PROSTATE SURGERY

What are the causes of benign prostatic hyperplasia?

The exact cause is not known. Enlargement of the prostate gland is a normal process that develops as men get older. Therefore it becomes more common with increasing age. it is thought that changes in the male sex hormones that occur with ageing may be at least part of the cause.

Prostate gland enlargement can be caused by other conditions such as prostate cancer, acute prostatitis and chronic prostatitis. See the separate leaflets called Prostate Cancer, Acute Prostatitis and Chronic Prostatitis.

What are the possible complications?

Urinary symptoms do not worsen in everyone. Serious complications are unlikely to occur in most men with an enlarged prostate. Complications that sometimes occur include:

• In some cases, a total blockage of urine occurs so you will no longer be able to pass urine. This is called urinary retention. It can be very uncomfortable and you will need to have a small tube (catheter) inserted to drain the bladder. It occurs in less than 1 in 100 men with an enlarged prostate each year. See the separate leaflet called Urinary Retention.
• In some cases, only some of the urine in the bladder is emptied when you pass urine. Some urine remains in the bladder at all times. This ongoing condition is called chronic retention. This may cause repeated (recurring) urine infections, or incontinence (as urine dribbles around the blockage rather than large amounts being passed each time you go to the toilet).

Note: the risk of prostate cancer is not increased. Men with a benign prostate enlargement are no more or less likely to develop prostate cancer than those without benign prostate enlargement.

Do I need any tests?

Benign prostatic enlargement is usually diagnosed based on the typical symptoms as described earlier. Tests are not needed to confirm the diagnosis but to make sure no complications have developed. Tests are also useful in ruling out other causes of your symptoms and sometimes give the doctor an idea of the size of your prostate. The following tests may be done:

• A doctor may examine your prostate to see how big it is. This is done by inserting a gloved finger into your back passage (through the anus into the rectum) to feel the back of the prostate gland. The size of your bladder may be assessed by examining your tummy (abdomen).
• Urine and blood tests may be done to check the function of your kidneys, to exclude a urine infection and to check there is no blood in the urine.

A referral to a bladder specialist (urologist) may be advised if your symptoms are troublesome or if complications develop. Tests may be done in these more severe cases, particularly if surgery is being considered as a treatment. For example:

• A look inside the bladder with a special telescope (cystoscopy).
• A urine flow test to assess how bad the obstruction has become.
• An ultrasound scan to see whether much urine remains in the bladder after you pass urine (void).

• Voiding diary. You may be asked to complete a diary over a week or so. This will have information about the number of times during the day and night you void, the amount passed and also the number and types of drinks you have had.
• A prostate specific antigen (PSA) blood test may be offered, although this test is not done routinely. This can be used as a marker for the size of the prostate. Larger prostates make more PSA. See the separate leaflet called Prostate Specific Antigen Test (PSA).

Note: a high PSA level is also found in people with prostate cancer. It has to be stressed that most men with prostate symptoms do not have prostate cancer.

What are the treatment options for prostate enlargement?

Enlarged Prostate Management Options

Each treatment option for an enlarged prostate has various benefits, risks and consequences. In collaboration with health.org.uk, we've put together a summary decision aid that encourages patients and doctors to discuss and assess what's available.

If symptoms are mild then this may be the best option. You may be happy just to see how things go if the symptoms are not too bothersome and are not affecting your life very much.

Medicines

The decision to treat with medicines usually depends on how much bother the symptoms are causing you. There are two groups of medicines that may help: alpha-blockers and 5-alpha reductase inhibitors. Medicines do not cure the problem, nor do they usually make symptoms go completely. However, symptoms often ease if you take a medicine.

Alpha-blocker medicines. These medicines work by by relaxing the smooth muscle of the prostate and bladder neck. This can improve the flow of urine.

5-alpha reductase inhibitor medicines. These are alternatives to alpha-blockers. These work by blocking the conversion of the hormone testosterone to dihydrotestosterone in the prostate. They do this by blocking a chemical (an enzyme) called 5-alpha reductase.

Surgery

Removal of part of the prostate is an option if symptoms are very bothersome or if medicines do not help. Around one in four men with an enlarged prostate will have an operation at some stage. In these operations, only the central part of the prostate is removed (creating a wide channel for urine to flow through), leaving the outer part behind. This is different to prostate cancer when, if surgery is carried out for cure, all the prostate is removed.

There are many different types of operation now available that can remove prostate tissue. Your surgeon will discuss the most suitable operation for you in more detail. Some of the more commonly done operations are listed below:

Endoscopy: Transurethral resection of the prostate (TURP). This is the most common operation carried out for an enlarged prostate. Under anaesthetic, either spinal or general, a rigid cystoscope is inserted through the urethra into the bladder. A cystoscope is a narrow tube-like telescope through which small instruments pass to allow the operation to be carried out. A semicircular loop of wire has an electrical current passed through it. It is this loop that sticks out from the end of the cystoscope and cuts out small chips of prostate that are then washed out at the end of the operation. This operation nearly always gives good relief of symptoms.

Transurethral incision of the prostate (TUIP). This may be offered if you only have a slightly enlarged prostate. For this operation, the surgeon makes small cuts in the prostate where the prostate meets the bladder. This then relaxes the opening to the bladder, resulting in there being an improved flow of urine out of the bladder. There is less risk of retrograde ejaculation with this operation.

Open prostatectomy (Surgery a knife). This is a more traditional operation which involves cutting the skin to get to the prostate. It is now rarely done. It is only performed when the prostate is very large and when it would not be practicable to remove an adequate amount of prostate tissue through a narrow cystoscope inserted through the urethra.

Laser prostatectomyThis is simply the application of newer technologies to achieve the same goal as either TURP or open prostatectomy. It has the advantage of fewer side-effects, a shorter period of having a catheter in and a shorter stay in hospital (often just one night). There are two types of lasers:

• Green light which vaporises the prostate tissue to create a cavity.
• Holmium laser enucleation (HoLEP). Lasers can very effectively core out large pieces (lobes) of prostate which, in turn, are chopped into small pieces in order to be removed from the bladder. Thulium lasers can also be used.

In the hands of experienced laser surgeons, very large prostates, which in the past could only be dealt with by open surgery, can be removed by this technique.