IQWIG. Germany: Urinating frequently, getting up in the night to go to the toilet, and the feeling that your bladder
is never really empty are all typical signs of a benign enlarged
prostate. This condition affects 1 in 5 men between the ages of 50 and
60, and is even more common in older men.
Many men adapt and cope well with these symptoms. For some men,
though, it is a big problem: they might have to go to the toilet so
often that they no longer get enough sleep at night, and feel exhausted
during the day. That can cause problems in their personal lives and at
work.
Although a benign enlarged prostate can be very bothersome, it is
usually not dangerous. If treatment is needed, there is generally no
reason to rush into anything. So you can take your time to consider the
pros and cons of the various treatment options before deciding which
treatment to have.
Symptoms
If the prostate is very enlarged, it pushes against the bladder and urinary tract. This can lead to various problems:
- Needing to urinate more often and more urgently, especially at night.
- It taking a while for the urine to start flowing.
- Weaker urine flow, and needing longer to finish urinating.
- Dripping and leaking after urinating, and the bladder does not feel empty.
The medical term for these symptoms is "benign prostatic hyperplasia"
(BPH). This means prostate enlargement (hyperplasia). The word "benign"
means that, although it is a growth, it is not cancerous. This
condition is also sometimes called “benign prostatic syndrome” (BPS).
There is not always a direct relationship between the size of the
prostate and the symptoms. Some men with a very enlarged prostate have
few symptoms, while others have a lot of problems even though their
prostate is not very enlarged.
Causes
The prostate is located just beneath the bladder, between the rectum
and the base of the penis. It wraps around part of the urethra (the
tube that urine passes through). If the prostate grows, it may push
against the bladder and urethra. This means that men might feel the need to urinate although their bladder is not at all full. The muscles at the bottom of the bladder are also affected, and already start contracting even if there is only a small amount of urine in the bladder. The constant pressure can also weaken the bladder muscles. As a result, the bladder
can no longer empty itself properly, and some urine always stays
behind. The pressure on the urethra prevents urine from flowing out
normally too.
During puberty, the prostate grows to about the size and shape of a
walnut. That happens quite quickly. At the age of about 25 it starts
growing again, but very slowly. This slow prostate growth is a normal
part of growing older.
In some men the prostate grows a lot more than in others. It is not
exactly clear why that is. Researchers have looked into the influence of
factors such as smoking, vasectomy (surgical sterilization), being
overweight and drinking a lot of alcohol. These factors have not been
proven to affect prostate growth. It is probably just a normal part of
aging.
Prevalence
It is very rare for men under the age of 40 to have a benign enlarged
prostate. About 20 out of 100 men between the ages of 50 and 59 are
affected by this condition. Enlarged prostates become more common later
in life: it is thought that 70 out of 100 men over the age of 70 have
prostate problems.
Effects
Occasionally men with an enlarged prostate quite suddenly have
difficulties urinating, or cannot urinate at all. Known as acute urinary
retention (anuria), this condition is an emergency and needs immediate
medical attention. First a catheter is used to relieve the bladder.
A few days later, surgery is usually carried out to allow the urine to
flow normally again. But this complication is fairly rare. Over a
five-year period, only about 1 to 3 out of every 100 men with an
enlarged prostate will have acute urinary retention. The risk is higher
in men who have a very enlarged prostate.
Diagnosis
Although problems with urination are most commonly caused by an
enlarged prostate, they can be caused by other things too. To find out
what is causing the symptoms and to judge how enlarged the prostate is,
there are a number of tests that doctors can do.
First the doctor will ask questions about the symptoms, including how
often you need to urinate. Many people find it difficult to say exactly
how often they go to the toilet, so it might be helpful to keep a diary
for one or two days before going to the doctor. The doctor will
probably also ask what medicines you are taking. This is because some
medicines have side effects similar to the symptoms of an enlarged
prostate.
The doctor will also do a physical examination. The prostate gland is
usually palpated (felt) first. To do so, the doctor puts on a
disposable glove and gently inserts a finger into the rectum to feel the size and structure of the prostate gland (rectal examination).
A urine test can be done to help detect a prostate infection (prostatitis). Prostatitis can cause similar symptoms to a benign enlarged prostate. Urine can be tested for a variety of other illnesses too.
A blood test known as the PSA test is often done to see how much of a
certain protein (called PSA or prostate-specific antigen) is being made
in the prostate gland. The prostate gland produces more PSA if it is
enlarged. Measuring the PSA levels before and after a treatment is one
way to see if the treatment has reduced the size of the prostate. The
PSA test is also done to rule out prostate cancer. But the results are
not very reliable here.
A urine flow test (uroflowmetry) can be done to see how much urine
flows out per second. The test involves urinating into a special device
that measures how quickly the urine comes out. More than 15 milliliters
per second is normal. To do this test properly, it is best for the bladder
to be as full as possible. Ultrasound scans can be used to see how
large the prostate is. They can also be done to see how much urine is
left over in the bladder after urinating (residual urine).
Treatment
The treatment options mainly depend on how severe and bothersome the
symptoms are in everyday life, and how high the risk of complications
like urinary retention is. Most men with an enlarged prostate have mild
to moderate symptoms, and cope with them quite well. Sometimes the
symptoms improve or go away without treatment. But the symptoms usually
tend to get a little worse over the years, even if this happens very
slowly. It takes some time to see whether the symptoms will stabilize at
a manageable level or develop into a bigger problem.
The main treatment options for a benign enlarged prostate include:
-
Active monitoring of symptoms (often called “watchful waiting”):
After an initial examination, the doctor will explain what to look out
for and give advice on how to cope with the related problems. The doctor
will regularly examine the prostate and monitor the development of the
symptoms (usually once a year). Most men choose this approach if they do
not have signs of urinary retention, and if their symptoms do not
affect their everyday lives and wellbeing too much. Monitoring is all
that is needed for about 30 out of 100 men who seek medical help because
of an enlarged prostate.
-
Pelvic floor training: Pelvic floor training involves doing exercises to strengthen the pelvic floor muscles. The pelvic floor is a stable group of muscles that relax when you urinate.
-
Herbal medicine products: There are several
over-the-counter herbal products for the relief of symptoms associated
with a benign enlarged prostate. Most of these products have not been
well studied.
-
Medications: About 70 out of 100 men who seek medical
advice for an enlarged prostate decide to take medication. The most
commonly used drug is called tamsulosin. This drug relaxes the muscles
in the lower urinary tract to help relieve problems with urination.
-
Surgical procedures to reduce the size of the prostate:
There are a number of surgical techniques that are used to remove or
destroy prostate tissue. Surgery is only necessary if there are
complications, or if the symptoms are severe and nothing else has
provided enough relief.
Each of the treatment options has certain advantages and
disadvantages. They particularly differ a lot in the side effects that
they may have.
Prostate problems generally develop gradually over many years. This
slow development probably makes it easier to adjust to the associated
problems. But many men find them unpleasant, and feel embarrassed about
needing to go to the toilet more often and having problems that are
closely related to their sexual organs. An enlarged prostate need not
get in the way of a fulfilled sex life for men and their partners,
though. Over time, it might become easier to talk openly about and
accept the age-related changes.