The prostate is normally a walnut-sized gland located just below the urinary bladder. Its primary function is the secretion of seminal fluid, or semen, to nourish and protect sperm. Because of its location, however, it is also intimately involved in urination. Prostatic diseases such as benign prostatic hypertrophy, more commonly known as BPH, often manifest as difficulties with urination. For example, those with an enlarged prostate might find they have a decreased flow of urine or that they have to strain more than they did previously to start their urinary stream. In addition, they might find that they have to get up once, twice, or even three times during the night to urinate.
In order to understand diseases of the prostate and how they affect urination the normal process of urination must be understood. When men attempt to urinate, the urinary bladder contracts and the urinary sphincter relaxes. This allows urine to pass from the bladder and out of the body through the urethra, a tube that runs from the bladder through the prostate and the penis. The prostate completely surrounds the first part of the urethra. Thus, it is a conduit through which the urine must flow before leaving the body. Also, by virtue of its location just below the bladder, the prostate is involved to a certain degree in holding urine or what one can think of as the male continence mechanism or male urinary sphincter.
BPH is the nonmalignant enlargement of the prostate gland. Prostatic growth and enlargement is a natural process that occurs in all normal men. It occurs to varying degrees; in some men growth can be excessive and can obstruct the flow of urine.
The prostate is tightly confined within the body by a capsule and cannot expand outward. Therefore, as the prostate enlarges it is forced inward, into the urethra (the urine passage). The result is the blockage of the urethra and the flow of urine. In some cases, obstruction of urine flow may occur without dramatic prostatic enlargement. For other patients, significant enlargement of the prostate can be present without noticeable urinary symptoms. Although urinary problems are more common as men age and the prostate enlarges, prostate size does not always directly correlate with urinary symptoms or obstruction.
BPH primarily affects men over the age of 40, of all races and ethnic backgrounds. In fact, approximately 80% of men over the age of 70 have some degree of BPH. Fortunately, not all men will suffer bothersome symptoms. Currently, it is estimated that 25%-50% of men with an enlarged prostate have some degree of bothersome urinary symptoms and can benefit from some form of medical or surgical treatment.
First & Foremost
Benign enlargement of the prostate, or BPH (benign prostatic hyperplasia), is a common condition in older men. Significant enlargement of the prostate may occur before causing symptoms. The first symptoms of BPH are usually slow urinary flow, frequent urination, and the need to return to the bathroom shortly after voiding.
Occasionally BPH causes urine to be retained in the bladder. When this happens, urine may back up into the kidneys, which can result in kidney failure, inability to empty the bladder (urinary retention), formation of stones within the bladder, or urinary tract infections (that are otherwise rare in men.)
Initial treatment of BPH involves medications, with other, more effective and more invasive options available for treatment if medications are not effective or not tolerated because of side effects. Improvement of symptoms by medications is all that is used for treatment in most cases.
BPH Causes & Risk Factors
BPH (benign prostatic hyperplasia) is a natural consequence of aging and is more likely to occur in men whose fathers or brothers experienced prostate enlargement. However, BPH occurs in nearly all men over time, as long as they have testes. About 50% of men who are 50 have evidence of microscopic enlargement of the prostate gland, and at least 30% of men require treatment by the time they reach 70 years of age.
Signs & Symptoms
The symptoms caused by BPH can be obstructive and irritative. Obstructive symptoms result from the mechanical obstruction of the flow of urine caused by the prostate. As a man’s bladder contracts to empty, it has to overcome the obstruction caused by the enlarged prostate. Irritative symptoms are often a combination of the mechanical obstruction and the effects of obstruction. Because the prostate is enlarged, the bladder must work harder to empty. In doing so it undergoes a series of changes that result in a “hypersensitive bladder”. The hypersensitive bladder then partly causes some of the irritative symptoms discussed below.
Obstructive Symptoms
• Hesitancy/straining – When the urethra is obstructed, it is often difficult to start urinating despite the urge. Men strain or bear down, as if attempting to have a bowel movement, to start their urinary stream.
• Weak stream/intermittency – Flow of urine may be slow or diminished and urination may be characterized by a repeated start-stop pattern that requires additional straining.
Irritative Symptoms
- Frequency – Due to changes in the bladder wall, as well as incomplete emptying of the bladder, needs to urinate frequently.
- Nocturia – Nighttime frequency, this symptom describes the inability to sleep through the night without having to get up to urinate.
- Urgency – The sudden, intense and sometimes uncontrollable urge to urinate that results from having a hypersensitive bladder.
Course
Benign prostatic hyperplasia often initially manifests as hesitancy (difficulty starting urination) or a weak urinary stream. Patients usually associate this with a need to strain their abdominal muscles when attempting to urinate. It also may present as a need to urinate more frequently during the day or at night. Urgency symptoms may or may not be present at this time. Blood in the urine, known as hematuria, can occur in patients with BPH either as a presenting symptom or later in the course of the disease.
As the disease progresses the nocturia, hesitancy, straining, and weak stream often worsen. The result is an inability to completely empty the bladder and the development of what is commonly referred to as “residual urine.” The presence of residual urine may lead to other problems such as urinary tract infection, bladder stones, or in the worst case scenario, kidney failure.
Changes in the bladder and its ability to function may occur over time, especially if the obstruction goes untreated. The bladder responds to prostatic obstruction by developing a thicker, stronger muscular wall. Often this “compensatory hypertrophy” of the bladder, which is associated with development of scar tissue (collagen deposition) in the bladder wall, may make the bladder sensitive or irritable. Patients with a hypersensitive bladder may suffer urgency, resulting in the constant urge to urinate. In more severe cases, a patient may develop urge incontinence, or the inability to get to the bathroom before losing control of their bladder.
Untreated BPH may worsen. Residual urine may increase in volume, putting patients at increased risk of having stones, infections, or kidney failure. In the final stages of the disease, the patient is unable to empty his bladder at all and urinary retention ensues. This necessitates immediate medical intervention with the placement of a catheter, or rubber tube, either through the penis or lower abdominal wall into the bladder to facilitate drainage. Once at this stage, if ignored, the bladder can enter a final phase where the bladder fails to contract. This situation requires long-term drainage of the bladder with a catheter. In some cases, this is continued until the bladder recovers and the obstruction is treated. If the bladder fails to recover, permanent drainage of the bladder with a catheter may be required.
Observation
Observation is usually reserved for those patients with minimal symptoms. Although symptoms are not particularly bothersome, these patients should continue to see their physicians regularly (yearly) for examinations and routine laboratory tests. These tests are designed to avoid having urine back up toward the kidneys (hydronephrosis) or bladder decompensation (“silent prostatism”). Patients followed by observation may eventually require medication or surgical intervention if they develop complications such as bladder stones, urinary retention (inability to urinate), recurrent urinary tract infections, or signs of kidney damage.
Standard surgical options include: transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), and open prostatectomy.