FAQs Prostate Enlargement

The symptoms of prostate enlargement are called lower urinary tract symptoms (LUTS), but these can also be caused by other conditions. As the prostate enlarges it may cause the first part of the urethra to narrow, which in turn may partially obstruct the flow of urine. Because of this symptoms can include:

• A poor urine stream where the flow of urine is weaker, and it takes longer to empty your bladder.
• Hesitancy in passing urine – you have to wait at the toilet for a while before urine starts to flow.
• Poor emptying of the bladder – you may have a feeling of not quite emptying your bladder.
• Dribbling towards the end of passing urine.

An enlarged prostate may also make the bladder irritable that can cause:

• Frequency, which is the passing of urine more often than normal. Getting up several times a night is a common symptom and is called nocturia.
• Urgency, which is needing to reach the toilet quickly when you need to go.

Usually symptoms are mild to begin with but over months or years they may become more troublesome and severe. Complications may develop in some cases.

However, an enlarged prostate does not always cause symptoms. Only 25-50% of men with an enlarged prostate will have symptoms. Also, the severity of the symptoms is not always related to the size of the prostate. Rather, it depends on how much the prostate obstructs the urethra.

What possible complications of protate enlargement are there?

Symptoms do not worsen in everyone and serious complications are unlikely to occur in most men with an enlarged prostate.

In 1% of cases, urinary retention can occur, which is when a total blockage of urine occurs and the person will no longer be able to pass urine. In this case, a catheter will need to be inserted to drain the bladder.

Another possible complication is chronic retention, where only some of the urine in the bladder is emptied when passing urine. This may cause recurring urine infections, or incontinence.

Have an enlarged prostate does not increase the risk of prostate cancer. Men with a benign prostate enlargement are no more or less likely to develop prostate cancer than those without the condition.

Tests are not always needed to confirm the diagnosis, rather benign prostatic enlargement is usually diagnosed based on the typical symptoms described above. However, the Consultant may wish to run tests in order to rule out other causes of symptoms. Tests may include:

• Examination of your prostate to see how big it is. This is done by inserting a gloved finger through the anus into the rectum to feel the back of the prostate gland. The size of your bladder may be assessed by examining your abdomen.
• Urine and blood tests to check kidney function and exclude a urine infection by checking that there is no blood in the urine.
• Cystoscopy – looking inside the bladder with a special telescope
• Urine flow test to assess how bad the obstruction has become
• An ultrasound scan to see whether much is left in the bladder after passing urine.
• Voiding diary – the patient is asked to record the number of times during the day and night they pass urine and the amount passed.
• PSA (prostate specific antigen) blood test can be used as a marker for the size of the prostate. Larger prostates make more PSA. A high PSA level is also found in people with prostate cancer. This test is not done routinely and most men with prostate symptoms do not have prostate cancer.

In most cases, an enlarged prostate does not do any damage or cause complications. Whether treatment is needed usually depends on how much bother the symptoms cause to the patient.

Symptoms can be greatly improved with treatment, although no treatment is likely to remove all symptoms. Which treatments your Consultant considers depends on how severe and troublesome your symptoms are.

General Measures

The following may help if you opt not to have treatment:

• After passing urine, go back in a few minutes and try to pass some more (this is known as double micturition). This may help to empty your bladder completely.
• Relaxing while passing using may help if hesitancy is a problem.
• Anticipate times when urinary frequency and urgency are likely to cause you the most inconvenience, then reduce the amount that you drink beforehand. For example, when you go out, don’t drink much for 2-3 hours before you go out. However, do not reduce the total amount of fluid to less than 1.5 litres each day.
• Reducing or stopping the amount of caffeine (tea, coffee, certain energy drinks, cola) and alcohol you drink, can help to ease frequency, urgency and nocturia.
• Distraction techniques such as breathing exercises or counting, to take your mind off the bladder, can help with urgency.
• Retrain your bladder by holding on for as long as you can each time before passing urine. The bladder muscle can be trained to expand more in this way. Eventually, the bladder may be trained to hold on for longer each time before you need to go to the toilet, thus helping frequency symptoms.
• Stopping smoking may significantly improve your symptoms. Nicotine irritates the bladder.

Watchful waiting

This may be recommended if your symptoms are quite mild and are not affecting your life too much. Your Consultant will review the situation every year, or sooner if there is change in symptoms. Symptoms do not always become worse and may even improve.

Medicines

There are two groups of medicines that may help: alpha-blockers and 5-alpha reductase inhibitors. Medicines do not cure the problem, nor do they usually make symptoms go completely. However, symptoms often ease if you take a medicine.

• Alpha-blocker medicines
  These medicines work by by relaxing the smooth muscle of the prostate and bladder neck. This can improve the flow of urine. There are several different types and brands of alpha-blockers which include: prazosin, indoramin, tamsulosin, alfuzosin, doxazosin and terazosin. There is no real difference between how effective these medicines are, but some tend to cause side-effects more often than others. In most cases, symptoms improve with taking an alpha-blocker. However, the amount of improvement varies from person to person. Some improvement usually occurs within a few days, but the full effect may take up to six weeks.Although side-effects are uncommon, they occur in some people. The most common side-effects are slight drowsiness, headaches and dizziness. If you are prescribed an alpha-blocker, read the leaflet that comes with the medicine packet for a full list of possible side-effects and cautions.

• 5-alpha reductase inhibitor medicinesThese are alternatives to alpha-blockers. There are two: finasteride and dutasteride. These work by blocking the conversion of the hormone testosterone to dihydrotestosterone in the prostate. They do this by blocking an enzyme (chemical) called 5-alpha-reductase. Dihydrotestosterone is partly responsible for making the prostate enlarge. Therefore, a reduced amount of dihydrotestosterone in the prostate causes it to shrink. These medicines have been shown in studies to improve prostate symptoms, reduce the risk of complications and also reduce the need for surgery. It can take up to six months for you to notice any effect from these medicines, as it takes time for the prostate gradually to shrink.It is unusual to have side-effects with 5-alpha reductase inhibitor medicines. However, they can occasionally cause impotence and reduced sex drive; these side-effects are usually reversible if the medication is stopped. (Again, read the leaflet in the medicine packet for a full list of possible side-effects.)

The severity of symptoms is not always related to the size of the prostate. A small or large enlargement may cause mild or severe symptoms. An alpha-blocker may help, whatever the size of the prostate, as it works by relaxing muscle fibres. Finasteride or dutasteride tend to work best if you have a larger prostate which has more tissue to shrink. Your doctor will advise which medicine may be best in your circumstances. Also, if you develop a problem or side-effect with one type of medicine, then another may be an option.

Combinations of medicines

In some cases, a combination of an alpha-blocker plus a 5-alpha reductase inhibitor is used. This may give quicker and better relief of symptoms than either alone. Some studies suggest that in men who take a combination of two medicines, about four in five men can stop the alpha-blocker after 6-12 months without their symptoms getting any worse. This is likely to be because the prostate will have shrunk with the 5-alpha reductase inhibitor after this time and the alpha-blocker is no longer then needed.

If symptoms are severe, or if medicines do not help, partial removal of the prostate is an option. Approximately 25% of men with an enlarged prostate will require an operation at some stage.

The operation involves only the central part of the prostate to be removed (thus creating a wide channel for urine to flow through), leaving the outer part behind. This is different to surgery for prostate cancer where the entire prostate may be removed.

There are many options for removing prostate tissue. Your Consultant will discuss the most suitable operation for you in more detail.

Transurethral resection of the prostate (TURP)
TURP is the most common operation carried out for an enlarged prostate. Under anaesthetic, either spinal or general, a rigid cystoscope is inserted through the urethra into the bladder. A cystoscope is a narrow tube-like telescope through which small instruments pass to allow the operation to be carried out. A semicircular loop of wire has an electrical current passed through it. It is this loop that sticks out from the end of the cystoscope and cuts out small chips of prostate that are then washed out at the end of the operation. This operation nearly always gives good relief of symptoms. 80-90% of men after this operation will have retrograde ejaculation, which is when semen goes backwards into the bladder at climax producing a ‘dry’ orgasm. Impotence and incontinence are rare complications after a TURP.

Transurethral incision of the prostate (TUIP)
TUIP may be offered if you only have a slightly enlarged prostate. For this operation, the surgeon makes small cuts in the prostate where the prostate meets the bladder. This then relaxes the opening to the bladder, resulting in there being an improved flow of urine out of the bladder. There is less risk of retrograde ejaculation with this operation.

HoLEP – minimally invasive procedure for very large prostates

HoLEP is a laser surgery for men who have a very large prostate. The procedure is minimally invasive and uses a high-powered laser to detach the ‘flesh’ of the prostate from the capsule. This is then transferred to the bladder and suctioned out. The major advantage of this procedure is that you can treat prostates too large to be operated on safely using other methods. A HoLEP procedure is safe and effective, even for the largest of prostates, and has a faster recovery time than other prostate procedures.

Laser prostatectomy
This is simply the application of newer technologies to achieve the same goal as either TURP or open prostatectomy. It has the advantage of fewer side-effects, a shorter period of having a catheter in, and a shorter stay in hospital (often just one night). There are two types of lasers: green light which vaporises the prostate tissue to create a cavity, and holmium or thulium lasers that can very effectively core out large pieces (lobes) of prostate which, in turn, are chopped into small pieces in order to be removed from the bladder. In the hands of experienced laser surgeons, very large prostates, which in the past could only be dealt with by open surgery, can be removed by this technique.