Prostate Problems

What is prostate and How does it interfere with Urinary flow?

The prostate is a small gland located just below the bladder at the place where the urethra joins the bladder. The urethra is the tube in the penis that conducts urine from the bladder out of the body. The prostate plays a role in supplying the fluid to add to the quantity of semen and some nutrients to the sperm in the semen.

prostate

Men can develop following disease conditions in the prostate

  • Benign Prostatic Enlargement
  • Prostatitis and Chronic Pelvic pain
  • Prostate Cancer

Benign Prostatic Enlargement

What happens when the prostate enlarges?

The prostate enlarges with age. Usually the enlargement is due to the benign enlargement of the prostate. As the prostate enlarges, it can put pressure around the urethra and result in symptoms of blockage or disturbances to the storage of urine.

An enlarging prostate causes disturbances to the storage (ability to store urine at low pressure) and voiding (ability to expel the urine in a socially appropriate and effortless manner) function of the bladder.

When the storage function is affected, a person will have the necessity to pass urine more frequently and need to urinate suddenly (urgency). In extreme case this could be resulting in inability to control urination and leakage of urine (incontinence).

When the prostate causes obstruction, it results in weak urinary flow, intermittency(starting and stopping) of the flow, dribbling towards the end of the stream and feeling of inadequate emptying of the bladder.

What other conditions could cause similar symptoms?

In men, the urinary symptoms can be caused by other conditions as well.

These are other disease conditions in the urinary tract as well as problems occurring in other organs. They are

  • Urinary Tract infections
  • Overactive Bladder
  • Underactive or weak bladder
  • Bladder stone
  • Bladder cancer
  • Neurological Conditions like stroke, Parkinson’s disease, Multiple sclerosis and Spinal cord tumours
  • Over production of Urine due to Diabetes
  • Night-time over production of Urine due to cardiac failure, Kidney failure, swollen legs etc
What are the complications of Prostate enlargement?

Acute Retention of Urine: When the obstruction is severe, it could result in total blockage of urine called urinary retention. Urinary retention is an emergency and when it happens suddenly it is very painful and distressing. This has to be treated by insertion of a tube into the bladder called catheter.

Chronic Retention: Prolonged obstruction can cause back pressure to kidneys and cause kidney failure(obstructive uropathy).

Prostatic obstruction can also lead to repeated urinary infections and formation of bladder stones.

How common is the prostate enlargement problem?

Enlarged prostate, or BPH (benign prostatic hyperplasia), affects over 14 million men in the US. BPH occurs in approximately half of all men 50 years and older and up to 90% of men over 80 years of age.

Is benign enlargement of prostate (BPH) life threatening?
As the name implies, the BPH is the non-cancerous enlargement of the prostate. But the symptoms can be very distressing and the complications of enlarged prostate like retention, frequent urinary infections, kidney failure and loss of quality of life due to the symptoms.
When should you seek medical treatment?
When these symptoms mentioned above, adversely influence your quality of life by affecting your participation in the activities of day-today life and your ability to sleep you should consider seeking treatment.
How would your doctor or Urologist assess your symptoms?

Your doctor or urologist will first try to assess if your symptoms are due to benign prostate enlargement or other conditions affecting the bladder and prostate. Certain symptoms like urinary frequency may be also caused by certain disease conditions like diabetes and cardiac failure. Therefore your doctor may assess you to find the cause of your symptoms.

This assessment will involve

1. Detailed history of your various symptoms

2. Information about your other health problems and co-existing diseases

3. To determine the severity of your symptoms, your doctor may ask you to complete the International Prostate Symptom Score(IPSS) (HTML link) questionnaire. This is a series of seven questions with five grades answers and the total maximum score will be 35. There is also a question about quality of life with six graded answers.

The higher your score, the more severe is your condition.

Mild 0-7

Moderate 8-19

Severe 20-35

4. In addition, your doctor may use the following to diagnose and better understand your condition

Physical exam – Abdomen and finger examination of your prostate through the back passage (rectum)

Urine Tests - to look for presence of infection and blood. If there is presence of invisible or visible blood, it may be necessary to rule out any significant bladder conditions

Blood tests: This may include PSA (prostate specific antigen) and if yoru doctor has concerns about your kidney function, he/she may do some blood tests to assess this as well.

Ultrasound imaging: If there is clinical suspicion of enlarged bladder, they may do an ultrasound scan of the bladder and the kidneys.

What is the importance of PSA Blood Test (HTML link)?

PSA blood test is used to diagnose some clinical conditions affecting the prostate. PSA is a normal substance produced by the prostate gland and its concentration is very high in semen. Its level in the blood is very small and its normal range varies according to the age of the person. The PSA level can be raised in benign enlargement of the prostate, inflammation of prostate and prostate cancer. Its level can be also temporarily raised during urinary infections and after any endosocopic examinations or procedures in the urethra and bladder.

When the PSA level is high (above the normal range for the age), it is important to determine if the cause of this rise is due to benign conditions or cancer of the prostate. If the prostate is abnormal by finger examination, then there is a high likelihood of prostate cancer and your doctor will refer you to a urologist for consideration of possible biopsy.

If the prostate is felt to be normal, then the decision making depends on your age and fitness as well as your choice. The only way to rule out significant prostate cancer in this situation is by undergoing a prostate biopsy (HTML). Alternatively you may be given an option to monitor the PSA over 6-12 months and decide for a biopsy if there is significant further rise in the level of PSA.

Apart from diagnosing or ruling out prostate cancer, PSA blood test is also useful to determine the risk of progression and potential for complications by the benign enlargement of the prostate.

When will you need a Bladder examination?

Your urologist will recommend bladder examination for the following reasons.

  • If your urine test shows presence of blood: Presence of blood in urine could be due to significant conditions like bladder tumour and bladder stone and you will need a cystocopy.
  • If there is too much uncertainty about the cause of your symptoms especially if you have predominant storage symptoms like frequency or urgency not responding to treatment.
  • If you have pain in the bladder or urethra
  • If any abnormal cells in the urine or if you have been exposed to occupations chemicals that are known to increase the risk of bladder cancer.
  • Some times your urologist may recommend cystoscopy prior to considerations of surgical treatment especially if you do not respond to medical treatment.
What are the Non-operative treatment options for the problems due to prostate enlargement?
Depending upon the severity of your symptoms as quantified by the IPSS score and other parameters of prostate size and PSA level, your doctor or urologist will recommend the appropriate treatment options. The treatments usually start with non-surgical option and then may be changed to surgical options if there is no progress with non-surgical treatment. Sometimes it may be necessary to consider surgical options early if there is significant risk of complications like retention of urine, or severe distressing symptoms with very high score or if the complications of prostatic enlargement have already occurred.

Lifestyle Modification

To help minimising the impact from your urinary symptoms, you may have to reduce any excessive beverage intake especially the bladder irritants like tea, coffee, fizzy drinks and high volume alcoholic drinks like beer. It is recommended to restrict coffee or tea intake to a maximum of two cups per day. If your main problem is interruption of sleep due to night time frequent urination, you may wish to restrict your beverage intake in the evenings for atleast 3-4 hours prior to your retiring to sleep.

Drug Treatment

Three groups of medication are for treating BPH related symptoms.

Alpha blockers
One group is alpha blockers and they relax the bladder neck and prostate and thereby reduce the resistance at the level of the prostate and thereby relieving the obstruction. These include Tamsulosin, Alfuzocin, Terazocin and Doxazocin. These address the symptoms of BPH but do not cure the disease. Symptom relief can cease when you stop taking the drugs. These drugs can interfere with other blood pressure medications and result in giddiness or dizziness due to fall in blood pressure and it is advisable to be cautious in the first few days of starting this medication. If the dizziness is severe, you should stop taking these drugs. In addition, this group of medicines can also cause retrograde ejaculation (dry orgasms)
5-Alpha reductase inhibitors
The second group of medicines used in BPH treatment is 5-Alpha reductase inhibitors.. This group of medicines prevent the conversion of Testosterone (male hormone) to its active component in the prostate. The active component is mainly responsible for the enlargement of prostate. Due to this effect, the prostate can shrink about 30% in its size over a period of 12 months of taking this medication. This effect is useful to prevent further progression of BPH. Currently there are two medications in this group which are Finasteride and Dutasteride. The common side effects of these drugs include, reduced sex drive, impotence and rarely engorgement of breasts.
Anti-muscarinics
These are group of drugs used to slow down the bladder. The prostatic obstruction can cause, bladder overactivity resulting in frequency and urgency of urination. If these symptoms are more pronounced, your doctor may prescribe these medication alone or with other two groups of medicines discussed above. These drugs include oxybutynin, Toltoredine, Fesoterodine, Solifenacin and Regurin. The common side effects of this group include dry mouth and eyes, indigestion, constipation, rarely sedation. More importantly, this group can trigger retention of urine if there is significant obstruction from prostate. Therefore you should be cautious if you have severe obstructive symptoms like difficulty starting urination, weak and intermittent flow of urine.

 

How would your doctor decide which drug to give when?

It is upto your doctor to choose depending on your symptoms and the result of the other assessments. If your symptoms are mild to moderate, your doctor may choose alpha blockers and add the second group if no adequate response. In the presence of severe storage symptoms of urgency and frequency, they may add the third group mentioned above.

If your symptoms are severe to start with, your doctor may start you on combination treatment of first two groups with the addition of third group if necessary.

What are the surgical options of treatment and when would that option be recommended to you?

Surgical treatment is recommended when non surgical options does not adequately improve the symptomatic bothersome symptoms. In the presence of ongoing bother with symptoms of obstruction, surgery is recommended.

If the symptoms are predominantly storage symptoms like frequency and urgency, then the urologist may want to confirm if these symptoms are secondary to obstruction. They may be able to determine this by doing a special test called Urodynamics. Only if these symptoms are confirmed to be due to the obstruction, then a prostate operation may be helpful.

The surgery will be recommended early if you who cannot urinate, have kidney damage, frequent urinary tract infections and/or significant urethral bleeding or bladder stones which are considered to be complications of prostatic enlargement.

What is achieved during surgery for Benign prostatic enlargement?

The surgical procedures are designed to relieve the obstruction at the level of bladder neck and the prostate. This is done by opening up the bladder neck by incision or by coring away the part of the prostate and bladder neck and prostate that is causing the obstruction.

What are the types of procedures done to relieve the Obstruction at the bladder neck and prostate?

These operations are done through an endoscope passed through the urethra(penis). Currently the video systems are used to monitor while operating inside the body. Special electrical knife and loop are used to cut and remove the tissues in the bladder neck and prostate in small pieces. These fragments of tissue are removed by washing them out. The operation is done under general or spinal anaesthesia. The bladder and the prostate are continuously irrigated with special fluids to keep the from being obscured by blood and also prevents the clotting of the blood.

Bladder Neck Incision: This is appropriate if the prostate is small but the circular muscles in the bladder neck is casing blockage.

Transurethral resection of the prostate or TURP is the standard surgical procedure to remove the prostate. In this procedure, the prostate is cut into fragments and removed.

Holmium Laser Treatment (also known as HoLAP – Holmium Laser Ablation of the Prostate) uses laser energy to cut and life the prostatic tissue and remove as a big pieces. The pieces of tissue is released into the bladder and removed through a special instrument called morcellator that cuts the big chunks of tissue into small pieces and suck them out. Laser surgery has the advantage of less bleeding and avoiding usage of irrigant fluid call Glycine that increase the risk of salt disturbances and a condition called TURP syndrome.

What can you expect after the operation?

Immediately after the operation, you will have a catheter fitted at the time of the operation. The bladder will be continuously irrigated from 6 to 24 hours after the operation depending on how long there is oozing of blood in the urine following the operation.

The catheter usually stays for anywhere from 24 to 48 hours and longer if there is prolonged bleeding in the urine.

You may be discharged on the first or second day after the procedure when the catheter comes out and you successfully manage to pass urine. It is usually uncomfortable in the urethra when the catheter comes out and the burning sensation could last for days.

If you do not manage to pass urine when the catheter comes out, you will be fitted with another catheter into the bladder and advised to come back for the removal of the catheter after few days.

You may continue to pass some blood or clots for upto 4 weeks following the operation.

What precautions you should take after the prostate operation?

You could minimise the irritation and burning sensation in the urethra by keeping your fluid intake high to the extent your urine almost colourless like water.

You should avoid strenuous activities like lifting or gardening for six weeks following the operation. These strenuous activities could result in the rupture of fragile blood vessels in the operated area and cause bleeding in the urine.

Sometimes people can develop urinary infection after the operation. If you feel unwell or develop fever or the pain and irritation in the urethra and bladder is increasing, you should seek immediate medical help.

What are the immediate and long term complications of surgery for benign prostatic enlargement ?

Immediate Complications:

There may be excessive loss of blood especially if the prostate is bid resulting in a prolonged procedure. This may be treated by blood transfusion if necessary.

During the operation especially if the procedure is prolonged, the irrigant fluid may get absorbed into the blood causing fall in salt level (sodium) in the blood and cause a condition called TURP syndrome. This is a serious condition some times resulting even in coma and death. If some one develop this state, that person will be intensively treated in a ward or unit with higher level of care. This condition is rare (1-2%) and risk can be further minimised by restricting the length of the procedure to a maximum of 60 minutes and using the irrigating fluid in a controlled way. Of course the Laser and Some special type of electric devices (Bipolar Diathermy) uses saline and this TURP syndrome risk is very much minimised.

Infection and sepsis (severe infection) can occur that will be treated with antibiotics. This risk may be reduced by using antibiotics as prevention the time of the operation.

What are the later consequences of the Prostate procedures?

Incontinence: This can occur due to damage to the sphincter( valve like muscle that maintains the continence) during the operation. This risk is small in less than 1%. Leakages due to urgency may occur for the first few weeks due to the irritation from the procedure and any infection.

Erectile Dysfunction (Impotence): There is 5-10% risk of impotence if your erectile function is normal prior to the procedure.

Retrograde Ejaculation (Dry orgasm): This occurs inevitably in a large proportion of patients undergoing prostate resection procedures. You should be able to have the same feeling of ejaculation (orgasm) with out the emission of semen. This occurs due to the passage of semen into the bladder instead of its expulsion down the urethra. This is usally permanent. If you think you are keen to father a child, you should consider alternate methods of treatment or you might wish to consider cryo-preservation of sperms.

Late scarring of bladder neck and urethra causing blockages: After the initial improvement in the flow and symptoms, if you feel that the flow is getting weaker, it may be due to development of scarring inyour bladder neck of urethra which may need further treatments.

What benefit I can expect from the operation?

Benefits: You may expect to see a good improvement in the flow from the beginning. The full improvement may be seen from few days to upto 6 weeks. Because the purpose of the operation is to relive the obstruction, the improvement in the flow will occur early.

The symptoms like frequency and urgency are due to the changes that occurred in the bladder due to the obstruction. Those symptoms may take upto 12 months and may not improve completely. If those symptoms still persist after 6 months, your doctor my consider giving the drugs called antimuscarinics to slow down your bladder.