Urology Information

Enlarged Prostate: Your guide to early diagnosis and treatment

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Basic facts
A common condition
Symptoms and diagnosis
Treatment options
ILC: A significant advance in BPH treatment
Questions and answers about enlarged prostate and ILC
Questions to ask your doctor

ENLARGED PROSTATE -- BASIC FACTS

Enlarged prostate, or benign prostatic hyperplasia, is a condition which eventually affects 80 percent of all men.

It rarely occurs in men before age 40, and most commonly after age 60.

Enlarged prostate is not prostate cancer, and is not life-threatening in and of itself.

The main problem from an enlarged prostate is difficulty in urination, which may lead to blockage and infection and have a negative impact on quality of life.

There are many treatment options for enlarged prostate, including new minimally invasive therapies that can be an alternative to traditional surgery.

Early diagnosis is the key to successful treatment. All men over the age of 50 should have a regular prostate exam. Men of African-American descent or those with a family history of prostate cancer should begin regular screenings at age 40.

Chances are you haven't given your prostate much thought. You may not even be sure exactly wait it is. But as all men get older, the prostate may become a source of problems, ranging from simply bothersome to serious. Learning about potential problems now can help you make better decisions about treatment should trouble ever arise.

This information covers the most common prostate condition: enlarged prostate, or benign prostatic hyperplasia. You'll learn what it is, what its symptoms are, and what you can do about it. But, most importantly, you'll learn that enlarged prostate is a condition that can be treated, especially when diagnosed early.

If you're having symptoms, see your doctor to discuss them. He or she can help you determine the steps to take toward successful treatment.

ENLARGED PROSTATE -- A COMMON CONDITION

Prostate enlargement (otherwise known as benign prostatic hyperplasia, or BPH) is one of the most common health problems faced by men over 40. In fact, about 50 percent of men will experience prostate problems in their sixties, a number that grows to about 80 percent of men by the time they reach their eighties. So if you are experiencing symptoms of enlarged prostate, you're not alone.

THE PROSTATE: WHAT IS IT?

The prostate is a gland involved in the male reproductive system. It is located just below the bladder, surrounding the bladder opening (called the urethra) like a doughnut.

The prostate is composed mostly of muscular and glandular tissue. Its primary job is to produce fluid for semen, the white fluid that transports sperm.

WHAT HAPPENS AS A MAN GETS OLDER

For most of a man's life, the prostate is small, about the size and shape of a walnut and weighing only about an ounce. In fact, it only undergoes two main growth periods during its life. The first is during puberty, when the prostate doubles in size. The second growth period begins at around age 25. This second growth phase is what often results, years later, in the condition known as enlarged prostate, or BPH. It's important to realize that this condition in a benign growth of the prostate. BPH is not cancer, nor does it lead to cancer.

The cause of BPH isn't entirely understood. Some researchers believe it may be related to hormonal changes that occur later in a man's life.

HOW AN ENLARGED PROSTATE AFFECTS YOU

Prostate enlargement usually starts at the innermost part of the prostate, the part closest to the urethra. It's easy to imagine what happens - as the prostate grows, it gradually begins to squeeze the urethra, like a clamp on a garden hose. Urination becomes more difficult, and the bladder may not be able to empty completely, keeping small amounts of urine behind. This combination of blocked urethra and irritated bladder, if left untreated, can lead to more serious problems, including infection and damage to the kidneys and bladder.

SYMPTOMS & DIAGNOSIS

Most symptoms of an enlarged prostate involve urination, and they can range from mild to bothersome to severe, when a man isn't able to urinate at all. It's important to check with your doctor as soon as you notice anything unusual with regard to urination.

MOST COMMON SYMPTOMS

The symptoms of an enlarged prostate may vary, but "typical" symptoms include:

• Weak urine stream
• Hesitancy of stream
• Nighttime urination
• Frequent urination
• Urgent urination
• Sensation of incomplete bladder emptying
• Starting and stopping of urination
• Painful or burning urination

Often, the severity of symptoms is related to how constricted the urethra is by the prostate. Without treatment, these symptoms may continue to worsen as the condition progresses.

Tests used to diagnose prostate enlargement

You may, especially if you're over 60, first notice symptoms yourself. Or, your doctor may find that your prostate is enlarged during a routine physical exam. During this exam, your doctor will take your medical history and check your urine. He or she will also perform a digital rectal exam (or DRE), which is a simple, painless test in which the doctor feels inside the rectum to check the size and consistency of your prostate.

When prostate enlargement is suspected, you may be referred to an urologist, a physician who specializes in problems of the urinary tract and male reproductive system. This doctor may want to perform other tests to help determine the best course of treatment. These tests may include:

-- Ultrasound, an image formed with sound waves that helps the doctors assess the prostate and any obstruction.

-- Urine flow study, a test to determine how quickly urine is flowing. A slow flow may suggest an enlarged prostate.

-- Intravenous pyelogram (IVP), an x-ray of the urinary tract. For this test, dye is injected into a vein, and an x-ray is taken. The dye helps doctors see urine on the x-ray and any blockage caused by the prostate.

-- Cystoscopy, a test in which the doctor inserts a small telescope through the urethra to see the inside of the urethra and bladder. With this, the doctor can see the size of the gland and the location of the obstruction.

-- Complete AUA Symptoms Score survey, a series of questions the doctor will ask to help better assess your symptoms.

Because enlarged prostate is so common, and so treatable, it's important to have an annual physical examination that includes a prostate exam after the age of 50 (or after 40, if you're an African-American or have a family history of the disease).

A VARIETY OF TREATMENT OPTIONS

The good news about prostate enlargement is that it is treatable. You don't have to endure its symptoms, and you and your doctor will probably find a treatment option that's right for you.

If you have prostate enlargement but are experiencing no symptoms or urinary obstruction, you and you doctor may decide that "watchful waiting" is the best option. This may mean no active treatment, but simply yearly or more frequent checkups to evaluate your condition.

Currently, treatment options for enlarged prostate fall into three categories:

• Drug therapy
• Surgery
• Minimally invasive treatments

Each treatment offers both advantages and disadvantages, and the treatments may vary in terms of their effectiveness. Be sure to discuss all your options with your doctor before reaching a decision.

Drug Therapy

If your prostate enlargement is in the mild to moderate range, your doctor may suggest medication as your first treatment option. There are currently four drugs on the market used to treat enlarged prostate. Proscar (finasteride) inhibits the production of the hormone that is involved with prostate enlargement. Hytrin (terazosin), Cardura (doxazosin), and Flomax (tamsulosin) all work to relax the muscle of the prostate and bladder neck to improve urine flow and reduce obstruction.

While many men find relief with medication, you should know that there are disadvantages as well. Drug therapy means a lifelong commitment to a drug regimen, because once the medication is ceased, symptoms will return. Also, some men experience side effects, and others have found that the effectiveness of medications decreases over time. Should that happen, your doctor may opt for another treatment option.

Surgery

In the past, removing the excess prostate tissue via surgery was recommended as the best long-term treatment for enlarged prostate. However, drug therapy and other less invasive treatments have given you more options.

When surgery is indicated, however, there are three main surgical options. In all of them, only the enlarged prostate tissue is removed, leaving the healthy portion intact.

Transurethral resection of the prostate (TURP) is probably the most common prostate surgery for enlarged prostate. No external incision is used. Instead, a surgeon inserts an instrument through the urethra in the penis and removes excess tissue one piece at a time. The tissue is "flushed" out of the body by the surgeon at the end of the procedure. Side effects of this procedure include risk of impotence, incontinence, and retrograde ejaculation (when a man's ejaculation fluid goes backwards into the bladder instead of existing out through the urethra). TURP typically requires a hospital stay of one to three days.

Transurethral incision of the prostate (TUIP), another transurethral procedure, widens the urethra by making a few small cuts in the bladder neck, where the urethra joins the bladder, and in the prostate itself to ease the flow of urine. No prostate tissue is removed. In some cases, TUIP relieves symptoms as effectively as TURP, with less risk of certain side effects. This procedure is typically limited to patients with relatively small prostate glands.

Open prostatectomy is typically reserved for cases in which the prostate is greatly enlarged or when a transurethral procedure cannot be done for other reasons. In this procedure, anesthesia is given and an incision is made in the abdomen. When a surgeon reaches the prostate, he or she scoops out the enlarged tissue. A hospital stay of two to three days is typically required.

It's important to note that with prostate surgery comes risks of certain side effects, including difficulty attaining erections, ejaculation problems, or incontinence. Side effects from these procedures are different for each patient.

Minimally invasive treatments

You may have heard of new, minimally invasive procedures being developed using a variety of new technologies and techniques. These options have been developed in the effort to find new options which both reduce the risk of side effects and enhance patient comfort.

Interstitial laser coagulation (ILC) is one of the newest and most widely used minimally invasive therapies. In ILC, excess prostate tissue is quickly heated and destroyed (coagulated) using a laser. The procedure is performed through a small telescope-like device that lets the doctor see the prostate directly. The precision of the laser helps surgeons destroy only the enlarged tissue, minimizing the risk to the surrounding prostate or urethra. The destroyed prostate tissue is absorbed naturally by the body, decreasing the symptoms of your prostate problem. A variety of anesthesia techniques, including local anesthesia, may be used, and for many patients, an overnight hospital stay is not required. Side effects such as retrograde ejaculation, impotence, or incontinence compare favorably with other procedures. Patients typically require catheterization after the procedure.

Transurethral microwave thermotherapy (TUMT) involves microwaves to heat and destroy excess prostate tissue. TUMT can be performed in an hour or two on an outpatient basis. Some patients may experience discomfort due to the high power level used during the procedure. Side effects include temporary urinary retention and a low risk of retrograde ejaculation. Some studies show many patients required re-treatment within four years of TUMT.

Transurethral needle ablation (TUNA) uses radio waves to relieve obstruction without damaging the urethra. Often, it can be performed under local anesthesia and doesn't require a hospital stay. Potential side effects include temporary difficulty and pain with urination, and a low risk of retrograde ejaculation and impotence. Not all parts of the prostate can be treated using this method.

Minimally invasive treatments are often appropriate as a alternative to medication or when medication fails. Not all patients may benefit, however, when surgery is needed.

ILC: A SIGNIFICANT ADVANCE IN BPH TREATMENT

This procedure, which is currently being performed world-wide, shows great promise in treating prostate enlargement.

How ILC works

In ILC, a special fiber optic is inserted directly into the prostate (via the urethra). That fiber delivers heat energy (from a laser source) to a precise area of the gland. The tissue is heated and dies, or coagulates. No cutting of tissue is involved. The coagulated tissue is gradually absorbed by the body. As the prostate tissue is absorbed, the urethra returns to its normal shape and size, and urine can flow more freely again. The symptoms of the enlargement decrease over time.

Studies have shown that ILC is a safe and effective treatment for enlarged prostate, resulting in significant improvement in symptoms.

Advantages to you

ILC offers many benefits to you. First, the fact that it's minimally invasive means you'll increase your chances of an easy recovery and lower your risk of surgical complications.

One clinical study has shown that ILC compares favorably with TURP with regard to post-operative complications - particularly incontinence and retrograde ejaculation - over the 6-month evaluation period of the study. In another study, no ILC patient became incontinent or impotent, and only one developed retrograde ejaculation.

And because the fiber is designed to treat a specific area of prostate tissue, the risk of damage to surrounding tissue of the prostate and urethra may be minimized, reducing your risk of complications.

The ILC procedure

The ILC procedure can be performed in an outpatient setting or in the hospital, whichever your doctor feels is best. Before treatment begins, you'll receive an anesthetic. One benefit of ILC is that it can be performed under a variety of anesthetics - an option you should discuss with your doctor. Some patients require only local anesthesia.

The urologist will then insert a cystoscope, with which he or she can view the prostate using a direct telescopic view. The cystoscope is inserted through the urethra. Once the doctor determines the area for coagulation, the special fiber is inserted directly into the prostate through the cystoscope. The laser is then switched on and energy is delivered to a precise area of prostate tissue for about three minutes. The process is repeated several times to several different areas of the prostate. Once complete, the doctor withdraws the fiber and the cystoscope, and the coagulated tissue is gradually absorbed by the body over time.

Because the procedure causes initial swelling, you'll need a catheter. This shouldn't restrict your activity and can be removed in about a week.

QUESTIONS AND ANSWERS ABOUT ENLARGED PROSTATE AND ILC

Compared with other treatment options, ILC may offer some important advantages for you. But you may still have questions, and you should discuss any questions or concerns with your doctor. This guide will answer some of the common questions about ILC and suggest some questions you may want to ask your doctor.

I'm currently on medication for BPH. Could ILC be an alternative for me?

Possibly. Some patients notice a decline in their medication's effectiveness after a couple of years. If this happens to you, ILC may be an appropriate next step.

I have friends that have had TURP's. How is ILC different?

In a TURP sections of the prostate are actually removed surgically. In ILC, a special laser is used to heat and destroy tissue which is then absorbed by the body. The ILC procedure is minimally invasive, and side effects that are often associated with TURP, such as incontinence and retrograde ejaculation, may be minimized.

By looking at a number of studies done in recent years, many doctors agree that ILC offers symptomatic relief in the same range as TURP.

It is important to realize that ILC is not necessarily an option for patients who require surgery.

Am I a candidate for ILC?

All patients are different, and your doctor must approach your treatment individually. However, for many patients with BPH, ILC is an effective option.

For many patients, hospitalization is not required following the ILC procedure, this will, of course, depend on your particular situation and recovery needs.

What sort of anesthesia is used?

ILC is a minimally invasive procedure, and can be performed with a variety of types of anesthesia, including local anesthesia. Your doctor will consult with you on the anesthesia method that is best for you.

How long will I need a catheter?

A catheter is needed because the treatment does cause some swelling initially. A catheter will facilitate urination for a short time post-operatively. Depending on the amount of swelling catheterization usually is only necessary for 7 to 10 days post-op, although some patients have their catheters removed within a few days after the procedure.

Will I experience any side effects?

Some slight bleeding and urinary discomfort aren't unusual in the days after the procedure. More permanent side effects, like impotence, retrograde ejaculation, and incontinence, while possible, compare favorably to other procedures.

What follow-up care is necessary?

You'll probably see your doctor 10 days after the procedure, then for regular checkups.

When will I notice relief from my symptoms?

You should notice symptom improvement within 3 to 4 weeks. Typically, peak improvement is seen at 6 weeks post-procedure, with symptoms continuing to improve over 8 to 12 weeks.

When can I return to work?

Your doctor is best able to judge when you'll be able to return to work and normal activity. Typically, the ILC treatment is designed to help you get back to your life quickly.

QUESTIONS TO ASK YOUR DOCTOR

What experience do you have with interstitial laser coagulation (or ILC)?

How has it worked for your BPH patients?

Am I a candidate for this procedure?

What type of anesthesia do you use?