Do I have an Enlarged Prostate?
What is Benign Prostatic Hyperplasia?
BPH or benign prostatic hyperplasia is the medical diagnosis for an enlarged prostate.
This terms tells us a couple things. The word benign reflects how this is not a cancer problem. Hyperplasia means that the number of cells in the prostate is greater. This is why you will commonly hear us call BPH an enlarged prostate
What does my prostate do?
Getting your prostate checked and having symptoms related to the prostate is almost a rite of passage for men as they get older. The funny thing is, most people do not even know why they have a prostate.
The prostate is a gland that sits after the bladder and surrounds the first part of the urine channel, or urethra. It has ducts (or tubes) that insert into the urethra and add fluid to your ejaculate to help sperm out when they reach the female genital tract.
It also converts testosterone to a more potent form within the body.
As men get older, the prostate commonly gets bigger, which is why people sometimes need to come to the doctor for an enlarged prosate.
This change in size may or may not affect how you urinate. For some men, this change will produce annoying symptoms. Those symptoms could include slow urine stream, difficulty starting to urinate, straining to urinate, and not feeling that the bladder is emptying well. It could also produce symptoms of frequency urination and/or having urgency and then need to rush to the bathroom when you get the feeling that you have to go. Additionally, sometimes you will get up several times at night to go to the bathroom. It is these symptoms that will prompt men to see out the urologist for help.
Medical terms you may hear during your appointment
Retrograde ejaculation
This is a potential side effect from an alpha blocker. Normally the opening of the bladder closes during ejaculation. This is impaired with these medications so instead of everything coming out, the ejaculate just sits in the bladder. Is there medical harm with this? No. It all just comes out the next time you urinate.
These symptoms sometimes are a bother for people or their partner but this is person-specific
Orthostatic hypotension
This is a potential side effect and may prevent you from being able to take the medication. It means that you feel dizzy when you sit or stand. I’ll go over this in more detail below.
Do I need treatment if I have an enlarged prostate?
This all depends on how bothersome your symptoms are. Usually, treatment for BPH is not medically mandatory.
What I mean by this is that just having an enlarged prostate is not a medical concern. It’s not like diabetes in that if you don’t take your insulin that you will have disastrous medical results.
However, the urinary symptoms can really put a stress on your quality of life and that is why many men will find relief with treatment. Many of my patients will tell me how their bladder will dominate their thought process when they are at work or a restaurant or a movie and with treatment this can really help you to getting back an enjoying more those aspects of your life.
There is some theory that if an enlarged prostate is left untreated that it could affect your bladder function as you get older, but this is more controversial, which is why I will usually focus on people’s symptoms the most when deciding to start treatment.
There are however certain instances were treatment is really really warrant. These are if the enlarged prostate is resulting in recurrent UTIs, blood in the urine, or blocking the urine flow that it affects your overall kidney function
What kind of symptoms would lead me to think that I have an enlarged prostate?
So when you come to the urologist’s office, he/she will typically give you this questionnaire below. This questionnaire really gets to the heart of what symptoms suggest that you are dealing with an enlarged. prostate.
So these questions really focus on how an enlarged prostate can cause bothersome urination.
If you notice that your urine stream is slow or that you have to rush to the bathroom, or that you are straining to urinate, then you are likely suffering from an enlarged prostate.
As a urologist, we will count up these numbers and studies have shown that this can help us evaluate how bad your enlarged prostate is for you. Additionally, this can also help guide us to see how effective your treatment is.
What I mean by this is that when you come back to the office after starting medication or having surgery, we can see what your “symptom score” is and track to see if we have improved your symptoms of an enlarged prostate.
What are the medication options for an enlarged prostate?
There are three different types of medications that can help.
1. Alpha Blockers
These help to relax the opening of the bladder and the prostate urine channel to make it easier for the bladder to empty. It basically makes the urethra that goes through the prostate less tight.
2. 5-alpha reductase inhibitors.
These medications help to shrink the prostate over time. As it may seem, by shrinking the prostate it makes it so that the prostate is blocking your urine flow less.
3. Phosphodiesterase 5-inhibitors.
This is Cialis that is used for erections can be also help with urinary symptoms and there are a whole bunch small reasons as to how this can help with urination.
Aren't there natural ways to treat this problem?
In terms of lifestyle, there are certain things that I will classify as bladder irritants. These irritants have a really variable response for patients and you should be mindful and conscious on whether these make a difference for you.
Classically, I will define bladder irritants as spicy foods, chocolate, caffeine, and/or alcohol. Now when I say that these can cause symptoms, I don’t mean that they are damaging to the bladder. What I mean is that if you take these substances, it is somewhat expected that you will have to run to the bathroom or go to the bathroom more often. So it’s really a personal choice as to what you want to do.
For example, I like a cup of coffee in the morning. I know that after I drink my cup that even if there are three patients waiting to see me, I’ll stop to go to the bathroom in like 45 minutes to an hour. But I like my coffee, so I deal with it. If on the flip side, if you have iced tea and you notice that this is causing you to go to the bathroom five or six times, then maybe switch to decaf.
There is a supplement called Saw Palmetto which you can get at any drugstore or supplement store. The data for this is really mixed and not technically the best designed. So I tell patients that it’s up to them if they want to try it. I have some that say it makes a difference and others say it doesn’t. I typically don’t recommend this for patients to take but don’t necessarily discourage patients from taking it if they do.
What’s an alpha blocker and how does it work?
The most common one that people have heard about in my practice is called Flomax or tamsulosin. Other examples of this class of medications include Tamsulosin (Flomax), sildosin (Rapaflo), doxazosin, terazosin, alfuzosin
These work by relaxing the prostatic urethra and opening of the bladder.
It typically takes about 7-10 days to notice if there is symptom improvement. So the urologist will typically see you back in 2-4 weeks and see if it is making a difference.
It does work better on an empty stomach.
Tell your doc if you have a sulfa allergy as some of the brands, like tamsulosin, may cause you to have an allergic reaction.
What are the side effects of tamsulosin?
One side effect is lightheadedness or orthostatic hypotension. The blood vessels in your body will adjust to changes in your position and Flomax can impair that.
This is why you need to take your time from lying down to sitting up or sitting up to standing. Usually this side effect goes away after the first week but I have seen patients get really dizzy and almost even pass out.
You get excited, the penis gets hard, but nothing comes out. This happens about 20-30% of the time. For some guys (and their girls) this isn’t a big deal. For others it is. If this is a big deal then this might not be the drug for you.
The last main side effect is intraoperative floppy iris syndrome. This is a fancy term to say your iris (part of your eye) behaves funny when you have cataract surgery. So even if you only took this medicine once, if you are having cataract surgery you need to let the Ophthalmologist know. The tamsulosin doesn’t affect your eyesight, it just makes the cataract surgery more challenging for that surgeon.
What’s a 5-alpha reductase inhibitor (5-ARI) and how does it work?
This is the main other group of medications for an enlarged prostate and these include Finasteride (Proscar) and Dutasteride (Avodart)
These medicines work over time to “shrink” an enlarged prostate. This is why they typically take 3-6 months to see symptom improvement.
One notable fact is that after you have been on this for several months, your urologist will need to “adjust” your PSA result when interpreting them and multiply by 2. For example, if your PSA result comes back at 1.8, the urologist will adjust the result to 3.6 and give recommendations accordingly. Likewise, when you stop the medication after 3-6 months your PSA number will turn back to its true value so don’t get nervous if you see it rise.
What are the side effects with finasteride?
Increased risk of high-grade prostate cancer
Now this is really controversial. These drugs have been studied actually to see if they can prevent the development of prostate cancer. The best way I can explain it is like this. Let’s say you have low-risk and high-risk prostate cancer. If you take these medications, they can reduce the number of people who get diagnosed with low-risk cancer. Now that leaves more people who are diagnosed as having high risk disease.
Some people will disagree with that interpretation and feel that the medication does increase the risk of developing high-risk prostate cancer. Although the likelihood of this side effect is very low.
Increased hair
Here’s a fun fact. Propecia is finasteride but at a lower dose. So you may see increased hair distribution with this medication.
Decreased libido, volume of ejaculate and breast enlargement.
All of these risks are very low but in theory possible. I personally have rarely had patients complain of this but worth mentioning.
My enlarged prostate really really bothers me, can I take both types of medications together?
So I have a decent number of patients who are on both groups of medicines above. There are several strong studies that show an advantage in terms of how your symptoms are controlled, decreased need for a catheter, and decreased need for surgery if both are taken together. The downside is being on two pills rather than one but overall it is pretty well tolerated.
I’ve taken the medications but I’m still unhappy, now what?
Sounds like we are ready for surgical options. Let’s briefly talk about the indications for surgery for an enlarged prostate.
- Symptoms that are still there after taking medications
- Blood in the urine whose source is the prostate
- Bladder stones (this is different than kidney stones, it is just stones that are hanging out in the bladder)
- Frequent or recurrent urinary tract infections
- Kidney disease that is felt to be related to the prostate
Talk to me about the “roto rooter”
The most tried and true management of surgery for an enlarged prostate is a transurethral resection of the prostate, or TURP. This is where the urologist will offer the ‘roto rooter’ or clean out or core out of the prostate.
The best way to think of this is to pretend the prostate is an orange. We take out the fruit but leave the peel on the outside.The next question I get is why not just take the whole thing out? The reason for that is that the risks are higher for when the whole prostate is taken out as is done for prostate cancer. Our focus is on the part of the prostate that is blocking your urine flow, which is why we don’t need to remove the whole thing.
This is done in the operating room. You are put to sleep.
A scope (a tube with a camera on the end) is inserted into the penis and a device is used to scrape or resect the part of the prostate that is blocking your flow. This usually takes 1-2 hours and oftentimes you will stay overnight in the hospital.
When you wake up, you will have a catheter coming out the penis and usually continuous bladder irrigation will be done overnight. This is where fluids will run constantly through the catheter into the bladder to help lessen the risk of bleeding and blockage of the catheter. Most of the time you will be able to go home the next day. There are differences in when your urologist will feel comfortable taking the catheter out.
What are the risks to a TURP? The most common risks that are discussed include infection (low), leaking urine (less than 5%), retrograde ejaculation (%). The odds of needing a blood transfusion are very low.
My friend had a ‘laser TURP’. What is that?
This is usually referring to a Greenlight TURP. This is where instead of using an instrument to scrape the prostate, a laser is used to ablate or dissolve the obstructing form in the prostate. This again is done in an operating room but oftentimes it can be an outpatient procedure where you go home with a foley the same day.
Is one better than the other?
As best as we can tell overall, no. Most studies show that the outcomes and side effects from these two approaches are pretty similar so just go with whichever one your urologist is better at.
I've seen some advertisements about a Urolift, what is that?
A Urolift is another great option for an enlarged prostate. Let’s go over what is different with this. When someone gets a TURP, there is a portion of the prostate that is removed. With a Urolift, none of the tissue is removed, instead there are stitches or implants that are placed on either side of the prostate to “open” up the channel. Think of it like Flomax on steroids.
So when you look at the diagram above taken from the Urolift website, you can see the steps. A camera is inserted into the prostatic urethra and using a special instrument, there are “implants” or sutures placed on either side of the prostate to open up the channel. The number of implants varies between patients based on the size of the prostate.
If you want to know the ins and outs of a Urolift in detail, click over here.
What are the advantages of a Urolift?
- Can be done in the office
- Quicker recovery
- Your ejaculation is preserved: this is a major one as a TURP will almost uniformly cause you to have a dry ejaculation
- Likely won’t need a catheter after the procedure: only needs to be placed for 1-3 days in about 10% of the cases
Am I a candidate for a Urolift?
For a Urolift, in my hands you need the right prostate shape and size. If you don’t have the right type of prostate for this, then the outcomes may not be as desirable. This is why I will perform a couple tests to see if this is the right procedure for you.
One is a cystoscopy which is a camera test where we look inside the penis. I do this because if you have an enlarged median lobe (the middle portion of the prostate that can sometimes block the opening of the bladder), then I am not as comfortable in doing this procedure. The other test is a prostate ultrasound which takes me two minutes where I place an ultrasound probe into the rectum. This allows me to adequately measure the size of the prostate because if the prostate is too big, the implants won’t be able to work properly.
All in all, I am seeing myself and many urologists doing more and more of these cases. The recovery is faster but I do tell my patients that there is an increased chance they will need to either start medications at five years versus a repeat treatment in comparison to the TURP. But for many, due to the advantages above, they really like this option.
Click over here to learn more about this procedure.
Dr. Jafri Wrapup
I know that having an enlarged prostate can be really bothersome and really affect your quality of life. Thankfully, there are a bunch of treatment options that are available both with medications and surgery.
When you sit down with your urologist, really have them focus on what bothers you the most and also review what potential side effects exist with treatment for your enlarged prostate so that you can be really satisfied with the treatment that is being provided for you.