Symptoms and Diagnosis
Prostate enlargement leads to obstruction to the flow of urine out of the bladder. As a direct result, a series of symptoms termed “Obstructive symptoms” occur and may become more severe over time. Examples of obstructive symptoms include:
- Weakening urinary flow
- Hesitancy (a longer than usual wait for the stream of urine to begin)
- The need to strain to force urine out
- Dribbling at the end of the flow
In addition to this, longstanding blockage to the flow of urine leads to changes in the function of the bladder muscle, making it stiff, thickened and irritable. These “Irritative symptoms” include:
- Urgency (an urgent, sometimes sudden feeling of the need to pass urine)
- Frequency (an ever-decreasing time between the need to pass urine)
- Nocturia (the need to wake from sleep to pass urine)
- Urge leakage (not making it to the toilet in time leading to incontinence).
Evaluating a man with symptoms suggesting Benign Prostate Enlargement
If you or a member of your family is experiencing the above symptoms, it is of vital importance that you are seen by your family doctor or sent to see a Urologist. The worst thing you can do is ignore the symptoms. Just as dangerous is the temptation to listen to radio advertisements selling over-the phone remedies. This is how serious problems can be missed.
The following steps form part of a proper evaluation:
- Full medical history. This may also include the completion of a Prostate Symptom Score Questionnaire and a Bladder Diary. These are available on the website.
- Prostate examination. This is an essential part of the evaluation. Whilst not comfortable, the digital prostate evaluation enables the doctor to assess the size of the prostate and whether there are any signs of prostate cancer on the outer rim of the gland.
- Urine tests. This is to look for blood or signs of abnormal cells that may prompt further evaluation.
- Prostate Specific Antigen (PSA) test. This blood test may help detect the early signs of prostate cancer, even if the prostate feels normal.
Other tests that may be required:
- Ultrasound of the urinary tract. To determine how well the bladder is emptying and whether there are signs of kidney blockage due to poor emptying of the bladder.
- Kidney function tests
- Cystoscopy. If there is an abnormality on the urine tests or any history of passing blood in the urine, it is important to look inside the bladder.
- Urodynamic studies. This is a sophisticated computer-based analysis of bladder function. It will tell us definitively whether there is a genuine blockage and is commonly performed before surgery is considered.
Not all men with prostate enlargement will need to be actively treated. Of all men who seek help for moderately severe prostate symptoms, approximately 25% will deteriorate over time and require treatment and 40% will actually improve without treatment. The remainder will have no significant change.
Therefore, it is sometimes reasonable to defer the use of medications and surgery if the symptoms are mild. However, it is important that each patient is followed up annually.
Simple self-help strategies are useful. These include:
- Restricting the amount of liquids and salads consumed for 3-4 hrs before bedtime
- Avoiding excess caffeine-containing beverages
- Adjusting the timing of certain medications such as diuretics (see your GP)
- Having a rest in the afternoon and “putting your feet up”. This helps get rid of fluid retained during the day before you go to bed.
For those who require active treatment, there are a variety of medications and herbal supplements that may be useful.
Alpha-blocker medications (Minipress, Pressin, Hytrin, Flomaxtra)
These are the first line prescription medications used for the symptoms of benign prostate enlargement. They do not shrink the prostate. Rather, they cause relaxation of muscle fibres at the neck of the bladder and within the prostate. This reduces the resistance to the flow of urine through the prostate and can have a dramatic effect on symptoms in some patients. This class of medications must be taken under strict supervision due to their potential effects on the cardiovascular system.
5 Alpha-Reductase Inhibitors (Proscar).
This class of medication works to inhibit the action of male hormones on the prostate and therefore causes shrinkage of the prostate. They work best in men with very large prostates and they take time (up to 6 months) to take maximum effect. Unfortunately they are not covered by the PBS and may cost over $100 for a 30-day supply.
Herbal Remedies (eg Saw Palmetto).
Some patients will respond well to over-the counter medications. Their precise mechanism of action and long-term safety have not been well determined.
There are a number of procedures which have been developed in order to reduce prostate obstruction. These operations should not be confused with Radical Prostatectomy, which is an operation performed to remove the entire prostate in cases of prostate cancer. Operations for benign prostate enlargement do not involve removal of the entire prostate. Rather, only the central portion is removed. Detailed information about some of these procedures is included in this website in the section Procedures and Treatments. These include:
- TransUrethral Resection of the Prostate (TURP). This remains the gold-standard procedure and has proved effective and safe for decades. It involves “shaving” the inner portion of the prostate to widen the channel through which urine passes. For more information, see TURP
- Laser Prostatectomy. There are various different types of laser that have been developed for benign prostate enlargement. At RPA Hospital, we have the latest Green-Light KTP laser. This technology works by vaporising the portion of the prostate that is causing blockage. Like the TURP, it is performed by insertion of a special instrument through the urethra. This technology is best for smaller prostates and is particularly advantageous in men taking anticoagulant medications.
- Bladder Neck Incision. It is possible to have obstruction to the flow of urine through the prostate despite not having any enlargement of the prostate. This can be due to scarring of the bladder neck after a previous TURP or simply because the bladder neck is naturally too tight. This procedure is similar to a TURP and causes similar side effects.
- Open (Suprapubic) Prostatectomy. When the prostate is extremely large, it may be impossible to safely perform a TURP. In these cases, the central portion of the prostate may be removed by means of an open operation, through a small incision just above the pubic bones. For more information, see Suprapubic Prostatectomy.
Other less commonly used technologies
A number of other devices have been developed in order to improve symptoms in patients with prostate enlargement. Over the years, several technologies have come and gone. Once it became apparent that the long term results were not as good as TURP and the complication rates were too high, many have fallen out of use. Examples of technologies that are still available but not in widespread use include:
Microwave therapy (patients after this treatment may require a catheter for up to one month to allow sloughing of the prostate!!)
Transurethral needle ablation