Enlarged Prostate - Urology Services
The prostate gland produces the fluid (semen) that carries sperm during ejaculation. The gland surrounds the urethra, the tube through which urine passes out of the body. An enlarged prostate — found in most all men as they age — can restrict the bladder passage and result in bothersome urinary symptoms such as dribbling and difficulty emptying the bladder.
Because the urine passage is being squeezed, the bladder must work harder to empty. It is important to know that an enlarged prostate, known as benign prostatic hyperplasia (BPH), is not cancer and does not raise the risk of cancer.
Is Treatment Needed?
Treatment for BPH is based on the severity of symptoms and whether they affect daily life. Not all men have symptoms — and not all require treatment. The key to a decision about treatment is whether the man is bothered by symptoms such as frequency of urination. For example, getting up twice a night to urinate may be intolerable for one man because of sleep interruptions. Another man — who falls back to sleep easily — may be OK with getting up four times.
Only a small proportion of men with enlarged prostates require treatment. Often, the most bothersome symptom is related to urgency — because fear of leaking can be just as bothersome as leaking. To gauge the need for treatment, men may be asked to answer a questionnaire about these symptoms:
- Having a sensation of not emptying your bladder completely after you finish urinating
- Having to urinate again less than two hours after you last went
- Stopping and starting again several times when you urinate
- Difficulty postponing urination
- A weak urinary stream
- The need to push or strain to begin urination
- Getting up multiple times a night to urinate
Out of 100 men with symptoms, about 55 will get worse with time, 30 will remain stable and 15 will improve. Improvement may occur during the summer months, for example, when we tend to sweat more and not produce as much urine.
How Is It Diagnosed?
The diagnosis of prostate enlargement and related symptoms can involve a simple physical examination, or can include testing such as an ultrasound, a test to measure flow rate and leftover urine (PVR), a cystoscopy (looking inside the bladder with a scope), a blood test to measure prostate-specific antigen (PSA), and urodynamics (a test that measures bladder pressure and uses x-ray to see how the bladder is working.)
There are many options for men who want to prevent or treat bothersome symptoms.
- Medications: In men who have a large prostate, a class of drugs known as 5-alpha-reductase inhibitors, which includes finasteride (Proscar®) or dutesteride (Avodart®), can shrink the gland and prevent additional growth and the potential for symptoms.
In men who already have moderate to severe symptoms, alpha blockers, such as Flomax®, Uroxatral®, or Rapaflow®, may be prescribed to treat symptoms. For patients with moderate to severe symptoms and a large prostate, a combination of a 5-alpha-reductase inhibitor and an alpha blocker may be effective.
Combination therapies for patients with obstruction and urgency include the use of alpha blockers and anticholinergics. Certain medications used for sexual dysfunction can also benefit urinary symptoms due to BPH.
Surgery: For men who do not benefit from taking medications or don’t want to take pills every day for the rest of their lives, surgery is an option. The most prevalent surgery, transurethral resection of the prostate (TURP), involves inserting a wire loop up the urine passage and using electric current to cut and remove the section of the prostate blocking urine flow.
Today, there are many minimally invasive alternatives to this traditional surgery — some that can be done in an office setting and require no anesthesia. Examples include:
- Transurethral microwave thermotherapy (TUMT): Basically a “microwave” procedure heats the area of the prostate affecting urine flow, so that it shrinks within three weeks to six months. This treatment is done in the physician’s office and requires no anesthesia. Disadvantages are that a urinary catheter must remain in place about one week. In addition, about 25 percent of men need subsequent treatment, so this option is often seen as a way to delay the need for more invasive procedures. Wake Forest Baptist Health was selected to test a newer “high energy” version of this equipment.
- Transurethral Needle Ablation of the Prostate (TUNA): The physician uses a camera to see the prostate, and passes needles into the area. High-energy radio waves heat the prostate tissue, which eventually causes it to shrink. Advantages include lower levels of anesthesia than traditional surgery. Disadvantages are similar to those of the TUMT procedure.
- Laser treatments are also available, including a new green light laser to vaporize the prostate. Because it does not cause bleeding, it is ideal for men who take blood thinners and therefore cannot undergo TURP.
- One of the newer device treatments recently introduced is called “Urolift”, which can be done under minimal anesthesia or sedation. It compresses the prostate tissue thus widening the urinary channel, without cutting any tissue. Early results are promising. The catheter time is reduced as is the anesthesia need. Long term results compared to other treatment options are pending. Insurance coverage for this is not uniform yet. A physician in our department has been a lead investigator for this device.
- Prostate glands with a very large volume can be removed with a robot-assisted procedure.
- The department experience in variety of these procedures and comparison is slated for a national presentation at the annual meeting of the AUA (American Urological Association).
Learn more about urology services at Wake Forest Baptist Health.