The prostate is a small, almond-shaped gland that sits at the base of the bladder. Its main function is to produce the majority of fluid that a man ejaculates, but it is not essential for life. It enlarges throughout a man’s life, and can commonly cause problems with a man’s “waterworks”. As can be seen from the diagram the urethra passes through the middle of the prostate, and as it grows it compresses this tubular structure. This compression in turns leads to the difficulty men often experience in passing urine as they get older.
Symptoms caused by problems with the prostate are often known collectively as “lower urinary tract symptoms” or LUTS.
Symptoms and signs of prostate problems include:
- a delay before starting to pass urine – hesitancy
- poor stream – slow, may stop & start
- the need to strain to keep urine flowing
- passing urine often – frequency
- needing to pass urine at night – nocturia
- the need to rush to pass urine urgently – urgency
- dribbling urine onto underpants after finishing urination – post-micturition dribbling
- the feeling the bladder is not empty
- burning pain when passing urine – dysuria
LUTS are rarely caused by cancer, though when you are investigated the Urologist will often seek to exclude this possibility (more later). The most common prostate problem that causes these symptoms is BPH (Benign Prostatic Hyperplasia).
BPH occurs in all men – prostates enlarge throughout adult life. The size of the prostate does not correlate well with the occurrence of symptoms. Many men with large prostate have few symptoms, whilst conversely some men with small prostates may experience quite severe LUTS.
The prostate can block the bladder (BOO = Bladder Outlet Obstruction) as it enlarges. Treating the prostate for enlargement does not result in incontinence, as the prostate sits above the urinary sphincter and is separate from that structure.
You will find that some or all of the following may be required to make an accurate diagnosis of LUTS caused by your prostate:
- History – your medical history, including medications, past problems or previous surgery.
- Symptom Score – a simple questionnaire that can help in judging the severity of your symptoms and your response to any treatments.
- Examination – especially a digital rectal examination (DRE) of the prostate. Abdomen & genitals are often examined as well.
The DRE should not cause you any anxiety. It is not painful (though perhaps a little embarrassing) and is performed with you laying on your left side or standing whilst bending over. This examination allows the doctor to obtain an indication of the size of your prostate as well as the presence of any lumps or nodules, etc.
- Urine tests – to look for infection, blood, sugar, etc.
- Blood tests – general blood count and kidney function tests.
- PSA – Prostate Specific Antigen – this is a blood test that is designed to assist in the diagnosis of prostate cancer. It is not always required but you should feel free to discuss this test with your doctor.
You may be required to have one or all of the following tests as well:
- Ultrasound (US) – to image the kidneys & bladder
- Post-void Residual (PVR) – usually performed at the same time as the US
- Cystoscopy – a telescopic inspection of the bladder
- Urodynamic Study – a computer-based test of your bladder function
The main risk men face when suffering from LUTS due to prostatic enlargement is acute urinary retention. This is the medical term for when a person cannot urinate – they usually suffer severe pain and need to go to hospital to have a catheter inserted in the bladder.
The other risks faced are urinary tract infections and more rarely kidney failure and bladder stones.
There are many treatment options for BPH that do not involve surgery. Once “dangerous” conditions such as prostate cancer, bladder cancer, kidney disease, bladder stones etc have been excluded, the need for any treatment depends on how bothered you are by your LUTS.
You will have noticed the so-called bother score you provided if you completed an IPSS -International Prostate Symptom Score – a simple questionnaire about your symptoms. Some of the treatment options are listed below.
What you can do for yourself – lifestyle changes
You may decide you do not wish any specific medical treatment at this point in time. Some of the following tips may help make some of your symptoms more bearable.
Drink a little less fluid in the evening
some drinks such as tea, coffee and alcohol can exacerbate the symptoms
some medications (such as diuretics) make you pass more urine – a consultation with your local doctor may enable these drugs to be taken in the morning
“urethral milking” – after passing urine run your finger from behind the scrotum forward to push out those last few drops of urine that often stain the underwear
“herbal” remedies that can be bought over the counter can often improve symptoms e.g. Saw palmetto & Trinovan
sometimes pelvic floor exercises help
You should have an annual prostate check as back-up to ensure you are not developing any hidden problems.
Medications
Alpha Blockers
These drugs block the nerves to the muscles of the prostate. This relaxes the prostate and allows easier passing of the urine. Symptoms improve 2-4 weeks after commencing the drugs.
Prazosin (Minipress or Pressin) is relatively nonspecific and in larger doses is used as a blood pressure tablet. Its big advantage is that it a PBS listed drug.
Tamsulosin (Flomax) a prostate-specific alpha-blocker that works more rapidly and often with more effect, but at this time is only on the Repatriation PBS scheme – therefore for most people it costs about $50 per script.
5 Alpha-Reductase Inhibitors
These drugs – the one available in Australia is Finasteride = Proscar – reduce some of the hormonal activities of testosterone in the prostate causing it to shrink. It is not commonly used in Australia as it is very expensive and less than 30% of men who try it find it provides them any relief of their symptoms.
Surgical Options
When your symptoms are severe, you do not respond to medication, or the prostate enlargement is putting you at risk, then surgical options may need to be explored. Your Urologist will explain these in detail.
Options range from the minimally-invasive to open surgery (though this is highly unlikely to be required today) and include:
TUNA -Trans-Urethral Needle Ablation of the prostate
The prostate shrinks over the following months
TUMT – Trans-Urethral Microwave Therapy
Trans-Urethral Microwave Therapy – uses microwave energy to acheive the same result as TUNA
TURP – Transurethral Resection of the Prostate
A transurethral resection of the prostate (TURP) involves a traditional endoscopic (no cuts) removal of the central part of the prostae. This is the basic operation that all the laser forms of surgery attempt to emulate e.g. Holmium.
Laser TURP – Laser prostate surgery a fiber optic cable pushed through the urethra is used to transmit lasers to vaporise the benign prostate tissue.
Bipolar TURP – Is a newer technique that uses bipolar current to remove prostate tissue.
UROLIFT
A minimally invasive approach which uses implants to open up the urethral lumen. Improvement in symptoms is comparable to medical therapy and there is commonly improved preservation of ejaculatory function.
REZUM
A new technique which uses water vapour (steam) to cause ablation of the enlarged prostate tissue.