4urology

The prostate is a walnut-sized gland that forms part of the male reproductive system. The gland is made of two lobes, or regions, enclosed by an outer layer of tissue. As the diagrams show, the prostate is located in front of the rectum and just below the bladder, where urine is stored. The prostate also surrounds the urethra, the canal through which urine passes out of the body.
Scientists do not know all the prostate's functions. One of its main roles, though, is to squeeze fluid into the urethra as sperm move through during sexual climax. This fluid, which helps make up semen, energizes the sperm and makes the vaginal canal less acidic.

It is common for the prostate gland to become enlarged as a man ages. Doctors call this condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy.

As a man matures, the prostate goes through two main periods of growth. The first occurs early in puberty, when the prostate doubles in size. At around age 25, the gland begins to grow again. This second growth phase often results, years later, in BPH.

Though the prostate continues to grow during most of a man's life, the enlargement doesn't usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and as many as 90 percent in their seventies and eighties have some symptoms of BPH.

Normal urine flow	Urine flow with BPE

As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself, so some of the urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH.

Many people feel uncomfortable talking about the prostate, since the gland plays a role in both sex and urination. Still, prostate enlargement is as common a part of aging as grey hair. As life expectancy rises, so does the occurrence of BPE.
 

The cause of Benign Prostatic Enlargement (BPE) is not well understood. No definite information on risk factors exists. For centuries, it has been known that BPE due to benign prostatic hyperplasia (BPH) of the glandular tissue occurs mainly in older men and that it doesn't develop in men whose testes were removed before puberty. For this reason, some researchers believe that factors related to aging and the testes may spur the development of BPE.

Throughout their lives, men produce both testosterone, an important male hormone, and small amounts of oestrogen, a female hormone. As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of oestrogen. Studies done on animals have suggested that BPE may occur because the higher amount of oestrogen within the gland increases the activity of substances that promote cell growth.

Another theory focuses on dihydrotestosterone (DHT), a substance derived from testosterone in the prostate, which may help control its growth. Most animals lose their ability to produce DHT as they age. However, some research has indicated that even with a drop in the blood's testosterone level, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage the growth of cells. Scientists have also noted that men who do not produce DHT do not develop BPE.

Some researchers suggest that BPE may develop as a result of "instructions" given to cells early in life. According to this theory, BPE occurs because cells in one section of the gland follow these instructions and "reawaken" later in life. These "reawakened" cells then deliver signals to other cells in the gland, instructing them to grow or making them more sensitive to hormones that influence growth.
 

Many symptoms of BPH stem from obstruction of the urethra and gradual loss of bladder function, which results in incomplete emptying of the bladder. The symptoms of BPH vary, but the most common ones involve changes or problems with urination, such as

• a hesitant, interrupted, weak stream
• urgency and leaking or dribbling
• more frequent urination, especially at night

The size of the prostate does not always determine how severe the obstruction or the symptoms will be. Some men with greatly enlarged glands have little obstruction and few symptoms while others, whose glands are less enlarged, have more blockage and greater problems.

Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to urinate at all. This condition, called acute urinary retention, may be triggered by taking over-the-counter cold or allergy medicines. Such medicines contain a decongestant drug, known as a sympathomimetic. A potential side effect of this drug may prevent the bladder opening from relaxing and allowing urine to empty. When partial obstruction is present, urinary retention also can be brought on by alcohol, cold temperatures, or a long period of immobility.

It is important to tell your doctor about urinary problems such as those described above. In eight out of 10 cases, these symptoms suggest BPH, but they also can signal other, more serious conditions that require prompt treatment. These conditions, including prostate cancer, can be ruled out only by a doctor's examination.

Severe BPH can cause serious problems over time. Urine retention and strain on the bladder can lead to urinary tract infections, bladder or kidney damage, bladder stones, and incontinence (the inability to control urination). If the bladder is permanently damaged, treatment for BPH may be ineffective. When BPH is found in its earlier stages, there is a lower risk of developing such complications.
 

You may first notice symptoms of BPH yourself, or your doctor may find that your prostate is enlarged during a routine checkup. When BPH is suspected, you may be referred to a urologist, a doctor who specializes in problems of the urinary tract and the male reproductive system. Several tests help the doctor identify the problem and decide whether surgery is needed. The tests vary from patient to patient, but the following are the most common.

Digital Rectal Examination (DRE)
This examination is usually the first test done. The doctor inserts a gloved finger into the rectum and feels the part of the prostate next to the rectum. This examination gives the doctor a general idea of the size and condition of the gland.

Other tests
Other tests will be carried out to make sure that your urinary problems are due to BPH and not other conditions. A urine test will check for infection or blood. Blood tests, including a prostate specific antigen (PSA) test may be carried out. Other blood tests include one to assess your kidney function and another for blood sugar to check for diabetes. Both of these problems can cause urinary symptoms.

Prostate-Specific Antigen (PSA) Blood Test
If the DRE is thought to be abnormal, to rule out cancer as a cause of urinary symptoms, your doctor may recommend a PSA blood test. PSA, a protein produced by prostate cells, is frequently present at elevated levels in the blood of men who have prostate cancer. A PSA test for use in conjunction with a digital rectal examination is suitable to help detect prostate cancer in men who are age 50 or older and for monitoring men with prostate cancer after treatment. However, much remains unknown about the interpretation of PSA levels, the test's ability to discriminate cancer from benign prostate conditions, and the best course of action following a finding of elevated PSA.

A fact sheet titled "The Prostate-Specific Antigen (PSA) Test” which answers common questions can be found on the Prostate Cancer Institute website at http://www.prostate-cancer.org.uk/info/tests_psa.asp

Rectal Ultrasound and Prostate Biopsy
If there is a suspicion of prostate cancer, your doctor may recommend a test with rectal ultrasound. In this procedure, a probe inserted in the rectum directs sound waves at the prostate. The echo patterns of the sound waves form an image of the prostate gland on a display screen. To determine whether an abnormal-looking area is indeed a tumour, the doctor can use the probe and the ultrasound images to guide a biopsy needle to the suspected tumour. The needle collects a few pieces of prostate tissue for examination with a microscope.

Urine Flow Study
Your doctor may ask you to urinate into a special device that measures how quickly the urine is flowing. A reduced flow often suggests BPH. An ultrasound scan at the end of this procedure will indicate how much urine is left in the bladder.

Cystoscopy
In this examination, the doctor inserts a small tube through the opening of the urethra in the penis. This procedure is done after a solution numbs the inside of the penis so all sensation is lost. The tube, called a cystoscope, contains a lens and a light system that help the doctor see the inside of the urethra and the bladder. This test allows the doctor to determine the size of the gland and identify the location and degree of the obstruction.
 

Although it is not known why only some men develop BPH, it is clear that advancing age is the prime risk factor. Eating a diet that is low in fat and rich in fruit and vegetables (five portions per day) may well help to reduce the risk of prostate cancer and has been showen to bring other health benefits. You should visit your doctor promptly if you develop urinary problems as early treatment is likely to be more simple.

Men who have BPH with symptoms usually need some kind of treatment at some time. The two mainstays of treatment for BPH are drugs and surgery. However, as any treatment can have unwanted effects, some men with mild symptoms may be advised to opt for "watchful waiting", where no immediate treatment is undertaken. If this is felt to be the best management option then the patient is closely monitored with routine check-ups. Then if symptoms do deteriorate, it is possible to opt for treatment.

Since BPH can cause urinary tract infections, a doctor will usually clear up any infection with antibiotics before treating the BPH itself. Although the need for treatment is not usually urgent, doctors generally advise going ahead with treatment once the problems become bothersome or present a health risk.

The following section describes the types of treatment that are most commonly used for BPH.

Drug treatment
There are two main types of drugs that are prescribed for BPH: alpha-blockers and 5-alpha-reductase inhibitors.

Alpha-blockers
These work by relaxing the muscles at the neck of the bladder and in the prostate thereby reducing the pressure on the urethra and so helping to increase the flow of urine. They do not cure BPH but they can help to alleviate some of the symptoms.

Approximately 60% of men find their symptoms improve significantly within the first 2 weeks of treatment with an alpha-blocker. There are several different alpha blockers. Currently, these are tamsulosin (Flomax MR), alfuzosin (Xatral), doxazosin (Cardura), indoramin (Doralese), prazosin (Hypovase) and terazosin (Hytrin BPH). Some of these drugs can also be used to treat high blood pressure. The most common side-effects of alpha-blockers are tiredness, dizziness and headaches.

5-alpha-reductase inhibitors
These drugs work by inhibiting the production of a hormone called DHT, which contributes to prostate enlargement. There are currently 2 drugs which work in this way, finasteride (Proscar) and dutasteride (Avodart). Unlike alpha blockers, 5-alpha- reductase inhibitors are able to reverse BPH to some extent and so may delay your need for surgery.

Potential side-effects include a reduced sex drive and difficulty in maintaining an erection. Approximately 4 months of treatment may be needed before the benefit is noticed.

Plant extracts
A number of plant extracts are popularly used to alleviate BPH, although scientific evidence of their benefit is often scanty. However, there is some evidence that an extract of saw palmetto (Serenoa repens) can be beneficial. If you decide to try a plant remedy you should discuss this first with your doctor or pharmacist as interactions with conventional medicines are possible.
 

Most doctors recommend removal of the enlarged part of the prostate as the best long-term solution for patients with significant symptoms due to BPH. With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed; the rest of the inside tissue and the outside capsule are left intact. Surgery usually relieves the obstruction and incomplete emptying caused by BPH. The following section describes the types of surgery that are used.

Transurethral surgery. In this type of surgery, no external incision is needed. After giving anesthesia, the surgeon reaches the prostate by inserting an instrument through the urethra.

A procedure called transurethral resection of the prostate (TURP) is the most common surgical procedure for BPH. With TURP, a thin instrument called a resectoscope is inserted through the penis. The resectoscope, which is about 12 inches long contains a light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels.

During the 60-minute operation, the surgeon uses the resectoscope's wire loop to remove the obstructing tissue one piece at a time. The pieces of tissue are carried by the fluid into the bladder and then flushed out at the end of the operation.

Transurethral procedures are less traumatic than open forms of surgery and require a shorter recovery period. One possible side effect of TURP is retrograde, or ‘dry ejaculation’. In this condition, semen flows backward into the bladder during climax instead of out the urethra.

Another surgical procedure is called bladder neck incision (BNI). Instead of removing tissue, as with TURP, this procedure widens the urethra by making a few small cuts in the bladder neck, where the urethra joins the bladder, and in the prostate gland itself. Although some people believe that TUIP gives the same relief as TURP with less risk of side effects such as retrograde ejaculation, its advantages and long-term side effects have not been clearly established.

Open surgery. In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. The location of the enlargement within the gland and the patient's general health help the surgeon decide which of the three open procedures to use.

With all the open procedures, anesthesia is given and an incision is made. Once the surgeon reaches the prostate capsule, he or she scoops out the enlarged tissue from inside the gland.

Laser surgery. This is a new transurethral treatment for BPH. As with TURP, laser surgery requires anesthesia and a hospital stay. One advantage of laser surgery over TURP is that laser surgery causes close to zero blood loss. It also allows for a quicker recovery time.
 

Anesthesia: A substance that prevents pain from being felt, given before an operation.
Anus: The opening of the rectum where solid waste leaves the body.
Bladder: The muscular bag in the lower abdomen where urine is stored.
Catheter: A tube inserted through the penis to the bladder in order to drain urine from the body.
Cystoscope: A tube-like instrument used to view the interior of the bladder.
Ejaculation: Discharging semen from the penis during sexual climax.
Gland: An organ that makes and releases substances to other parts of the body.
Hormone: A substance that stimulates the function of a gland.
Impotent: Unable to have an erection.
Incontinence: The inability to control urination.
Obstruction: A clog or blockage that prevents liquid from flowing easily.
Rectum: The last part of the large intestine (colon) ending in the anus.
Reproductive system: The bodily systems that allow men and women to have children.
Scrotum: The sac of skin that contains the testes.
Semen: The fluid, containing sperm, which comes out of the penis during sexual excitement.
Sterile: Unable to father children.
Testes: The male reproductive glands where sperm are produced.
Ultrasound: A type of test in which sound waves too high to hear are aimed at a structure to produce an image of it.
Urinary tract: The path that urine takes as it leaves the body. It includes the kidneys, ureters, bladder, and urethra.
Urination: Discharge of liquid waste from the body.
Urethra: The canal inside the penis that urine passes through as it leaves the body.