“Prostate” meaning “one who stands before” in Greek.
“Prostate” gland sits beneath the bladder deep inside the pelvic cavity, in front of the rectum and looking up from below when the urethra (waterpipe) leaves the bladder to traverse the prostate gland, it stands before the bladder like a bouncer on the doors of a night club.
Prostate is an accessory reproductive gland that participates in the male sexual / ejaculatory function, by contributing 20% to the volume of the ejaculate / semen.
From the age of 30 yrs. prostate gland gradually enlarges in size under the influence of the male hormone produced by the testes called: “testosterone”
When testosterone from blood circulation enters the prostate, it is converted by an enzyme (5 alpha reductase: 5AR) in the prostate into a biologically active product called: dihydrotestosterone (DHT), which fuels growth of the prostate from the age of 30 yrs.
There are other growth factors that also contribute to the enlargement of the prostate gland with advancing age.
In other words, No testes: No prostate enlargement, No enzyme (5AR): No prostate enlargement
Prostate gland has two distinct parts: fibromuscular and glandular.
In the early years the fibromuscular part enlarges creating a tight muscular ring around the urethra and cause symptoms like caused by prostate enlargement without an actual increase in the size of the prostate, hence referred to as: “prostatism sans prostate”
With enlargement of the glandular part of the prostate at or around 40 yrs. of age, the physical size of the enlarging prostate strangles the urethra as it leaves the bladder and causes symptoms termed as prostatism or prostate related symptoms.
Three types of prostate enlargement related symptoms affect men at or after 40 yrs. of age:
Storage type: Have to pee too often both day / nights, can’t hold urine long, leakage of urine
Voiding / Micturition type: Takes long to make a start, takes long to finish, slow, intermittent flow
Post Micturition type: Feeling of not emptying the bladder, dribbling urine after finishing to pee
In addition, in a significant majority of cases, men also suffer from sexual dysfunction (erectile dysfunction: ED) coexisting with urinary symptoms, which they hesitate to report on and as such it needs to be considered in their initial assessment and individual case-based treatment plan.
Initial treatment options based on severity of symptoms (mild – moderate – severe) inc.:
Life style changes: Caffeine / Alcohol
Education: Fluids restriction, Dietary changes, Bowel habits
Reassurance:
Next line of therapy includes various types of medications based upon:
Predominant type of symptoms: storage or voiding or mixed
Size of the prostate: < 30 cc (fibromuscular), > 30 cc (glandular)
Presence of Sexual dysfunction coexistent with prostate symptoms
It is only after these conservative, medical treatment options fail to address or improve prostate related symptoms that surgical or invasive interventional options need to be explored and discussed with these men who are in desperate search of a solution for their symptoms refractory to treatment received thus far and remain significantly bothered by their symptoms, adversely affecting their overall quality of life.
There is no such thing as the “most effective” treatment option for addressing prostate enlargement. Treatment plan is very much an individual based and need based plan, chiefly governed by the individual’s type and severity of symptoms and their impact on his quality of life and finally his expectations from the treatment he has been offered / he has accepted.
And that is why it is most important that the individual is involved at the outset in exploring all options available from top to bottom i.e. from non-invasive to minimally invasive to most invasive treatment options available and Urologist facilitating the process of “informed decision” that the individual makes re his chosen treatment option going forward.
If initial or first line treatment plan fails to deliver, then the individual has the option of moving on to the next best available in the order of treatment plan.
It is important at this stage to highlight the importance of “patient choice” as the most important and relevant in the context of choosing treatment and we as body of Urologists making it clear to the patient that we stick to the patients’ rights: “Nothing about me without me”
As stated above, an individual’s symptoms are stratified into mild, moderate, and severe as per a symptom scoring questionnaire called: International Prostate Symptom Score (IPSS).
Those with mild symptoms (IPSS: 0-7) should be offered life style advice, dietary / fluid changes in their symptom management and perhaps at 6-week review offered medications as appropriate.
Those with moderate symptoms (IPSS: 8-19) should be considered for life style changes and medications: single agent or combination, depending upon the size of prostate based on physical assessment and or prostate scanning.
Those with severe symptoms (IPSS: 20-35) should be considered for combinations of medications for a few weeks in addition to life style measures and if they fail to respond to this approach or indeed have already exhausted these options, then should be offered various surgical options and Urologist should carefully take the individual through the Maze of treatment modalities available (some of which the individuals are already aware of having read about them in newspapers or researched on Google).
The surgical options are again to be tailor-made to the individual’s circumstances and expectations.
Here is a list of factors that need to be given due consideration before helping the individual make an informed decision re surgical options better suited for his index individual scenario:
Age: e.g. < 60 yrs., 60 –80 yrs., > 80 yrs.
Risk status / co-morbidities:
Size of the prostate: e.g. < 80 cc, > 80 cc, > 200 cc etc.
Prostate related co existing conditions / complications namely,
Urinary retention with catheter in situ, Bladder stone, High pressure on Kidneys with large bladder residue: > 500 cc, Recurrent bleeding from prostate
Individual’s desire / need to preserve sexual function namely, normal ejaculation, normal erections etc.
It must be made clear to individuals throughout assessment times that treatment for prostate enlargement is not based on “One size fit all” principle, but on the contrary: “One size doesn’t fit all”:
And here is a list of surgical options (minimally invasive to invasive) readily available to the individual and it is for the Urologist to skillfully take the individual through all these options, explaining the pros and cons of each and risks and complications associated with an individual procedure and finally, facilitate an informed decision making process for the individual and for him to be prepared with an answer for a half expected question from the patient: “What would you choose if you were in my position”.
Urolift: (Staples)
Rezum: (Steam)
TPLA: (Laser through skin)
iTind: (Stent)
Aquablation: (Water Jet)
TURP: (Rebore surgery: Gold Standard)
HoLap: (Laser vaporization)
HoLep: (Laser enucleation / removal)
PAE: (Artery blockade: cutting off blood supply)
TUNA: (Needle ablation): Not popular in UK
TUMT: (Microwave treatment): Not popular in UK
Long term urethral / suprapubic catheter placement for those too old or too unfit for anything: last resort
Men need to understand, and if not, should be educated, that benign prostate enlargement (BPE) with advancing age is a norm and is as inevitable as greying hair and as such, is to be accepted as a way of life.
Men should also be aware that size of the prostate does not always equate with symptoms and that small prostates can cause as many symptoms as a large prostate; on the other hand, large prostates may not cause any symptoms at all.
Hence, men getting their prostate scanned off their own back should not get carried away by the sheer size of their prostate noted on the scan; but ought to put it in the context of their symptoms and seek appropriate advice before getting concerned or embarking on any treatment.
Men ought to be aware that we as Urologist treat their prostate related symptoms and not just the size of the prostate; but prostate size matters when it comes to choosing an appropriate treatment plan for an individual case. Hence a diagnosis of BPE would be made if and when men experiencing urinary +/- sexual symptoms would seek advice from Urologist, sooner rather than later.
The take home message here for men experiencing symptoms related to their waterworks (usually related to or secondary to BPE) is not to ignore or brush aside these symptoms accepting them as a part of ageing but to get them addressed in good time, particularly if symptoms are adversely affecting their overall quality of life as well as quality of their sex life.
Benign Prostate Enlargement (BPE) would tend to affect quality of life in those men experiencing symptoms related to BPE, namely, getting up to pass urine too often at night (or during sleeping hours), frequent visits to the loo during daytime upsetting day to day working life, urgency (sudden desire to pass urine) at times fearing or experiencing leakage (incontinence), difficulty in emptying bladder, urinary infection with burning / stinging in passing urine, blood in urine or semen, pain in perineum (behind testes) threatening inability to pass urine (Threatened retention), erectile dysfunction.
These BPE related symptoms as one can appreciate, affect two individuals: patient and his partner and as such it is advisable that men seek urgent advice re their worsening urinary and or sexual symptoms not only to put themselves out of misery but also their partners.
Men should get themselves checked out re possible BPE as soon as they notice any of the relevant symptoms from those listed above and that they believe is adversely affecting their quality of life.
This is where an element of subjectivity or individual variation creeps in but we presently do not have a good screener or screening test for men to help diagnose BPE in the absence of symptoms.
Contrary to BPE, men with prostate cancer do not have any early symptoms indicative of cancer and as such most men confuse BPE related symptoms for prostate cancer and urgently seek advice only to be reassured that all their symptoms are in keeping with BPE and may warrant a type of treatment based on their severity.
The answer is NO. As stated earlier, Urologist are meant to treat or address symptoms related to BPE and not just the BPE, if it has no relevant symptoms attached to it. Moreover, there are no predictors or screeners for BPE and related symptoms, hence it is for men to volunteer and to proactively seek advice from Urologists at their earliest convenience when they experience any BPE related urinary +/- sexual symptoms. Once initially and fully assessed, men can then remain under surveillance re further development of BPE and related symptoms or indeed embark on a focused treatment plan most suited for one on an individual basis.
Men with BPE related symptoms will naturally be inclined to look up for more information on Google and will only to end up feeling alarmed about the possibility of harboring prostate cancer which is not very helpful, given that prostate cancer does not cause any of their presenting symptoms. Instead, seeking advice from their GP in the first instance and or eventually Urologist would be of immense help; not only in reaching a definitive diagnosis of BPE but also allaying their anxieties re possible prostate cancer.
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