Problems of the Prostate Gland
ANATOMICAL STRUCTURES INVOLVED
Prostate Gland
The prostate gland is a small walnut-shaped organ that lies just below a man's bladder. It surrounds the urethra, the tube that carries urine from the bladder out of the body through the penis.
The prostate gland produces most of the fluid in semen.
Seminal Vesicles
The seminal vesicles are two sac-like structures that produce part of the thick fluid (semen) that contains sperm. The vesicles are located just above the prostate gland.
The Bladder
The bladder is a hollow organ in the lower abdomen. It stores urine, the waste that is produced when the kidneys filter the blood. The bladder has a muscular wall that allows it to get larger and smaller as urine is stored or emptied. Urine passes from the two kidneys into the bladder through two tubes called ureters. Urine leaves the bladder through another tube, the urethra.
Benign Prostatic Hyperplasia (BPH) Assessment
symptoms
Do you have any of the following symptoms that have not been evaluated by your doctor? (Check all that apply.)
( ) blood in your urine
( ) pain or burning upon urination
( ) persistent pain in your lower back, pelvis, or upper thighs
( ) new onset of impotence or inability to attain or maintain an erection
( ) none of the above
more information
If you have any of these symptoms, visit your primary healthcare practitioner right away. These symptoms are not typical of an enlarged prostate and may be caused by an acute, bacterial infection of the prostate called prostatitis, by prostate cancer, or by another medical condition. It is important to have your primary healthcare practitioner promptly determine what is causing the symptoms and to prescribe the appropriate treatment.
type of symptoms
Do you have urinary tract symptoms, such as a weak stream, low volume, a feeling that you have not emptied your bladder completely, or getting up to urinate frequently at night?
( ) yes
( ) no
more information
These urinary symptoms typically are caused by age-related, prostate changes that are attributed to an enlarged prostate and may be diagnosed as BPH. There are many treatment options available, but you may not need to treat your symptoms at all.
cause of symptoms
Has your primary healthcare practitioner told you that your urinary symptoms are due to benign prostate problems (e.g., BPH, enlarged prostate, obstruction caused by tissue enlargement, or smooth muscle tension in the prostate)?
( ) yes
( ) no
( ) unsure
more information
There are many possible causes of urinary symptoms. BPH is the most common and can result in several changes in the prostate that contribute to urinary symptoms. Be sure to see your primary healthcare practitioner to ensure that the cause of your symptoms is diagnosed properly.
completion
During the past 4 weeks, how often have you had the feeling that you did not empty your bladder completely after you finished urinating?
( ) not at all
( ) less than 1 time in 5
( ) less than one-half the time
( ) about one-half the time
( ) more than one-half the time
( ) almost always
more information
This symptom is usually, but not always, caused by BPH. An enlarged prostate or a constriction of the smooth muscles of the gland can narrow the urethra and cause urinary difficulties. How often you experience this problem does not necessarily indicate how much your prostate is enlarged or how severely your urethra is obstructed.
stopping and starting
During the past 4 weeks, how often have you found that, when urinating, you stopped and started again several times?
( ) not at all
( ) less than 1 time in 5
( ) less than one-half the time
( ) about one-half the time
( ) more than one-half the time
( ) almost always
more information
This symptom is usually, but not always, caused by BPH. An enlarged prostate or a constriction of the smooth muscles of the gland can narrow the urethra and cause urinary difficulties. How often you experience this problem does not necessarily indicate how much your prostate is enlarged or how severely your urethra is obstructed.
weak stream
During the past 4 weeks, how often have you had a weak urine stream?
( ) not at all
( ) less than 1 time in 5
( ) less than one-half the time
( ) about one-half the time
( ) more than one-half the time
( ) almost always
more information
This symptom is usually, but not always, caused by BPH. An enlarged prostate or a constriction of the smooth muscles of the gland can narrow the urethra and cause urinary difficulties. How often you experience this problem does not necessarily indicate how much your prostate is enlarged or how severely your urethra is obstructed.
pushing or straining
During the past 4 weeks, how often have you had to push or strain to begin urination?
( ) not at all
( ) less than 1 time in 5
( ) less than one-half the time
( ) about one-half the time
( ) more than one-half the time
( ) almost always
more information
This symptom is usually, but not always, caused by BPH. An enlarged prostate or a constriction of the smooth muscles of the gland can narrow the urethra and cause urinary difficulties. How often you experience this problem does not necessarily indicate how much your prostate is enlarged or how severely your urethra is obstructed.
frequency
During the past 4 weeks, how often did you have to urinate less than 2 hours after your last urination?
( ) not at all
( ) less than 1 time in 5
( ) less than one-half the time
( ) about one-half the time
( ) more than one-half the time
( ) almost always
more information
This symptom is usually, but not always, caused by BPH. An enlarged prostate or a constriction of the smooth muscles of the gland can narrow the urethra and cause urinary difficulties. How often you experience this problem does not necessarily indicate how much your prostate is enlarged or how severely your urethra is obstructed.
postponement
During the past 4 weeks, how often have you found it difficult to postpone urination?
( ) not at all
( ) less than 1 time in 5
( ) less than one-half the time
( ) about one-half the time
( ) more than one-half the time
( ) almost always
more information
This symptom is usually, but not always, caused by BPH. An enlarged prostate or a constriction of the smooth muscles of the gland can narrow the urethra and cause urinary difficulties. How often you experience this problem does not necessarily indicate how much your prostate is enlarged or how severely your urethra is obstructed.
night habits
During the past 4 weeks, how many times did you most typically get up to urinate from the time that you went to bed until the time that you got up in the morning?
( ) 0 times
( ) 1 time
( ) 2 times
( ) 3 times
( ) 4 times
( ) 5 or more times
more information
This symptom is usually, but not always, caused by BPH. An enlarged prostate or a constriction of the smooth muscles of the gland can narrow the urethra and cause urinary difficulties. How often you experience this problem does not necessarily indicate how much your prostate is enlarged or how severely your urethra is obstructed.
lifetime symptoms
How would you feel if you were to spend the rest of your life with your prostate symptoms exactly the way they are now?
( ) pleased
( ) mostly satisfied
( ) mixed (about equally satisfied and dissatisfied)
( ) mostly dissatisfied
( ) unhappy
( ) terrible
more information
As a rule, nothing is done for mild symptoms that are related to an enlarged prostate. But as symptoms become more severe, treatment becomes more appropriate.
current treatment
Which, if any, of the following treatments are you currently using for your urinary symptoms? (Check all that apply.)
( ) herbal therapy (e.g., saw palmetto or
Pygeum africanum)
( ) alpha-blocker drugs [e.g., terazosin (Hytrin), doxazosin (Cardura), and tamsulosin (Flomax)]
( ) finasteride (Proscar)
( ) none of the above
more information
The response to different treatments varies among men. If you have had a previous treatment that was not successful, you may have to try another approach. Generally, the optimal strategy is to use the least invasive approach necessary to get the desired improvement in symptoms.
habits and lifestyle
Which of the following activities do you do on a regular basis? (Check all that apply.)
( ) sitting for long periods
( ) getting little exercise
( ) tending to hold urination
( ) taking cold or allergy medicine regularly
( ) eating a diet low in fruits and vegetables
( ) drinking fluids 2-3 hours before bed
( ) drinking coffee
( ) drinking alcohol
( ) ejaculating infrequently
( ) experience stress
( ) none of the above
more information
All of these activities can affect prostate function negatively and worsen urinary symptoms. While few studies have actually investigated the relationship of these behaviors with urinary symptoms--or the effects that these behaviors may have on improving symptoms--these habits may help to improve overall prostate health.
diagnosis or DRE
Have you been diagnosed with prostate cancer or had a digital rectal exam (DRE) with a possibly abnormal result on which you did not follow up?
( ) Yes, I've been diagnosed with prostate cancer.
( ) Yes, I've had a DRE with a possibly abnormal result.
( ) No, I've had a DRE with a NO abnormal result.
more information
BPH and prostate cancer often occur at the same time because they both become more common as you age. Prostate cancer is obviously a more serious concern and is more important to treat. A possibly abnormal (or suspicious) DRE is usually the result of BPH, but there is a chance that it could be prostate cancer.
prostate cancer concerns
Are you concerned that your BPH may increase your risk of prostate cancer?
( ) yes
( ) no
more information
Neither BPH nor its associated urinary symptoms has been shown to increase the risk of prostate cancer. The only major risk factors of prostate cancer are having a family history of the disease or being African American.
related conditions
Do you have a history of any of the following conditions? (Check all that apply.)
( ) recurrent urinary tract infections
( ) recurrent or persistent blood in your urine
( ) bladder stones
( ) acute urinary retention (complete inability to urinate)
( ) renal insufficiency or hydronephrosis
( ) overflow incontinence
( ) urethral stricture
( ) prior lower urinary tract surgery (e.g., TURP )
( ) none of the above
( ) unsure
more information
These conditions are related to BPH and could be causing or contributing to your symptoms. If you have a history of any of these conditions, your primary healthcare practitioner should evaluate them before considering treatment for BPH. With these conditions, non-surgical options for treating BPH may be less likely to help.
coexisting medical conditions
Do you have any of the following symptoms? (Check all that apply.)
( ) high blood pressure
( ) diabetes
( ) congestive heart failure
( ) neurological problems, such as stroke or Parkinson's disease
( ) none of the above
more information
Certain coexisting medical conditions make treating BPH more complicated. Because BPH is usually more of an annoyance than a real threat to longevity, its treatment may follow the treatment of the other diseases.
How You're Doing
The following set of recommendations are based on the results from your Benign Prostatic Hyperplasia (BPH) Assessment (above). If you feel that your condition has changed, you may want to go back to the
Questionnaire and change your answers.
Severity of Symptoms
Your urinary symptoms are classified as mild. Usually this means that treatment is not necessary until symptoms worsen. If you do start some treatment, you may have difficulty noticing improvement because your symptoms are mild. The key factor in deciding whether to start treatment is to determine how much your symptoms bother you--not how severe your symptoms are.
Severity of Bother
Because you have indicated that you are significantly bothered by your symptoms, treatment is warranted. Treatment options include drug therapy; newer, low-risk surgical procedures; and traditional TURP, which still provides the best long-term symptom relief but with more risks involved.
Men under age 50
BPH that is so advanced as to cause significant urinary problems is unusual in men under the age of 50. See your primary healthcare practitioner to determine the cause of your symptoms. BPH is often a diagnosis by exclusion; that is, other more serious causes are ruled out to confirm that it is BPH.
Sitting
Avoid sitting continuously for long periods of time. Develop the habit of getting up and moving around once in while. Doing so helps maintain the circulation in the prostate region (and the rest of the body) and stimulates normal, urinary-tract function.
Exercise
Exercise, for about 30 minutes a day, can play an important role in balancing hormones in the body, by keeping testosterone levels in check. A higher testosterone level means a greater amount is converted into dihydrotestosterone (DHT), which stimulates prostate growth. Exercise also can reduce the activity of the sympathetic nervous system, which may help reduce smooth muscle tone in the prostate.
Holding Urination
Getting in the habit of holding your urination can increase the tone in the bladder sphincter muscle, which, in turn, can lead to symptoms related to BPH. When you feel the urge to urinate, relieve yourself.
Fluid Intake
Make sure that you drink plenty of water. However, if you must frequently get up at night to urinate, don't drink any fluids after 6:00 pm in the evening and go take a piss before you go to bed.
Stress
The smooth, involuntary muscle of the prostate and the bladder neck are contracted when adrenal hormones, which are brought on by stress, trigger the sympathetic nervous system. To avoid this, take some measures to reduce the stress in your life.
Behaviour
You have checked at least one behaviour that could be changed to possibly receive some relief from your BPH-related symptoms. Consider changing your behaviours to determine if your symptoms improve.
What You're Doing Right
Avoiding Over The Counter Cold Medications
It is good that you do not take too many nonprescription (over-the-counter) decongestants or antihistamines for colds or allergies because they can make your urinary symptoms worse. Remember, if you need a cold or allergy medication, ask your doctor for one that will not aggravate your prostate.
Eating a Diet with Plenty of Fruits and Vegetables
It is good that you eat a healthful diet, especially with plenty of fruits and vegetables. This helps keep your bowels regular, which reduces the pressure on your prostate.
Limiting Coffee Intake
It is good that you are limiting your consumption of caffeine. This helps keep your prostate relaxed, so urination is easier. In addition, limiting your consumption of caffeine reduces the amount of urine your body produces. Be sure to drink plenty of water, spread out over the day.
Limiting Alcohol
You are helping your urinary problems by limiting your alcohol consumption. Keep this up. It doesn't mean that you cannot drink any alcohol, simply keep it to a minimum.
Having Regular Ejaculations (go wank a lot!)
You are helping your prostate by having regular ejaculations. The fluids produced by the prostate need to be regularly released to keep your prostate from getting stale.
Your Treatment Choices and Options
An Overview of BPH Treatments
Treating the symptoms of BPH is not necessary unless symptoms are bothersome or some complication exists that places the urinary system at risk. Men who suffer from mild symptoms are usually advised to use watchful waiting.
For a man with moderate-to-severe symptoms, alpha-blocker medications that specifically target the prostate are the usual initial treatment. These drugs are less expensive, work faster, and address symptoms better than the alternative medication, an enzyme inhibitor called finasteride (Proscar). However, for a man who has a palpably enlarged prostate and does not respond to alpha-blockers, finasteride is usually prescribed.
Because good medications are available and the use of herbs, such as
saw palmetto, is more widely accepted, surgery--including new, minimally invasive procedures--is declining in use. Other surgical approaches, such as balloon dilation and hyperthermia, are used primarily as temporary fixes.
Try An Herbal Treatment - Speak With Your Doctor
The severity of your symptoms is mild, and you report that your symptoms bother you very significantly. You can try an herbal treatment--namely,
saw palmetto--to achieve symptom relief. Remember, continuously taking the herbal therapy for at least six months will probably be required to achieve full results. If this seems too long to wait, consult with your primary healthcare practitioner about taking a prescription drug that acts more rapidly.
What to Expect from Your Doctor
If you choose to visit your primary healthcare practitioner about treatment for bothersome urinary symptoms, expect a physical examination, including a blood pressure check and a digital rectal examination to check the size and consistency of your prostate. You also may need an analysis of a urine sample and other laboratory tests, depending on your history and physical exam findings, before your primary healthcare practitioner prescribes treatment.
An Overview of Treatment for BPH:
A quick guide
Benign prostatic hyperplasia (BPH) is a quality-of-life disease. While the condition is extremely common in older men, BPH will not kill you and will rarely make you sick. But BPH can cause urinary problems that can be extremely bothersome.
The course of BPH in a particular man is unpredictable, and there is little consensus about when it becomes necessary to treat the condition. The only clear-cut indication for treatment is when a complication arises that threatens the urinary tract. Otherwise, the indications for treatment are dependent on each man's perception of how the symptoms affect his quality of life.
The purpose of this decision guide is to help you decide whether treatment is reasonable and, if you want treatment, to suggest which therapies will best fit your situation.
The Right Time for Treatment
The most important factor in seeking treatment is how bothered you are by your urinary difficulties--regardless of how often the symptoms arise. The frequency with which you experience difficulties is known as the severity of symptoms and are classified as mild, moderate, or severe.
Mild
Your symptoms are mild, meaning that they occur infrequently. Generally, treatment is not recommended at this stage. But continued monitoring is important to spot when urinary problems are becoming troublesome enough to make treatment worth the risks. You can also change certain habits that affect urinary function or use a low-risk, herbal supplement to treat your BPH symptoms.
The Difference Between Severity and Bother
The severity (or frequency) of symptoms is not necessarily indicative of how bothered you are by urinary difficulties. Tolerance for, and acceptance of, symptoms varies greatly among men. That's why the need for treatment really comes down to how you personally feel about living with the symptoms.
Sorting Out the Options
Drug therapy is the initial treatment for BPH and is usually prescribed by primary healthcare practitioners and internists. A referral to a urologist is typically made, if drug therapy does not yield satisfactory relief of BPH-related symptoms. At this level of treatment, you and your urologist may consider surgery or less-invasive alternatives. You might also consider using herbal therapy before seeking medical care. So, the next step in the decision-making process is determining which options best fit your needs and preferences.
Preferences and Values
While the need for treatment depends on your feelings about the impact of your urinary problems on your daily life, the type of treatment that you choose depends on your values and preferences. The benefits and risks of each option vary, so the final decision must be a personal one.
The first decision that you will make is whether to have surgery.
If you think you would prefer surgery, consider whether you want to:
1) have a long-lasting fix so that you won't have to undergo another procedure to treat BPH later on (Recommended approach: TURP)
2) have the best chance of improvement (Recommended approach: TURP)
3) maintain sexual function and potency (Recommended approach: TUIP or a minimally invasive procedures)
4) minimize complications--even at the expense of less durable improvement (Recommended approach: a minimally invasive procedure)
5) avoid general anesthesia and hospitalization (Recommended approach: a minimally invasive procedure)
If you think you would prefer a nonsurgical alternative, consider whether you want to:
1) avoid drug side effects (Alternative treatment: herbal therapy)
2) prompt relief of symptoms (Alternative treatment: alpha-blocker drugs)
3) prevent complications (Alternative treatment: finasteride)
4) maintain sexual function and desire (Alternative treatment: alpha-blocker drugs or herbal therapy)
Work With Your Primary Healthcare Practitioner
Whatever you decide, consult with your primary healthcare practitioner who can best evaluate your personal risks, other medical conditions that may affect your urinary difficulties, and your potential for improvement. The probabilities presented here are averages taken from the best evidence available. Your personal risks and benefits may be a little different.
THE DIAGNOSIS
Benign Prostatic Hyperplasia (BPH)
Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate that occurs in almost all men as they age. It is not clear if BPH is a disease, because the process may be natural. The
enlargement is usually harmless, but as the gland gets bigger, it may cause problems such as difficulty urinating,
getting up many times a night to urinate, frequently feeling an urge to urinate, or having the sense that the bladder is not completely empty after urination.
BPH
does not cause prostate cancer,
does not have an effect on a man's ability to father children, and
does not usually result in erection problems. However, there is some association between severe symptoms of BPH an increased risk of erection problems. See
Erectile Dysfunction and
Better Living Through Urology.
I only have a mild case of BPH, what my urologist calls irritative symptoms of the Lower Urinary Tract (see items in
blue, above.)
Severity of Symptoms
Your urinary symptoms are classified as mild. Usually this means that treatment is
not necessary until symptoms worsen. If you do start some treatment, you may
have difficulty noticing improvement because your symptoms are mild.
If a man desires treatment for symptoms of an enlarged prostate, his options include medications and surgery. Neither is indicated in my case. My treatment is simply to avoid caffeine (coffee, tea, cola drinks), diuretics (
petai, asparagus being two of them) and to take a piss every two hours whether I feel like having one or not.
DIAGNOSTIC PROCEDURES
Transrectal Ultrasound (not indicated)
During a transrectal ultrasound (TRUS), an instrument is placed into the rectum that produces and detects sound waves that bounce off the prostate gland. The pattern of the sound waves creates a picture of the prostate gland that can help locate areas of abnormal tissue. TRUS can also be used to help a doctor guide a needle to the correct spot in the prostate gland for collecting a tissue sample (biopsy).
Transabdominal Ultrasound (not indicated)
You will need to drink 4 to 6 glasses (240 ml) of liquid about an hour before the test and avoid urinating until the test is over. If you cannot drink enough liquid, your bladder may be filled with water through a thin, flexible tube (catheter) inserted through your urethra.
You will be asked to lie on your back on a padded examination table. A special gel will be spread on your abdomen to improve the transmission of the sound waves, which do not pass easily through air. The transducer is pressed against your skin and moved across your abdomen multiple times. You need to lie very still while the ultrasound scan is being done. You may be asked to take a breath and hold it for several seconds during the scanning.
When the test is finished, the gel is cleaned off your skin. You can urinate as soon as the test is done. Transabdominal ultrasound takes about 30 minutes. You may be asked to wait until the radiologist has reviewed the information. The radiologist may want to do additional ultrasound views.
Pelvic Ultrasound in Men (not indicated)
Normal:
The prostate gland and seminal vesicles are normal in size and shape. No growths, tumours, or other abnormalities (such as cysts) are seen.
The bladder is normal in size and shape. No stones or abnormal growths are seen. If the bladder is evaluated before and after urination, it empties completely during urination.
Urine flows from the ureter openings into the bladder.
Abnormal:
Benign prostatic hypertrophy is one of the most common abnormal findings. Other abnormal results may include an abscess, a kidney stone in the urinary tract, or a tumour in or near the prostate gland or bladder.
The bladder may have an abnormal shape or a thickened wall. A growth or stone may be seen in the bladder. If the bladder is evaluated before and after urination, it may not empty completely during urination.
An abnormal amount of fluid is present in the pelvis.
Digital Rectal Examination (done)
You lie on your left side on a bed. The doctor wears a latex examination glove and lubricates the index finger with KY jelly. He places his finger against your anus. He asks you to relax and take in a deep breath. As you suck in your breath, he inserts his finger into your rectum; it's as if you "suck in" his finger. He asks if there is any pain. I said there is NO pain, NO discomfort. In fact, it is even mildly pleasurable as he palpates my prostate (but of course I didn't tell him that!). My prostate is slightly enlarged, about 30 g (this is a subjective, qualitative assessment based on his experience; normal would be between 15 to 25 g range). My prostate is soft and smooth, indicating that the hyperplasia is benign. (If malignant, it would have been hard and knobbly, with nodules.)
Flow Rate Test (done)
I drank 2.5 litres of water in one go and pissed onto a machine. If it means anything to you, here are my results (I repeated it twice as I had so much piss inside me after drinking 2.5 litres of mineral water):
RESULTS 1
July 6, 2004; 5.10 pm
Voiding Time: 21 s
Flow Time: 19 s
Time to Max Flow: 4 s
Max Flow Rate: 20.9 ml/s
Average Flow rate: 14.1 ml/s
Voided Volume: 272 ml
Filter: Standard
Sensor: Spinning Disk
RESULTS 2
July 6, 2004; 5.16 pm
Voiding Time: 16 s
Flow Time: 15 s
Time to Max Flow: 5 s
Max Flow Rate: 27.0 ml/s
Average Flow rate: 15.7 ml/s
Voided Volume: 239 ml
Filter: Standard
Sensor: Spinning Disk
RESULTS 3
July 6, 2004; 5.42 pm
Voiding Time: 33 s
Flow Time: 25 s
Time to Max Flow: 11 s
Max Flow Rate: 33.5 ml/s
Average Flow rate: 13.1 ml/s
Voided Volume: 337 ml
Filter: Standard
Sensor: Spinning Disk
Nota Bene:
Results 3 is inaccurate as I did it while taking 2 samples ~ one in the beginning of the flow and one in mid-flow. These samples were to investigate for sub-clinical infections and for microscopic blood in the urine which may determine the underlying aetiology for my BPH. I shall get the results of these investigations in two weeks.
Further Reading
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