Do You Have an Enlarged Prostate?

As we age, our bodies change along with it, although just how they change is usually out of our control. Of course, with a good diet, healthy lifestyle and ample exercise, it's possible to age gracefully with less bumps along the way.

However, did you know that for most men, their prostate grows larger as they get older? It's a part of ageing, but after a certain point, the enlarged prostate leads to a condition called benign prostatic hyperplasia (BPH).

It's not the most well-known body part, but the prostate is a walnut-sized gland found at the base of the bladder and surrounds part of the urethra – the tube that channels urine and semen out of your penis. The prostate is part of the male reproductive system and produces the seminal fluid that a man ejaculates. As men grow older, the prostate grows in size; and as it grows, it squeezes the urethra and causes a range of symptoms. Don't panic because BPH is a common condition, especially in older men, and thus, there are plenty of treatment options for it.

What are the symptoms of an enlarged prostate?

As a man ages, the prostate grows larger and starts to pinch the urethra which causes problems with your urine flow. Urinary symptoms include:

• Weak urine stream
• Frequent urination
• Waking up at night to go to the bathroom, which affects quality of sleep
• Feeling like the bladder isn't fully emptied
• Extra effort needed to start urine flow
• Incontinence or urine leakage
• Blood in the urine

Complications which could arise from unmanaged BPH include blood in the urinary tract and urinary obstruction which may prevent urine from being passed. This may lead to:

• Urinary tract infections
• Urinary stones
• Kidney damage

Such urinary symptoms may sometimes be due to diseases other than BPH, such as infections, bladder stones and cancers of the prostate or bladder. As such, urinary symptoms should not be regarded as a normal part of growing older, and should be evaluated by a doctor to exclude more sinister conditions.

How is BPH diagnosed?

To diagnose BPH, a urologist will perform a digital rectal examination where the size and consistency of the prostate is determined. You will be asked to fill up a questionnaire regarding your symptoms, called an International Prostate Symptom Score or IPSS in short. This helps your doctor better understand the severity of your symptoms.

The IPSS questionnaire will ask about the severity of symptoms such as:

• Incomplete emptying
• Frequency
• Intermittency
• Urgency
• Weak stream
• Straining
• Nocturia

It is advised that anyone with a score of more than 8/35 should see a urologist for an evaluation.

Your urologist will perform a urine test called a Uroflowmetry test, to find out how fast urine is passed and how much urine is left behind. Following that, an ultrasound is done to check the bladder to see how well the bladder is emptied, as well as check the size of the prostate. A blood test may also be required to check for kidney problems and assess the risk of prostate cancer.

How is BPH treated?

Lifestyle changes

For men with mild symptoms, your doctor may recommend the following lifestyle changes:

• Do exercises to strengthen the pelvic floor muscles for better urinary control
• Reduce the amount of fluids being consumed, especially before going out or bedtime
• Drink less coffee, tea and alcohol

Medication

For men with more significant symptoms, doctors may prescribe medication. There are 2 main types of medication.

Alpha blockers – These have a quick acting effect on relaxing the smooth muscles around the prostate and bladder neck, easing the obstruction. These medications may cause dizziness as a side effect by lowering your blood pressure. Other side effects include a blocked nose, or reduced volume of ejaculation.

5-alpha reductase inhibitors (5-ARI's) – These drugs stop the prostate from growing and cause it to shrink. However, these medications take a longer time to work, so patients will have to wait for as long as 6 months to a year until symptoms improve. They work best when combined with alpha blockers, which can provide more immediate relief.

There are few side effects with 5-ARI's, but they may reduce your libido and weaken your erections. Unfortunately, these sides effects may not always be reversible when you stop taking the medication.

While both classes of drugs are effective, they do need to be taken on a long-term basis to treat BPH.

Surgery

If medication does not provide sufficient relief from bothersome urinary symptoms, or if a patient cannot tolerate the side effects, or does not want to rely on long-term BPH medication, there are many surgical options available for a longstanding solution.

Recently, 3 new minimally invasive surgical treatments (MIST) for BPH have become available in Singapore. These MIST have the following advantages over the previous standard surgery of TURP (Transurethral Resection of Prostate). Firstly, it helps preserve a patient's preservation of sexual function. Secondly, they do not require hospital admission, and general anaesthesia/spinal anaesthesia. Thirdly, they reduce the changes of complications and allow patients to return to normal activity earlier.

What are the new MISTs for BPH?

Prostate lift

This procedure involves passing a small camera into the urethra (cystoscope) and putting small permanent implants into the prostate. These implants will lift, and hold, the obstructing prostate tissue apart, increasing the width of the urethral passage. This reduces obstruction to the urinary flow, improving the speed of the flow and reducing BPH symptoms.

Transurethral water vapour therapy

This works by inserting sterile water vapour (steam) through a cystoscope, into the prostate gland during a series of nine-second treatments. The therapy is targeted to a defined area because steam will travel only between cells until it encounters natural barriers within the prostate. When the steam comes into contact with the prostate tissue, all the stored energy is released into the tissue. Over time, the body absorbs the treated tissue, shrinking the prostate. With the extra tissue removed, the urethra opens up, reducing BPH symptoms.

Transurethral microwave therapy

This therapy uses a catheter that is passed into the prostate part of the urethra, and combines the use of focused Microwave Heating (to destroy prostate tissue) together with a Pressurised Balloon (to push apart the prostate tissue). This creates a wider passage in the prostate for urine to flow through.

The treatment takes approximately 45 minutes, and can be performed under local anaesthesia.

All 3 MISTs can effectively relieve BPH symptoms while preserving sexual function. Most men see improvement in their symptoms within a few weeks and can return to regular activities within a few days after the treatment.

However, there are selection criterias for these treatments. The choice of MIST needs to be individualised, and carefully selected by the treating urologist, based on the size and configuration of the patient's prostate.

Surgical options requiring hospital admission

Not all prostates can be treated by MIST. Very large prostates or men who have complications from BPH such as urinary retention (complete inability to pass urine), bladder stones, or blocked kidneys, need surgery that can treat larger volumes of prostate tissue.

Transurethral resection of the prostate (TURP)

This is the most common surgical treatment for BPH, and remains the standard upon which other surgical treatments are compared to.

In a TURP, the urologist inserts an instrument called a resectoscope through the tip of your penis and into the urethra. The resectoscope helps your doctor see and trim away excess prostate tissue that's blocking urine flow. After which, a urinary catheter is inserted for 1 – 2 days. TURP is performed under general or spinal anaesthesia, and a patient will need to stay in the hospital for between 1 – 3 days.

Photoselective vaporisation of the prostate

This laser therapy involves using a laser fibre through a cystoscope to heat up and vapourise obstructing prostate tissue. This unblocks the urethra and restores normal urine flow from the bladder. This procedure is performed under general or spinal anaesthesia, and can be done as a day surgery or with an overnight stay. Recovery is generally quick.

The advantage of photoselective vaporisation of the prostate over the TURP is that it offers the doctor better control over bleeding. It is especially useful for men who are on blood thinners for prevention of a heart attack or stroke.

Do note that photoselective vaporisation of the prostate and TURP may have side effects that include retrograde ejaculation and erectile dysfunction.

What should you do?

If you find yourself displaying any of these symptoms, consult a urologist and get yourself checked out. It is important to understand that while these urinary symptoms are more common with ageing, they should not be regarded as a normal part of life. Men should be evaluated to rule out more sinister causes of urinary symptoms.

Men do not need to suffer from urinary symptoms of BPH. There are many treatment options available, and a urologist can help men find a suitable treatment option for their individual needs, and improve their quality of life.