Prostate Enlargement

Prostate Enlargement: Straight Answers

Thirty percent of men over fifty years of age have at least moderate lower urinary tract symptoms (LUTS) often arising from enlargement of the prostate. Symptoms include slowing of the urine stream, urinary dribbling, nighttime urinating, urinary frequency and urgent urination. Evaluation includes urine analysis, PSA and creatinine blood testing, physical examination and sometimes cystoscopy and urodynamic evaluation.

While the symptoms are generally benign, careful urological examination is needed to exclude the possibility of more serious medical problems which may effect not only the prostate and bladder but also the body as a whole. These conditions may include prostate cancer, bladder cancer, kidney stone disease, infections, sexually transmitted disease and others.

... [without treatment] 25 percent of patients improve, 50 percent stabilize and 25 percent eventually undergo surgical treatment.

When LUTS are caused by the prostate, treatment options include simple observation without treatment, medications, minimally invasive surgical options, endoscopic surgical options and open surgical treatment. Simple observation, sometimes known as "watchful waiting" implies that no treatment is given. In such cases approximately 25 percent of patients improve, 50 percent stabilize and 25 percent eventually undergo surgical treatment. Of the patients who initially choose that treatment, about 10 percent eventually become unable to urinate, requiring surgery and about 15 percent develop progressive symptoms, also requiring surgery. It is very likely that the majority of the remaining symptomatic patients will eventually undergo treatment. Nonetheless, there's nothing wrong with choosing to have no treatment as long as it is understood that there is a risk for deterioration of the bladder and a very small risk of deterioration of the kidneys.

If medications are stopped, their beneficial effects are reversed and some patients become unable to urinate.

Medications are commonly used for LUTS. This treatment primarily involves the use of a class of medications known as alpha blockers. Common alpha blocker medications include (from oldest to newest) prazosin (Minipress), terazosin (Hytrin), doxazosin (Cardura) and tamsulosin (Flomax). The beneficial effects of these medications are noticeable almost immediately, certainly within 1-2 weeks. A few side effects are common to this class of drugs including dizziness, stuffy nose, reduced ejaculate volume and generalized tiredness. All of these medications with the exception of tamsulosin (Flomax) are sometimes used as blood pressure medications.

While alpha blocker medications certainly are very useful, they do not produce the same results as surgical intervention. Furthermore, medications must be continued indefinitely. If medications are stopped, their beneficial effects are reversed and some patients become unable to urinate.

Another commonly used medication is in a drug class known as 5-alpha reductase inhibitors. Presently, the only available medication in this drug class is finasteride (Proscar). Proscar is effective but very slow acting, often taking 3-6 months to produce beneficial results. Because it is slow acting, some physicians simultaneously prescribe an alpha blocker medicine, such as Flomax.

Proscar has very few side effects such as impotence, decreased libido and reduced ejaculate volume. However, one of the most interesting side effects of Proscar is that it stops the balding process in up to 80 percent of patients! In fact the company who manufactures finasteride (Proscar) also sells the same medication under the name Propecia. Propecia is marketed for the treatment of balding.

Proscar is the only drug which has been proven to reduce the chance of urinary retention and the need for subsequent surgical intervention.

Proscar is the only drug which has been proven to reduce the chance of urinary retention and the need for subsequent surgical intervention. Studies have shown that Proscar is most effective for significantly enlarged prostate glands of volumes greater than 40 cc (twice normal size). In general, estimation of the size of the prostate may be most accurately performed by a urologist able to perform ultrasonography of the prostate.

When taking Proscar patients must remember that the drug reduces serum prostate specific antigen (PSA) levels by about 50 percent, without necessarily reducing the risk of prostate cancer. When these patients have their PSA tested they must inform their physicians that they are using Proscar so that the doctor may adjust the normal range of PSA accordingly. Otherwise, there is a danger that the physician may interpret the relatively low PSA as being normal, when in fact the PSA of a man on Proscar may be abnormal and the patient might have prostate cancer. Studies are underway to investigate whether or not the use of Proscar might actually prevent prostate cancer. Some doctors combine Proscar with alpha blocker medications such as Flomax. Like alpha blockers, Proscar must be continued indefinitely. If Proscar is stopped, its beneficial effects are reversed and LUTS often return.

The gold standard treatments for LUTS (lower urinary tract symptoms) associated with an enlarged prostate are known as transurethral resection of the prostate (TURP) and simple open prostatectomy. These procedures are the only LUTS treatments which remove portions of the prostate so that a pathologist can inspect the removed tissue for prostate cancer. In the age of PSA screening and ultrasonography, this point is not as critical as in years past.

There is no treatment of any type more effective for the relief of LUTS ... than simple open prostatectomy.

Open prostatectomy means surgical removal of the inner portion of the prostate through an open surgical incision. Simple open prostatectomy may be performed either through a small lower abdominal skin incision just above the pubic bone or through a perineal incision between the scrotum and anus. This results in the relief from LUTS in greater than 95 percent of men undergoing to surgery. There is no treatment of any type more effective for the relief of LUTS due to a greatly enlarged prostate than simple open prostatectomy. While this treatment has an overwhelming success rate, it should be reserved for men with very large prostates, greater than 60 cc in total size (three times normal size).

TURP is the standard by which all other treatments are compared.

The second and more common of the so-called gold standard treatments for LUTS related to an enlarged prostate is TURP. In fact, TURP is the standard by which all other treatments are compared. TURP is effective in relieving LUTS in greater than 85 percent of men. It involves an anesthetic in the operating room during which the urologist passes a rigid cystoscope through the urethra of the penis into the prostate. The center portion of the prostate is removed bit by bit, during the procedure. The procedure is commonly associated with significant bleeding although blood transfusions are required in less than 10 percent the cases. A common problem with TURP results from the absorption fluids into the bloodstream. Special irrigation fluids are necessary to wash away the blood during the procedure to allow the surgeon to visualize the prostate. Absorption of these fluids may produce electrolyte imbalances.

Impotence and incontinence are commonly listed side effects of TURP; however, the incidence of these problems in TURP patients is said to be no greater than the incidence of these problems in the age matched general population. Additionally, other potential complications of TURP include scarring of the bladder neck (bladder neck contracture) in approximately 10 percent of the cases, scarring of the urethra (urethral stricture) and retrograde ejaculation.

... retrograde ejaculation is not known to produce any ill effects ...

Retrograde ejaculation implies that semen fluid passes backward into the bladder rather than going out forward through the urethra. Beyond the potential for infertility, retrograde ejaculation is not known to produce any ill effects. Some men report that the feeling of ejaculation is slightly different. While some physicians perform TURP procedures on an outpatient basis, most urologists hospitalize their patients for 1-2 nights. In either case, a catheter is required for 1-2 days. Postoperatively, pain is minimal but patients are restricted from performing any significant physical activity for a period of at least six weeks. Patients who fail to abide by these instructions often experience heavy blood in the urine which sometimes clots, resulting in the inability to urinate and the necessity for emergency replacement of a catheter.

Transurethral incision of the prostate (TUIP) is a procedure designed for smaller prostates. The procedure is similar to TURP in the requirement for an anesthetic in an operating room. A rigid cystoscope type device is used but instead of removing prostate tissue, the urologist simply makes two incisions through the prostate, relieving the obstruction. While the results are not quite as good as the results of TURP, there are fewer side effects. Transurethral electrovaporization of the prostate (TVP) is also a procedure similar to TURP. However, instead of removing prostate tissue, the urologist vaporizes the prostate tissue through a cystoscopic type instrument. Of course, this also requires an operating room and a more prolonged anesthetic. Both TUIP and TVP also require that patients restrict their physical activity and wear catheters for least a short time after surgery.

... minimally invasive techniques ... offer the potential for fewer side effects [of treatment] as compared to TURP.

So-called minimally invasive techniques for the removal of obstructing prostate tissue and treatment of LUTS include laser prostatectomy, transurethral microwave thermotherapy (TUMT), transurethral needle ablation of the prostate (TUNA), balloon dilation, water induced thermotherapy (WIT) and high intensity focus ultrasound (HIFU) treatment. These treatment options offer the potential for fewer side effects, as compared to TURP. While the results of some of these minimally invasive treatment options may approach the results of TURP, none have been absolutely proven to measure up to the proven very long-term results of TURP. Additionally, most all of these alternative treatment options require patients to wear catheters for a longer period time, as compared to TURP. Nonetheless, there is a great deal of interest and these forms of treatments because patients are anxious to avoid side effects, complications of treatment and the operating room. Some of these treatments may be delivered in the physician's office without a general or spinal anesthetic, and in some cases even without IV sedation.

Perhaps the most widely accepted minimally invasive treatment for LUTS caused by the prostate is transurethral microwave thermotherapy (TUMT). This technology was approved by the FDA in 1995 and the physicians at the Urology Center have been using this technology in selected patients for several years. The results have been impressive, although again patients must understand that wearing a catheter is necessary for 5-10 days after the procedure. As with all prostate procedures, the healing process continues for upwards of six weeks after the procedure with continuing improvement in urination over that time period.

Thermatrx equipment now allows the TUMT [microwave] procedure to be performed in the physician's office .... As of the time of this writing, the Urology Center is the only facility in this area offering this advanced treatment.

The company who originally developed the first TUMT equipment has improved upon its original design. Thermatrx equipment now allows the TUMT procedure to be performed in the physician's office, without an IV anesthetic and without injections of any kind. As of the time of this writing, the Urology Center is the only facility in this area offering this advanced treatment. Patients do receive oral medications primarily to help them relax during the procedure. A local anesthetic jell is also used to help the patient tolerate the catheter during the procedure. Treatment is fast, an hour or less, and patients may return home immediately. Again, the catheter remains in place for about five days, after which nearly every patient is able to urinate very well. Urination continues to improve over the following weeks and months.

Satisfaction rates are very high [with Thermatrx] ...

Satisfaction rates are very high and most patients are pleased that they are eventually able to stop their alpha blocker prostate medications (Flomax, Cardura, Hytrin and others) and return to normal urinating habits. As with all of the new minimally invasive forms of treatment, long term results have not been published. Nonetheless, this procedure has been proven to be safe and effective with fewer side effects than the gold standard treatment, TURP.

In summary, lower urinary tract symptoms secondary to benign prostate problems are easily treatable with medications and various forms of surgery. While no alternative treatment has such long-term results as TURP and open prostatectomy, minimally invasive office-based outpatient techniques, such as Thermatrx microwave thermotherapy (TUMT), produce excellent results with increased treatment tolerability usually with no side effects whatsoever.

(Also see these related links: Office Prostate Microwave Thermotherapy, BPH, Lower Urinary Tract Symptoms, Prostate Surgery, Prostatitis, Prostate Cancer, Bladder Cancer, or visit http://www.prostate.org.)