Enlarged Prostate

  • Is very common and increases in incidence as men increase in age
  • Is sometimes referred to as Benign Prostatic Enlargement (BPE), Prostatomegaly or Benign Prostatic Hyperplasia (BPH)
  • May or may not cause symptoms
  • Does not always require treatment
Enlarged Prostate
How is This Different to Prostate Cancer?
  • An enlarged prostate is VERY different to prostate cancer
  • An enlarged prostate is simply a larger than expected prostate gland
  • Whether or not an enlarged prostate has a cancer within it or no is investigated in just the same way as in a man without an enlarged prostate
What Are Some Common Symptoms?
  • Commonly, an enlarged prostate may not be causing you any issues: in this instance you do not need to have it treated.
  • Because the prostate wraps around the urethra, as it enlarges, it may sometimes lead to a degree of blockage in the urethra and so make it more difficult to pass urine.
  • The common signs or symptoms encountered may include:
    • Hesitancy – slow to initiate urination
    • Weak urinary stream
    • Intermittent stream of urine
    • End dribbling
    • Straining to empty your bladder
    • Incomplete bladder emptying
  • The extent of these symptoms and how bothered you are by them is usually checked by what is called an IPSS questionnaire.
  • Occasionally, men may also experience more significant consequence of an enlarged prostate. These include recurrent urine infections, rising post-void residuals, urinary retention requiring catheterisation, bladder stones and kidney damage
    • In these settings treatment of the prostatic enlargement becomes more important
How Might My Urologist Assess My Symptoms?
  • History: apart from a general medical and surgical history, your Urologist will focus their questions on the following issues:
    • Urological history
    • Lifestyle
      • Fluid intake: volume and type (specifically: caffeine, tea & alcohol)
      • Smoking
      • Blood in urine
    • Most bothersome lower urinary tract symptoms (LUTS)
  • Examination
    • abdominal examination
    • genital examination
    • prostate examination (digital rectal exam)
    • occasionally a lower limb neurological examination is required
  • Investigations
    • Symptom score – IPSS (International Prostate Symptom Score)
    • Bladder diary
    • Uroflow
      • A test to measure the speed at which the urine comes out
    • Post void residual
      • An ultrasound examination to check how much urine is left in the bladder after you pass urine
    • Urine test: to exclude an infection
    • Blood test: kidney function check and a PSA test
  • Imaging
    • Ultrasound
      • post void residual – volume of urine left in the bladder after voiding
      • prostate volume
      • changes in the bladder wall to suggest a blockage to the passage of urine
      • examination of the kidneys
    • CT – occasionally required if there is suspicion of an anatomical abnormality or other suspected pathology
    • MRI
      • Of the brain and spinal cord: rarely required, only if a neurological cause for your bladder symptoms are suspected
  • Sub-specialised tests
    • Urodynamics – is particularly helpful when it is not very clear what the cause of your LUTS are
    • Not all LUTS are due to a prostate that is blocking your ability to void; sometimes the underlying pathology is in the bladder muscle itself rather than the prostate
  • Procedure
    • Cystoscopy – an internal camera inspection of the urethra and bladder
Do I Need to Have Treatment?

Sometimes this question is simple to answer and other times a little more challenging to answer.

If the prostate enlargement is causing you significant problems such as retention requiring catheter insertion, recurrent infections or causing kidney damage then the answer is usually yes.

If the prostate enlargement is not causing any serious issues and is only regarded to be a minor inconvenience to you, then other options such as on-going monitoring or oral medications are options.

It should again be noted that LUTS are not always due to blockage from an enlarged prostate. Working out the primary cause of your symptoms can sometimes be challenging. Your Urologist will be able to guide you through this.

What Are My Treatment Options?

The treatment plan may be simple or a little more complex: your Urologist will guide you through this.

If the prostate enlargement is causing you one of the more serious consequences of prostate enlargement then the treatment is usually surgical in the form of a TURP (Transurethral Resection of Prostate).

If the prostate enlargement is causing you some LUTS which are of some bother to you, treatment typically involves a step-wise progression starting at life style measures then medications then surgery. Some of the treatment options are outlined below (some may not be relevant to yourself).

  • Lifestyle measures
    • Reduction in caffeinated and alcoholic drinks
    • Reduction of evening fluid intake if excessive night time voiding is a problem
    • Maintain regular bowel habit
    • Weight loss
  • Medication
    • If your symptoms are largely voiding symptoms, medications that may be helpful include
      • Tamsulosin
      • Duodart
      • Tadalafil
    • Surgical
      • Least invasive
        • Urolift
          • Not always suitable – depends on size and configuration of the prostate
          • Main advantage: least invasive and preserves ejaculation
      • Traditional Surgery
        • TURP (transurethral resection of prostate) – gold standard of treatment
          • Is done endoscopically
          • Prostate tissue is resected away in order to create a larger passageway for urine to flow through
        • Open or robotic simple prostatectomy
          • Is not a ‘simple’ procedure in itself
          • Reserved for the very large prostate
        • Non-surgical
          • Catheter
            • clean intermittent self catheterisation
            • long term catheter: urethral or suprapubic
          • Prostate artery embolisation
            • Only in very select cases

You may come across many other forms of a ‘TURP’. Some of these include HoLEP and Green Light Laser Prostatectomy amongst others. The underlying principle behind these procedures is essentially the same: to create a wider passage way for urine to flow through thereby relieving your symptoms. Each modality uses a different energy source to achieve this aim. Each has its own particular set of advantages and disadvantages and not all are available to every Urologist and to every Hospital. Your Urologist will be able to guide through this complexity.

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