Benign Prostate Enlargement
In this condition the prostate enlarges, and as it does so it may compress the urethra (the tube that carries urine from the bladder through the penis) causing problems urinating. It is extremely common, being found to some degree in most men beyond middle age.
BPH can cause various urinary symptoms, known collectively as lower urinary tract symptoms (LUTS) but commonly these include:
- difficulty in starting to pass urine.
- slowing of the urinary stream.
- dribbling at the end of the stream.
- bladder irritability, or feeling the need to pass urine often, including at night, and the feeling that you need to rush to pass urine.
- passing blood in the urine.
When you see your urologist, typically you will be asked about your symptoms and medical history, and then he will examine you, including a rectal examination to feel the prostate. You should also bring a fresh urine sample with you so that your urologist can do a urinalysis. It is also likely that you will be asked to do a flow rate, which involves you passing urine into a measuring device which then measures the rate at which you pass urine. For this reason you should try and come to the clinic with a comfortably full bladder. Following this, a measurement of residual urine in the bladder will be taken, using a small ultrasound probe placed on the lower part of your abdomen. There are a series of other studies that may be offered. These include:
- prostate specific antigen (PSA), a blood test which measures activity of the prostate gland. Your GP may have already done this, but if not then it will usually be done at your clinic visit after discussion with you.
- flexible cystoscopy, allows direct visualisation of the urethra and/or bladder using a small flexible scope.
In order to assess how bad your prostate symptoms are, you may be asked to complete an IPSS symptom score sheet which scores your symptoms. You may also be asked to complete a urinary frequency volume chart. This is a record of the amount of urine you pass each time over a 24 hr period, and usually three days worth of recordings are needed. These days do not have to be consecutive.
The symptoms of BPH do not always require treatment. Some men are able to cope with them by altering their fluid intake or making changes to their lifestyle. Others take medication. If neither of these help, then surgery is usually the best option.
There are two groups of drugs which may be prescribed for patients with BPH. These are alpha blockers, and 5 alpha-reductase inhibitors. Sometimes antimuscarinic drugs are prescribed in combination with these drugs.
These drugs work by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and reduce bladder outlet obstruction. Although alpha blockers may relieve the symptoms of BPH and improve the flow rate, they do not reduce the size of the prostate. They are usually taken orally, once a day and they work almost immediately. The most commonly prescribed alpha blockers are alfuzosin and tamsulosin. Side effects can include headaches, dizziness, light-headiness, fatigue and ejaculatory dysfunction, but the tablets are well tolerated by the vast majority of men.
5-alpha-reductase inhibitors (5ARIs):
These drugs work by reducing the size of the prostate by preventing the conversion of testosterone to one of its more active metabolites. Two different 5ARIs are available, finasteride and dutasteride. They can relieve BPH symptoms (though they may take upto 6 months to do have an effect) and improve urinary flow rate. Studies suggest that these medications may be best suited for men with relatively large prostate glands. Side effects can include impotence, decreased libido and reduced semen release during ejaculation. These side effects are rare.
These drugs inhibit the nerves that cause bladder contraction and
Beta-3 agonist (Mirabegron aka Betmiga)
This acts to stimulate the nerves that calm down bladder activity.
If there is no response to drugs, symptoms can be improved by an operation on the prostate gland.
Surgical options include:
- Urolift – surgical “anchors” to retract the prostate internally
- Rezum – “steam injections” to shrink the prostate
- Prostate artery embolisation (PAE) – an interventional radiological option to block off the arteries that supply the prostate.
- TURP – transurethral resection of prostate
- HOLEP – Holmium enucleation of prostate.
Your urologist can discuss the benefits and potential side effects of these different procedures.