Prostate Enlargement

Definition

An enlarged prostate is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream. The medical term for an enlarged prostate is benign prostatic hyperplasia (BPH) or benign prostatic hypertrophy.

Description

An enlarged prostate is part of the normal aging process in men. It causes inconvenience and occasionally can be a major threat to health. However, effective and usually non-invasive treatments are available if symptoms interfere with normal daily living. BPH results in a swelling of the prostate gland that causes obstruction of the urethra. This can cause painful urination, reduced urine flow, difficulty

starting or stopping the flow, dribbling after urination, and more frequent nighttime urination. In addition to causing pain and embarrassment, BPH can lead to serious kidney problems if undiagnosed and left untreated.

The prostate is a small gland that is part of the male reproductive system. It sits just below the bladder and in front of the rectum and is normally about the size of a walnut. When enlarged, it can reach the size of a lemon. It surrounds the urethra, the passage which carries urine from the bladder through the penis during urination. The prostate gland secretes fluid, which forms part of the semen in which sperm are transported. During sexual activity and orgasm, the semen enters the urethra and passes along it through the penis to the outside (ejaculation). Prostate problems occur mainly in men over the age of 50. Most men are unaware of their prostate until they begin to experience symptoms of BPH.

Demographics

Prostate enlargement is a common problem in men over the age of 40. It occurs only in men since women do not have a prostate gland. Estimates are that 50–60% of all men will develop BPH in their lifetimes. Between 40% and 50% of men in their 60s have BPH and this increases to 80% in men over the age of 80. The Agency for Health Care Policy and Research estimates there are six million American men between the ages of 50–79 who have BPH serious enough to require some type of therapy. Yet only half of them seek treatment from physicians. Health practitioners recommend annual prostate exams for men over the age of 50, and an annual blood test that measures prostate specific antigen (PSA), a marker for prostate cancer . Worldwide, BPH affects an estimated 33 million men over the age of 60 and costs about $10 billion annually in treatment.

Causes and symptoms

Scientists do not know the exact cause of an enlarged prostate but it appears to be related to subtle changes in hormone production, which occur with aging and, possibly, as a result of environmental factors such as diet . An enlarged prostate is not a cancer . Prostate enlargement causes problems because, as the gland enlarges, it compresses the urethra and blocks the passage of urine from the bladder. This can prevent the bladder from emptying, sometimes leading to damage to the bladder and kidneys or the inability to pass urine. These serious effects are relatively uncommon and the more usual result of BPH is to cause bothersome symptoms while urinating.

Symptoms

Symptoms of an enlarged prostate include:

• Frequent urination
• Waking up at night to urinate
• Feeling an urgent need to urinate and being unable to postpone it
• Feeling of being unable to empty the bladder
• Difficulty or delay in starting to urinate
• Straining to urinate or having a weak urine stream
• An intermittent (stopping and starting) urine stream
• Loss of urinary control (incontinence)
• Being unable to urinate
• Painful urination
• Blood in the urine
• Dribbling of urine after finishing urinating

Other diseases such as prostate cancer, prostatitis (prostate inflammation), bladder cancer , bladder stones , and kidney stones , can cause some of these symptoms. A family practice doctor may refer a male with any of these symptoms to a urologist (a doctor who specializes in diseases of the urinary tract and reproductive system) for further evaluation.

Diagnosis

A physician will usually perform a physical examination as well as conduct blood tests to determine if the patient has an enlarged prostate or prostate cancer. The primary diagnostic tool is the digital rectal examination. This is a simple examination in which the doctor will pass a lubricated, gloved finger into the rectum. Because the prostate is located just in front of the rectum, it can be easily felt. Enlargement can be detected as well as any lumps or firm areas which can suggest the presence of prostate cancer. The doctor may do other tests including checking the level of prostate specific antigen (PSA). PSA is a substance produced by the prostate which can be measured by a blood test. Prostate cancer often releases more PSA into the blood than a normal prostate or a prostate enlarged due to BPH. Elevated levels of PSA may suggest the presence of prostate cancer, although BPH and prostatitis may also cause elevated levels. The physician typically will use the estimated size of the prostate and the PSA level to determine the risk of future BPH progression and other prostate problems.

Treatment

There are a number of treatment options available that are considered safe, effective, and their benefits are lasting.

Drug therapy

The use of drugs to treat an enlarged prostate has become popular and for many patients is the first treatment choice. There are two types of drugs available to treat BPH that work in different ways. The two classes of drugs are prescribed separately or in combination.

Drugs called alpha-blockers relax muscle tissue in and around the prostate and bladder neck and improve urination. Benefit usually occurs within a few days or weeks and will last for as long as the medication is taken. Side effects occur in about 10% of men and include fatigue, dizziness , headaches , nasal congestion, and ejaculation back into the bladder (retrograde ejaculation), which is not harmful. Examples of alpha-blockers include terazosin (Hytrin), doxazosin (Cardura), prazosin (Minipress), tamsulosin (Flomax), and alfuzosin (Uroxatral).

Another class of drugs, called 5 alpha-reductase inhibitors, blocks the action of the hormones that contribute to the development of BPH. They mostly are used in men with large prostates and those with higher levels of PSA. These drugs prevent the progression of BPH and reduce the risk of acute urinary retention and the need for future prostate enlargement-related surgery. One 5 alpha-reductase inhibitor, finasteride (Proscar and Propecia), has been shown to reduce the risk of developing prostate cancer by as much as 25%. Side effects occur in less than 10% of men using these drugs and include sexual problems such as a decrease in ejaculate volume, loss of sex drive, and erectile dysfunction . Another 5 alpha-reductase inhibitor is dutasteride (Avodart).

Surgery

The most common surgery done for an enlarged prostate is called transurethral resection of the prostate (TURP). The patient is placed under anesthesia and an instrument, sometimes a laser, is inserted through the urethra and the prostate is cored out. In a small number of cases, when the prostate in unusually large, an open prostatectomy is needed. In this procedure, an incision is made through the abdomen and the inner tissue of the prostate is removed. The majority of men who undergo TURP will experience a loss of ejaculation. This means the patient will not be able to impregnate a woman. However, it does not interfere with the ability to engage in sexual activity. A less invasive procedure is called transurethral incision of the prostate (TUIP). Instead of coring out the prostate, a surgical instrument is used to make an incision inside the prostate. TUIP is primarily used in men with slight prostate enlargement. Another procedure, called transurethral microwave thermo-therapy (TUMT), does not require hospitalization or anesthesia. A special catheter that uses microwaves is inserted into the urethra to heat and destroy tissue inside the prostate, restoring normal urine flow.

As of late 2007, a number of new treatments for BPH were being investigated, ranging from newly developed drugs to existing drugs used to treat other conditions. One of these new drugs, NX-1207, was undergoing clinical trials in the United States. Initial results showed the drug was extremely effective in treating BPH with minimal side effects and no sexual side effects, according to researchers at the Johns Hopkins University School of Medicine. Further studies were underway as of late 2007 and there is no estimated date when the drug might be ready to submit to the U.S. Food and Drug Administration for approval. Existing drugs that are being looked at as treatments for BPH include the anti-wrinkle drug botulinum toxin A (Botox), the over-the-counter pain relievers aspirin and ibuprofen, and the erectile dysfunction medications sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis).

QUESTIONS TO ASK YOUR DOCTOR

• Do I need treatment for my enlarged prostate?
• What are my treatment options?
• Which treatment option is best suited for me?
• What are the side effects and benefits of my treatment options?
• Will any treatments cause problems with any medications I am taking?
• If I do not receive treatment, what might happen?

Alternative treatment

Saw palmetto , an extract derived from the deep purple berries of the saw palmetto fan palm (Serenoa repens), is often used as a natural treatment for an enlarged prostate. Saw palmetto does not reduce prostate enlargement. Instead, it is thought to work in a variety of ways. First, it inhibits the conversion of testosterone into dihydrotestosterone (DHT). BPH is thought to be caused by an increase in testosterone to DHT. Secondly, saw palmetto is believed to interfere with the production of estrogen and progesterone, hormones associated with DHT production. People taking saw palmetto should use only standardized extracts that contain 85–95% fatty acids and sterols. Dosages vary depending on the type of saw palmetto used. A typical dose is 320 mg per day of standardized extract or 1–2 g per day of ground, dried, whole berries. It may take up to four weeks of use before beneficial effects are seen.

Nutrition/Dietetic concerns

There is no scientific evidence that diet or nutrition plays a direct role in the development of an enlarged prostate. However, a 2006 study reported that obese men were up to 3.5 times more likely to have an enlarged prostate than men with a normal weight.

Prognosis

About 70% of all men with BPH are relatively symptom-free. The remaining 30% that require treatment usually respond extremely well to medication, especially a combination therapy of two classes of drugs called alpha-blockers and 5 alpha-reductase inhibitors. Only a very small percentage of men with BPH require surgical procedures and the prognosis for these men after surgery is also extremely good. Studies show that of men who receive no treatment for BPH, 31–55% show an improvement, and only 1–5% ever develop complications, according to the American Medical Association.

KEY TERMS

Benign prostate hyperplasia (BPH) —Enlargement of the prostate gland.

Estrogen —A hormone that stimulates development of female secondary sex characteristics.

Progesterone —A steroid hormone that is a biological precursor to corticoid (another steroid hormone) and androgen (a male sex hormone).

Prostate specific antigen —A substance produced by the prostate that can be measured by a blood test.

Prostatitis —Inflammation of the prostate gland.

Testosterone —A male hormone produced in the testes or made synthetically that is responsible for male secondary sex characteristics.

Urethra —The tube that carries urine from the bladder out of the body and in males also carries semen.

Urologist —A doctor who specializes in diseases of the urinary tract and reproductive system.

Prevention

There are no known ways to prevent an enlarged prostate, other than castration prior to puberty, a medically and ethically unacceptable option.

Caregiver concerns

Caregivers can be a great help to someone with an enlarged prostate. Caregivers can initiate discussion of the condition and look for symptoms of BPH. Men with BPH are often reluctant to discuss the problem with family, friends, or health practitioners. Caregivers can also help their charge with making decisions about treatment.

Resources

books

Katz, Aaron E. Dr. Katz's Guide to Prostate Health: From Conventional to Holistic Therapies Topanga, CA: Freedom Press, 2005.

Moyad, Mark A., and Ian M. Thompson. Complementary Medicine for Prostate Health Totowa, NJ: Humana Press, 2008.

Scardino, Peter, and Judith Kelman. Dr. Peter Scardino's Prostate Book: The Complete Guide to Overcoming Prostate Cancer, Prostatitis, and BPH New York: Avery, 2006.

periodicals

Fernberg, Patricia M. “Botulinum Toxin Appears Safe, Effective in BPH/LUTS: Symptoms Relieved for Up to 1 Year.” Urology Times (September 2007): 27–28.

Giordano, Jill. “Prompt Diagnosis of BPH Can Prevent Complications.” American Family Physician (May 1, 2006): 1632.

Guttman, Cheryl. “Daily NSAID Use May Protect Against BPH, LUTS.” (February 2007): 1.

Ludwig, Cynthia D. “Understanding Benign Prostatic Hyperplasia (BPH).” MedSurg Nursing (October 2007):340(2).

MacDougall, David S. “Obesity, Diabetes Increase BPH Risk; Enlarged Prostate More Than Three Times as Likely in Obese Men Than in Men With a Normal BMI.” Renal & Urology News (July 2006): 29.

Tennant, Scott. “ED Drugs May Offer Intriguing Therapy for BPH/LUTS: New Data Also Confirm Connection Between Metabolic Syndrome and Prostate Enlargement.” Urology Times (August 15, 2007): 12.

organizations

American Prostate Society, P.O. Box 870, Hanover, MD, 21076, (410) 859-3735, (410) 850-0818, ameripros@mindspring.com, http://www.american-prostatesociety.com.

American Association of Clinical Urologists, 1100 E. Woodfield Road, Suite 520, Schaumburg, IL, 60173, (847) 517-1050, (847) 517-7229, info@aacuweb.org, http://www.aacuweb.org.

American Urological Association, 1000 Corporate Blvd., Suite 410, Linthicum, MD, 21090, (410) 689-3700, (866) 746-4282, (410) 689-3800, aua@auanet.org, http://www.auanet.org.

National Kidney and Urologic Diseases Information Clearinghouse, 3 Information Way, Bethesda, MD, 20892-3580, (800) 891-5390, (703) 738-4929, nkudic@info.niddk.nih.gov, http://www.kidney.niddk.nih.gov.

Canadian Urological Association, 1155 University, Suite 1155, Montreal, QC, Canada, H3B 3A7, (514) 395-0376, (514) 875-0205, central.office@cua.org, http://www.cua.org.

Urological Society of Australia and New Zealand, 180 Ocean St., Suite 512 Eastpoint, Edgecliff, NSW, Australia, 2027, 61 2 9362 8644, 61 2 9362 1433, secretary @usanz.org.au, http://www.usanz.org.au.

Ken R. Wells