Benign Prostatic Hyperplasia (BPH)
Because men are living longer, it is likely that most men will eventually experience some kind of prostate problem. In general, there are three types of prostate disorders: infection, benign enlargement, and malignancy. Benign enlargement is the most common among men over 60.
In many cases, men become aware of prostate enlargement because they experience frequent urination, difficulty in urination or involuntary loss of urine. However, prostate problems - particularly cancer - may develop without any outward indication.
The Prostate Gland
The prostate gland is located just below the bladder. It surrounds the urethra, which is the tube that carries urine from the bladder to the outside. The prostate is the gland that produces semen - the milky fluid that carries sperm for reproduction.
At puberty, the prostate is about the size of a golf ball. Later in life, usually around the age of 50, it starts growing and gradually may reach the size of a racquetball, or even a baseball.
Types of Prostate Disorders
Prostatism/Benign Prostatic Hyperplasia
Prostatism, or benign prostatic hyperplasia (BPH), is the name for benign (non-cancerous) obstructive urinary problems. It is the most common prostate disorder among men over 60. Although BPH is not life threatening, it causes inconvenience, discomfort and anxiety.
BPH occurs when a different kind of tissue, called adenoma, grows in the prostate and causes enlargement. The enlargement is called hyperplasia.
As the prostate enlarges, it grows inward as well as outward. It restricts the urethra and creates a series of problems.
The narrowing of the urethra reduces the natural urine flow. The bladder then compensates and works harder to push the urine out. Because of this exertion, the bladder wall becomes thick and distorted, the system becomes less productive, and some urine may remain in the bladder. If left untreated, this condition can lead to infection - and even to kidney failure.
Some of the obvious symptoms of BPH are increased urination, particularly at night. You may not be able to start to urinate right away. The flow may not be as strong and steady as you have been used to. You may feel the urge to urinate again after you have just finished. At times, you may not be able to urinate at all. Conversely, at other times you might pass urine unintentionally.
These symptoms may also be the result of other factors, including but not limited to the amount of liquid you have been drinking, periods of increased stress, infection, bladder abnormalities, neurological diseases, or obstructions such as stones. Most often, however, these symptoms are related to growth of the prostate.
Prostatitis is an infection of the prostate gland, which often occurs among younger men. It can cause burning during urination or ejaculation. Pus might also be noticed in the urine.
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Cancer of the Prostate
When cancer occurs, it usually starts near the outside of the prostate gland. Although cancer of the prostate can cause symptoms that are similar to those of BPH, frequently cancer has no symptoms at all until it is in an advanced stage.
Diagnosing Prostate Disorders
When a prostate problem is suspected, the urologist will begin with a detailed medical history with emphasis on your urinating patterns and sexual activity. He will also perform a general physical examination including a simple digital rectal examination.
Several diagnostic tests may be required for precise identification of a prostate problem:
- Samples of your blood and urine will be analyzed for information about your general health and kidney function.
- You may be asked to urinate into a special device called a flowmeter to determine the rate of urinary flow.
- A catheter may be used to measure how much urine is left in your bladder. A catheter is passed through the opening of the penis into the urethra, the tube that carries urine from the bladder.
- A cystoscopy is an internal examination of the bladder and prostate, which may be performed in the office or on an outpatient basis. A small metal instrument, called a cystoscope, is inserted in the urethra and into the bladder. The bladder is then filled with water. The cystoscope contains a lens and a light so that the urologist can see into the bladder.
- Two tests may be used to reveal abnormalities such as kidney stones, bladder stones or bladder tumors. Both tests are done on an outpatient basis in the office or in the hospital.
- An intravenous pyelogram, sometimes referred to as an IVP, is an X-ray of the urinary system. A special dye is inserted through an IV tube in your arm. The dye collects in the urinary tract and shows up on the X-ray for evaluation by a radiologist or urologist.
- A renal sonogram is an ultrasound imaging process that also evaluates kidney anatomy and architecture.
- A blood test has emerged in recent years to detect the presence of a protein, known as prostate specific antigen, associated with prostate cancer.
- A prostatic needle biopsy may be performed in the office or on an outpatient basis. It is used to determine whether a nodule that is felt during a digital examination is benign or malignant.
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- In cases where diseases of the nervous system might be involved, the urologist may use a special catheter to measure the pressure and flow of urine from the bladder. The procedure, called cystometrogram, is usually performed in the office.
Treatment of Prostate Disorders
Depending on the nature and extent of the benign prostatic enlargement, there are several treatments that may be employed.
Over the years, researchers have developed drugs to shrink, or at least stop the growth of the prostate. The FDA has approved six drugs to relieve common symptoms of BPH, and they are often used in combination.
- Enzyme inhibitors: Drugs including finasteride (Proscar) and dutasteride (Avodart) that inhibit the production of DHT (Dihydrotestosterone), a hormone that is involved in prostate growth.
- Alpha blockers: Drugs including terazosin (Hytrin), doxazosin (Cardura), tamsulasin (Flomax), and alfuzosin (Uroxatral), that act by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow. The original alpha blockers were initially used to control high blood pressure. Consequently they often involved side effects of lowered blood pressure, such as fainting spells. These new drugs work more selectively on the prostate gland and the blood pressure side effects are seen infrequently.
Medication does have certain drawbacks. First, it is expensive. Second, it must be taken for the rest of the patient's life.
Removal of adenoma tissue:
If removal of the adenoma tissue that has grown inside the prostate is indicated, the surgery is called a prostatectomy. In a simple prostatectomy, only the adenoma tissue is removed. The prostate gland and its function remains.
The most common method for the prostatectomy is a transurethral resection known as a Transurethral Prostatectomy, or TURP. The procedure is relatively simple, but does require anesthesia and is performed in the hospital.
In a TURP, an instrument called a resectoscope is inserted through the penis. The obstructing tissue is removed in small pieces and flushed out with water through the resectoscope. This procedure is the preferred method because there is no external incision, limited blood loss and a short recovery period.
Sometimes the size of the prostate is too large for TURP. In those cases, the adenoma tissue can be more safely removed through an incision in the lower abdomen.
Although this prostatectomy operation is somewhat complex and requires longer time for recovery, it is important to be aware that only the adenoma tissue has been removed. Just as with a TURP, the prostate gland remains.
With either of these procedures, you can expect to attain greatly improved functioning of your urinary system. Within a short time, you will be able to return to normal activities, including sexual functions. Nearly all men who elect to have the procedures are satisfied with the results.
Minimally invasive treatments:
A range of treatment options has emerged in recent years involving the application of high temperatures directly to the prostate tissue. These treatments are typically provided on an outpatient basis in the doctor's office, and require no or only local anesthesia. These treatment options Interstitial Laser Coagulation, Transurethral Needle Ablation (TUNA), Transurethral Microwave Therapy (TUMT), laser surgery, and Photoselective Vaporization of the Prostate (PVP).
Prostatitis is a relatively mild condition that may be treated with sulfa drugs, antibiotics, hot baths, and perhaps bed rest.
Where cancer is detected, a range of treatments may be selected depending upon your age and general health as well as the extent of the disease. In some cases, the treatment may include removal of adenoma tissue by TURP or a prostatectomy. In other cases, it will involve complete removal of the prostate - called a radical prostatectomy - radiation therapy or forms of chemotherapy. Valley Urological Associates physicians now offer a robotic-assisted minimally invasive treatment option that provides an enhanced microscopic view of the surgical field and extraordinarily precise, physician-directed and computer-guided movements of miniaturized instruments that minimizes damage to surrounding healthy tissue, reduces blood lost during surgery, pain following surgery, and reduces hospital stays.
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The Treatment Decision
Prostatism is considered a symptomatic disease. We have outlined several diagnostic tests that are used to identify the extent of the prostate problem. However, the tests do not indicate the amount of inconvenience that urinary obstructions cause in each person.
Some people are extremely troubled when their sleep is disturbed by getting up once or twice a night. Others may be light sleepers who are not very concerned about getting up several times. It is a matter of individual perceptions.
The urologist's first obligation is to make sure that the prostate enlargement is not causing a medical problem, such as impaired kidney function, urinary stones or thickening of the bladder.
After that, our role is to set up a dialogue with each patient so that he understands his condition, and we understand how he feels about the difficulties he is experiencing.
We will offer a treatment recommendation based on our medical judgment and experience with similar cases. We will attempt to estimate how much improvement can be expected from the treatment and what changes in your symptoms are likely to occur if treatment is deferred. Then, the decision is up to the individual.
The Most Important Things to Remember About Prostate Disorders
- When you have trouble with urination, see your urologist for an evaluation.
- The longer you wait to see a doctor, the harder your bladder will have to work. The more out of shape it gets, the longer it will take to recover. Delay also increases the risk of infections and other urinary complications.
- Your decision to go to a urologist, or to have a prostatectomy, should not be influenced by the fear of a TURP or a prostatectomy. Both procedures have stood the test of time, recovery is rapid and nearly everyone is pleased with the improvement in urinary functioning.
- There are seldom any recognizable symptoms of prostate cancer. So, it is important that you have a simple prostate examination annually after age 40. That examination can be performed in the office by your family doctor, internist, or urologist.