Prostate Enlargement: Benign Prostatic Hyperplasia
The prostate is a walnut-sized gland that forms part of the male reproductive
system . The gland is made of two lobes, or regions, enclosed by an outer
layer of tissue. As the diagrams show, the prostate is located in front
of the rectum and just below the bladder, where urine is stored. The prostate
also surrounds the urethra, the canal through which urine passes out of
the body.
Scientists do not know all the prostate's functions. One of its main
roles, though, is to squeeze fluid into the urethra as sperm move through
during sexual climax. This fluid, which helps make up semen , energizes
the sperm and makes the vaginal canal less acidic.
One of the gland's main roles is to squeeze fluid into the urethra as
sperm move through during sexual climax.
The Male Urinary Tract.
It is common for the prostate gland to become enlarged as a man ages.
Doctors call the condition benign prostatic hyperplasia (BPH), or benign
prostatic hypertrophy.
As a male matures, the prostate goes through two main periods of growth.
The first occurs early in puberty, when the prostate doubles in size.
At around age 25, the gland begins to grow again. It is this second growth
phase that often results, years later, in BPH.
Though the prostate continues to grow during most of a man's life, the
enlargement doesn't usually cause problems until late in life. BPH rarely
causes symptoms before age 40, but more than half of men in their sixties
and as many as 90 percent in their seventies and eighties have some symptoms
of BPH.
As the prostate enlarges, the surrounding capsule stops it from expanding,
causing the gland to press against the urethra like a clamp on a garden
hose. The bladder wall becomes thicker and irritable. The bladder begins
to contract even when it contains small amounts of urine, causing more
frequent urination . As the bladder weakens, it loses the ability to empty
itself, and urine remains behind. This narrowing of the urethra and partial
emptying of the bladder cause many of the problems associated with BPH.
Many people feel uncomfortable talking about the prostate, since the
gland plays a role in both sex and urination. Still, prostate enlargement
is as common a part of aging as gray hair. As life expectancy rises, so
does the occurrence of BPH. In the United States alone, 350,000 operations
take place each year for BPH.
It is not clear whether certain groups face a greater risk of getting
BPH. Studies done over the years suggest that BPH occurs more often among
married men than single men and is more common in the United States and
Europe than in other parts of the world. However, these findings have
been debated, and no definite information on risk factors exists.
Normal urine flow.
Urine Flow with BPH
The cause of BPH is not well understood. For centuries, it has been
known that BPH occurs mainly in older men and that it doesn't develop
in males whose testes were removed before puberty. For this reason, some
researchers believe that factors related to aging and the testes may spur
the development of BPH.
Throughout their lives, men produce both testosterone, an important
male hormone , and small amounts of estrogen, a female hormone. As men
age, the amount of active testosterone in the blood decreases, leaving
a higher proportion of estrogen. Studies done with animals have suggested
that BPH may occur because the higher amount of estrogen within the gland
increases the activity of substances that promote cell growth.
Another theory focuses on dihydrotestosterone (DHT), a substance derived
from testosterone in the prostate, which may help control its growth.
Most animals lose their ability to produce DHT as they age. However, some
research has indicated that even with a drop in the blood's testosterone
level, older men continue to produce and accumulate high levels of DHT
in the prostate. This accumulation of DHT may encourage the growth of
cells. Scientists have also noted that men who do not produce DHT do not
develop BPH.
Some researchers suggest that BPH may develop as a result of "instructions"
given to cells early in life. According to this theory, BPH occurs because
cells in one section of the gland follow these instructions and "reawaken"
later in life. These "reawakened" cells then deliver signals
to other cells in the gland, instructing them to grow or making them more
sensitive to hormones that influence growth.
Many symptoms of BPH stem from obstruction of the urethra and gradual
loss of bladder function, which results in incomplete emptying of the
bladder. The symptoms of BPH vary, but the most common ones involve changes
or problems with urination , such as:
- a hesitant, interrupted, weak stream
- urgency and leaking or dribbling
- more frequent urination, especially at night.
The size of the prostate does not always determine how severe the obstruction
or the symptoms will be. Some men with greatly enlarged glands have little
obstruction and few symptoms while others, whose glands are less enlarged,
have more blockage and greater problems.
Sometimes a man may not know he has any obstruction until he suddenly
finds himself unable to urinate at all. This condition, called acute urinary
retention, may be triggered by taking over-the-counter cold or allergy
medicines. Such medicines contain a decongestant drug, known as a sympathomimetic,
which may, as a side effect, prevent the bladder opening from relaxing
and allowing urine to empty. When partial obstruction is present, urinary
retention also can be brought on by alcohol, cold temperatures, or a long
period of immobility.
It is important to tell your doctor about urinary problems such as those
described above. In 8 out of 10 cases, these symptoms suggest BPH, but
they also can signal other, more serious conditions that require prompt
treatment. These conditions can be ruled out only by a doctor's exam.
Severe BPH can cause serious problems over time. Urine retention and
strain on the bladder can lead to urinary tract infections, bladder or
kidney damage, bladder stones, and incontinence . If the bladder is permanently
damaged, treatment for BPH may be ineffective. When BPH is found in its
earlier stages, there is a lower risk of developing such complications.
You may first notice symptoms of BPH yourself, or your doctor may find
that your prostate is enlarged during a routine checkup. When BPH is suspected,
you may be referred to a urologist, a doctor who specializes in problems
of the urinary tract and the male reproductive system . Several tests
help the doctor identify the problem and decide whether surgery is needed.
The tests vary from patient to patient, but the following are the most
common:
Rectal Exam
This exam is usually the first test done The doctor inserts a gloved
finger into the rectum and feels the part of the prostate next to the
rectum. This exam gives the doctor a general idea of the size and condition
of the gland.
Ultrasound
If there is a suspicion of prostate cancer, your doctor may recommend
test with rectal ultrasound . In this procedure, a probe inserted in the
rectum directs sound waves at the prostate. The echo patterns of the sound
waves form an image of the prostate gland on a display screen.
Urine Flow Study
Sometimes the doctor will ask a patient to urinate into a special device
which measures how quickly the urine is flowing. A reduced flow often
suggests BPH.
Intravenous Pyelogram (IVP)
IVP is an x-ray of the urinary tract . In this test, a dye is injected
into a vein, and the x-ray is taken. The dye makes the urine visible on
the x-ray and shows any obstruction or blockage in the urinary tract.
Cystoscopy
In this exam, the doctor inserts a small tube through the opening of
the urethra in the penis. This procedure is done after a solution numbs
the inside of the penis so all sensation is lost.) The tube, called a
cystoscope, contains a lens and a light system, which help the doctor
see the inside of the urethra and the bladder. This test allows the doctor
to determine the size of the gland and identify the location and degree
of the obstruction.
Men who have BPH with symptoms usually need some kind of treatment at
some time. However, a number of recent studies have questioned the need
for early treatment when the gland is just mildly enlarged. These studies
report that early treatment may not be needed because the symptoms of
BPH clear up without treatment in as many as one-third of all mild cases.
Instead of immediate treatment, they suggest regular checkups to watch
for early problems. If the condition begins to pose a danger to the patient's
health or causes a major inconvenience to him, treatment is usually recommended.
Since BPH may cause urinary tract infections, a doctor will usually
clear up any infection with antibiotics before treating the BPH itself.
Although the need for treatment is not usually urgent, doctors generally
advise going ahead with treatment once the problems become bothersome
or present a health risk. The following section describes the types of
treatment that are most commonly used for BPH.
Most doctors recommend removal of the enlarged part of the prostate
as the best long-range solution for patients with BPH. With surgery for
BPH, only the enlarged tissue that is pressing against the urethra is
removed; the rest of the inside tissue and the outside capsule are left
intact. Surgery usually relieves the obstruction and incomplete emptying
caused by BPH. The following section describes the types of surgery that
are used.
Transurethral Surgery. In this type of surgery, no
external incision is needed. After giving anesthesia , the surgeon reaches
the prostate by inserting an instrument through the urethra.
A procedure called TURP (transurethral resection of the prostate) is
used for 90 percent of all prostate surgeries done for BPH. With TURP,
an instrument called a resectoscope is inserted through the penis. The
resectoscope, which is about 12 inches long and 1/2 inch in diameter,
contains a light, valves for controlling irrigating fluid, and an electrical
loop that cuts tissue and seals blood vessels.
TURP is used for 90 percent of all surgeries done for BPH.
During the 90-minute operation, the surgeon uses the resectoscope's
wire loop to remove the obstructing tissue one piece at a time. The pieces
of tissue are carried by the fluid into the bladder and then flushed out
at the end of the operation.
Although this procedure is delicate and requires a skilled surgeon,
most doctors suggest using TURP whenever possible. Transurethral procedures
are less traumatic than open forms of surgery and require a shorter recovery
period.
Another surgical procedure is called transurethral incision of the prostate
(TUIP). Instead of removing tissue, as with TURP, this procedure widens
the urethra by making a few small cuts in the bladder neck, where the
urethra joins the bladder, and in the prostate gland itself. Although
some people believe that TUIP gives the same relief as TURP with less
risk of side effects such as retrograde ejaculation , its advantages and
long-term side effects have not been clearly established.
Open Surgery. In the few cases when a transurethral
procedure cannot be used, open surgery, which requires an external incision,
may be used. Open surgery is often done when the gland is greatly enlarged,
when there are complicating factors, or when the bladder has been damaged
and needs to be repaired. The location of the enlargement within the gland
and the patient's general health help the surgeon decide which of the
three open procedures to use.
With all the open procedures, anesthesia is given and an incision is
made. Once the surgeon reaches the prostate capsule, he scoops out the
enlarged tissue from inside the gland.
Laser Surgery.
Some researchers are exploring the use of lasers to vaporize obstructing
prostate tissue. Early studies suggest that this method may be as effective
as conventional surgery.
Following surgery, you'll probably stay in the hospital from 3 to 10
days depending on the type of surgery you had and how quickly you recover.
At the end of surgery, a special catheter is inserted through the opening
of the penis to drain urine from the bladder into a collection bag. Called
a Foley catheter, this device has a water-filled balloon on the end that
is placed in the bladder, which keeps it in place.
This catheter is usually left in place for several days. Sometimes,
the catheter causes recurring painful bladder spasms the day after surgery.
These may be difficult to control, but they will eventually disappear.
Foley Catheter
You may also be given antibiotics while you are in the hospital. Many
doctors start giving this medicine before or soon after surgery to prevent
infection. However, some recent studies suggest that antibiotics may not
be needed in every case, and your doctor may prefer to wait until an infection
is present to give them.
After surgery, you will probably notice some blood or clots in your
urine as the wound starts to heal. If your bladder is being irrigated
(flushed with water), you may notice that your urine becomes red once
the irrigation is stopped. Some bleeding is normal, and it should clear
up by the time you leave the hospital. During your recovery, it is important
to drink a lot of water (up to 8 cups a day) to help flush out the bladder
and speed healing.
Do's and Don'ts
Take it easy the first few weeks after you get home. You may not have
any pain, but you still have an incision that is healing -- even with
transurethral surgery, where the incision can't be seen. Since many people
try to do too much at the beginning and then have a setback, it is a good
idea to talk to your doctor before resuming your normal routine. During
this initial period of recovery at home, avoid any straining or sudden
movements that could tear the incision. Here are some guidelines:
- Continue drinking a lot of water to flush the bladder.
- Avoid straining when moving your bowel. Eat a balanced
diet to prevent constipation, and take a laxative if you become constipated.
- Don't do any heavy lifting.
- Don't drive or operate machinery.
Getting Back to Normal
Even though you should feel much better by the time you leave the hospital,
it will probably take a couple of months for you to heal completely. During
the recovery period, the following are some common problems that occur:
Problems Urinating. You may notice that your urinary
stream is stronger right after surgery, but it may take awhile before
you can urinate completely normally again. After the catheter is removed,
urine will pass over the surgical wound on the prostate, and you may initially
have some discomfort or feel a sense of urgency when you urinate. This
problem will gradually lessen, though, and after a couple of months you
should be able to urinate less frequently and more easily.
Inability to Control Urination (Incontinence).As the
bladder returns to normal, you may have some temporary problems controlling
urination , but long-term incontinence rarely occurs. Doctors find that
the longer problems existed before surgery, the longer it will take for
the bladder to regain its full function after the operation.
Bleeding. In the first few weeks after transurethral
surgery, the scab inside the bladder may loosen, and blood may suddenly
appear in the urine. Although this can be alarming, the bleeding usually
stops with a short period of resting in bed and drinking fluids. However,
if your urine is so red that it is difficult to see through or if it contains
clots or if you feel any discomfort, be sure to contact your doctor.
Sexual Function After Surgery
Many men worry about whether surgery for BPH will affect their ability
to enjoy sex. Some sources state that sexual function is rarely affected,
while others claim that it can cause problems in up to 30 percent of all
cases. However, most doctors say that even though it takes awhile for
sexual function to return fully, with time, most men are able to enjoy
sex again.
Complete recovery of sexual function may take up to 1 year, lagging
behind a person's general recovery. The exact length of time depends on
how long BPH surgery was postponed despite symptoms and on the type of
surgery that was done. Here is a summary of how surgery is likely to affect
the following aspects of sexual function.
Erections
Most doctors agree that if you were potent (able to maintain an erection)
shortly before surgery, you will probably be able to have erections afterward.
Surgery rarely causes a loss of potency. However, surgery cannot usually
restore potency that was lost before the operation.
Ejaculation
Although most men are able to continue having erections after surgery,
a prostatectomy frequently makes them sterile (unable to father children)
by causing a condition called "retrograde ejaculation" or "dry
climax."
During sexual activity, sperm from the testicles enters the urethra
near the opening of the bladder. Normally, a muscle blocks off the entrance
to the bladder, and the semen is expelled through the penis. However,
the coring action of prostate surgery cuts this muscle as it widens the
neck of the bladder. Following surgery, the semen takes the path of least
resistance and enters the wider opening to the bladder rather than being
expelled through the penis. Later it is harmlessly flushed out with urine.
Orgasm
Most men find little or no difference in the sensation of orgasm, or
sexual climax, before and after surgery. Although it may take some time
to get used to retrograde ejaculation, you should eventually find sex
as pleasurable after surgery as before.
Many people have found that concerns about sexual function can interfere
with sex as much as the operation itself. Understanding the surgical procedure
and talking over any worries with the doctor before surgery often help
men regain sexual function earlier. Many men also find it helpful to talk
to a counselor during the adjustment period after surgery.
Is Further Treatment Needed?
In the years after your surgery, it is important to continue having
a rectal exam once a year and to have any symptoms checked by your doctor.
Since surgery for BPH leaves behind a good part of the gland, it is
still possible for prostate problems, including BPH, to develop again.
However, surgery usually offers relief from BPH for at least 15 years.
Only 10 percent of the men who have surgery for BPH eventually need a
second operation for enlargement. Usually these are men who had the first
surgery at an early age.
Sometimes, scar tissue resulting from surgery requires treatment in
the year after surgery. Rarely, the opening of the bladder becomes scarred
and shrinks, causing obstruction. This problem may require a surgical
procedure similar to transurethral incision (see section on surgery).
More often, scar tissue may form in the urethra and cause narrowing. This
problem can usually be solved during an office visit when the doctor stretches
the urethra.
Balloon Urethroplasty. In this procedure, a thin tube
with a balloon is inserted into the opening of the penis and guided to
the narrowed portion of the urethra, where the balloon in inflated. This
action widens the urethra, easing the flow of urine.
Balloon urethroplasty. is a simple procedure that can
be done on an outpatient basis, so it may eventually offer men a safe
alternative to surgery. Since the procedure doesn't actually remove the
tissue causing the obstruction, more studies are needed to judge its long-range
effectiveness.
Transurethral Hyperthermia. Researchers are also investigating
a procedure that uses heat to shrink the prostate. During a series of
treatments spread over several weeks, a doctor inserts a catheter containing
a heating antenna into the urethra and then applies concentrated heat
to the enlarged tissue, gradually shrinking it and relieving the obstruction.
However, the long-range effectiveness of hyperthermia is not clear, and
studies have indicated that the frequent insertion of a catheter and the
use of heat can cause side effects such as irritation of the urethra,
bleeding, or painful bladder spasms.
Prostatic Stents. Doctors in Europe are studying the
use of devices, or stents, which are inserted through the urethra to the
narrowed area and allowed to expand, like a spring. The stent pushes back
the prostatic tissue, widening the urethra.
Medical Treatment. Over the years, researchers have
tried to find a way to shrink or at least stop the growth of the prostate
without using surgery. Recently, scientists have developed several new
medications that are now being tested in clinical trials to determine
whether they are safe and effective.
The Food and Drug Administration (FDA) has approved two drugs to treat
BPH. Finasteride (marketed under the name Proscar), FDA approved in June
1992, inhibits production of the hormone that is involved with prostate
enlargement. Its use can actually shrink the prostate in some men.
In September 1993, FDA also approved the drug terazosin (marketed under
the name Hytrin) to treat BPH. Terazosin acts by relaxing the smooth muscle
of the prostate and bladder neck to improve urine flow and to reduce bladder
outlet obstruction. Terazosin, which belongs to the class of drugs known
as alpha blockers, has been used as a treatment for hypertension since
1987.
Because drug treatment is not effective in all cases, surgery remains
a common form of treatment for benign enlargement of the prostate.
Although some of the signs of BPH and prostate cancer are the same,
having BPH does not seem to increase the chances of getting prostate cancer.
Nevertheless, a man who has BPH may have undetected prostate cancer at
the same time or may develop prostate cancer in the future. For this reason,
the National Cancer Institute and the American Cancer Society recommend
that all men over 40 have a rectal exam once a year to screen for prostate
cancer.
After BPH surgery, the tissue removed is routinely checked for hidden
cancer cells. In about 1 out of 10 cases, some cancer tissue is found,
but often it is limited to a few cells of a nonaggressive type of cancer,
and no treatment is needed.
- Anesthesia
- A substance given before an operation that prevents pain from being
felt.
- Anus
- The opening of the rectum where solid waste leaves the body.
- Bladder
- The bag in the lower abdomen where urine is stored.
- Catheter
- A tube inserted through the penis to the bladder in order to drain
urine from the body.
- Ejaculation
- Discharging semen from the penis during sexual excitement.
- Hormone
- A substance that stimulates the function of a gland.
- Impotent
- Unable to have an erection.
- Incontinence
- The inability to control urination .
- Obstruction
- A clog or blockage that prevents liquid from flowing easily.
- Perineum
- The area between the scrotum and the anus.
- Rectum
- The last part of the colon ending in the anus.
- Reproductive system
- The system that allows a person to have children.
- Retropubic
- Behind the pubic bone.
- Scrotum
- The sac of skin that contains the testes .
- Semen
- The fluid, containing sperm, which comes out of the penis during sexual
excitement.
- Sterile
- Unable to father children.
- Suprapubic
- Above the pubic bone.
- Testes
- The male reproductive glands where sperm are produced.
- Ultrasound
- A type of test in which sound waves too high to hear are aimed at
a structure to produce an image of it.
- Urinary tract
- The path that urine takes as it leaves the body. It includes the kidneys,
ureters, bladder, and urethra.
- Urination
- Discharge of liquid waste from the body.
- Urethra
- The canal inside the penis that urine passes through as it leaves
the body.
Source:
NIH Pub. No. 91-3012, Revised September 1991
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