Symptoms, investigation and managment of an enlarged prostate

The prostate is a walnut sized gland that is situated below the bladder and produces secretions which make up approximately 30% of the ejaculate.
The prostate grows after puberty under the influence of testosterone. This is called benign prostatic hyperplasia (BPH). The size will vary between men and only in some does it grow enough to squeeze the urethra (water pipe) and produce symptoms. These are called lower urinary tract symptoms (LUTS).
In some men the prostate can become inflamed (prostatitis) and malignant (prostate cancer).
Symptoms of an enlarged prostate
  • frequency - going to the toilet more often
  • urgency - getting little or no warning
  • nocturia - getting up at night needing to go to the toilet
  • weak stream - a poor urinary flow
  • incomplete bladder emptying - feeling that the bladder is not sufficiently empty after going to the toilet
  • stopping and starting and feeling the need to push and strain whilst going to the toilet
Investigation of an enlarged prostate
The majority of men with LUTS are diagnosed with uncomplicated BPH with a few simple tests. These are carried out to exclude the rare complications of LUTS secondary to BPH which include urinary retention requiring a catheter, chronic infection, incontinence, bladder stones and renal failure. All of these complications are managed surgically.
Simple tests include:
  • symptom assessment with the International Prostate Symptom Score (IPSS) and a frequency / volume chart
  • urinalysis
  • blood tests to assess renal function
  • PSA blood test after a digital rectal examination to assess prostate cancer risk
  • flow rate and bladder ultrasound 
Complex tests include:
  • prostatic ultrasound
  • flexible cystoscopy (telescopic inspection of the urethra, prostate and bladder)
  • urodynamics (pressure / flow studies of the bladder to mimic real time voiding) 
Management of an enlarged prostate
Depending on the severity of symptoms several options exist including conservative management or self-management, drug therapy and surgery.
Conservative management or self-management
Men with mild to moderate symptoms that are not particularly bothersome can be successfully managed with lifestyle and behavioural interventions including:
  • drinking less in the evening to reduce nocturia (getting up at night to go to the toilet)
  • caffeine (tea, coffee and energy drinks), alcohol and smoking avoidance
  • adjusting the timing of commonly prescribed drugs such as diuretics
  • double voiding - taking extra time to go to the toilet and trying to go after 2 minutes to empty bladder further
  • avoiding constipation
Drug therapy
Medication can be used in conjunction with self-management or when symptoms are not adequately controlled by self-management. There are several different types of medications that can be taking on its own or in combination including:
  • alpha-blockers e.g. tamsulosin, alfuzosin and doxazosin. These drugs relax the smooth muscle of the prostate reducing the resistance of the prostate and improving urinary flow. They work quickly within hours but are best taken for 4-6 weeks to see improvement. They can cause light-headedness and retrograde ejactlation.
  •  5-alpha reductase inhibitors e.g. dutasteride and finasteride. These drugs shrink the size of the prostate and reduce the risk of urinary retention and needing prostate surgery. They are slow to work and need to be taken for up to 6 months to see improvement. Rarely they can cause reduced libido and ejaculatory problems.
There have been many advances in the surgical management of BPH over the last 10 years. Nearly all prostates can be managed via a key-hole technique called trans-urethral surgery. This involves a general anaesthetic and a surgeon introducing an operating telescope down the water pipe to increase the size of the urethra as it passes through the prostate. Various techniques exist including:
  • Trans urethral resection of the prostate (TURP)
  • Holmium laser enucleation of the prostate (HoLEP)
  • Green-Light laser photo-selective vaporisation of the prostate (PVP)
    • Day-case procedure
    • State of the art XPS machine used
    • Little or no bleeding
    • Catheter overnight only and in some cases no need for catheterisation at all