Benign Enlargement of the Prostate Gland

The prostate gland lies just beneath the bladder in men. It goes around the top of the urethra (the tube that passes urine from the bladder). It is normally about the size of a chestnut.

The prostate helps to make semen but most semen is made by another gland nearby (the seminal vesicle). The prostate enlarges gradually after the age of 50. By the age of 70, about 8 in 10 men will have an enlarged prostate. It is therefore as normal to have a benign (non-cancerous) enlargement of the prostate in later life as it is to have grey hair or wrinkles. (Prostate cancer is a separate condition that is much less common and is not dealt with in this article).

What are the Symptoms of Benign Prostate Enlargement?

An enlarged prostate does not necessarily mean symptoms will occur. Some men with enlarged prostates have no symptoms. However, as the prostate enlarges it tends to press on the urethra just below the bladder which may cause symptoms. About 1 in 3 men aged over 50 have some symptoms due to an enlarged prostate.

 Symptoms include one or more of the following.

Usually the symptoms are mild to begin with. Perhaps a slight reduction in flow or having to wait a few seconds to start passing urine. As the years go by, symptoms may become more troublesome. In some people the symptoms become quite severe and a complete blockage of urine may develop (‘retention of urine’) needing urgent treatment.

NOTE: not all urinary symptoms in men are due to ‘prostatism’. In particular, passing blood or pain may be due to other bladder, kidney or prostate conditions. A doctor should be consulted if these symptoms occur or if there is a change from any usual symptoms.

Assessment and Investigations

Sometimes the symptoms can mimic other bladder problems. Doctors may examine the abdomen and the prostate gland. Examining the prostate is done by a rectal examination (examining inside the anus with a gloved finger). A urine and blood test is commonly done to check the function of the kidney and to rule out other causes of going to the toilet frequently (such as diabetes or urine infections). If symptoms are troublesome, a referral to a bladder specialist (urologist) is considered. Urine flow tests are sometimes done to confirm the diagnosis.

 Is Treatment Always Necessary?

No. As symptoms range from mild to severe, the options for treatment vary. For the majority of people, an enlarged prostate does not do any actual ‘damage’. Whether treatment is needed really depends on how much bother the symptoms cause. For example, to be woken 6 times a night, every night, with an urgent need to go to the toilet may be intolerable. Treatment may then be welcomed. On the other hand, slight ‘hesitancy’ each time urine is passed and getting up once a night to go to the toilet may cause little concern.

However, in a small number of people with an enlarged prostate, the examination or urine flow tests may indicate there is a partial blockage of urine causing ‘back pressure’ on the bladder and kidneys. This can cause further kidney damage or urine infections. In this less common situation, surgical treatment would usually be advised to prevent further ‘back pressure’ and damage. For some people who develop a sudden total blockage of urine, urgent treatment is usually needed.

Treatment Options for Benign Prostate Enlargement
No treatment or ‘watchful waiting’

If symptoms are mild then no treatment may be the best option. It depends on how bad the symptoms are affecting your life. The situation can be reviewed every year or so or sooner if there is a sudden change in symptoms. Symptoms do not always become worse. They may even improve.

One study of men followed up for 5 years with moderate symptoms and no treatment found the following:
In 9 out of 20 men the symptoms remained about the same.
In 8 out of 20 men the symptoms improved (without treatment).
In 3 out of 20 men the symptoms became worse.

Medication

There are two types of medicines that may help. Taking medication is an option for men with moderate symptoms or if surgery is not advisable due to other medical problems. Medication does not cure the problem, nor do symptoms usually go completely. However, symptoms may improve to a more tolerable level.

Alpha-blocker medication is usually the first treatment tried. There are several different types and brands available. These medicines work by relaxing the muscle tissue of the prostate gland and the outlet of the bladder. Most people will notice some improvement in symptoms when taking one of these medicines. However, the amount of improvement varies from person to person. Some men notice only a small improvement or none at all.

If symptoms are helped, the improvement is usually apparent within a few days but the full effect may take 4-6 weeks. A low dose is usually started and gradually built up over a few weeks. Side effects may be a problem with some people. These include slight drowsiness and dizziness. For this reason, alpha-blocker medication is usually taken at bedtime.

Finasteride is an alternative and is classed as a ‘5 alpha reductase inhibitor’. It works by interfering in the prostate with the conversion of the hormone testosterone to another hormone called dihydrotestosterone. Dihydrotestosterone is thought to cause the enlargement of the prostate. Therefore a reduced amount in the prostate tends to cause it to ‘shrink’. Symptoms may improve as the prostate becomes smaller. The full effect of finasteride may take up to six months whilst the prostate gradually ‘shrinks’.

It is important not to give up on this medicine too soon. In time, most people will notice some improvement in symptoms. As with alpha-blockers, the amount of improvement varies from person to person and may only be small or none at all in some people. Side effects are few and for most people this medicine is usually ‘well tolerated’. Two examples of uncommon side effects whilst taking finasteride are impotence and reduced sex drive.

The severity of symptoms of ‘prostatism’ are not related to the size of the prostate. A small or large enlargement may cause mild or severe symptoms. An alpha-blocker may help whatever the size of the prostate enlargement as it works by ‘relaxing’ the muscle fibres. Finasteride tends to work best in men with prostates that are particularly large that have more tissue to ‘shrink’.

Surgery Removal of the prostate gland is the common and well established treatment. This is an option for people with more severe symptoms or if medication has been tried and it did not help. The common operation is called ‘Trans Urethral Resection of Prostate’ (TURP). In effect the prostate is chipped away by a special instrument passed up the urethra of the penis. This operation is usually successful with a good improvement in symptoms in most people. However, in a small number of people symptoms are not improved and in some people complications may occur after the operation.

For example, about 1 in 10 men become impotent and about 1 in 100 men become incontinent of urine after the operation. More than half of men have ‘retrograde ejaculation’ after this operation. This means that during sex, the semen ejaculates into the bladder and is then passed out later with the urine. As in all operations, there is a small risk of death.

Other surgical techniques such as microwave shrinkage or laser treatment of the prostate are being developed. The role of these techniques is not yet established but they may become an option in the future.