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Enlarged Prostate

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Posted by on Wednesday, March 9, 2011, 3:32
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The prostate gland is located just below the bladder and surrounds the urethra, the tube that carries urine from the bladder to the outside. The main function of the prostate is to secrete fluids that nurture the sperm that come out with ejaculation.

Enlarged Prostate
Enlarged Prostate

An enlarged prostate means the gland has grown bigger. Prostate enlargement happens to almost all men as they get older. As the gland grows, it can press on the urethra and cause urination and bladder problems.

Symptoms of enlarged prostate include frequent urination (especially if the man wakes up continually during the night to go to the bathroom), burning with urination and a discharge from the penis. Additionally, one can have a sensation of fullness behind the scrotum and in front of the rectum. These symptoms occur because infection makes the prostate gland swell.

When a man has an enlarged prostate, he will have a thin stream of urine which stops and starts rather than a full stream of urine. He may have difficulty starting his urinary stream and may often have dribbling after he finishes urinating. As the symptoms progress, the bladder may not empty entirely and urine is retained, increasing the risk of infection.

The diagnosis is made by a rectal examination, urinalysis, a check of the discharged fluid for signs of infection or inflammation, a prostate specific antigen (PSA) blood test, and frequently with ultrasound.

Studies now show that PSA is a predictor of prostate size as well as prostate cancer. The larger the prostate, the higher the PSA. And the higher the PSA, the greater the urinary problems and the likelihood of needing surgery.  Typically, enlargement becomes an issue when the number goes above about 1.3 to 1.5, but we do also have to rule out cancer.

Ultrasound has proven a particularly useful tool in diagnosing enlargement. It allows us to produce an image of the bladder, which tells us how well a man is emptying his bladder. The device is handheld and totally painless.

In some cases we also have the man urinate into an apparatus that measures flow rate. Other men may benefit from developing a voiding diary, in which they record the amount of urine voided and the time. It may also be helpful to record fluid intake, since many men have problems when they drink too much, such as four beers right before bed.

Treatment may involve antibiotics, medications to shrink or relax the prostate, soaking in a warm tub of water and frequent ejaculation. (See not all medicine is bad, guys.) The goal is to avoid reaching the point of urinary retention, where the man can’t urinate at all. This can lead to catheterization or even surgery.

For most patients suffering from an enlarged prostate who do not have kidney damage or serious infection, the ultimate decision must be left to the patient. While there are absolute indications of intervention, most situations depend on how bothersome the symptoms are to the individual. All options need to be discussed and considered along with their advantages and disadvantages.

Sometimes men may take antibiotics for a long period of time without any true benefit. In fact, many of these conditions are not infections but simply muscle spasms involving the prostate and surrounding tissue. This is a condition called prostatosis or prostadynia. Treatment for this includes muscle relaxants and warm baths. Hytrin or Cardura, typically used for high blood pressure are also muscle relaxants and have been shown to be successful. These days, however, Flowmax or Uroxitrol are more often prescribed.

Over the past five years, a large amount of research has been done on the prostate gland and BPH. Doctors now know more and can provide more useful treatments. Always look into the latest treatment alternatives—there are constantly new treatments coming out.

A doctor may recommend treatment when:

• the man is unable to urinate
• there are recurrent urinary tract infections
• there is recurrent blood in the urine
• there are hemorrhoids and hernias
• there may be damage done to the kidneys or bladder
• there are bothersome symptoms like frequently interrupting sleep to go to the bathroom
• there is an annoying sensation of always having to urinate
• there is dripping of urine after stopping

Most experts agree that more serious symptoms such as the inability to urinate, kidney or bladder damage may require surgical treatment.

However, for other less serious symptoms, patients may need to consider whether the symptoms are bad enough to warrant some type of treatment. There is no one absolute treatment for bothersome symptoms. Each of the treatment alternatives listed below has its advantages and disadvantages.

Home remedies for an enlarged prostate

1. For night-time frequency, drink as little fluid as possible after 6:00 or 7:00 p.m. Cut down on caffeine-containing liquids (tea, coffee, colas). At the very least, don’t drink them or alcoholic beverages after dinner.
2. Get up and urinate as soon as you feel the first night-time urge, then stand there for a minute and urinate again. If you get a fair amount out, repeat this one more time.
3. Relax, or learn to relax if you don’t know how.
4. Reduce the fat content of your diet.
5. Have intercourse frequently. Ejaculation will remove prostatic fluid and shrink the prostate. (See, it’s true, every rain cloud has a silver lining.)
6. Get some physical exercise.
7. Avoid antihistamines and other over-the-counter decongestants and cold remedies.
8. Avoid cold weather if possible.
9. Soak in a warm bath or hot tub for 20 minutes two or three times per day. The heat of the water will penetrate the prostate to reduce swelling and promote healing.
10. Avoid prolonged sitting. A man sits on his prostate. If the onset of symptoms coincides with physical activity (biking, exercise), increased sitting (includes car and plane), or a new chair, your routine should be changed.
11. There is some debate regarding whether zinc is of benefit to the prostate. Zinc in quantities of 30-60 mg daily can be tried if you are interested. These preparations can be obtained at various health food stores.
12. A medicine from the berry of a saw palmetto tree has been used in Europe as an herbal treatment for enlarged prostates. There are some scientific studies that document an improvement, and many men state that they have had marked reduction in their urinary symptoms. Although saw palmetto hasn’t been shown to affect PSA levels, it is important if you elect to take this medicine that you make your physician aware at the time of any PSA blood test being performed.

Watchful Waiting
For the individual with mild symptoms, no treatment or minimal treatment is indicated. In fact, one study out of Milwaukee found a 30% improvement in mild symptoms over a six-month period with no treatment.

For those individuals electing no treatment, close follow-up with urinary flow rates are indicated. As the prostate enlarges the symptoms potentially will worsen. Treatment can then be selected. This, however, is a decision primarily left up to the individual, and, again, it depends on the bothersome symptoms, their impact on daily living and quality of life.

Let me stress again, though, that you absolutely do not want to let this go to the point where you develop acute urinary retention. Not only can that lead to catheterization or even to emergency surgery, but your bladder will have lost much of its elasticity, reducing its function. If the condition isn’t sever, a man may have a catheter for 3 to 5 days but as long as two weeks. Severe cases may require that a man catheterize himself four times  per day to drain his bladder, but that at least is preferable to leaving the catheter in.

2: Drugs
There are several prescription medications to treat the enlarged prostate. Because the prostate is made up of both glandular and muscular tissue, there are two basic categories of drugs—those that shrink glandular tissue and those that relax muscles.

Proscar, a 5-alpha reductase inhibitor, has been shrinking prostate glandular tissue for going on a decade now. (It will soon go generic.) This drug works intracellularly by blocking an enzyme in the prostate that converts testosterone to the active ingredient dihydrotestosterone, but it does not effect testosterone itself. It has been shown to shrink the prostate over a period of six months to a year, reducing the risk of surgery by half in men who take it.

Avodart, another 5-alpha reductase inhibitor has been on the market for four or five years. It blocks not only the enzyme in the prostate but also the one that’s found in the liver and skin, so it also eliminates blood-borne dihydrotestosterone. It has a couple of advantages over its competitor. First, it works more quickly—in one to three months. And second, it has a half life in the body of about five weeks. Thus, once a man has taken it for long enough to reduce the size of his prostate, we can cut back the amount of Avodart he needs to take. He may only need to take it two or three times per week, which saves money.

These medications must be taken indefinitely or the prostate will start to grow again. Complications are minimal with the rare reported case of decrease in desire or loss of sexual ability.

An interesting side effect of the 5-alpha reductase inhibitors is reversal of baldness, a nice benefit for bald guys. On the other hand, few of the men I treat mention regrowth of hair.

Both Proscar and Avodart reduce PSA (prostate-specific antigen, measured for the blood test to detect early prostate cancer) by about half. After a period of a year, one can continue to monitor and screen for prostate cancer with this test, but it must be remembered that the values will be reduced. At the same time, Proscar has been shown to reduce the risk of prostate cancer by about 25%. Studies for similar effects by Avodart are ongoing, but I think it will also reduce risk.

Alternatively, alpha blockers, a class of medications sometimes used to treat high blood pressure, have been found to relax the muscle fibers within the prostate and outflow tube. This relaxation enlarges the channel and decreases the blockage. The medications do not shrink the prostate, and the prostate will continue to enlarge in size. They are, however, quite effective at reducing symptoms.

Flowmax is the most popular of the alpha blockers, followed by Uroxatrol. They have less tendency to reduce blood pressure than the old-line (and now generic) medications Hytrin and Cardura, but none of these medications is likely to kill two birds with one stone.

The symptoms will return immediately if the medication is stopped. Studies have shown a success rate of 40-50% in terms of a decrease in symptoms and improving urinary flow. Side effects include dizziness, fatigue, light headedness and fainting. For the first few days, the medication should be taken with caution at night, since when getting up to urinate there is the potential to pass out.

Nothing says that these two classes of medications can’t be used together, and that is, in fact, a common approach. A typical regimen after evaluation might be to start Flowmax and return in two weeks for further evaluation. If prostate cancer has been ruled out, PSA is over 2, and a digital rectal exam indicates enlargement, then I add Avodart. About a third of men can stop the Flowmax after three months, 60% can drop it at six months, and 90% are off within nine months. As noted previously, Avodart can also be reduced over time.

3: Medication for Overactive Bladder
Something we’ve come to realize in recent years is that men, like women, can develop a condition called overactive bladder. Because the bladder is working so hard to overcome prostate enlargement, it can develop a number of problems: First is increased residual urine, which is the result of the bladder losing its elasticity. It may also develop abnormalities in neuromuscular junctions. These problems produce the symptoms of frequency, urgency and nocturia (getting up during the night to urinate).

The primary medications for overactive bladder are Detrol and Sanctura, but there are also Enablex, Vesicare, and Ditropan XL. There was a time when these medications were prescribed with some reluctance, because it was thought that they could cause some men not be able to urinate at all. Recent studies have indicated that this isn’t really the case, and they can be quite helpful.

4: Prostate surgery
The first prostate surgery was performed in 1844 by L. A. Mercier from France who designed specific metal dilators to internally stretch the prostate and bladder opening.

In the early 1900s, surgical procedures were designed to cut out the prostate completely. In the 1930s and 40s, the current form of treatment, trans urethral resection (TURP) started to evolve.

This is a procedure performed under direct visual control of the surgeon—that is, the surgeon can see exactly what he is doing. Using a fiber optic telescope, the lining of the prostate is internally shaved down to its outer shell with a cautery (hot wire). This reopens the urethra channel that the patient urinates through. Only the enlarged part of the prostate is removed.

A general or spinal anesthesia is required, and the procedure takes approximately an hour to perform. The TURP procedure requires hospitalization of three to five days (catheterization is required for 2-3 days), after which the patient must recuperate at home for two weeks. Hospital charges of up to $12,000 are not abnormal. Significant restrictions on patient activities are imposed for 4-6 weeks following the surgery.

Complications of the TURP surgery include:

• inability to control urine and attain erections (both less than 5%)

• bleeding, infection, and retrograde ejaculation of semen (sperm at the time of ejaculation passing back into the bladder and voided out with urination)

• urinary control can take days to weeks to return to normal

A modification TURP is TUIP, or transurethral incision of the prostate. In this procedure, an internal cut is made the length of the prostate on either side of the mid-line. This can be done with either a cauterizing knife or a laser.

This is like placing a knife inside of a donut hole and cutting from the inside out and allowing the hole to open. The theory behind TUIP is similar in that only the prostate itself is allowed to spread out. This procedure can be done on an out-patient basis with a catheter left in place for one to two days.

The recovery time is usually only one to two weeks. It is not as successful as TURP and rarely can be associated with bleeding or retrograde ejaculation. On the plus side, the recovery time is not as long as TURP. This procedure is indicated in men who have smaller prostate glands.

An additional modification of TURP is the use of a laser to remove prostate tissue. Lasers have been used in medicine for a number of years. They work by either vaporizing or destroying tissue. A laser fiber can be passed through a telescope and focused on the prostate gland to vaporize or eliminate tissue. This can produce the same results as the standard transurethral resection of the prostate. However, this can be done without the added risks of bleeding or requirement for prolonged catheterization.

A recent improvement on the old-style lasers is the “green light” laser. It does require a general anesthetic, but 90% of men leave the hospital as outpatients and without a catheter. Sometimes the symptoms can get worse before they get better, but it definitely is effective long term.

4: Microwaves
The FDA approved the use of microwaves nearly a decade ago, and many urologists treat less-severe cases of enlargement with this technique in the office. This essentially shrinks the prostate and destroys some of the inner tissue. The procedure is done with a catheter which is passed through the penis and left in place for a couple of days. Treatment results have been variable to date and patients are known to urinate loose tissue for three to four months after the procedure. Still, for someone who doesn’t want a general anesthetic, it’s a good option.

5: Stents
Another available and FDA-approved treatment is the use of prostatic stents. These are titanium/gold-like springs that are placed under direct vision through the penis into the prostate to hold the prostate apart. They haven’t caught on widely and are used most commonly in men who are confined to nursing homes or can’t undergo general anesthetic.

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