Over 50? You are at risk of prostate enlargement

December 9, 2013

Don’t let the name fool you. There is hardly anything ‘benign’ about Benign Prostatic Hyperplasia,(BPH) swelling of the prostate gland if it goes unchecked and leads to renal impairment or even kidney failure. Although those with a family history of the condition are considered to be predisposed, any male over the age of 50 is at risk of developing BPH.

The prostate gland is an accessory sexual organ in males. It’s the size of a walnut, on the average consisting 30 to 40 cubic centimeters. It’s shaped like a doughnut, placed around the urethra (urinary tract) at the base of the bladder. Although testosterone is responsible for the growth of the prostate in children it is also responsible for the enlargement of the prostate gland in men over the age of 50. “This process could take place in anyone and clinical manifestations occur in the majority of people,” says Kalubowila Hospital Consultant in Urological Surgery, Prof Srinath Chandrasekera. He explained that clinical manifestation of BPH starts at the age of 50. Because it is a continuous process, symptoms become more pronounced as a person ages. “Although it is not unheard of, it is unusual for people below 45 to show symptoms of BPH.” Although he reiterated that certain other conditions can also demonstrate similar symptoms.

Symptoms

As Prof Chandrasekara explained symptoms are twofold; obstruction related symptoms, resulting from the enlargement of the prostate impinging or blocking the flow of urine through the urethra; and symptoms related to bladder over-activity, when the bladder may inadvertently pump out urine frequently.
LUTS (lower urinary tract symptoms) Obstruction related symptoms Bladder over-activity related symptoms Poor urinary stream Hesitancy when passing urine Frequent need to pass urine Intermittent flow Need to pass urine at night
Need to strain in order to pass urine Urgency Feeling that bladder is not quite emptied BPH related symptoms, known as lower urinary tract symptoms (LUTS), are not specific to BPH. “It is like headache or cough. We get headaches or coughs for a variety of sicknesses. Prostate cancer, strictures or narrowing of urethra and in some cases weakness of the bladder muscle can also induce symptoms similar to the first group. The second group of symptoms can occur due to urine infection, bladder stones or cancer, diabetes and even neurological problems,” explained Prof Chandrasekara.

Complications

Prolonged obstruction of the urethra due to swollen prostate can cause various complications such as recurrent urinary stasis (stoppage of urine flow), resulting in bladder stone formation and infection, explained Prof Chandrasekara. Stasis of urine can result in high bladder pressure which could in turn be transferred to the kidneys. In which case the kidneys enlarge and could lead to renal impairment. This is referred to as Hydronephrosis literally ‘water inside the kidney’. This, if gone unchecked can even lead to kidney failure.

In some cases prostate enlargement can cause bleeding in the prostate, which manifests as blood in urine. Extreme obstruction of the urethra due to prostate enlargement can lead to urine retention (a lack of ability to urinate). “At this stage patients may experience painful or painless urine retention or inability to pass urine,” said Prof Chandrasekara.

Diagnosis

Prof Chandrasekara emphasized the importance of seeking medical advice if one or more of these symptoms persist for a few days. “A family physician can easily differentiate between these conditions. Because conditions such as prostate cancer and BPH are quite common, it is imperative that the condition is conclusively diagnosed,” reiterated Prof Chandrasekara.
Initial diagnosis involves evaluation of the history of the condition, which can be deduced by questioning the patient. “The major criterion is the degree of bother to the patient, whether they have had to pass urine frequently, whether they experience difficulty in passing urine or whether they dribble,” explained Prof Chandrasekara.

The condition of the prostate gland can then be ascertained by a basic urine analysis and a physical examination. During this procedure known as Digital Rectal Examination (DRE), the physician explores the rectum using the index finger. “DRE is considered mandatory for a patient above the age of 50, who display these symptoms…” Prof Chandrasekara point out. “Because prostate cancer can present itself in an identical manner. And a DRE is the first step towards diagnosing whether it is BPH or prostate cancer.”

However it could be difficult to differentiate BPH from early malignancy or prostate cancer of a very early stage. “Because early prostate cancer is not palpable and therefore can go unnoticed during the DRE,” explained Prof Chandrasekara. In such situations, in order to further refine the diagnosis and completely exclude prostate cancer, a tumor marker, a PSA (Prostate Specific Antigen) blood test is conducted.

He explained that this is done in consultation with the patient, because it is imperative that the patient understands the implications of the test. “The objective of a PSA blood test is to diagnose prostate cancer, but it is not conclusive because several other conditions can result in increased PSA levels as well. Besides, even if prostate cancer is conclusively diagnosed it has a variable course of progression.” Patients should be made aware that prostate cancer is often not terminal; in fact patients may have ten to 15 years before the cancer reaches advanced stage.

Once BPH is positively diagnosed, further tests are required to determine the extent of enlargement, such as urine flowmetry and ultrasound scan, which measures the volume of the prostate and could help identify BPH related complications mentioned above.

Treatment

According to Prof Chandrasekara 50 percent of people with clinical manifestations of BPH will require surgical intervention. Patients who experience extreme obstruction of the urethra would have to be put on catheter. “But in the case of patients who are diagnosed with early stage BPH, the condition can be managed by following simple lifestyle measures, such as taking less fluid at night so the patient may not feel the urge to pass urine, passing urine at regular intervals so the bladder does not become too full, emptying the bladder at frequent intervals during long journeys and avoiding constipation.”
Prof Chandrasekara explained that such lifestyle measures can alleviate the symptoms. He further explained that some people will not respond to this and will require medical intervention. “Medical therapy is the first line of treatment for patients with BPH, who do not exhibit complications.”

Medical intervention

Medical therapy is twofold; it involves symptomatic treatment and prescribing medication that delay the progression of the disease. As the prostate enlarges, all elements in the prostate grow, explained Prof Chandrasekara. Tension in the smooth muscles in the prostate is responsible for the obstruction of the urethra. This type of obstruction is referred to as dynamic obstruction as it is variable and can be relieved by short acting medication that relaxes the smooth muscles. Although these medications take immediate effect by relaxing prostate muscle and thereby relieving obstruction of the urethra, it only provides symptomatic relief. “They do not alter the progression of the disease,” said Prof Chandrasekara.
The swelling of glandular elements result in the increase of bulk of the prostate. “This is treated with 5 alpha-reductase Inhibitors such as Finasteride and Dutasteride. These drugs block the conversion of testosterone into its active form DHT (Dihydrotestosterone), responsible for the growth of the prostate.” Because the conversion is impeded by these drugs, over a period of months, the prostate ceases to grow and in fact regresses in the absence of DHT. These drugs can alter disease progression, but take weeks or months to produce results. “In a minority of patients these drugs can cause breast enlargement and mild erectile dysfunction,” said Prof Chandrasekara.
Those who do not respond to these drugs or patients who experience BPH related complications listed above will require surgical intervention.

Surgery

“BPH related prostate surgery can be carried out on any patient, irrespective of age. Whether a certain patient is fit for surgery depends on the physical performance of the patient,” explained Prof Chandrasekara. “A person need not be athletic; but should be fit to go about his day to day activities.”

The whole prostate need not be removed anymore in order to treat BPH. The procedure referred to as Transurethral resection of the prostate (TURP) involves reboring the prostate to make space for the urethra. This is a camera guided procedure conducted under local anesthesia, via the urethra and involves a limited removal of prostate tissue around the urethra. “It does not require any incisions or suturing and roughly only 30 percent of the prostate is removed,” explained Prof Chandrasekara. The object of the procedure is to alleviate the symptoms and related complications while also minimizing potential side effects of surgery. “The more you cut the greater the risk of bleeding or damage to nerves,” reiterated Prof Chandrasekara.

Other options such as vaporizing the prostate or using laser for the removal of prostate tissue are available. “Irrespective of surgery method a patient can resume normal activity after only 24 to 48 hours.” Post surgery bleeding is rare and pain is negligible.

Prof Chandrasekara reiterated that surgery should cause minimum side effects or morbidity. According to statistics over two decades, more than 70 percent of patients who underwent prostate surgery for BPH experienced retrograde ejaculation (semen, normally ejaculated via the urethra, is redirected to the bladder); some patients experienced impotence (erectile dysfunction) and some others urinary incontinence or inability to control passing of urine. Therefore Prof Chandrasekara emphasized the importance of counseling the patient prior to the procedure, especially in the case of sexually active patients.

However prostate related surgery has become perfectly safe in the recent past. “The rates of complications such retrograde ejaculation, impotence and urinary incontinence have dropped considerably to perhaps negligible levels,” emphasized Prof Chandrasekara. “In fact complications like inability to control urine are extremely rare and retrograde ejaculation has been brought down from 70 to 20 percent using special techniques.”

Source: The Nation
Published: 22 Sept 2013

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