Benign Prostatic Enlargement

This section provides an overview of the Disease process, its impact on the Quality of life and various organ systems. It also provides a brief overview of the treatment options available. Please go the specific section for details about the surgical procedures and pelvic floor exercises.

Q 1. What is prostate?

A.  It is a gland located in the lower urinary tract, under the bladder and around the urethra and is exclusive to males. It produces the fluid which carries semen. A healthy prostate is about the size of a large walnut and has a volume of 15-25 millilitres (ml). The prostate slowly grows as men grow older

Q 2. What is Benign Prostatic enlargement?

A. Benign prostatic enlargement is a common condition, which is related to hormonal changes which happen as men grow old. It can cause bothersome symptoms in the lower urinary tract in men over the age of 50. Other conditions can also cause these symptoms.

Q 3. Is there a risk for cancer prostate?

A. BPE is not prostate cancer. It does not become prostate cancer, even if it is left untreated. However, both benign prostatic enlargement and prostate cancer may develop with age. Some people may have both diseases. Get a professional consult for any doubts and clarifications.

Q4. What are the symptoms of benign prostatic enlargement?

The enlarged prostate puts pressure on the urethra at the outlet of the bladder leading to lower urinary tract symptoms (LUTS) which may range from mild to bothersome and may negatively affect your quality of life.
These symptoms can be classified as:

The need to urinate more often than usual

Storage symptoms:

• The need to wake up at night to urinate
• The sudden need to urinate and having trouble holding it
• Any involuntary loss of urine (incontinence)

Voiding symptoms:

• A weak stream of urine
• Splitting or spraying of the urine stream
• The flow of urine starts and stops (intermittent)
• Straining when urinating
• It takes a while before the urinary flow starts
• It takes longer to finish urinating
• In rare cases acute or chronic urinary retention

Post-micturition symptoms:

• The feeling that the bladder is not completely empty
• Involuntary loss or dribbling of urine into your underwear shortly after leaving the toilet.

Q 5. What is the impact of this disease on my life?

A. Many men with BPE have to deal with lower urinary tract symptoms (LUTS) as they grow older. For some, this causes a lot of unhappiness and bother, while others experience only mild discomfort. For example, one man can suffer greatly from waking up at night to urinate while another may hardly be affected by it. That is why your personal experience and your quality of life should not be underestimated. They are as important as diagnostic tests and treatment results. They should not stop you from being happy in your relationships and participating in all aspects of your life. Seek help if your symptoms bother you: consult your family doctor, general practitioner, or a urologist.

Q6. How will it affect my personal and social life?

A. Symptoms associated with BPE, such as urgency or the need to urinate often, can have a negative effect on your social life. Some men suffer so much from these symptoms that they avoid all social activities. They are afraid to find themselves in a situation where there is no toilet nearby. Furthermore, losing sleep because of the need to urinate at night may lower energy levels and make it more difficult to maintain daily activities.

Symptoms caused by BPE can have a negative effect on your personal relationships and sex life. It can be difficult to feel attractive and confident or be intimate with your partner. Episodes of incontinence or urgency can be embarrassing and lower your self-esteem. Side effects of drug treatment such as lack of sexual drive or erectile dysfunction can also add to these feelings.

These changes can be very difficult to deal with because for most men sexuality remains important throughout their whole life. Some men may even go into denial or suffer from depression. That is why the effect of BPE on the quality of life should not be underestimated.

This is not only challenging for you but also for your partner. Your intimacy as well as your daily interaction may be affected. Your partner may suffer without saying much, so it is very important that you openly discuss the best way to cope with this condition.

You should not let fear of embarrassment prevent you from seeking help and improving your quality of life. Do not let a prostate condition rule your life.

Q 5. How do you diagnose benign prostatic enlargement?

A. The diagnosis is based on clinical history, physical examination which will include a Digital rectal Examination and Investigations.

Q 6. How to prepare for an out-patient consultation?

A. Find preparations below

• Make a list of any previous surgeries
• Make a list of the medication you are taking
• Mention other diseases you suffer from
• Describe your lifestyle (exercising, smoking, alcohol, and diet)
• Describe your current symptoms
• Note how long you have had the symptoms for

Q 7. What do you mean by physical examination?

A. Your doctor will do a general physical examination.

He/She will be looking for:

• A distended bladder (your bladder may stretch if it does not empty completely)
• Skin damage on the penis and scrotum (the pouch of skin that contains your testes)
• This can be a sign of urinary incontinence
• Discharge from the urethra, at the end of the penis (a sign of infection)
• Abnormalities in the penis, scrotum, and testicles
• Rectal examination with a finger to feel the size, shape, and consistency of the prostateThis test is known as digital rectal examination

Q 8. What investigations will I need?

A. Urine test: You will need to give some of your urine for testing. The test will show if you have a urinary tract infection or if there are traces of blood in the urine. It may also show glucose which could be a sign of diabetes mellitus.

Blood test: Kidney function test (KFT) and PSA. PSA is a protein produced by the prostate and it may increase in men with a benign prostatic enlargement, prostatic inflammation, or prostate cancer. PSA testing is based on shared decision making.

Bladder diary: You will note down how much you drink, how often you urinate, and how much urine you produce by measuring the volume of urine at home with the help of a measuring jug. It helps your doctor to understand your symptoms better.Uroflowmetry: This is an electronic record of the flow of urine. It is easily done in privacy at the hospital or clinic. You will urinate in a container, called a uroflowmeter. This test helps your doctor to check if the enlarged prostate causes a blockage in the lower urinary tract.

Ultrasonography: Ultrasound uses high-frequency sounds to create an image of your bladder and your prostate. It also checks how much urine is left in the bladder after urinating. This information helps to see if your symptoms are caused by chronic urinary retention, which can occur in men with BPE. It also measures the size of prostate volume. This may help to select the best treatment option for you.

Urodynamic Study (UDS): It provides more information about your urination cycle and how your bladder muscles work. Catheters are inserted in your urethra and rectum to measure the pressure in your bladder and abdomen. The bladder is slowly filled with sterile fluid through the catheter in the urethra, simulating normal filling of bladder with urine. When the bladder is full, you will urinate into a uroflowmeter.

Your doctor may decide to give you this test if:

• You have a neurological dysfunction
• You have had pelvic or prostate surgery
• You have too much urine left in the bladder after urination
• BPE is uncommon in your age group
• More information is needed to understand the cause of your symptoms

Q 9. What treatment options do I have?

A. You will be provided with one of the following treatment options, depending on the severity of your symptoms and the stage of the disease.

• Watchful waiting with Life style changes
• Medical Management
• Surgical Management
• Minimally Invasive Therapy like TURP, HOLEP
• Rarely Open Prostatectomy

Q 10. What do you mean by Watchful waiting with Life style changes?

A. The urologist will explain your condition to you, how it can develop, and how you can adjust your lifestyle to reduce your symptoms and cope with them. The urologist will closely observe your condition over the following months or years and will start active treatment when needed. This is called Watchful Waiting.

It is a good option if your symptoms are mild/moderate and if you feel that your quality of life has not declined. It includes regular check-ups to make sure your condition does not get worse. Some symptoms can improve on their own while others may remain stable for years.

A Watchful Waiting programme includes:

• Evaluation of your symptoms
• A physical examination
• Blood and urine tests
• Education about your condition
• Support and reassurance
• Lifestyle and self-management advice

Q 11. What are the Lifestyle and self-management advices, I need to follow?

A. Lifestyle advice:

• Drink at least 1 litre every day and discuss with your doctor if you can drink more
• Drink more if you live in a hot climate or do a lot of physical exercise
• Drink less before and during long trips
• Drink less in the evening to avoid getting up at night to urinate
• Avoid alcohol and caffeine because they increase urine production and irritate the bladder
• Try to exercise 2 or 3 times a week. Lack of movement can make it more difficult to urinate and cause urinary retention
  Have a balanced and varied diet
• Always try to keep your lower abdomen dry and warm. If you go swimming, bring an extra set of dry clothes and change as soon as you are out of the water. Dampness and cold may increase the need to urinate and can cause a urinary infection.
• Sometimes urine sprays and it can wet the toilet seat or the bathroom floor. Some men prefer to sit down when urinating to avoid this, while others prefer to urinate in a cup and empty it in the toilet.
• This table indicates some of the food habits which may affect the feeling of urgency.

Self-management: It can reduce symptoms and keep your condition stable.

• Completely empty your bladder each time you urinate. It may help if you sit down.
• If you feel your bladder is not empty after urinating, try again after 5 minutes Use a small pad to catch involuntary urine loss. (Double Voiding)
• After urinating, press under the scrotum with your fingers onto the urethra and then slide your fingers from the base to the tip of the penis to squeeze out the last drops of urine. This will help to avoid wetting your underwear. (Milking of urine)
• Use breathing exercises to distract yourself from the feeling of urgency
• Apply pressure to your penis or perineum to divert your attention from urination
• Encourage yourself to “hold on” longer when you feel the urgency to urinate. This will train your bladder to keep more urine so that you will urinate less often. (Bladder Training)
• Avoid constipation by adapting your diet
• Avoid sudden exposure to cold weather and always try to keep your lower abdomen warm
• Keep a bladder diary

Q11. What do you mean by medical therapy or drug therapy?

A. This treatment is advised when the symptoms are bothersome and affect your quality of life.

Factors which influence this decision include:

• Your symptoms
• The size of your prostate
• Your medical history
• Drugs available in your country
• Your personal preferences and values

There are several groups of drugs to treat the symptoms caused by BPE:

• Alpha-blockers
• 5alpha-reductase inhibitors (5ARIs)
• Muscarinic receptor antagonists (MRAs)
• Phosphodiesterase 5 inhibitors (PDE5Is)
• Beta-3 agonist
• A combination of drugs
• Herbal drugs

Each group of drugs works in a different way and can have different results and side effects.

Q 12. How do I decide when to opt for surgery?

A. Factors which influence this decision include:

• Your symptoms and quality of life
• The size of your prostate
• Your medical history
• Your personal preferences and values. There is no single treatment which is ideal for all patients.
• You will be advised surgery in following situation:
• When your symptoms get worse, even if you already receive drug treatment
• When you have complications of BPE or if you are at risk of getting them:
  • Kidney failure
  • Dilatation of your kidneys
  • Inability to urinate (urinary retention)
  • Recurring urinary tract infection
  • Recurring blood in the urine
  • Bladder stone

• If you do not tolerate drug treatment very well
• If you prefer surgery over drug treatment

Q 13. What are the surgical treatment options?

A. During surgical treatment the doctor will remove the enlarged part of your prostate (also known as adenoma). There are different types of surgical procedures, but all of them aim to relieve your symptoms and improve the flow of urine.

The main procedures are:

• Transurethral resection of the prostate (TURP)
• Transurethral incision of the prostate (TUIP)
• Open prostatectomy
• Laser treatment eg. HOLEP
• Prostate stents
• Transurethral needle ablation (TUNA)
• Transurethral microwave therapy (TUMT)