate cancer
patients after treatment. However, much remains unknown about the
interpretation of PSA levels, the test's ability to discriminate cancer
from benign prostate conditions, and the best course of action following a
finding of elevated PSA.
Because many unanswered questions surround the issue of PSA screening,
the relative magnitude of its potential risks and benefits is unknown.
Both PSA and ultrasound tests enhance detection when added to DRE
screening. But they are known to have relatively high false-positive
rates, and they may identify a greater number of medically insignificant
tumors. Thus, PSA screening might lead to treatment of unproven benefit
that could result in morbidity (including impotence and incontinence) and
mortality. It cannot be determined from earlier studies whether PSA
screening will reduce prostate cancer mortality. Ongoing studies are
addressing this issue.
Rectal Ultrasound
If there is a suspicion of prostate cancer, your doctor may recommend a
test with rectal ultrasound. In this procedure, a probe inserted in the
rectum directs sound waves at the prostate. The echo patterns of the sound
waves form an image of the prostate gland on a display screen.
Urine Flow Study
Sometimes the doctor will ask a patient to urinate into a special
device that measures how quickly the urine is flowing. A reduced flow
often suggests BPH.
Intravenous Pyelogram (IVP)
IVP is an x ray of the urinary tract. In this test, a dye is injected
into a vein, and the x ray is taken. The dye makes the urine visible on
the x ray and shows any obstruction or blockage in the urinary tract.
Cystoscopy
In this exam, the doctor inserts a small tube through the opening of
the urethra in the penis. This procedure is done after a solution numbs
the inside of the penis so all sensation is lost. The tube, called a
cystoscope, contains a lens and a light system, which help the doctor see
the inside of the urethra and the bladder. This test allows the doctor to
determine the size of the gland and identify the location and degree of
the obstruction.
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Treatment
Men who have BPH with symptoms usually need some kind of treatment at
some time. However, a number of recent studies have questioned the need
for early treatment when the gland is just mildly enlarged. These studies
report that early treatment may not be needed because the symptoms of BPH
clear up without treatment in as many as one-third of all mild cases.
Instead of immediate treatment, they suggest regular checkups to watch for
early problems. If the condition begins to pose a danger to the patient's
health or causes a major inconvenience to him, treatment is usually
recommended.
Since BPH may cause urinary tract infections, a doctor will usually
clear up any infection with antibiotics before treating the BPH itself.
Although the need for treatment is not usually urgent, doctors generally
advise going ahead with treatment once the problems become bothersome or
present a health risk.
The following section describes the types of treatment that are most
commonly used for BPH.
Drug Treatment
Over the years, researchers have tried to find a way to shrink or at
least stop the growth of the prostate without using surgery. The Food and
Drug Administration (FDA) has approved four drugs to relieve common
symptoms associated with an enlarged prostate.
Finasteride (marketed under the name Proscar), FDA-approved in 1992,
inhibits production of the hormone DHT, which is involved with prostate
enlargement. Its use can actually shrink the prostate in some men.
FDA also approved the drugs terazosin (marketed as Hytrin) in 1993,
doxazosin (marketed as Cardura) in 1995, and tamsulosin (marketed as
Flomax) in 1997 for the treatment of BPH. All three drugs act by relaxing
the smooth muscle of the prostate and bladder neck to improve urine flow
and to reduce bladder outlet obstruction. Terazosin, doxazosin, and
tamsulosin belong to the class of drugs known as alpha blockers. Terazosin
and doxazosin were developed first to treat high blood pressure.
Tamsulosin is the first alpha blocker developed specifically to treat BPH.
NIDDK's Medical Therapy of Prostatic Symptoms (MTOPS) Trial recently
found that using finasteride and doxazosin together is more effective than
either drug alone to relieve symptoms and prevent BPH progression. The
two-drug regimen reduced the risk of BPH progression by 67 percent,
compared to 39 percent for doxazosin alone and 34 percent for finasteride
alone.
Nonsurgical Treatment
Because drug treatment is not effective in all cases, researchers in
recent years have developed a number of procedures that relieve BPH
symptoms but are less invasive than surgery.
Transurethral Microwave Procedures. In May 1996, FDA approved
the Prostatron, a device that uses microwaves to heat and destroy excess
prostate tissue. In the procedure called transurethral microwave
thermotherapy (TUMT), the Prostatron sends computer-regulated microwaves
through a catheter to heat selected portions of the prostate to at least
111 degrees Fahrenheit. A cooling system protects the urinary tract during
the procedure.
A similar microwave device, the Targis System, received FDA approval in
September 1997. Like the Prostatron, the Targis System delivers microwaves
to destroy selected portions of the prostate and uses a cooling system to
protect the urethra. A heat-sensing device inserted in the rectum helps
monitor the therapy.
Both procedures take about 1 hour and can be performed on an outpatient
basis without general anesthesia. Neither procedure has been reported to
lead to impotence or incontinence.
While microwave therapy does not cure BPH, it reduces urinary
frequency, urgency, straining, and intermittent flow. It does not correct
the problem of incomplete emptying of the bladder. Ongoing research will
determine any long-term effects of microwave therapy and who might benefit
most from this therapy.
Transurethral Needle Ablation. In October 1996, FDA approved
Vidamed's minimally invasive Transurethral Needle Ablation (TUNA) System
for the treatment of BPH.
The TUNA System delivers low-level radiofrequency energy through twin
needles to burn away a well-defined region of the enlarged prostate.
Shields protect the urethra from heat damage. The TUNA System improves
urine flow and relieves symptoms with fewer side effects when compared
with transurethral resection of the prostate (TURP). No incontinence or
impotence has been observed.
Surgical Treatment
Most doctors recommend removal of the enlarged part of the prostate as
the best long-term solution for patients with BPH. With surgery for BPH,
only the enlarged tissue that is pressing against the urethra is removed;
the rest of the inside tissue and the outside capsule are left intact.
Surgery usually relieves the obstruction and incomplete emptying caused by
BPH. The following section describes the types of surgery that are used.
Transurethral Surgery. In this type of surgery, no external
incision is needed. After giving anesthesia, the surgeon reaches the
prostate by inserting an instrument through the urethra.
A procedure called TURP (transurethral resection of the prostate) is
used for 90 percent of all prostate surgeries done for BPH. With TURP, an
instrument called a resectoscope is inserted through the penis. The
resectoscope, which is about 12 inches long and 1/2 inch in diameter,
contains a light, valves for controlling irrigating fluid, and an
electrical loop that cuts tissue and seals blood vessels.
During the 90-minute operation, the surgeon uses the resectoscope's
wire loop to remove the obstructing tissue one piece at a time. The pieces
of tissue are carried by the fluid into the bladder and then flushed out
at the end of the operation.
Most doctors suggest using TURP whenever possible. Transurethral
procedures are less traumatic than open forms of surgery and require a
shorter recovery period.
Another surgical procedure is called transurethral incision of the
prostate (TUIP). Instead of removing tissue, as with TURP, this procedure
widens the urethra by making a few small cuts in the bladder neck, where
the urethra joins the bladder, and in the prostate gland itself. Although
some people believe that TUIP gives the same relief as TURP with less risk
of side effects such as retrograde ejaculation, its advantages and
long-term side effects have not been clearly established.
Open Surgery. In the few cases when a transurethral procedure
cannot be used, open surgery, which requires an external incision, may be
used. Open surgery is often done when the gland is greatly enlarged, when
there are complicating factors, or when the bladder has been damaged and
needs to be repaired. The location of the enlargement within the gland and
the patient's general health help the surgeon decide which of the three
open procedures to use.
With all the open procedures, anesthesia is given and an incision is
made. Once the surgeon reaches the prostate capsule, he scoops out the
enlarged tissue from inside the gland.
Laser Surgery. In March 1996, FDA approved a surgical procedure
that employs side-firing laser fibers and Nd: YAG lasers to vaporize
obstructing prostate tissue. The doctor passes the laser fiber through the
urethra into the prostate using a cystoscope and then delivers several
bursts of energy lasting 30 to 60 seconds. The laser energy destroys
prostate tissue and causes shrinkage. Like TURP, laser surgery requires
anesthesia and a hospital stay. One advantage of laser surgery over TURP
is that laser surgery causes little blood loss. Laser surgery also allows
for a quicker recovery time. But laser surgery may not be effective on
larger prostates. The long-term effectiveness of laser surgery is not
known.
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Your Recovery After Surgery in the Hospital
If you have surgery, you'll probably stay in the hospital from 3 to 10
days depending on the type of surgery you had and how quickly you recover.
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Foley
Catheter |
At the end of surgery, a special catheter is inserted through the
opening of the penis to drain urine from the bladder into a collection
bag. Called a Foley catheter, this device has a water-filled balloon on
the end that is placed in the bladder, which keeps it in place.
This catheter is usually left in place for several days. Sometimes, the
catheter causes recurring painful bladder spasms the day after surgery.
These may be difficult to control, but they will eventually disappear.
You may also be given antibiotics while you are in the hospital. Many
doctors start giving this medicine before or soon after surgery to prevent
infection. However, some recent studies suggest that antibiotics may not
be needed in every case, and your doctor may prefer to wait until an
infection is present to give them.
After surgery, you will probably notice some blood or clots in your
urine as the wound starts to heal. If your bladder is being irrigated
(flushed with water), you may notice that your urine becomes red once the
irrigation is stopped. Some bleeding is normal, and it should clear up by
the time you leave the hospital. During your recovery, it is important to
drink a lot of water (up to 8 cups a day) to help flush out the bladder
and speed healing.
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Do's and Don'ts
Take it easy the first few weeks after you get home. You may not have
any pain, but you still have an incision that is healing--even with
transurethral surgery, where the incision can't be seen. Since many people
try to do too much at the beginning and then have a setback, it is a good
idea to talk to your doctor before resuming your normal routine. During
this initial period of recovery at home, avoid any straining or sudden
movements that could tear the incision. Here are some guidelines:
- Continue drinking a lot of water to flush the bladder.
- Avoid straining when moving your bowel.
- Eat a balanced diet to prevent constipation. If constipation occurs,
ask your doctor if you can take a laxative.
- Don't do any heavy lifting.
- Don't drive or operate machinery.
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Getting Back to Normal
Even though you should feel much better by the time you leave the
hospital, it will probably take a couple of months for you to heal
completely. During the recovery period, the following are some common
problems that can occur.
Problems Urinating
You may notice that your urinary stream is stronger right after
surgery, but it may take awhile before you can urinate completely normally
again. After the catheter is removed, urine will pass over the surgical
wound on the prostate, and you may initially have some discomfort or feel
a sense of urgency when you urinate. This problem will gradually lessen,
though, and after a couple of months you should be able to urinate less
frequently and more easily.
Inability to Control Urination (Incontinence)
As the bladder returns to normal, you may have some temporary problems
controlling urination, but long-term incontinence rarely occurs. Doctors
find that the longer problems existed before surgery, the longer it will
take for the bladder to regain its full function after the operation.
Bleeding
In the first few weeks after transurethral surgery, the scab inside the
bladder may loosen, and blood may suddenly appear in the urine. Although
this can be alarming, the bleeding usually stops with a short period of
resting in bed and drinking fluids. However, if your urine is so red that
it is difficult to see through or if it contains clots or if you feel any
discomfort, be sure to contact your doctor.
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Sexual Function After Surgery
Many men worry about whether surgery for BPH will affect their ability
to enjoy sex. Some sources state that sexual function is rarely affected,
while others claim that it can cause problems in up to 30 percent of all
cases. However, most doctors say that even though it takes awhile for
sexual function to return fully, with time, most men are able to enjoy sex
again.
Complete recovery of sexual function may take up to 1 year, lagging
behind a person's general recovery. The exact length of time depends on
how long after symptoms appeared that BPH surgery was done and on the type
of surgery. Following is a summary of how surgery is likely to affect the
following aspects of sexual function.
Erections
Most doctors agree that if you were potent (able to maintain an
erection) shortly before surgery, you will probably be able to have
erections afterward. Surgery rarely causes a loss of potency. However,
surgery cannot usually restore potency that was lost before the
operation.
Ejaculation
Although most men are able to continue having erections after surgery,
a prostatectomy frequently makes them sterile (unable to father children)
by causing a condition called "retrograde ejaculation" or "dry
climax."
During sexual activity, sperm from the testes enters the urethra near
the opening of the bladder. Normally, a muscle blocks off the entrance to
the bladder, and the semen is expelled through the penis. However, the
coring action of prostate surgery cuts this muscle as it widens the neck
of the bladder. Following surgery, the semen takes the path of least
resistance and enters the wider opening to the bladder rather than being
expelled through the penis. Later it is harmlessly flushed out with
urine.
Orgasm
Most men find little or no difference in the sensation of orgasm, or
sexual climax, before and after surgery. Although it may take some time to
get used to retrograde ejaculation, you should eventually find sex as
pleasurable after surgery as before.
Many people have found that concerns about sexual function can
interfere with sex as much as the operation itself. Understanding the
surgical procedure and talking over any worries with the doctor before
surgery often help men regain sexual function earlier. Many men also find
it helpful to talk to a counselor during the adjustment period after
surgery.
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Is Further Treatment Needed?
In the years after your surgery, it is important to continue having a
rectal exam once a year and to have any symptoms checked by your doctor.
Since surgery for BPH leaves behind a good part of the gland, it is
still possible for prostate problems, including BPH, to develop again.
However, surgery usually offers relief from BPH for at least 15 years.
Only 10 percent of the men who have surgery for BPH eventually need a
second operation for enlargement. Usually these are men who had the first
surgery at an early age.
Sometimes, scar tissue resulting from surgery requires treatment in the
year after surgery. Rarely, the opening of the bladder becomes scarred and
shrinks, causing obstruction. This problem may require a surgical
procedure similar to transurethral incision (see section on Surgical
Treatment). More often, scar tissue may form in the urethra and cause
narrowing. This problem can usually be solved during an office visit when
the doctor stretches the urethra.
Prostatic Stents
Stents are small devices inserted through the urethra to the narrowed
area and allowed to expand, like a spring. The stent pushes back the
prostatic tissue, widening the urethra. FDA approved the Urolume
Endoprosthesis in 1996 to relieve urinary obstruction in men and improve
ability to urinate. The device is approved for use in men for whom other
standard surgical procedures to correct urinary obstruction have failed.
BPH and Prostate Cancer: No Apparent Relation
Although some of the signs of BPH and prostate cancer are the same,
having BPH does not seem to increase the chances of getting prostate
cancer. Nevertheless, a man who has BPH may have undetected prostate
cancer at the same time or may develop prostate cancer in the future. For
this reason, the National Cancer Institute and the American Cancer Society
recommend that all men over 40 have a rectal exam once a year to screen
for prostate cancer.
After BPH surgery, the tissue removed is routinely checked for hidden
cancer cells. In about 1 out of 10 cases, some cancer tissue is found, but
often it is limited to a few cells of a nonaggressive type of cancer, and
no treatment is needed.
Keeping on Top of Your Condition
Keeping in tune with your disease or condition not only makes treatment less intimidating but also increases its chance of success, and has been shown to lower a patients risk of complications. As well, as an informed patient, you are better able to discuss your condition and treatment options with your physician.
A new service available to patients provides a convenient means of staying informed, and ensures that the information is both reliable and accurate. If you wish to find out more about HealthNewsflash's innovative service, take the tour.
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Additional Reading
De La Rosette, J. J. M. C. H., D'Ancona, F. C. H., & Debruyne, F.
M. J. (1997). Current status of thermotherapy of the prostate. The
Journal of Urology, 157(2), 430-438.
Dixon, C. M., & Lepor, H. (1993). Lasers add a glow to the search
for BPH therapies. Contemporary Urology, 5(10), 44, 46, 48-50, 53,
56-58, 60, 62.
Hollander, J. B., & Diokno, A. C. (1996). Prostatism: Benign
prostatic hyperplasia. Geriatric Urology, 23(1), 75-86.
Oesterling, J. E. (1995). Benign prostatic hyperplasia: Medical and
minimally invasive treatment options. The New England Journal of
Medicine, 332(2), 99-109.
Oesterling, J. E., & Monda, J. M. (1994). A new reality for
urology: Drugs that alleviate BPH symptoms. Contemporary Urology,
6(1), 46-50, 54-56, 58, 60.
Regan, J. B. (1996). Thermotherapy: A new treatment for BPH (enlarged
prostate). Family Urology, 12-13.
Schulman, C. C., & Zlotta, A. R. (1995). TUNA: A promising new
therapy for BPH. Contemporary Urology, 7(10), 59-60, 62, 64, 67,
72.
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