As men get older, prostate gland enlargement becomes a common accompaniment. And it may cause bothersome urinary symptoms — often the condition is known as benign prostatic hyperplasia (BPH) or benign enlargement of prostate (BEP). Untreated it often causes damage to the bladder & kidneys. But one should not forget that enlargement sometimes may be because of cancer.

Modern day medicines offer you variety of effective treatments for your problem. Your urologist will hear your symptoms, examine & investigate you and after taking into consideration your other health parameters will advise you what treatments you need. Your choices may also depend on what treatments are available in the area you live. Treatment usually include:

  • MEDICATIONS.
  • LIFESTYLE CHANGES.
  • SURGERY
  • SYMPTOMS: Just an enlargement of gland doesn’t necessarily mean you will have worsening symptoms. Small prostate may cause very serious symptoms & on the other hand a large prostate may not give you much trouble at all. In some men symptoms may stabilize & may even improve over time.

CONSULT YOUR UROLOGIST WHEN YOU EXPERIENCE THE FOLLOWING SYMPTOMS:

  • Weak stream.
  • Hesitancy i.e. difficulty in starting urination.
  • Sense of not able to empty the bladder completely.
  • Taking longer time to empty your bladder.
  • Straining while passing urine.
  • Frequent urination especially at night.
  • Urgent need to urinate, leaking before you reach toilet.
  • Passing blood in urine.
  • You may experience fever & burning sensation during urination (Urinary Tract Infection).
  • Bladder stone formation causing interrupted stream or burning sensation.
  • Sometimes kidneys get swollen up due to backpressure leading to kidney failure and which can be the only symptom.
  • At times you may not be able to pass urine at all, what we call as urinary retention.

YOU MAY NOT NEED TREATMENT IF YOUR SYMPTOMS ARE NOT TROUBLESOME BUT STILL YOU HAVE TO SEEK UROLOGIST’S OPINION SO THAT YOUR SYMPTOMS ARE NOT CAUSED BY ANOTHER GRAVE CONDITION CALLED “PROSTATE CANCER”.

SOME FACTS ABOUT PROSTATE GLAND

Prostate gland is a walnut shaped gland that sits just below the bladder. Urethra i.e. the tube that transports urine from the bladder out of your penis, passes through the center of the prostate. When prostate enlarges, it constricts the tube from all around & causes obstruction to urine flow & subsequently all the symptoms mentioned above start appearing. It is not known why in old age prostate starts enlarging. As men grow older, changes in the balance of sex hormones may be the predisposing cause. However, there are certain risk factors:

(RISK FACTORS FOR PROSTATE ENLARGEMENT)

Age: Aging is a significant risk factor. It is rare before 40. About 50% of men in 60s & 80% in 90s have signs & symptoms of enlarged.

Family history: A blood relative having prostate problems means you are more likely to suffer from enlarged prostate.

Ethnic background: More common in white & black men.

(COMPLICATIONS OF ENLARGED PROSTATE)

Symptoms of prostate enlargement if untreated may lead to serious complications. However, most men with enlarged prostate don’t develop these complications. Any of the complications that are mentioned below often cause serious health hazards & most of them do need surgeries.

Acute urinary retention: Sudden painful inability to pass urine. Doctor/ Nurse may have to pass a catheter through the penis into your bladder to give you relief. Urinary retention may be seriously troublesome if happens in a flight or journey or when you are in a remote area where medical facilities are not available.
Frequent urinary tract infections: Due to retained urine, repeated infections are common which often necessitates surgery.

Bladder stones: Again happens due to retained urine, causes burning micturition, blood in urine or obstructed urine flow.

Bladder damage: Continued untreated obstruction & retained urine may cause the muscle layer of bladder to become very weak & thin. Bladder becomes flabby & doesn’t contract properly. If too late this never recovers even after

Kidney failure: Too much of retained urine in bladder due to obstruction often causes both kidneys to swollen up thus resulting in kidney failure which may be of grave concern.

SO, GOLDEN RULE IS TO TAKE TREATMENT EITHER MEDICAL OR SURGICAL BEFORE COMPLICATIONS SET IN

You will have to see a urologist for your symptoms. Tell him all about your problems and its duration, bring list of all medications. Inform him about any medical illness you had prior or any surgery that you have undergone in the past. You should be prepared to ask your doctor following questions so that you can have an overview about your condition.

(HOW TO CONSULT AN UROLOGIST?)

  • Are my symptoms due to prostate enlargement or something else?
  • What tests do I need?
  • What are my treatment options?
  • What are the alternatives to the primary approach that you are suggesting?
  • I have other health conditions like diabetes, hypertension, heart problem, and pace I take blood thinning drugs.
  • How can I best manage them together?
  • Are there any restrictions that I need to follow?
  • Is there any alternative to allopathy medicines?
  • If I need surgery, what surgical method is the best option & how much it will cost?

(HOW UROLOGIST WILL EVALUATE YOU OR RUN TESTS & DIAGNOSIS?)

After a detailed questioning about your symptoms, most important tests that doctor will carry out next is DIGITAL RECTAL EXAMINATION/ DRE. Here doctor checks your prostate by inserting a finger into your rectum. This way doctor assesses whether prostate is enlarged or how much it is enlarged & checks for signs of prostate cancer. After DRE, doctor will carry out a brief neurological examination.

This may help identify other causes of urinary problem, other than enlarged prostate. After this, urologist will carry out certain tests that are listed below to confirm the diagnosis & to rule out other problems.

ABDOMINAL/ TRANSRECTAL ULTRASOUND: This helps us to know about size of the prostate, how much urine is retained in the bladder after urination, if any stone has formed or whether the kidneys are bearing the brunt of prostate obstruction. Transrectal ultrasound is a procedure where a probe like a large cigar is inserted to your rectum to visualize the prostate from close proximity & thus gives more detailed picture of prostate than ultrasound done through This is especially helpful if prostate cancer is suspected.

UROFLOWMETRY: Urine flow test measures the strength & amount of your urine flow. You urinate into a receptacle attached into a special machine. The result of this test over time helps determine if your condition is getting better or

URINE ANALYSIS: Urine test rules out any associated infection.

PSA TEST: It is the best screening test that is available till date to rule out prostate cancer. High level of PSA indicates prostate cancer though elevated levels may also be seen following urinary infection, endoscopic surgeries, following intercourse, prostate biopsies & even in large BPH.

URODYNAMIC OR BLADDER PRESSURE STUDIES: Long standing obstruction may cause weakening of bladder muscle. If it is too weak, sometimes it doesn’t recover even after surgery & patient may need lifelong catheter. This test allows your urologist to determine how well your bladder muscle is working or how weak they are.

CYSTOSCOPY: This is an endoscopy procedure. A fine rigid or flexible instrument is passed through the urethra to visualize the prostate & bladder. Usually done under local or general anesthesia when diagnosis is in doubt.
CT scan, MRI etc. are rarely required. They are of main use if prostate cancer is suspected.

(TREATMENT DRUGS & SURGERIES)

A wide variety of treatments are available which I will be discussing below:

WAIT & WATCH: If symptoms are mild & stable over a period of time, then probably no treatment is Treat when symptoms become troublesome.

MEDICATIONS: Two type of medications are generally used.

ALPHA-BLOCKERS: Commonly known in market as URIMAX, FLOTRAL, ALFOO, SILDOO etc.

Response is very quick & many times very effective too. Prolonged use doesn’t cause any side effects. Patients may sometimes experience giddiness which may necessitate stopping the treatment. This drugs may also cause another harmless side effect known as retrograde ejaculation — semen going back into the bladder rather not coming out of penis during intercourse.

5 Alpha reductase inhibitors: Known as finasteride or They shrink the prostate. To notice the change, it may take many months & be only effective for large prostate.

Combination drug therapy: Combination of above drugs are better — symptoms relief will be quicker & gland may shrink over time thereby giving lasting relief. This combination drugs in market are available as Dutas-T, Urimax-D, Veltam plus, Flotral-D etc.

SURGERY: When medication doesn’t help or you have severe symptoms and/or when complications mentioned earlier develop, then you will surely need surgery.

Surgery if done properly — usually gives very lasting benefit.

Standard surgeries that are available today for prostate are mainly of 2 types.

TUR’P’.

LASER PROSTATECTOMY.

TUR’P’

Or Transurethral Resection of Prostate, where an endoscope is passed though the penis & prostate is resected bit by bit using electric current. Procedure is very effective for small & medium sized prostates.

But difficulty comes for large prostate, say more than 80-100 gms. Significant bleeding, infection, electrolyte imbalance are seen quite frequently resulting in more morbidity & mortality. Infection rate is also more with TUR’P’ & you may have to keep catheter for longer period following the surgery. Procedure is more dangerous if patient is taking blood thinning agents and not possible for patients on cardiac pacemaker. Glands more than 100 gms, say @ 150 gms of prostate may not be tackled at one go. Patient may have to undergo two stage surgeries.

LASER PROSTATECTOMY
(HoLEP)

HoLEP uses high energy laser to destroy & remove prostate tissue. By virtue of its all-round advantages it has put the TUR’P’ into the back burner.

The holmium laser is ideal for precisely & clearly removing prostatic tissue without bleeding or overheating. Consequently blood pressure during surgery remains stable and effect on heart and circulation is minimal. As blood vessels don’t open up bacteria from infected urine and prostate don’t enter the blood stream, so very small chance of septicemia in old age. These two virtues for an old patient is really a boon and I hope very soon laser surgery will replace all other forms of prostatic surgery.

OTHER ADVANTAGES OF LASER SURGERY OF PROSTATE

Many patients with diabetes, hypertension and heart disease take aspirin (Ecosprin). You need not stop that prior to surgery. But patient on clopidegrol and acitrom need to stop the drug beforehand.

Patient with pacemaker can’t undergo TUR’P’ as electric current that is passed through may cause dysfunction of the pacemaker. But laser application is absolutely safe in such situations.

Shorter hospital stay (< 36 hours), shorter catheterization time and shorter recovery time. Overheating of tissue is not there, so after surgery urethral and bladder neck narrowing (stricture) is rare. For very large prostate > 100.0 gms, TURP is often a difficult procedure with high complication rates. But in such situation, laser surgery (HoLEP) is very safe. Even for a prostate of > 150.0 gms, you don’t have to arrange for blood provided your hemoglobin before surgery is good.

CASE STUDY 1

Dr. Raj Singh 86 years old doctor at Jaipur, had acute retention of urine recently. He had prostate weighing 140.0 gms. He underwent laser surgery recently and was discharged within 48 hours from hospital. He is passing urine today as a normal person.

CASE STUDY 2

Mr. Achla Ram, 97 years old man, resident of Jodhpur, came to me. He had a prostate of 70.0 gms and was on catheter since last 2 years. He went everywhere but he was refused for surgery due to his age. We did a laser surgery and his happiness knew no bounds when he started passing urine after long gap of 2 years.

There are many more instances. During the last 8 years, we have performed more than 2000 laser surgeries for enlarged prostate and I strongly believe sooner laser surgery (HoLEP) will be the gold standard surgical treatment for enlarged prostate.

(LIFESTYLE AND HOME REMEDIES)

Making some lifestyle changes can often help control the symptoms of an enlarged prostate and prevent your condition from worsening. Try these measures:

Limit beverages in the evening: Don’t drink anything for an hour or two before bedtime to help you avoid wake-up trips to the bathroom at night.

Don’t drink too much caffeine or alcohol: These can increase urine production, irritate your bladder or worsen your symptoms.

If you take water pills (Diuretics), talk to your doctor: May be a lower dose, taking them only in the morning, a milder diuretic, or change in the time you take your medication will help ease urinary symptoms. Don’t stop taking diuretics without first talking to your doctor.

Avoid decongestants or antihistamines: These drugs tighten the band of muscles around your urethra that control urine flow, which makes it harder to

Urinate when you feel the urge: Try to urinate when you first feel the urge. Waiting too long to urinate may overstretch the bladder muscle and cause

Schedule bathroom visits: Try to urinate at regular times to “retrain” the This can be done every four to six hours during the day and can be especially useful if you have severe frequency and urgency.

Stay active: Inactivity causes you to retain urine. Even a small amount of exercise can help reduce urinary problems caused by an enlarged prostate.

Urinate — and then urinate again a few moments later: This is known as double voiding.

Keep warm: Colder temperatures can cause urine retention and increase your urgency to urinate.

(ALTERNATIVE MEDICINE)

There is some evidence that herbal treatment may help urinary symptoms caused by an enlarged prostate, and they are commonly used in Europe. However, certain herbal products may increase your risk of bleeding or interfere with other medication you are taking. Doctors have differing opinions about their use. Herbal treatment that show some evidence of helping reduced enlarged prostate symptoms include:

  • Saw palmetto extract, made from the ripe berries of the saw palmetto shrub.
  • Beta- sitosterol extracts, made from several plants, such as certain grasses and
  • Pygeum, an oil made from the bark of an African prune tree.
  • Rye grass extract, made from rye-grass pollen.
  • Stinging nettle extract, made from the roof of the stinging nettle plant.
  • If you take any herbal remedies, be sure to tell your doctor. These may help treat some of your symptoms but are generally less effective than are prescription medications.