Jeanie Lerche Davis
Charles E. Jennings, MD
All his life, he slept like a stone. But now, there's an annoying trip to the bathroom every night, sometimes once or twice a night.
For most men, these nightly bathroom runs may be the first sign of an enlarged prostate. Other symptoms may include trouble starting a stream of urine, leaking, or dribbling. And, like gray hair, an enlarged prostate is a natural by-product of getting older, doctors say. Trouble is, the nightly bathroom runs become more frequent -- eventually edging their way into the daytime routine.
"They can't sit through a meeting or a plane flight without getting up," says Kevin Slawin, MD, a professor of urology at Baylor School of Medicine in Houston. "It's very annoying … and when they have to go, they really have to go."
It's a problem that has several names -- enlarged prostate, benign prostate hyperplasia, or simply BPH. According to the National Kidney and Urological Disease Information Clearinghouse, the most common prostate problem for men over 50 is prostate enlargement. By age 60, over one-half of men have BPH; by age 85, the number climbs to 90%, according to the American Urological Association (AUA).
In men, urine flows from the bladder through the urethra. BPH is a benign (noncancerous) enlargement of the prostate that blocks the flow of urine through the urethra. The prostate cells gradually multiply, creating an enlargement that puts pressure on the urethra -- the "chute" through which urine and semen exit the body.
As the urethra narrows, the bladder has to contract more forcefully to push urine through the body.
Over time, the bladder muscle may gradually become stronger, thicker, and overly sensitive; it begins to contract even when it contains small amounts of urine, causing a need to urinate frequently. Eventually, the bladder muscle cannot overcome the effect of the narrowed urethra so urine remains in the bladder and it is not completely emptied.
Symptoms of enlarged prostate can include:
When the bladder does not empty completely, you become at risk for developing urinary tract infections. Other serious problems can also develop over time, including bladder stones, blood in the urine, incontinence, and acute urinary retention (an inability to urinate). A sudden and complete inability to urinate is a medical emergency; you should see your doctor immediately. In rare cases, bladder and/or kidney damage can develop from BPH.
Most men put up with an enlarged prostate for months, even years, before seeing a doctor, says Slawin. "When they're getting up several times a night, and have trouble falling asleep again, that's when they come in," he tells WebMD.
It's not always obvious what's going on, Slawin adds. "When men start having urinary problems, it's hard to know the reason. They should see a doctor when anything changes, because there can be bladder cancer, stones, prostate cancer. BPH is often a diagnosis of exclusion … after we make sure nothing more serious is going on."
Urologists use the BPH Impact Index, a symptom questionnaire developed by the American Urological Association to determine if a man's symptoms from BPH require treatment. "It helps us understand how severe the problem is," says Slawin. Higher scores indicate more severe symptoms.
Prostate growth -- and the trouble it causes -- varies greatly from person to person, says O. Lenaine Westney, MD, division director of urology at The University of Texas Medical School at Houston. "Some people have more growth than others. Some people with very large prostates don't have trouble with voiding. It's a very individual thing."
When the symptoms of an enlarged prostate gland are mild, with low scores on the BPH Impact Index (less than 8), it may be best to wait before starting any treatment -- what's known as "watchful waiting."
With regular checkups once a year or more often, doctors can watch for early problems and signs that the condition is posing a health risk or a major inconvenience. That's where the BPH Index is especially helpful, Westney tells WebMD. "It lets us know how high the symptom score is … when to start treatment."
The "driving force in treatment," she explains, is whether the symptoms are affecting your quality of life -- and whether a blockage is causing serious complications, such as inability to urinate, blood in the urine, bladder stones, kidney failure, or other bladder problems.
A few questions to ask yourself:
A range of treatments can relieve enlarged prostate symptoms -- medications, minimally-invasive office procedures, and surgery. The best one for you depends on your symptoms, how severe they are, and whether you have other medical conditions.
The size of your prostate gland, your age, and your overall health will also factor into treatment decisions. What's best for a man in his 50s might not be optimal for an 80-year-old. An older man may want immediate symptom relief through drugs or surgery, whereas a younger man may lean toward a minimally invasive treatment. According to the American Urological Association, surgery often does the best job of relieving symptoms, but it also has more risks than other treatments.
Consider the options carefully with your doctor, says Westney. "We can start with medications, and if there's no improvement, we look at minimally invasive therapy to reduce a portion of the prostate," she tells WebMD. "These procedures are very effective, and side effects are very rare."
If symptoms are really bothersome -- or if you have complications like urine retention -- it may be best to bypass medication. The minimally invasive treatments have benefits over surgery, like quick recovery time; however, you may need a second procedure later on. There is also less risk of serious side effects like long-term incontinence or erection problems -- which can occur rarely with surgery.
Several drugs are FDA-approved to relieve common symptoms of an enlarged prostate. Each works differently, says Westney. They either shrink the enlarged prostate or stop the prostate cell growth, she explains. "For many men, medications are very effective," Westney tells WebMD. "They have a significant change in symptoms, and side effects are very uncommon … so medications are an attractive treatment."
Doctors use the BPH Index to gauge how the patient responds to medication, Westney adds. "We see how symptoms are progressing … if they've stabilized or not."
Alpha blockers: These drugs don't reduce the size of the prostate, but they are very effective at relieving symptoms. They work by relaxing the muscles around the prostate and bladder neck, so urine can flow more easily. These drugs work quickly, so symptoms improve within a day or two. They are most effective for men with normal to moderately enlarged prostate glands.
The drugs: Flomax (tamsulosin), Uroxatral (alfuzosin), Hytrin (terazosin), Cardura (doxazosin), and Rapaflo (silodosin).
Alpha blockers were originally created to treat high blood pressure; dizziness is the most common side effect; other side effects are generally mild and controllable. Possible side effects include headache, stomach irritation, and stuffy nose. These drugs are not for men with significant urine retention and frequent urinary tract infections.
5-Alpha reductase inhibitors: These drugs can partially shrink the prostate by reducing levels of a male hormone -- dihydrotestosterone (DHT) -- which is involved in prostate growth. These drugs take longer to work than alpha blockers, but there is urine flow improvement after three months. These drugs can reduce risk of acute retention (inability to urinate) -- and also reduce the need for prostate surgery. You may need to take them for 6 to 12 months to see if they work.
The drugs: Proscar (finasteride) and Avodart (dutasteride).
Possible side effects include erection problems, decreased sexual desire, and reduced amount of semen. These side effects are generally mild and may go away when you stop taking the drugs -- or after the first year of taking the drugs.
There is also drug combination therapy, which may be effective against symptoms associated with BPH. Some examples of combined drugs include an alpha-blocker and a 5-alpha-reductase inhibitor; or an alpha-blocker and an anticholinergic.
When medications don't help your enlarged prostate, several procedures can relieve symptoms -- without surgery. They are performed in a doctor's office. "These procedures use various types of heat energy to shrink a portion of the prostate," explains Westney. "They are very effective."
TUMT (transurethral microwave thermotherapy): This therapy for mild to moderate blockage reduces urinary frequency, urgency, straining, and intermittent flow -- but does not correct any bladder-emptying problems. In this procedure, computer-regulated microwaves are used to heat portions within the prostate to destroy select tissue. A cooling system protects the wall of the urethra during the procedure. TUMT is performed in a doctor's office and requires only topical anesthesia and pain medications.
Possible side effects include painful urination for several weeks. Temporary urgency and frequency of urination is also possible. There may be less semen ejaculated. Many men must have this procedure repeated, either because symptoms return or do not improve.
TUNA (transurethral radio frequency needle ablation): This procedure also destroys prostate tissue to improve urine flow and relieve symptoms. It involves heating the tissue with high-frequency radiowaves transmitted by needles inserted directly into the prostate (some anesthesia is used). The procedure does not require a hospital stay. Possible side effects include painful, urgent, or frequent urination for a few weeks.
Prostatic stents: In some cases, a tiny metal coil called a stent can be inserted in the urethra to widen it and keep it open. Stenting is done on an outpatient basis under local or spinal anesthesia. Usually, stents are only for men who are unwilling or unable to take medications -- or who are reluctant or unable to have surgery. The majority of doctors don't consider stents a good option for most men.
There could be serious side effects, and some men find that stents don't improve their symptoms. Sometimes a stent shifts position, which can worsen the symptoms. In some cases, men experience painful urination or have frequent urinary tract infections. Stents are expensive, and there can be difficulty in removing them.
For most men with very enlarged prostates, surgery can relieve symptoms -- but there are both risks and benefits with each type of operation. Discuss them with your doctor. After a careful evaluation of your situation and your general medical condition, your doctor will recommend which is best for you.
TURP (transurethral resection of the prostate): This is the most common surgery for an enlarged prostate, and considered to bring the greatest reduction in symptoms. Only the tissue growth that is pressing against the urethra is removed to allow urine to flow easily. The procedure involves an electrical loop that cuts tissue and seals blood vessels. Most doctors suggest using TURP whenever surgery is required, as it is less traumatic than open surgery and requires shorter recovery time.
With the TURP procedure, patients can expect to have retrograde ejaculation afterwards, says Westney. This is a condition in which a man ejaculates backward into the bladder instead of through the urethra. "Retrograde ejaculation generally isn't painful," she tells WebMD. "It shouldn't be an issue unless fertility is a concern." Other possible side effects include blood loss requiring transfusion (rare), painful urination, recurring urinary tract infections, bladder neck narrowing, and blood in the urine.
After TURP, the odds of erection problems range from 5% to 35%. However, this is often temporary -- and the ability to have an erection and an orgasm returns after a few months.
TUIP (transurethral incision of the prostate): This procedure involves making cuts in the prostate instead of removing prostate tissue. These cuts reduce pressure on the urethra, making urination easier. Patients go home the same day, and wear a catheter for a day or two.
Symptom relief is slower with TUIP, compared with TURP. However, most men are satisfied with their ultimate symptom relief from this. Also, retrograde ejaculation is less common and less severe than after TURP. Risk of erection problems is similar to TURP.
Laser Surgery: This procedure uses a high energy vaporizing laser to destroy prostate tissue. It is done under general anesthesia and may require an overnight stay at the hospital. It provides immediate relief of symptoms, yet men may suffer from painful urination for a few weeks. In general this procedure causes less blood loss, and side effects can include retrograde ejaculation. These procedures include:
Open Prostate Surgery (Prostatectomy): When a transurethral procedure cannot be used, open surgery (which requires an incision in the abdomen) may be used. This allows the surgeon to remove tissue in the prostate. Open prostatectomy is typically done when the prostate gland is greatly enlarged, when there is bladder damage, if there are bladder stones, or if the urethra is narrowed. The inner part of the prostate is removed. This surgery is done under general or spinal anesthesia, and recovery can take a few weeks to several months.
Side effects are similar to TURP, including blood loss requiring a transfusion, urinary incontinence, erection problems, and retrograde ejaculation.
Several herbal supplements are marketed for enlarged prostates. Saw palmetto, beta-sitosterol, and pygeum are all are widely used in Europe. They are available in the U.S. and don't require a prescription.
However, researchers and doctors are cautious about advising patients to try herbal supplements. Because they are not FDA-regulated, there are concerns about a product's quality from batch to batch, according to the NIH's Office of Dietary Supplements. Also, the safety of an herbal product depends on many things -- the chemical makeup, how it works in the body, how it is prepared, and the dosage.
Something else to consider: Like any drug, a herbal remedy can affect how other medications or treatments work, or interact dangerously with your other medications. They can also have side effects. And, the AUA points out, they have not been well-studied for effectiveness or safety.
Before trying any alternative treatment, learn as much as you can about it, the AUA says. Most importantly -- talk to your doctor before you try an herbal remedy. Many doctors consider alternative therapies like saw palmetto to "have no effect on symptoms, except as expensive placebos," Slawin tells WebMD.
Saw palmetto: Saw palmetto is one of the most popular herbal supplements taken for BPH. The extract comes from ripened berries of the saw palmetto shrub. Extracts are thought to prevent testosterone from breaking down and triggering prostate tissue growth, similar to the 5-alpha reductase inhibitor medications. Studies of this supplement have had varied results.
"Saw palmetto does not work," Slawin tells WebMD. He points to a recent "very nicely done" randomized study that found palmetto was no more effective than a placebo in relieving BPH symptoms. However, other studies have found it to be as effective as Proscar, a BPH medication. Varying quality of herbal products (dosages, ingredients, or purity) may account for the conflicting results, researchers say. Also, many studies of herbals have not been well-controlled.
Beta-sitosterol: This compound is extracted from pollen of rye grass. There has been some evidence that it provides relief from urinary symptoms. However, in four studies the supplement did not increase urinary flow rates, shrink the prostate, or improve bladder emptying.
Pygeum: This extract comes from the bark of the African plum tree. Numerous studies have found positive results for pygeum. In 18 studies, this extract relieved BPH symptoms twice as often as the placebo; it also increased urinary flow by nearly 25%.
Researchers continue to investigate new therapies for enlarged prostates. "Another category of drugs is under development," says Slawin. "We've come a long way in treating BPH. It's no longer the life-threatening disease it once was. Now, in treatment, we're working on quality of life issues… reducing side effects of treatment."
Also being studied is a procedure called water-induced thermotherapy (WIT), an experimental procedure that involves destroying excess prostate tissue utilizing heated water and an air-filled balloon, which protects normal prostate tissue. The procedure is performed with only local anesthesia. Results may not be fully apparent for three to four months. However, preliminary studies examining WIT have shown positive results, with a near doubling in urine flow. However, the American Urological Association has not thus far endorsed WIT as a viable treatment option for symptoms of BPH.
SOURCES:Kevin Slawin, MD, professor of urology, Baylor School of Medicine, Houston.O. Lenaine Westney, MD, division director of urology, The University of Texas Medical School, Houston.American Urological Association Foundation: "Benign Prostate Hyperplasia."Mayo Clinic.com: "Enlarged Prostate (BPH)."National Kidney and Urologic Diseases Information Clearinghouse: "Prostate Enlargement: Benign Prostatic Hyperplasia."Bent, S. New England Journal of Medicine; Feb. 9, 2006.DiPaola, R. New England Journal of Medicine; Feb. 9, 2006.eMedicine: "Benign Prostate Hyperplasia."Drug Digest: "Pygeum."NIH Office of Dietary Supplements.American Urological Association Education and Research. Guideline on the management of benign prostatic hyperplasia (BPH). American Urological Association Education and Research, Inc.; 2010.
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