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Benign prostatic enlargement

Benign prostatic enlargement (BPE), also known as benign prostatic hypertrophy (BPH) refers to the growth of the central part of the prostate gland which occurs with aging. It may begin during a man’s 40’s or 50’s and continues throughout life.

This enlargement involves the central part of the prostate gland through which the urethra runs. It is not a cancerous growth (although cancers can grow in this region too). BPE/BPH often manifests as trouble with urination, characterised by a weak urine flow, going to the toilet frequently during the day and/or overnight, a feeling of not emptying the bladder fully, difficulty starting the flow and dribbling towards the end. It can also cause symptoms of having to go in a hurry and sometimes leaking before arriving at the toilet (urgency and urge incontinence). The symptoms can take many years to appear and can get progressively worse. These symptoms can culminate in complete “urinary retention” - a situation in which a patient has a full bladder but cannot urinate at all. This is usually extremely uncomfortable and will usually need a visit to a nearby Emergency department where a catheter will be inserted into the bladder to drain it by the Emergency doctor.

Patients who present to a urologist with symptoms suggestive of BPE/BPH will undergo a thorough history and investigation, including a rectal exam of the prostate, and also usually have an ultrasound scan of the bladder and kidneys which searches for any signs of damage from the enlarged prostate, such as swelling of the kidneys, thickening of the bladder wall, and too much urine remaining behind after urination. It also assesses the size of the prostate. In addition many urologists ask the patient to perform a “flow test”, in which the patient urinates into a metal flask attached to an electronic flow measurement device which measures how fast the bladder is emptied, how long it takes, the volume of urine emptied out, and the top speed or “peak flow” of urine flow achieved. These metrics all help to evaluate how bad a patient’s prostate problem is and gives useful information for deciding whether to try medical therapy with tablets or proceed straight to surgery if there are any danger signs. Generally a patient having an episode of urinary retention is a strong indication to proceed straight to surgical treatment such as TURP (see below), as the chances of it happening again within the next 6-12 months are fairly high.

Treatment for BPE/BPH includes the following:

  1. Reassurance and monitoring – if the symptoms are not too bad and the patient can tolerate them, and other investigations do not point to any serious problems, then the symptoms can be simply monitored, with follow up visits every 6 to 12 months.
     
  2. For more serious problems, the first step in treatment is usually medical therapy. This includes two major groups of drugs:
     
    1. Alpha-blockers – tablets (such as Tamsulosin or Minipres) which relax the bladder muscle fibres at the top of the prostate and allow the flow to start easier, the bladder to empty better, and generally decrease the overall amount and severity of symptoms the patient is experiencing. The improvement is usually noted within 48 hours, and patients can remain on these tablets indefinitely if well tolerated.
    2. 5-alpha reductase inhibitors – these tablets prevent the conversion of testosterone to the active form within the prostate cells, and result in gradual shrinkage of the prostate over 6 months by up to 40% in volume. The two brands available in Australia are “Dutasteride” and “Finasteride”. Generally these are used in patients with larger prostates, and do have some side effects in some men including effects on libido and erectile quality which can impact their ongoing use.
    3. A combination of the above two types of drugs combined into one pill – Combodart or Duodart.

Generally patients can remain on medical therapy indefinitely if it controls their symptoms and if it is well tolerated.

  1. Surgical treatment of the prostate enlargement. This includes, but is not limited to:
     
    1. TURP – transurethral resection of the prostate. This is the so-called gold standard operation in that it has been available for many decades and all urologists are well trained with this technique. It involves operating on the prostate through a telescope via the urethra – a “cystoscope” – fitted with a camera and a light and an electrocautery “loop” which is used to “shave out” the inner part of the prostate in multiple chips (picture coring out the inside of an apple or pumpkin) until the urethra is enlarged to a wide channel from the top of the prostate to the end (or apex).
    2. Laser prostate surgery – this includes a number of different laser technologies and techniques which are either used to vaporise the prostate tissue (Greenlight laser) or remove it piecemeal by enucleation (HOLEP).