Prostate Gland

The Prostate Gland - Synonyms - (Benign Prostatic Enlargement, BPH, Enlargement of Prostate, Benign Hyperplasia)

The prostate is a walnut-sized gland that forms part of the male reproductive system. The gland is made up of two lobes or regions enclosed by an outer layer of tissue. It is located in front of the rectum and just below the urinary bladder which is the storage organ for urine. The prostate gland surrounds the urethra, the canal through which urine passes out of the body.

Benign enlargement of the prostate or benign prostatic hyperplasia (BPH) is a non cancerous growth of the prostate gland. It is considered more as an aging disorder rather than a disease.

The 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.

Benign Prostatic Hyperplasis (BPH) - An aging process

Benign Prostatic Hyperplasis (BPH) is not considered a disease but it is an aging process. As the age advances and hair turns grey, the prostate gland enlarges aroung the same time. The prostate gland continues to grow during most of a man's life. However, it does not cause symptoms before 40 years of age. After 50 years of age, a man begins to complain of symptoms due to Benign Prostatic Hyperplasis (BPH). 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 Benign Prostatic Hyperplasis (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 gray hair. As life expectancy rises, so does the occurrence of Benign Prostatic Hyperplasis (BPH). In the United States in 2000, there were 4.5 million visits to physicians for Benign Prostatic Hyperplasis (BPH).

Symptoms that may indicate Prostate problems are

Most of the symptoms of BPH arises from the obstruction of the urethra and gradual loss of bladder function, resulting in incomplete emptying of the bladder. The symptoms of BPH may vary and they can be described as irritative and obstructive symptoms of the lower urinary tract (LUTS). The following are the symptoms:-

Obstructive Symptoms Irritative Symptoms
A weak Urinary Stream Frequent Urination
Difficulty in Passing Urine. Urgency ( difficulty in postponing urination)
Hesitency in starting urination Awakening frequently at night for urination
Interrupted stream of urine Pain or burning while passing urine
Blood in urine Dribbling of urine after urination
Sense of Incomplete voiding Urge incontinence

Symptoms of BPH could be due to complications occurring secondary to neglecting the treatment of enlarged prostate.

These could be:-

  • Recurrent Urinary Tract Infection (UTI)
  • Bladder and / or Kidney damage
  • Acute Retention of urine
  • Chronic Retention of urine leading to kidney failure due to severe untreated back pressure changes
  • Bladder Calculi secondary to obstruction by Benign Prostatic Hyperplasis (BPH).

When BPH is detected and treated in its earlier stages, there is a lower risk of developing such complications.

The size of the prostate gland enlargement does not matter or correlate with the symptoms of benign enlargement of the prostate (BPH). One may have a very large and an enlarged prostate gland without much symptoms of obstructions (LUTS) whereas other men with even smaller gland may have great irritative as well as obstructive symptoms of outflow obstruction (LUTS).

Diagnosis of BPH / Prostate Disease

The patient may first notice the irritative or obstructive symptoms of out flow obstruction (LUTS) secondary to BPH or it could be detected during a routine health check up. When BPH is suspected the patient should be examined by Urologist (a specialist who deals and treats in the problems of urinary tract and the male reproductive system). The urologist will evaluate the symptoms and may order to basic investigations. 

  • Digital rectal examination of prostate to look for size, consistency, and nodules in the prostate.
    This examination is done by the urologist in his clinic. He inserts a gloved finger into the rectum and feels part of the prostate next to the rectum. This examination helps him to evaluate the size, consistency and nodules in the prostate.
  • Routine Urine Analysis to look for urinary infection.
  • Blood test, Prostate specific antigen (PSA).

PSA is the protein produced by the prostate glands or prostate cells and found in the blood. These levels generally elevated in the blood of men who have prostate cancer. However, PSA may also be elevated in severe urinary tract infection, prostate abscess, or large voluminous prostate gland. PSA levels can also be used for monitoring men with prostate cancer who have undergone treatment. Recently much remains debated about the interpretation of PSA levels. 

  • Ultrasonography of Abdomen and Pelvis with full Bladder and Post void residual urine.
    The ultrasonography of the abdomen and pelvis is done to assess the any secondary pathology in the kidney, ureter and the bladder and also to measure the post void residual urine.
  • Uroflowmetry: 
    One is asked to pass urine into a special commode which is connected to computerized device which measures the quantity and flow of urine. Reduced and obstructed flow will signify outflow obstruction secondary to BPH or stricture urethra.
  • Cystoscopy:
    The urologist inserts a small tube through the opening of the urethra into the penis. This procedure is done under local or general anaeasthesia. The cystoscope allows the urologists through its lens and light system to visualize the inside the urethra and the bladder. This also helps to assess the size of the prostate gland and rule out any other cause of obstruction.

The disease which involves the prostate commonly are: 

  • Benign prostate hyperplasia (BPH).
  • Prostate cancer (CA of Prostate, Prostatic Adenocarcinoma).
  • Prostatitis.

Treatment of Benign prostate hyperplasia (BPH)

The symptoms of outflow obstructions or LUTS secondary to Benign prostate hyperplasia (BPH) usually waxes and vanes with time. These symptoms can be described as mild, moderate or severe.

In early cases, the symptoms can sometimes disappear even without any treatment. During that period the patient may need some help and can be treated conservatively. They may be advised to do regular checkups with the urologists to detect earlier complications. However, if the symptoms increase and the condition begins to create a danger to patient's health or causes a major inconvenience to his life style, the treatment is recommended. Benign prostate hyperplasia (BPH) can also be brought to light by the presence of Urinary Tract Infection (UTI) which generally is treated first.

There are various types of treatment available for the mild, moderate and severe Benign prostate hyperplasia (BPH):

Mild BPH

Moderate BPH

Severe BPH

Conservative or Medical Treatment for BPH:

  • There has been a constant research to find a newer drug for the treatment of BPH. These drugs are either aimed at shrinking the prostate gland and/ or prevent the growth of the prostate or facilitate the passage of urine by relaxing the obstructed passage which is been caused by BPH. FDA has approved a few drugs. The FDA also approved the drugs terazosin (Hytrin) in 1993, doxazosin (Cardura) in 1995, tamsulosin (Flomax) in 1997, and alfuzosin (Uroxatral) in 2003 for the treatment of BPH. All four drugs act by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and to reduce bladder outlet obstruction. The four drugs belong to the class known as alpha blockers. Terazosin and doxazosin were developed first to treat high blood pressure. Tamsulosin and alfuzosin were developed specifically to treat BPH.
  • Though the medical treatment may give relief in some selected cases it is important not to prolong the medication just to escape surgery.

Minimal invasive therapy

Because drug treatment is not effective in all cases, researchers in recent years have developed a number of procedures that relieve BPH symptoms but are less invasive than conventional surgery.

High-intensity focused ultrasound. The use of ultrasound waves to destroy prostate tissue is still undergoing clinical trials in the United States. The FDA has not yet approved high-intensity focused ultrasound.

Surgical Treatment for Benign prostate hyperplasia (BPH):

Most of the urologists will recommend removal of the enlarged part of the prostate which is symptomatic.The gold standard for the surgical treatment for Benign prostate hyperplasia (BPH) is Trans Urethral Resection of Prostate (TURP). This treatment is offered to the patients with signs and symptoms of outflow obstruction / LUTS secondary to Benign prostate hyperplasia (BPH). In this surgery, only the enlarged tissue that is causing obstruction to the urethra is removed. The rest of the peripheral tissue which is outside the capsule are left intact. This usually helps them in relieving the obstructions and other symptoms of Benign prostate hyperplasia (BPH).

Trans Urethral Resection of Prostate ( TURP)

This surgery is generally performed under spinal / epidural anesthesia and there is no external incision or cut is required. The urologist passes a fine instrument through the urinary passage called urethra and reaches the prostate.

Trans Urethral Resection of Prostate (TURP) is the procedure done for the Benign prostate hyperplasia (BPH). More than 90% of prostate surgery can be done through this trans urethral route. The technique of Trans Urethral Resection of Prostate (TURP) uses an instrument called resectoscope which is passed through the penis. This resectoscope is about 12 inches long and ½ inch in diameter contains a light source a lens which is connected with the camera, valves for controlling irrigating fluids and electrical loupe that cuts the tissue (prostate) and controls the bleeding.

The urologist uses the wire loupe to remove the obstructed tissue in piece meal. These pieces of tissue are carried by the fluid into the bladder and finally flushed at the end of the procedure.

Trans urethral procedures are less traumatic than open surgery and require a much shorter recovery period. The patient can be discharged in 2-3 days time. This procedure is not undertaken in individuals who have yet to complete their family planning. This is so, as there is a side effect of retrograde or backward ejaculation. In this situation semen flow backward into the bladder during the climax instead of flowing out of the urethra.

Some urologists sometimes may perform TUIP that is Trans Urethral incision of prostate for a smaller gland. They do not remove the tissue, as in case of Trans Urethral Resection of Prostate ( TURP), but simply make few cuts at the bladder neck. The advantage of this procedure and long term results 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

Holmium lasers are used to enucleate obstructing prostate lobe. The doctor passes the laser fiber through the urethra into the prostate using a cystoscope and then delivers holmium laser. The laser energy cuts and coagulates the prostate tissue. Hence there is no bleeding As with Trans Urethral Resection of Prostate (TURP), laser surgery requires anesthesia and a hospital stay. One advantage of laser surgery over Trans Urethral Resection of Prostate (TURP) is that laser surgery causes little blood loss. Laser surgery also allows for a quicker recovery time. But laser surgery may not be effective on larger prostates. The long term effectiveness of laser surgery is not known.

Your Recovery After Surgery in the Hospital

The amount of time you will stay in the hospital depends on the type of surgery you had and how quickly you recover.

Foley catheter

At the end of surgery, a special catheter is inserted through the opening of the penis to drain urine from the bladder into a collection bag. Called a Foley catheter, this device has a water-filled balloon on the end that is put in the bladder, which keeps it in place.

This catheter is usually left in place for several days. Sometimes, the catheter causes recurring painful bladder spasms the day after surgery. These spasms may be difficult to control, but they will eventually disappear.

You may also be given antibiotics while you are in the hospital. Many doctors start giving this medicine before or soon after surgery to prevent infection. However, some recent studies suggest that antibiotics may not be needed in every case, and your doctor may prefer to wait until an infection is present to give them.

After surgery, you will probably notice some blood or clots in your urine as the wound starts to heal. If your bladder is being irrigated (flushed with water), you may notice that your urine becomes red once the irrigation is stopped. Some bleeding is normal, and it should clear up by the time you leave the hospital. During your recovery, it is important to drink a lot of water (up to 8 cups a day) to help flush out the bladder and speed healing.

Do's and Don'ts

Take it easy the first few weeks after you get home. You may not have any pain, but you still have an incision that is healing-even with transurethral surgery, where the incision can't be seen. Since many people try to do too much at the beginning and then have a setback, it is a good idea to talk with your doctor before resuming your normal routine. During this initial period of recovery at home, avoid any straining or sudden movements that could tear the incision.

Here are some guidelines:

  • Continue drinking a lot of water to flush the bladder.
  • Avoid straining when having a bowel movement.
  • Eat a balanced diet to prevent constipation. If constipation occurs, ask your doctor if you can take a laxative.
  • Don't do any heavy lifting.
  • Don't drive or operate machinery.
  • Getting Back to Normal After Surgery

Even though you should feel much better by the time you leave the hospital, it will probably take a couple of months for you to heal completely.

Dilip Raja