What is the prostate?
The prostate is a gland about the size of a walnut that is only present in men. It is located just below the bladder and surrounds the urethra, the tube through which urine flows from the bladder and out through the penis. The prostate gland contributes to the seminal fluid produced during ejaculation.
What is an enlarged prostate?
As men age the prostate can increase in size. Enlargement of the prostate is referred to as benign prostatic hyperplasia (BPH). It increases more in some men than others. It is unclear why this occurs but it is likely that genetic, environmental and hormonal factors play a part. As the prostate enlarges it can narrow the urethra.
What are the symptoms of an enlarged prostate?
An enlarged prostate narrows the tube (urethra) through which urine must pass to leave the bladder. This narrowing creates two problems.
Firstly, it makes it difficult for the bladder to emptying. This results in delay in starting urination (hesitancy), a slow stream, an intermittent (stopping and starting) stream and a feeling of incomplete emptying.
Secondly, since the bladder can’t empty well, it doesn’t like to store too much. The bladder therefore can respond by emptying more often (frequency) and with less warning (urgency). You may also need to get up frequently at night (nocturia)
Urological surgeons often use a questionnaire to help score the severity of the symptoms. This questionnaire, which is answered by the patient, is called the International prostate symptoms score (IPSS).
International Prostate Symptom score (IPSS)
| Over the past month, how often have you… | Not at all | Less than 1 in 5 times | Less than ½ the time | About half the time | More than ½ the time | Almost always |
| 1….had a sensation of not emptying your bladder completely after you finished urinating? | 0 | 1 | 2 | 3 | 4 | 5 |
| 2…had to urinate again less than two hours after you finished urinating | 0 | 1 | 2 | 3 | 4 | 5 |
| 3…stopped and started again several times when you urinated? | 0 | 1 | 2 | 3 | 4 | 5 |
| 4…found it difficult to postpone urination? | 0 | 1 | 2 | 3 | 4 | 5 |
| 5…had a weak urinary stream | 0 | 1 | 2 | 3 | 4 | 5 |
| 6…had to push or strain to begin urination? | 0 | 1 | 2 | 3 | 4 | |
| 7. Over the past month, how many times did you most typically get up to urinate at night? | None | Once | Twice | 3 times | 4 times | ≥5 times |
| 0 | 1 | 2 | 3 | 4 | 5 |
To find your IPSS score, combine the sum of your answers: IPSS Score
A score of 0-7 indicates mild symptoms, 8-19 indicates moderate symptoms, 20-25 indicates severe symptoms
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QUALITY OF LIFE DUE TO URINARY SYMPTOMS If you were to spend the rest of your life with your urinary conditions the way it is now, how would you feel about that? |
||||||
| Delighted | Pleased | Mostly satisfied | Mixed – equally satisfied and dissatisfied | Mostly dissatisfied | Unhappy | Terrible |
| 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Not all men however have symptoms. Sometimes a man might be told he has an enlarged prostate after it has been identified on a scan or after investigations for an elevated PSA. Unfortunately, some men might only discover they have a prostate problem until after they develop a complication.
What problems can occur from having an enlarged prostate?
Apart from symptoms, an enlarged prostate can cause the following problems:
- Urinary tract infection: Most often occurs in men who are unable to empty the bladder.
- Blood in the urine (haematuria):
- Incomplete bladder emptying: This is usually identified on a renal tract ultrasound or other imaging. After passing urine, only a small amount of urine (20ml) should be left in the bladder. This can increase as the bladder struggles to empty out past an obstruction.
- Urinary retention: This is the inability to pass any or only a small amount, despite the bladder being full (>500ml). It is often associated with pain but not always.
- Renal/kidney failure:
- Bladder stones
- Erectile and sexual dysfunction: Problems emptying the bladder can impact negatively on the sexual function in some men. Treatment of the enlarged prostate can improve sexual function in some men.
What are the treatment options for an enlarged prostate?
Not all men need treatment. If they have minimal bother and no evidence of a complication, observation may be all that is required. For other men, treatment options include:
- Lifestyle changes: This includes decreasing alcohol and caffeine intake. Eating a healthier diet, managing fluid intake more effectively, and losing weight.
- Medication: There are 4 classes of medication used to treat an enlarged prostate.
- Alpha blockers (Tamsulosin): Relax the smooth muscle of the bladder neck and prostate, opening up the passage.
- 5-alpha reductase inhibitors (Avodart, duodart): Shrinks the prostate tissue. No advised in young men (<55yo).
- Anticholinergics (Ditropan, vesicare): Acts on the bladder, decreasing its response to the blockage, therefore decreasing the frequency (number of urinations) and urgency (sudden desire to urinate).
- PDE5 inhibitors (Cialis, Viagra): Broad mechanism of action. Improves both storage and voiding symptoms.
- Minimally invasive surgery: Urolift is a minimally invasive procedure which staples the prostate open.
- Endoscopic prostatectomy: Surgical ‘de-bulking’ of the prostatic tissue obstructing the urethra. This can be done with laser or electro-cautery.
KEY POINTS
- An enlarged prostate is a common condition in men.
- It can cause bothersome symptoms with urination.
- It can lead to significant complications.
- There are many treatment options.