OVERVIEW

What is the prostate?

The prostate is a small gland located below the bladder and in front of the rectum in males. It surrounds the urethra, the tube that carries urine and semen out of the body. The primary function of the prostate is to produce seminal fluid, which nourishes and transports sperm during ejaculation.

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What is BPH (Prostate Enlargement)?

In layman’s terms, the expansion of the prostate is called benign prostatic hyperplasia. Benign Prostatic Hyperplasia (BPH) occurs when the prostate and surrounding tissue expand. The prostate grows twice in a man's life: during early puberty and around age 25. With age, the prostate may become larger, causing problems.

Normally, the prostate is the size of a walnut or golf ball, but it can grow as big as an orange. If it enlarges on the outer side and does not cause any pressure on the path that we urinate through, then it is not a problem. But if it creates pressure on that path and leads to problems with urine flow, then we need to take action.

When it enlarges, it can squeeze the urethra and thicken the bladder wall. This leads to lower urinary tract symptoms (LUTS), like a weak urine stream or the need to strain. In severe cases, urine retention or renal failure may occur and require immediate attention.

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BPH is not cancerous and does not cause cancer. However, it is possible to have BPH and cancer simultaneously. Treatment for BPH may not be necessary unless symptoms arise. It's important to note that BPH is common, with around 50% of men aged 51 to 60 experiencing it, and up to 90% of men over 80 having it.

When the prostate enlarges, it can cause discomfort and obstruct the bladder. Frequent urination is a common symptom of BPH, occurring every 1 to 2 hours, especially during the night. In severe cases of BPH, it may become impossible to urinate at all, which requires immediate medical attention.

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SYMPTOMS

What are the symptoms of enlargement of the prostate?

Enlargement of the prostate, also known as benign prostatic hyperplasia (BPH), is a common condition in aging men. The symptoms of prostate enlargement can vary but often include:

• Frequent or urgent need to urinate
• Increased frequency of urination, especially at night
• Difficulty initiating urination
• Weak urine stream or intermittency
• Dribbling at the end of urination
• The Feeling of incomplete bladder emptying

At times, the patient is not able to clearly recognize these symptoms. Hence, we give them a questionnaire termed ‘IPSS’. It gives us an idea about the severity of the problem. Although IPSS is an international system and not an Indian system, at Aashray Urology Institute we follow it to get input from the patients, and it really helps us understand the problems faced by the patients in a better way.

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DIAGNOSIS

What is IPSS?

The International Prostate Symptom Score is an eight-question written screening tool used to screen for, rapidly diagnose, track the symptoms of, and suggest management of the lower urinary tract symptoms of benign prostatic hyperplasia. These answers guide us about the severity and the future course of action.

After we understand the severity of the prostate problem, we guide the patient. Most of the time, the problem can be healed by medicine; otherwise, we recommend surgery. To be doubly sure before recommending surgery, we recommend the following investigational tests.

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What are the investigational tests to be done for an enlarged prostate?

To diagnose an enlarged prostate, we perform several investigational tests, including:

• Digital Rectal Exam (DRE): A physical examination where we insert a finger into the rectum to check for prostate enlargement
• Urine Test: A lab analysis of a urine sample to rule out other conditions with similar symptoms as BPH
• Prostate-Specific Antigen (PSA) Blood Test: It is a blood test that measures the levels of PSA, a protein produced by the prostate. Elevated PSA levels can indicate prostate enlargement, but they can also be caused by other factors such as recent procedures, illnesses, surgery, or prostate cancer.
• Urinary Flow Test: It is a test that measures the strength and volume of urine flow, providing insights into the severity of the condition.
• Postvoid Residual Volume Test: This test measures the amount of urine left in the bladder after urination to determine if the bladder is adequately emptying. 
• Transrectal Ultrasound: It is a  procedure that uses sound waves to create images of the prostate, helping evaluate its size and condition.
• Prostate Biopsy: If there are concerns about prostate cancer, a biopsy may be performed to collect tissue samples from the prostate for further examination.
• Urodynamic and Pressure Flow Studies: These tests involve measuring bladder pressure and the functionality of bladder muscles using a catheter.
• Cystoscopy: It is a procedure where a flexible tool with a light is inserted into the urethra to visualize the urethra and bladder. It helps detect any abnormalities.
• Sonography: To check the size of the prostate

Apart from the above-mentioned tests, at Aashray Hospital we do a special computerized test called the ‘Uroflowmetry' test. It is a painless procedure wherein the patient is just asked to urinate in the usual manner. 

The urine pot is connected to the computer, and through that, we get the graph. This helps us understand the volume of urine released from the body, the speed with which it is released, and how long the release takes. Most importantly, it also gives guidelines about how much urine is retained in the bladder and cannot be passed.

To understand whether the prostate gland is cancerous or not, we usually recommend a serum PSA blood test. This test is specifically recommended as there are no specific symptoms of prostate cancer, unlike other types of cancer.

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What is serum PSA?

Prostate-specific antigen, or PSA, is a protein produced by normal as well as malignant cells of the prostate gland. The PSA test measures the level of PSA in the blood. A blood sample is sent to a laboratory for analysis for this test.

Men with a PSA level between 4 and 10 (often called the “borderline range”) have about a 1 in 4 chance of having prostate cancer. If the PSA is higher than 10, the chance of having prostate cancer is over 50%

However, it is necessary to understand that high PSA levels do not always mean that you have prostate cancer. Even conditions such as an infection (prostatitis) or an enlarged prostate can cause high PSA levels. If your PSA levels are higher than normal, you need to consult a urologist who can recommend more tests to diagnose the cause. 

It is essential to understand that the prostate gland keeps growing according to age; however, if it causes problems while urinating, you should refer to a urologist.

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Common myths about prostate

Myth: A slow urinary stream is due to advanced age.

Fact: While prostate enlargement can lead to a weak urinary stream, it is not solely attributed to age. BPH is the primary cause of this symptom, and timely diagnosis and appropriate management can alleviate the issue.

Myth: If the prostate gland enlarges, it will rupture or develop into cancer.

Fact: Prostate enlargement, or BPH, is not linked to the risk of prostate cancer. However, both conditions can coexist. Regular check-ups and discussions with healthcare providers are crucial to monitoring and addressing any concerns.

Myth: Is the prostate present in women?

Fact: No, the prostate gland is not present in women. It is a male reproductive organ responsible for semen production.

Myth: After prostate surgery, an ultrasound (USG) showing prostate enlargement indicates an incomplete procedure.

Fact: Post-surgery ultrasound may show residual prostate tissue or temporary swelling, which can mimic enlargement. It does not necessarily imply an incomplete procedure. It is essential to consult the surgeon for a comprehensive evaluation.

Myth: Urinary problems are always due to the prostate.

Fact: While an enlarged prostate can cause urinary problems, there are various other conditions that can contribute to urinary symptoms. Consulting a healthcare professional can help identify the underlying cause and determine the appropriate treatment.

Myth: In cases of urinary problems, it is okay to take medicines for prostate without doing further tests.

Fact: You should not take medicine for a long time for any urine-related issue because it can increase your problem two-fold. It is better to consult a urologist and get the reports done before taking medicine.

A urologist is a better person to guide you in this matter. At timely intervals, we ask patients to undergo certain tests so that we have a clarity regarding whether we need to discontinue the medicine or continue it. Prostate enlargement does not require life-long medication. 

Alpha-blockers that are commonly used to treat prostate can cause postural hypotension, headaches, nose block etc. Hence, it is recommended to consult a urologist for prostate problems. These side effects can be effectively handled by a urologist.

This brings us to an important discussion, which is regarding treatment options for prostate. The treatment of prostate can be done orally or surgically. How it is done totally depends on the gravity of the problems that prostate is causing.

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TREATMENT

Medical Management - Alpha-blocker for prostate enlargement

For mild to moderate symptoms of prostate enlargement, medications are often prescribed. Alpha-blockers are a common class of drugs used in medical management. They work by relaxing the smooth muscles of the prostate and bladder neck, improving urine flow. Some commonly prescribed alpha-blockers include alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax), silodosin (Rapaflo), and terazosin.

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When is surgery for prostatic enlargement needed?

Surgery for prostatic enlargement is typically considered when other treatment options have not effectively managed the symptoms or when the condition significantly affects a person's quality of life. The decision to undergo surgery is based on various factors, including:

• The Severity of Symptoms: If the symptoms of prostatic enlargements, such as urinary retention, recurrent urinary tract infections, kidney damage, or bladder stones, become severe and impact daily life activities, surgery may be recommended.
• Failed Medical Management: If medications or other conservative treatments have been tried but have not provided sufficient relief or have caused intolerable side effects, surgery may be considered.
• Bladder Dysfunction: When prostatic enlargement leads to significant bladder dysfunction, such as an inability to empty the bladder completely or chronic urinary retention, surgery may be necessary to restore normal urinary function.
• Complications: If prostatic enlargement results in complications like recurrent urinary tract infections, bladder stones, or kidney damage, surgery may be required to address these issues.
• Large Prostate Size: In cases where the prostate is significantly enlarged, causing urinary obstruction and other complications, surgery may be the most effective treatment option.
• Patient Preference: Ultimately, the decision to undergo surgery for prostatic enlargement depends on the individual's preferences and goals, as well as discussions with their healthcare provider.

It is important to note that surgery is typically considered a last resort and is not always necessary for managing prostatic enlargement. The choice of surgical procedure depends on several factors, including the size of the prostate, overall health status, and patient preferences. 

Surgical options for prostatic enlargement

Several surgical options are available for the treatment of prostatic enlargement. The choice of procedure depends on factors such as prostate size, the patient's health status, and the surgeon's expertise. Some common surgical options include:

1. Transurethral Resection of the Prostate (TURP): A minimally invasive procedure where excess prostate tissue is removed using a resectoscope inserted through the urethra.
2. Laser Surgery: Various laser techniques, such as Holmium laser enucleation, Green Light laser vaporization, or thulium laser procedures, can be employed to remove or reduce prostate tissue. These procedures offer a shorter recovery time and potentially fewer complications compared to traditional surgery.
3. Transurethral Incision of the Prostate (TUIP): This procedure involves making small incisions in the prostate to relieve the pressure on the urethra, improving urine flow. TUIP is typically performed for smaller prostates.

1. Transurethral Microwave Therapy (TUMT): In TUMT, microwaves are used to generate heat and destroy excess prostate tissue. It is a minimally invasive procedure performed on an outpatient basis.
2. Prostatic Urethral Lift (PUL): PUL is a newer procedure where small implants are placed to lift and hold the enlarged prostate tissue away from the urethra, relieving the obstruction. It is a less invasive option that preserves sexual function.

Each surgical option has its own benefits and potential risks. The choice of procedure should be discussed with a urologist, who can provide personalized recommendations based on the individual's specific circumstances.

Understanding the prostate and its associated conditions like benign prostatic hyperplasia (BPH) is crucial for men's health. Recognizing the symptoms, seeking timely medical evaluation, and considering appropriate treatment options can help manage prostate-related concerns effectively. Accurate information and open communication with a urologist are essential for making informed decisions regarding prostate health.

If you are facing any problem related to the prostate, then you can book an appointment with us. We’ll try to help you in the best way possible.