Prostate gland

prostate gland comparisonThe prostate gland is the male organ that produces semen, the milky-colored fluid that nourishes and transports sperm during ejaculation. It sits beneath your bladder and surrounds your urethra — the tube that drains urine from your bladder. When it becomes enlarged, the prostate can put pressure on your urethra and cause difficulty urinating.

Most men have a period of prostate growth in their mid- to late 40s. At this time, cells in the central portion reproduce more rapidly, resulting in prostate gland enlargement. As tissues in the area enlarge, they often compress the urethra and partially block urine flow. Benign prostatic hyperplasia (BPH) is the medical term for prostate gland enlargement.

Treatment of prostate gland enlargement depends on your signs and symptoms and may include medications, surgery or nonsurgical therapies. Prostate gland enlargement is not related to the development of prostate cancer.

Prostate gland enlargement varies in severity among men and doesn’t always pose a problem. Only about half the men with prostate gland enlargement experience signs and symptoms that become noticeable or bothersome enough for them to seek medical treatment. These signs and symptoms may include:

  • Weak urine stream
  • Difficulty starting urination
  • Stopping and starting while urinating
  • Dribbling at the end of urination
  • Straining while urinating
  • Frequent need to urinate
  • Increased frequency of urination at night (nocturia)
  • Urgent need to urinate
  • Not being able to completely empty the bladder
  • Blood in the urine (hematuria)
  • Urinary tract infection

At birth, your prostate gland is about the size of a pea. It grows slightly during childhood and then at puberty undergoes a rapid growth spurt. By age 25, your prostate is fully developed and is about the size of a walnut.

Doctors aren’t sure exactly what causes prostate enlargement. It’s thought that with age, changes in the ratio of male hormone (testosterone) and female hormone (estrogen) levels in men stimulate the prostate to grow. Another theory is that with aging, the prostate gland becomes more sensitive or responsive to normal levels of male hormone and grows more rapidly.
The main risk factors for prostate gland enlargement include:

  • Aging. Prostate gland enlargement rarely causes signs and symptoms in men younger than 40, but about half the men in their 60s have some signs and symptoms.
  • Heredity. A family history of prostate enlargement can increase the odds of developing problems from prostate enlargement.
  • National origin. Prostate enlargement is more common in white and black men than in Asian men.

If you’re having urinary problems, seek medical advice. Your doctor can help determine whether you have prostate gland enlargement and whether your symptoms warrant further evaluation and treatment. If you’re unable to pass urine at all, seek immediate medical attention.
If you don’t find urinary symptoms too bothersome and they don’t pose a health threat, you may not need treatment. But you should still have your symptoms evaluated by a doctor to make sure they aren’t caused by another condition, such as a bladder stone, a bladder infection, side effects of medication, heart failure, diabetes, a neurological problem, inflammation of the prostate (prostatitis) or prostate cancer.

An evaluation for enlarged prostate will likely include:

Detailed questions about your symptoms. Your doctor will also want to know about other health problems, medications you’re taking and whether there’s a history of prostate problems in your family. Over-the-counter (OTC) drugs, such as aspirin, decongestants and antacids, are considered medications, so tell your doctor about those too. Your doctor may have you complete a symptom questionnaire.

Digital rectal exam. Wearing a lubricated examination glove, your doctor gently inserts a finger into your rectum. Because the prostate is located next to the rectum, your doctor can determine whether your prostate is enlarged and check for signs of prostate cancer.

Urine test. Analyzing a sample of your urine in the laboratory can help rule out an infection or other conditions that cause BPH-like symptoms, such as temporary inflammation of the prostate (prostatitis), bladder infection and kidney disease.

Other tests your doctor may use to help confirm a BPH diagnosis include:

Transrectal ultrasound (TRUS). This test estimates the size of your prostate gland and can be helpful in diagnosing or ruling out prostate cancer. After a lubricating gel is applied to your rectum, the ultrasound probe — about the size and shape of a large cigar — is inserted. Sound waves bouncing off your prostate create an image of your prostate gland. Ultrasound takes about five minutes and isn’t painful, though you may feel some uncomfortable pressure.
Urodynamic pressure-flow studies. This test measures bladder pressure and function while you urinate. After you receive a local anesthetic, a small catheter is threaded through your urethra into your bladder. Water is slowly injected into your bladder to measure internal bladder pressure and to determine how effectively your bladder contracts. Bladder pressure and urinary flow may be measured while you urinate. The test takes 30 to 60 minutes. Generally this test is reserved for men with complicated or unusual urinary symptoms.
Cystoscopy. This procedure allows your doctor to see inside your urethra and bladder. After you receive a local anesthetic, a thin tube containing a lighted lens (cystoscope) is gently inserted into your urethra. Your doctor can tell if you have urethral compression caused by an enlarged prostate, blockage of the urethra or bladder neck, anatomical abnormalities, or bladder stones. The instrument is inside you for five minutes or less. The procedure can be moderately painful.
Intravenous pyelogram or CT urogram. These studies use X-ray images of your urinary tract to help find obstructions and other abnormalities. These tests are most often used for those who have bladder stones, blood in the urine (hematuria) or frequent urinary tract infections. Dye containing iodine is injected into a vein, and an X-ray or CT scan is taken of your kidneys, bladder and the tubes that connect your kidneys to your bladder (ureters). The dye helps outline the drainage systems of the kidneys. If you’re allergic to iodine, you may need special preparation for these tests or an alternative test that doesn’t use dye.

Additional tests sometimes used to evaluate BPH include:

Prostate-specific antigen (PSA) blood test. It’s normal for your prostate gland to produce PSA, which helps liquefy semen. A small amount of PSA normally circulates in your blood. Higher than normal PSA values are often associated with BPH — but some men have normal PSA values despite having an enlarged prostate. Higher than normal levels in your blood also can be signs of prostate cancer or an inflamed prostate (prostatitis). Most doctors use this test in men with BPH to be sure that a hidden prostate cancer isn’t missed.
Urinary flow test. This test measures the strength and amount of your urine flow. You urinate into a receptacle attached to a special machine. The test takes no longer than a normal urination. Charting the results of this test over time helps determine if your condition is getting better or worse. It’s normal for peak urine flow to decrease with age, but it can also be a sign of BPH or a weakened bladder muscle.
Postvoid residual volume test. This test measures whether you can empty your bladder completely. The test is done one of two ways: by inserting a thin, soft tube (catheter) into your urethra through your penis and up into your bladder after you urinate, or by using ultrasound imaging to measure the size of your bladder after you urinate. Ultrasound is more commonly used and less uncomfortable. Test results can vary, so you may need to have it done more than once to determine an accurate pattern. These tests take only a couple of minutes.

Prostate gland enlargement becomes a serious health threat only if it interferes with your ability to empty your bladder. A bladder that’s continuously full can interfere with your sleep, cause recurrent bladder infection or result in kidney damage. Men who have an enlarged prostate are at increased risk of:

Acute urinary retention (AUR). AUR is a sudden painful inability to urinate. To empty the bladder, a catheter must be inserted into the bladder through the penis. Some men with BPH require surgery to treat AUR.
Urinary tract infections (UTIs). Some men with BPH end up having surgery to remove part of the prostate to prevent frequent UTIs.
Bladder stones. These are mineral deposits that can cause infection, bladder irritation, blood in the urine and obstruction of urine flow.
Bladder damage. This occurs when, over a long period of time, the bladder hasn’t emptied completely. The muscular wall of the bladder stretches, weakens and no longer contracts properly. Often, men with BPH-caused bladder damage improve after surgery to remove part of the prostate.
Kidney damage. This is caused by frequent infections and acute urinary retention. BPH can also cause a condition called hydronephrosis, a swelling (dilation) of the urine-collecting structures in one or both kidneys due to pooled urine that can’t drain out of the kidney.

Most men with BPH don’t develop these complications. However, acute urinary retention and kidney damage in particular can be serious health threats when they do occur.

Treatments for prostate gland enlargement don’t reduce or increase the risk of prostate cancer. Even if you’re being treated for an enlarged prostate gland, you still need to continue regular prostate exams to screen for cancer. Surgical treatment for prostate gland enlargement can identify cancer in its early stages.

Treatment for an enlarged prostate is determined by your signs and symptoms and their severity. If you have significant problems, such as urinary bleeding, persistent urinary tract infections, bladder and kidney damage, your doctor will probably recommend treatment. If your prostate is enlarged but your symptoms aren’t too bothersome, treatment may not be necessary.

A wide variety of treatments are available to ease the signs and symptoms of an enlarged prostate. They include medications, other nonsurgical therapies and surgical procedures.

Medications are the most common method for controlling moderate symptoms of prostate enlargement and include:

Alpha blockers. These drugs were originally developed to treat high blood pressure. They relax muscles around your bladder neck and make it easier to urinate. Four alpha blockers have been approved by the Food and Drug Administration (FDA) for treatment of BPH: terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax) and alfuzosin (Uroxatral).

All four alpha blockers are equally effective. These medications work quickly. Within a day or two, you’ll probably have increased urinary flow and need to urinate less often. Doctors are uncertain about the long-term benefits and risks of alpha blockers. To reduce your risk of side effects, your doctor may start with a low dose of medication and gradually increase the dosage.
Alpha blockers taken with drugs for impotence, such as sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis), may interact and cause low blood pressure. Discuss with your doctor the possible side effects of these medications before taking them.
Alpha blockers can cause a pupil disorder that interferes with eye surgery. If you take tamsulosin or any other alpha blocker, be sure to tell your eye doctor if you’re planning to have eye surgery. Some of the alpha blockers can cause dizziness and lightheadedness if you stand up too fast. In many cases simply changing from one type to another is all that needs to be done.
Enzyme (5 alpha reductase) inhibitors. These drugs shrink your prostate gland. Two that have been approved by the FDA for BPH are finasteride (Proscar) and dutasteride (Avodart).

For some men with large prostates, these drugs may produce a noticeable improvement in symptoms. They’re generally not effective for men who have only a moderately enlarged or normal-sized prostate.
Enzyme inhibitors take longer to work than alpha blockers do. You may notice some urine flow improvement after a few months, but it can take up to a year for complete results.

Finasteride and dutasteride lower prostate-specific antigen (PSA) levels in your blood. Your doctor needs to know that you’re taking these medications to properly interpret your PSA test results.
Combination drug therapy. Taking an alpha blocker and an enzyme inhibitor at the same time can sometimes be more effective than taking just one type of BPH drug. Combination therapy can be more effective for relieving symptoms and preventing your symptoms from getting worse. It can also be more effective at lowering your long-term risk of developing acute urinary retention or needing surgery. The most tested combination is doxazosin and finasteride, though it’s believed any combination of alpha blocker and enzyme inhibitor is equally effective.

Also called minimally invasive treatments, several nonsurgical treatment methods are available to reduce the size of the prostate. These therapies focus on enlarging the urethra, making it easier for you to urinate. These include: Microwave therapy. Also called transurethral microwave therapy (TUMT), this procedure uses heat in the form of microwave energy to safely destroy the inner portion of the enlarged prostate gland.
Your doctor will insert a catheter through the tip of your penis. A tiny internal microwave antenna inside the catheter delivers a dose of microwave energy that heats and destroys enlarged cells. A local anesthetic helps control pain. You may feel some heat in the prostate and bladder area and have a strong desire to urinate. These responses usually disappear after the treatment is finished. You can go home when you’re urinating satisfactorily, usually the same day.
The size and shape of an enlarged prostate is critical to the success of microwave therapy. If your prostate is very large or growing in an unusual shape into your bladder, this treatment generally isn’t effective. TUMT isn’t recommended if you have a pacemaker or any metal implants.
It may take several weeks before you begin to see a noticeable improvement in your symptoms. Those who seem to respond best over time are men whose initial symptoms are mild. The long-term effectiveness of the procedure is uncertain.
It’s normal to have frequent, painful urination and small amounts of blood in your urine during recovery. You may ejaculate less semen after the procedure. However, unlike more invasive surgery, TUMT generally doesn’t produce impotence, incontinence or retrograde ejaculation – semen flowing backward into the bladder instead of out through the penis during ejaculation.
Transurethral needle ablation (TUNA). Also called radiofrequency therapy, this outpatient procedure uses radio waves to heat and destroy the part of your prostate that’s blocking urine flow.
During this procedure, a cystoscope is passed into your urethra and needles are placed into your prostate gland under visual guidance. Radio waves pass through the needles and heat the prostate and destroy the blockage.
TUNA typically is less effective than is traditional surgery in reducing symptoms and improving urine flow. Its long-term effectiveness also isn’t known. Another drawback of the procedure is that it doesn’t work as well in men who have very large prostates. Side effects may include urine retention, blood in your urine, painful urination and a small risk of retrograde ejaculation.
Interstitial laser therapy (ILT). Also called interstitial laser coagulation, this procedure destroys overgrown prostate tissue by directing laser energy at the inside of your enlarged prostate gland.
During ILT, a small tube containing a laser fiber is inserted through a cystoscope into the prostate tissue by puncturing through the part of the urethra that’s next to your prostate. Several punctures are usually needed to treat the entire prostate. Once the laser fiber is inside the prostate tissue, laser energy is activated to heat and destroy the tissue and shrink the gland.
You may be given spinal or general anesthesia to control pain. Or, you may be given a combination of local anesthetics in the urethra and intravenous sedation.
You may have small amounts of blood in your urine for a few days after treatment. Most men resume routine activities and sexual activity in a week or two.
Laser therapy is used less commonly than TUMT or TUNA. It’s similar to other heat therapies, except it uses a laser instead of microwave energy, radio waves or electrical current to produce heat. It generally doesn’t cause impotence or prolonged incontinence.
Prostatic stents. A prostatic stent is a tiny metal coil that is inserted into your urethra to widen it and keep it open. Tissue grows over the stent to hold it in place.
Although this procedure produces little or no bleeding and doesn’t require a catheter, in most cases doctors don’t consider stents a viable long-term treatment. Usually, they are used only for men who are unwilling or unable to take medications or who are reluctant or unable to have surgery.
While stents can provide immediate relief, some men find that stents don’t improve their symptoms. A stent may shift positions, cause painful urination or frequent urinary tract infections. Stents often become obstructed by tissue growth and can be extremely difficult to remove. These side effects, along with the cost, have made stents a less popular treatment option. They’re not the best choice for most men.

Surgery
At one time surgery was the most common treatment for BPH. But because of increased use of medications and the development of other less invasive therapies, surgery is on the decline. Today it’s used mainly for more-severe signs and symptoms or if you have complicating factors, such as:

  • Frequent urinary tract infections
  • Recurring episodes of urine retention
  • Bladder stones
  • Blood in your urine
  • Kidney damage from urine retention

Surgery is the most effective of all therapies for relieving symptoms of an enlarged prostate. It’s also the most likely to produce side effects — but fortunately, most men experience few problems.

Surgery is probably not the best choice if you have a serious medical problem that would make undergoing anesthesia risky.

Some surgical procedures for the prostate require a hospital stay while others can be done in an outpatient setting. Depending on the procedure chosen and other medical problems you may have, you may need to avoid strenuous activities for up to a month. You’ll probably need to take one to four weeks off work.

The types of surgery for an enlarged prostate include:

Transurethral resection of the prostate (TURP). Before the procedure, you’re given a general anesthesia or anesthetized from the waist down with a spinal block. A surgeon threads a narrow instrument (resectoscope) into your urethra and uses small cutting tools to scrape away excess prostate tissue.

You can expect to stay in the hospital for one to three days after surgery. During your recovery, you may have a urinary catheter in place for one or more days but most patients can have it removed by the next day. At first you may feel some pain or a sense of urgency when urine passes over the surgical area. This discomfort should gradually improve. You can expect some blood or small blood clots to appear in your urine after TURP.

TURP is the most effective surgical procedure and relieves symptoms quickly. Most men experience a stronger urine flow within a few days.

In few cases, TURP can cause impotence and loss of bladder control. Generally, these conditions are only temporary. Pelvic floor muscle exercises (Kegels) often help restore bladder control. Normal sexual function often returns within a few weeks to months.

Another more common side effect of surgery is retrograde ejaculation, but you shouldn’t have any trouble with achieving climax and the sensation of orgasm. TURP may also produce scarring and narrowing in the urethra or bladder neck. This often can be remedied by stretching of the scar tissue, done on an outpatient basis. Some men who have TURP may need some sort of prostate surgery again if the prostate grows back or the scar tissue from a previous procedure needs to be removed.

Transurethral incision of the prostate (TUIP). This surgery is an option if you have only a moderately enlarged or small prostate gland. It’s also an option for men who aren’t good candidates for more invasive surgery for health reasons or because they don’t want to risk sterility.

Like TURP, TUIP involves special instruments that are inserted through the urethra. But instead of removing prostate tissue, the surgeon makes one or two small cuts in the prostate gland. The cuts help enlarge the opening of the urethra, making it easier to urinate.

The procedure produces less risk of complications than do other kinds of surgery. It doesn’t require an overnight hospital stay, but it’s less effective and often needs to be repeated. Some men experience only a small improvement in urinary flow.

Laser surgery. Laser surgery uses a high-energy laser to destroy overgrown prostate tissue. The laser doesn’t penetrate tissue deeply, so surrounding tissue isn’t harmed.

The most common types of laser surgery are photosensitive vaporization of the prostate (PVP) and holmium laser enucleation of the prostate (HoLEP).

Laser surgery is done under general or spinal anesthesia. Depending on what type of surgery you have, you may need to stay overnight in the hospital and you may go home with a urinary catheter. Modern laser therapies use a high-energy, low-penetration laser that destroys prostate tissue on contact. After laser treatment, you can resume sexual activity and return to any type of work within a few weeks.

Laser surgery often provides immediate symptom relief, but you may have painful urination for days to weeks. Compared with TURP, laser surgery causes significantly less blood loss and recovery is quicker. Retrograde ejaculation also is a common side effect of laser surgeries.

Laser surgery to relieve BPH symptoms is relatively new, so its long-term effectiveness is unknown. Over time, your symptoms may worsen again and you may need re-treatment.

Open prostatectomy. This type of surgery is generally performed only if you have an excessively large prostate, bladder damage or other complicating factors, such as bladder stones or urethral strictures. It’s called open because the surgeon makes an incision in your lower abdomen to reach the prostate rather than going up through the urethra. During an open prostatectomy, only the inner portion of your prostate gland is removed, leaving the outer portion intact.

Open prostatectomy is the most effective therapy for men with extreme prostate enlargement. But it poses the greatest risk of side effects. Complications of the procedure are similar to those of TURP, and their effects may be more severe. The procedure usually requires a hospital stay of two to three days.

Self-care

Making some lifestyle changes can often help control the symptoms of an enlarged prostate and prevent your condition from worsening. Consider 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.
  • Limit caffeine or alcohol. These can increase urine production, irritate your bladder and worsen your symptoms.
  • Limit diuretics. If you take water pills (diuretics), talk to your doctor. Maybe a lower dose, a milder diuretic or a change in the time you take your medication will help. Don’t stop taking diuretics without first talking to your doctor.
  • Limit decongestants or antihistamines. These drugs tighten the band of muscles around your urethra that control urine flow, which makes it harder to urinate.
  • Go 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 damage.
  • Schedule bathroom visits. Try to urinate at regular times to “retrain” the bladder. 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 BPH.
  • Keep warm. Colder temperatures can cause urine retention and increase your urgency to urinate.

Herbal treatments for BPH are available at pharmacies, at grocery stores, over the Internet and in magazines. Common herbal treatments that show some evidence of helping reduce enlarged prostate symptoms include:

  • Saw palmetto, made from the ripened berries of the saw palmetto shrub
  • Beta-sitosterol, extracted from rye grass pollen and other plants
  • Pygeum, made from the bark of an African plum tree

Be aware, This means their safety and effectiveness has not been proved. Dosages, purities and ingredients available on the market vary, so it’s not known which dosage is most effective and safe. The American Urological Association doesn’t recommend using these remedies, and doctors have differing opinions about their use. Despite these drawbacks, growing evidence indicates that some alternative treatments may help relieve urinary symptoms caused by BPH. Herbal medications are commonly used in Europe to treat BPH.

Herbal products may increase your risk of bleeding and cause adverse drug interactions. Saw palmetto may suppress your baseline PSA level, which can interfere with the effectiveness of the PSA test for prostate cancer. If you take any herbal remedies, be sure to tell your doctor.