Obstruction ahead!
By Prof Dr AZAD HASSAN ABDUL RAZACK
Sunday February 12, 2012
Are you at risk of benign enlargement of the prostate?
THE prostate gland is walnut-sized gland that is located below the bladder and in front of the rectum. It is surrounded by the urethra (urinary passage for the flow of urine from the bladder to the outside of the body).
The prostate gland produces fluid which forms part of the semen that carries the sperm on ejaculation.
This gland starts to increase in size from puberty onwards, but there is a greater increase from 40 years of age onwards, and by the age of 80, more than 80% of men will have an enlarged prostate.
Enlarged prostate gland
The reason for the enlargement of the prostate gland, or benign prostatic hyperplasia (BPH), is not very clear, but is related to the male hormone, testosterone.
Ageing is a definite risk factor. It is well known that boys who have their testes removed before puberty, for various reasons, do not develop BPH.
In Malaysia, more than 50% of men above 50 years of age have symptoms attributed to an enlarged prostate gland. With the expected change in the population demography, it is expected that the number of men with these symptoms will continue to increase.
Men with enlarged prostate glands can develop various symptoms which are generally classified as lower urinary tract symptoms (LUTS). They include:
*Slowing down of the urinary stream
*Straining to pass urine
*Delayed start of the urinary stream
*Dribbling at the end of micturition
*Feeling of incomplete emptying of bladder
*Inability to pass urine (urinary retention)
*Incontinence of urine
*Passing urine more frequently
*Waking up at night to pass urine, usually more than twice a night
*Strong and sudden urges to pass urine
*Pain during urination
*Blood in the urine
Patients can have some of the symptoms or all of the symptoms. It is also possible for patients with an enlarged prostate gland not to have any symptoms at all.
These symptoms can be assessed more objectively using what is called the International Prostate Symptom Score (IPSS). It consists of questions grading the severity of each symptom. This is then added up to indicate the severity of the symptoms.
The IPSS can vary from 0-35. Generally, a score of 0-7 is considered mild, 8-19 is moderate, and 20-35 is severe.
All these symptoms are non-specific and do not always indicate prostate enlargement. Other conditions which can give rise to these symptoms include urinary tract infection, bladder stones, bladder tumours and narrowing of the urethra (urethral stricture).
Patients with neurological problems can also experience some of the urinary symptoms mentioned above as any interference of the nerve supply to the bladder can have an impact on the behaviour of the bladder, resulting in some of the symptoms above.
It is also useful to point out another symptom which is not related to an enlarged prostate gland, but is common in older men, and which can also occur in younger men – what is called post-micturition dribble. This happens after passing urine and as the person starts to wear his pants, a few drops of urine will leak out.
The reason for this is simply because a few drops of urine remain in the urethra after the bladder has stopped contracting, which then slowly trickles out of the urethra. It is not due to an enlarged prostate gland and does not improve with the usual treatment for BPH.
In view of the varied symptoms and different underlying causes for similar symptoms, it is important for men with these symptoms to consultant a doctor.
Physical symptoms
Men with these symptoms need to have some basic physical examination. These include a general examination, a focused neurological examination and examination of the abdomen.
Examination of the external genitalia is important as conditions such as narrowing of the external meatus and phimosis (tightening of the foreskin over the glans) can give rise to similar symptoms.
Digital rectal examination is used to initially assess the size and consistency of the gland. Since the prostate is just in front of the rectum, it is the best way to clinically assess the gland.
New studies indicate that bigger glands are better treated with different types of medication compared to smaller glands. This will be discussed further in the treatment section.
Diagnosing BPH
Some of the tests carried out to help diagnose BPH include the following:
Urine analysis – to look for evidence of possible infection and for presence of any red blood cells, which could indicate other underlying causes for the symptoms.
Blood test – to assess kidney function to ensure that the enlarged gland has not resulted in obstruction that could lead to impairment of kidney function. This will also have an impact on the choice of treatment.
Urine flow – a patient is asked to pass urine into a special machine that is able to measure the speed of the urinary flow. It is a very simple test and it is best if the patient passes urine as naturally as possible to improve the accuracy of the test.
Blood test for prostate specific antigen (PSA) – there has been a lot of controversy regarding this test, as can be seen by the response to the recent recommendation in the US by the US Preventive Service Taskforce. Generally, PSA is tested on patients who present with symptoms, but the implications of this test need to be understood by the patient before agreeing to it.
PSA is a marker for prostate cancer. However, it is not an accurate test as not all those with raised PSA have prostate cancer, and not all patients with PSA below the normal level do not have prostate cancer.
Basically, PSA alone cannot be used to determine if a patient has prostate cancer. So any patient who agrees to do a PSA test should be willing to further undergo a biopsy of the prostate to determine if there is prostate cancer or not.
Measurement of residual urine – this is to determine the amount of urine left behind in the bladder after passing urine. This is measured in most instances by performing an ultrasound. The larger the residual urine, the more likely the patient could have urinary retention in the future.
Treating BPH
Watchful waiting – BPH is a disease of symptoms and needs treatment only if the symptoms are bothersome or if the enlargement is giving rise to life-threatening complications.
Those with mild symptoms and with no impact on their quality of life can be followed-up with regular assessment of symptoms and looking out for possible complications.
Medical treatment
*lAlpha blockers – relax the smooth muscles around the bladder neck and the urethra. By this action, the resistance to the flow of urine is reduced and makes the flow of urine faster.
*5-Alpha Reductase Inhibitors (5 ARI) – this drug works by reducing the size of the prostate gland – generally, the size of the gland reduces by 25% after about six months of treatment. It is a very useful drug in the treatment of patients with bigger glands. It is also known to help patients with symptoms of bleeding from an enlarged prostate gland.
Surgical treatment
*TURP or transurethal resection of the prostate gland is still the most common operation performed on patients with BPH who require surgical intervention. The operation is performed using special instruments introduced via the urethra and doesn’t result in any external scar.
*lLaser prostatectomy – there are various types of lasers available and are used to vapourise, resect or enucleate the prostate gland.
*Open prostatectomy – this operation was the original procedure performed for treatment of an enlarged prostate gland. However, with the availability of minimally invasive procedures, this is used less frequently. Currently, in most centres, this is reserved for very large glands.
*Other minimally invasive procedures used are Needle Ablation (TUNA), microwave (TUMT), High Intensity Focused Ulatrsound (HIFU) or urethral stent. Generally, these methods are less effective, but the main advantage is minimal side effects compared to the other methods above.
These procedures are currently carried out in patients who are not medically fit for the other more invasive procedures. The duration of improvement is also shorter compared to the above methods.
Risks associated with surgical treatment include:
*Bleeding – which settles in most instances and only rarely is blood transfusion required.
*Infection – in most cases, patients will be covered with prophylactic antibiotics to reduce the risk of infection.
*Retrograde ejaculation – the majority of patients will have this symptom as the resection or vapourisation widens the urethra and opens the bladder neck, resulting in semen flowing retrogradely. This is not a problem for most patients as they would have completed their family by the time they are considered for surgical treatment.
*Erectile dysfunction – the incidence varies between 3% and 32% depending on the type of procedure, amount of gland resected and duration of the procedure
*Uretheral stricture – 2.2% to 9.8% mainly due to the movement of the instruments within the urethra during the procedure.
*Urinary incontinence – about 30% to 40% of patients might notice this symptom immediately after the urinary catheter is removed, but the majority will recover, with a late incontinence rate of 0.5%.
Generally, patients with mild symptoms and with minimal impact on their quality of life will be advised to stick to watchful waiting. Patients with moderate and severe symptoms can be offered medical treatment. Those with a larger gland can be started on a combination of alpha blocker and 5-ARI.
Some patients can be started with alpha blockers first, with 5-ARI added later based on the clinical response.
Alternative treatments, especially saw palmetto and pumpkin seeds, are very popular worldwide, used by men with lower urinary tract symptoms. However, up to today, the evidence for the efficacy of these products is lacking.
Surgical treatment is offered to those who have failed medical treatment or those with the following complications:
*Impairment of kidney function secondary to obstruction caused by the enlarged prostate gland.
*Bladder stone.
*Recurrent urinary tract infections as a result of the enlarged prostate gland.
*Refractory retention of urine.
*Recurrent bleeding from the enlarged prostate gland.
Generally, most patients are mainly bothered by the symptoms and seek treatment because of the impact on quality of life. The treatment needs to be tailored based on the symptoms and after discussions with the patients.
However, patients who present with the complications as a result of an enlarged prostate gland will very likely require some form of surgical intervention.
This article is a collaborative effort by Prof Dr Azad Hassan Abdul Razack and MSD.
http://thestar.com.my/health/story.asp?file=/2012/2/12/health/10708032&sec=health
