Treating an enlarged prostate

SATYENDRA PERSAUD and JOEL LEACH

What is the prostate?

The prostate is a small gland at the bottom of the bladder which secretes a substance that is part of the semen. The gland is the size of a walnut in young men but usually gets bigger with age. It lies in front of the rectum, which is why your doctor can feel the prostate through your back passage. Urine has to flow through the prostate and this is why diseases of the prostate affect urine flow.

What is BPH?

You may have heard the term BPH. This means Benign Prostatic Hyperplasia and refers to an enlarged prostate. While the prostate gets larger with age, the exact cause of BPH is unknown. It is a very common disease and can cause significant bother. As the prostate enlarges, it presses on the urethra (urine tube) and can block the outflow – it does this both via an increase in the smooth muscle contraction in the gland as well as a mass effect from a having bigger gland.

What are the symptoms of BPH?

The most common symptoms include slow start up of urination, weak stream or a sense of not being able to empty your bladder fully. Eventually the bladder becomes thicker and irritable and you may find yourself going to the bathroom often, even at nights. An enlarged prostate may also cause bleeding in the urine. In the long term, complications may arise including urinary retention (stoppage of water), bladder stones, recurrent infections or even kidney failure.

What will happen if you seek help?

If you have suspicious symptoms, your doctor will refer you to a urologist. Your urologist should take a very detailed history of your symptoms and may even ask you to fill out a questionnaire called the IPSS (International prostate symptom score) score which gives him a better idea of your symptoms. He will examine your tummy as well as your prostate, feeling for anything suspicious such as lumps. He may request some blood tests, including a kidney function test as well as a PSA which tells him more about the prostate. He may also opt to do a flow test which involves urinating into a funnel – the machine translates the urine flow into a graph and this can tell him if your urine flow is abnormal. We will also be able to tell how much urine is left behind after you have finished. He may request an ultrasound to check the size of your prostate.

What are the treatment options?

If you have very little bother, simple lifestyle changes may make a difference. Avoiding caffeinated beverages or liquids close to bedtime may make a real difference. However, some men will require treatment. If your symptoms are not too bad, medication may help. Some work by relaxing the muscles around the neck of the bladder and prostate and some work by shrinking the prostate. The latter may take a few months to work, so do not expect immediate results. If going too often is a problem, there are several different medications which may help. Often, your urologist may use a combination of drugs. Over-the-counter herbal medications are often used in TT with saw palmetto being the most common – the available evidence suggests that saw palmetto is not effective in treating BPH.

What about surgery?

If your symptoms are bad enough or you are either unresponsive to or not keen on using medications, you may need surgery. You may also need surgery if you develop stoppage of water, bladder stones, bleeding or infections. The choice of procedure will depend on the size of your prostate and your wishes. The options and risks of each procedure should be discussed with your urologist.

Transurethral resection of the prostate (TURP) – The surgeon uses a camera with a loop at the end of it to scrape the prostate from the inside, layer by layer. Since he goes through the penis, there are no cuts. Contrary to popular belief, this does not use a laser.

Open prostatectomy – This is used for very large prostates measuring over 100 grammes by ultrasound. The surgeon makes a cut on the lower part of your tummy and cuts into the prostate. If you think of your prostate as an orange, the surgeon scoops out the meat of the orange (the overgrown part) and leaves the skin (the capsule). He stitches the capsule back together leaves a catheter (urine tube) in the bladder for a few days.

Laser prostatectomy/HoLEP– This uses a laser to achieve the same thing as an open prostatectomy, without the cut on the tummy – it is done through the penis. Think of it as combining the best features of the above two operations – a thorough removal of the obstructing parts of the prostate with no cut! Generally, bleeding is less and the catheter is usually removed the next day. Fortunately, this is now available in TT, however, it is not available in the public sector.

There are several other treatment options, unavailable in TT, such as prostatic urethral lift (Urolift) which tacks the prostate out of the way and Rezum which uses steam to destroy the prostatic tissue.

Dr Satyendra Persaud is a lecturer in urology at the University of the West Indies and is responsible for both undergraduate and post graduate teaching. He is a consultant based at the San Fernando General Hospital and is co-ordinator of the Residency Program in Urology. He is a Fellow of the Royal College of Surgeons of England.

Dr Joel Leach
is a urologist in training at the Eric Williams Medical Sciences Complex/University of the West Indies.

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