What is a benign prostate enlargement?
Benign Prostate Enlargement: Prostatic Therapy Treatment & Surgery: The prostate gland is a small, about chestnut-sized gland, which lies below the bladder and surrounds the urethra in the man like a ring. Together with the seminal vesicles and the testicles, the prostate is responsible for the formation of the seminal fluid.
An enlarged prostate gland can cause discomfort during urination, such as increased nocturnal urination, a weakened stream of urine, or a delayed onset of urination. There are various treatment approaches from waiting to medication to different surgical techniques in question. Patients should discuss with their doctor which are suitable and promising in their case.
From the age of 35, the prostate gland can gradually increase in volume. From the age of 75, almost all men find a benign enlargement of the prostate gland. The sole enlargement of the prostate, however, is not yet to be regarded as a disease; This can be compared, for example, with a large nose, which also has no disease value.
However, enlarge exactly the glandular parts surrounding the urethra. One possible consequence: The urethra is gradually constricted (see graphic above). This can lead to discomfort when urinating – and thus to a need of treatment benign prostate enlargement ( benign prostatic hyperplasia, BPH ).
All in all, problems with urination are the most common benign disease of the elderly man. The prostate does not always have to be enlarged. Difficulty urinating, so-called “lower urinary tract symptoms” or “Lower Urinary Tract Symptoms” (LUTS) alsooccur in men without an enlarged prostate gland. Difficulty in urination includes both urinary retention disorders in the urinary bladder and bladder emptying. Urinary retention disorders are subdivided into frequent urination (pollakisuria), nocturnal urination (nocturia), and a needleless urge to empty the bladder (imperative urgency or primary symptoms) with or without incontinence .
Because the symptoms are similar, benign prostate enlargement, LUTS, and a narrowing of the bladder outlet, which also causes urinary symptoms, sometimes caused by prostate enlargement, are now often referred to as “Beningnes prostate syndrome (BPS) .”
Bladder emptying disorders due to a benign prostate enlargement are usually characterized by symptoms such as a delayed start of urination, a weakening of the urinary stream, prolonged urination and a residual urinary sensation.
Since various diseases can be behind the symptoms of urination, it is important to have the symptoms cleared up early by the doctor. Standardized questionnaires, ultrasound examinations and special urological examination methods help to make a diagnosis and to estimate the extent of the disease.
The benign enlargement of the prostate has nothing to do with prostate cancer and must be clearly distinguished from this disease! Find out more about prostate cancer in the guide prostate cancer .
Prostate enlargement: Causes and Risk Factors
Hormones appear to play a role in the development of benign prostate enlargement. The exact causes are not yet known.
Despite much effort by researchers, the exact cause of benign prostate enlargement is still not fully understood.
Hormones seem to play an important role . There are indications that dihydrotestosterone, which is formed from the male sex hormone testosterone , is involved in the development of benign prostatic hyperplasia .
Apparently there is also a familial predisposition to the disease: If there are already cases of benign prostate enlargement in the close relationship, the own disease risk increases.
The role of the metabolic syndrome is controversial. As a metabolic syndrome doctors refer to the combination of morbid obesity (obesity), diabetes mellitus , lipid metabolism disorders ( high cholesterol and LDL values) and high blood pressure . In one study, patients with metabolic syndrome experienced faster prostate growth. In contrast, another study found no association between benign prostatic hyperplasia and metabolic syndrome.
Whether a benign prostate enlargement is related to different nutritional factors is the subject of research. Special nutritional rules can not yet be derived at the present time.
The microscopic examination of prostate tissue in patients with an enlarged prostatealmost always showed inflammatory changes – but with no association with a bacterialn infection seems to exist. Researchers therefore suspect that malfunctions of the immune system may also contribute to the development of benign prostatic hyperplasia.
Prostate enlargement: Symptoms
Characteristic symptoms include difficulty in starting to urinate, nocturnal and frequent urination, and a strong urge to urinate.
When enlarging the prostate , there are often disorders in the bladder emptying (“let water”) and in the bladder (“keep water”).
Bladder Dull Disruption : Affected men have difficulty starting urination. The urine stream can become weaker. Urination takes longer than usual. It can also happen that after urinating drops urine from the urethra. Sometimes several attempts are needed to completely empty the bladder. Often, even after urination, the feeling remains that there is still a small amount of urine in the bladder (residual urgency).
Urinary memory disorders : People often need to go to the toilet, sometimes at short intervals and often at night. Sudden strong urination with unwanted leakage of urine (urge incontinence) is often particularly distressing for those affected.
If residual urine remains in the bladder, germs can settle there more easily, which increases the risk of urinary tract infections or bladder stones. About one third of the affected men additionally suffer from erection problems, even more with difficulties in ejaculation; in most cases there is a significant decrease in ejaculate volume.
If it comes to an acute urinary retention , the affected person can not empty the bladder, although it is full and he feels a strong urinary urgency. The overstretched bladder can cause severe pain. In this case, the physician must derive the urine as an immediate measure using a thin plastic tube (catheter).
In many patients, however, there is no acute urinary retention, but the overstretching of the bladder and the formation of residual urine occurs creeping and unnoticed ( chronic urinary retention ). The result is a so-called urine dripping or an overflow incontinence. The urinary tract can continue into the ureters and up into the kidneys and permanently damage them.
Prostate enlargement: Diagnosis
The doctor first inquires about the current symptoms and the medical history of the person affected. He asks about already known diseases of the urinary tract and nerves . It is also of interest which medication the patient takes.
The doctor then palpates the prostate from the intestine with his finger. Although studies have shown that in this digital-rectal examination, the size of the prostate is often significantly underestimated. However, their consistency and shape can be easily determined. For example, if the doctor detects nodules or hardening, it may indicate a co-existing prostate cancer .
An examination of the urine to rule out infection of the urinary tract is a routine investigation.
Mandatory is the doctor a determination of the so-called PSA value in the blood. Suspicious is an elevated PSA level . It may indicate prostate enlargement or prostate cancer, but it may also have benign causes. For example, the PSA value may be elevated after cycling or digitally rectal exam – which is why blood should never be taken directly after sampling the prostate to determine this value.
Standardized questionnaires such as the International Prostate Symptom Score ( IPSS ) allow the physician to better assess the patient’s symptoms. The evaluation shows whether the symptoms are mild, moderate or severe. The doctor also asks how much they affect the quality of life of the person affected. Patients with a benign prostate enlargement and an IPSS score of less than eight points whose quality of life is barely affected are treated as “inactive”. This means: one waits and regularly checks the findings in order to intervene if necessary. Patients with moderate or severe symptoms require further diagnosis, which should take place at the specialist in urology.
The most important study to determine prostate size is transrectal ultrasound . It is usually done by the urologist. The doctor determines the size of the prostate gland by examining it through the rectum with an ultrasound machine.
The kidneys and upper urinary tract are also monitored for changes by ultrasound. To check whether urine remains in the bladder after urination, the doctor also ultrasonicallyexamines the bladder from the outside – after the patient has emptied the bladder .
A urinary stream measurement (uroflowmetry) provides evidence that the urinary tract below the bladder is constricted, for example, by an enlarged prostate or the bladder muscles are not functioning properly. Whether this is one or the other cause of changing measured values, can not be found out with this investigation.
The distinction can only be made with special tests such as the urodynamic examination. Here, a differentiation is made possible by measuring the pressure conditions in the bladder, urethra and abdomen. This accurate examination is essential in patients with nerve disorders and bladder dysfunction before surgery.
Patients with urinary blood also require a cystoscopy to exclude a tumor in the urinary tract.
Prostate Enlargement: Therapy with Drugs
Certain medications effectively and quickly relieve the symptoms, while others slow down the progression of the disease. In case of mild symptoms, herbal medicines, for example from medicinal squash, saw palmetto or nettle, can help.
Patients should also clarify minor ailments to the doctor and be advised for individually appropriate therapy.
Under certain conditions, it may be acceptable not to start treatment at first ( controlled wait-and-see ). For example, if the patient has very little discomfort and the ultrasound examination shows that after urination (almost) no urine remains in the bladder (small amount of residual urine). However, this wait and see procedure should be discussed with the doctor and under regular medical supervision. This is the only way to recognize in time when therapy is needed.
For drug therapy of symptoms of the lower urinary tract with enlarged prostate a number of substance classes are available. Traditionally, doctors in Germany prescribe herbal medicines (phytopharmaceuticals). Furthermore, α1 receptor blockers and 5-alpha reductase inhibitors have proven their effectiveness in many studies. In addition, there are new active ingredients and drug combinations, for example, have the goal of treating the symptoms of prostate enlargement in addition to existing diseases such as erectile dysfunction (“impotence”). The available active ingredients in their entirety represent the gold standard in the treatment of mild to moderate symptoms.
However, it should be noted that certain factors can speak against drug therapy (contraindications). These include bladder stones, kidney failure (renal insufficiency) or repeated urinary tract infections. In such cases, the doctor is usually more likely to recommend surgical treatment, unless there are other reasons against such an intervention.
When choosing the appropriate drug, the physician considers how great the individual risk of the patient is for progression of benign prostate enlargement. Only one substance class, the 5-alpha reductase inhibitors, is known to help prevent the disease from deteriorating, thereby reducing the risk of acute urinary retention or the need for surgery. All other substances only reduce the symptoms of the affected patients and must therefore be taken permanently.
We give you an overview of some commonly used drug groups. Of course, depending on the individual case, different combinations of these substances are possible, and there are other drugs that may play a role in the treatment of benign prostatic syndrome. Let your doctor advise you!
For generations, plant extracts have been used in Germany for the natural treatment of mild forms of benign prostatic hyperplasia. For the most part, these are medicines with a long tradition.
Most preparations are made from seeds, barks, roots or fruits of a few medicinal plants. The largest role is played by preparations containing the medicinal gourd , saw palmettoand nettle . Frequently used products are the pumpkin seed preparations from the medicinal squash, phytosterols / beta-sitosterols and rye pollen extracts. These remedies are considered to have few side effects and are suitable for mild symptoms.
In large, well-made studies compared to a drug with known effect and random assignment of patients into the groups, however, no significant effect of these drugs could be demonstrated. The herbal medicines did not work better here than a so-called placebo drug (for example, glucose).
The effectiveness of α1-blockers has been extensively demonstrated in numerous studies. The studies agree that the administration of α1-receptor blockers can reduce subjective symptoms of patients and improve objective measurements. In comparative long-term studies, all of the α1 receptor blockers tested (alfuzosin, doxazosin, tamsulosin, terazosin) were equally effective at the same dose.
The α1 receptor blockers relax the smooth muscles in the prostate and bladder neck, increasing the maximum urinary flow rate and relieving discomfort. Another advantage of the substance class is the rapid onset of action within a few days compared to other drugs. However, as mentioned above, α1-receptor blockers have no influence on the progression of the disease – ie the possible occurrence of an acute urinary retention, the worsening of symptoms or the impairment of renal function.
Therefore, α1-blockers should be used primarily in patients with symptoms of the lower urinary tract (such as an attenuated urinary stream, increased residual urine), but at the same time have little risk of worsening their condition. It is important that patients consult their doctor in detail about possible side effects of the drugs. Those affected should also know that they need to take the medication permanently.
5-alpha reductase inhibitors (5-ARI)
The endogenous enzyme 5-alpha reductase converts the male sex hormone testosteroneinto the active form dihydrotestosterone (DHT). Drugs of the group 5 alpha-reductase inhibitors (5-ARI) inhibit this transformation in the prostate cell and thus reduce the hormonal action on the prostate. As a result, the volume of the prostate can shrink by 20 to 25 percent within three to six months. The maximum treatment effect occurs after six to twelve months. 5-ARI is particularly effective in patients with a prostate volume greater than 30 milliliters.
Possible side effects include erection problems, a decreased sense of pleasure (libido) and a reduced ejaculate volume. The two available 5-ARI – finasteride and dutasteride – have a comparable effect. Dutasteride also lowers the DHT level in the blood .
Both substances reduce the subjective symptoms and improve the maximum urinary flow rate. As the only substance class, 5-ARI can reduce the risk that the disease will progress.
Important to know: If the prostate volume is reduced by the medication, the PSA value in the blood also drops . This parameter is used for the early detection of prostate cancer . For preventive medical examinations, the doctor must therefore know about the use of this medicine and consider the influence of the 5-ARI on the PSA level.
Recently, it has been speculated that finasteride in particular leads to an accumulation of particularly aggressive prostate cancers. This was assumed based on the results of large studies, but a clear correlation could not yet be confirmed.
Combination therapy α-receptor blocker and 5-ARI
The combination therapy of α1-blocker and 5-alpha-reductase inhibitor takes advantage of the different mechanism of action of the two substance classes. α1-blockers have a rapid onset of action and improve maximum urinary flow rate and subjective symptoms. 5-ARI has a slower onset of action, but as the only class of drugs, it can reduce the risk that the disease will progress and require surgery. The efficacy of the combination therapy has been confirmed in studies.
However, with the combined administration of two active substances, the possible side effects of both substance classes also add up. Therefore, in patients with mild to moderate symptoms, the doctor may consider discontinuing the α1 blocker after six to nine months. Often this is possible without worsening the subjective symptoms and reduces the side effects. A long-term combination therapy – not least because of the significant additional costs – should be reserved primarily for patients who are at high risk of the disease getting worse.
Muscarinic receptor antagonists (MRA)
If symptoms such as urgency and frequent urination are in the foreground and the residual urine volume is not too high, the use of so-called muscarinic receptor antagonists comes into question. There are five different muscarinic receptors in the body, with M2 receptors around 80 percent and M3 receptors around 20 percent around the bladder outlet. Above all, MRA inhibit the M3 receptors that are crucial for urination and thus contribute to inhibiting the muscle action of the bladder.
The efficacy of MRAs has been studied in several studies lasting up to 12 weeks. There was a marked improvement in the (memory) symptoms with an acceptable side effect profile (for example, a low rate of dry mouth, constipation and dizziness). The fear of triggering an acute urinary retention with these drugs does not seem to be confirmed. However, they should not be used in patients with very high residual urine, because there is no experience here.
Acute urinary retention
If there is an acute urinary retention ( see chapter Symptoms) , the doctor will try to drain the urine through a thin plastic tube (catheter). At the same time drugs are used (α1-blocker). If a urinary retention occurs repeatedly, an early surgery is inevitable.
Prostate enlargement: surgical therapy
Benign prostate enlargement can be treated with a variety of surgical techniques. Particularly well established is transurethral resection of the prostate (TUR-P) and holmium laser enucleation (HoLEP).
If there are certain problems with a benign prostate enlargement , the doctor usually recommends surgery, These problems include:
- recurrent urinary retention despite treatment with medication
- frequent urinary tract infections
- a deterioration of kidney function
- the appearance of visible amounts of blood in the urine
- the formation of bladder stones .
Many patients today receive medications for a longer period of time that relieve the symptoms of prostate enlargement without slowing down the growth of the gland. Once the prostate reaches a volume that requires surgery, those affected are often older and suffer from additional illnesses – which can make surgery more risky. Not least because of this, physicians are focusing their research on developing new and less burdensome (minimally invasive) surgical techniques to complement the existing surgical proceduresto improve. The focus is currently on the use of different laser systems, which promise a lower blood loss during surgery, as well as on modifications of the classical methods.
With every form of surgical technique there are advantages and possible disadvantages. Patients should seek advice from the doctor in detail to find the most appropriate procedure for them.
Here are some important and common practices. There are also other methods that can be used. Let your doctor inform you!
Transurethral Resection of the prostate (TUR-P)
Transurethral resection of the prostate is still considered the “gold standard” of prostate surgery. The efficiency of this established method has been proven in many large studies.
During the operation, the doctor guides an instrument through the urethra to the enlarged prostate. Through a built-in optics, he can locate the part of the gland that narrows the urethra. This prostate tissue is removed with the help of an electrical sling and removed via the urethra. Colloquially, the method is sometimes referred to as “prostate planing”. The doctor cuts in this operation so not with the scalpel, but with electric current. For this to work, an electrolyte-free rinsing fluid is required. It is also the cause of the dreaded “TUR syndrome”: Electrolyte-free irrigation fluid enters the bloodstream, which disrupts the salt and mineral balance of the body. Possible consequences are circulatory disorders with nausea and confusion.
Advantages of the TUR-P:
- Despite possible complications, the TUR-P is the reference method. For no other form of therapy similar good long-term data to the result. In the long run, five to eight percent of patients will have to undergo surgery again.
- The tissue is removed very quickly in the TUR-P. Therefore, an experienced surgeon can treat a prostate up to a volume of about 80 milliliters.
- Another advantage over most modern laser procedures (see below): The doctor wins in the TUR-P prostate tissue, which can be examined under the microscope accurately. In this way, a possible prostate cancer can be identified and treated accordingly.
- In addition to the laser-based methods, the TUR-P is also relatively inexpensive.
Transurethral bipolar resection of the prostate:
The so-called bipolar resection represents a technical advancement of the conventional TUR-P. The physicians place an additional electrode, so that they no longer need an electrolyte-free irrigation fluid. Instead, they use physiological saline as a rinse. If this gets into the circulation, it still threatens to burden the right ventricle. However, the dreaded TUR syndrome (see above) no longer occurs.
The results and possible disadvantages of the two methods are comparable. The first generation of devices described an increased rate of urinary tract narrowing. This does not seem to be the case with advanced surgical instruments. Since the technique is a relatively recent procedure, it is necessary to wait for the long-term results of the treatment to make a final comparison between the two methods.
Bipolar plasma vaporization
A relatively new development is bipolar plasma vaporization. This method works in principle similar to the TUR-P (see above). The treatment thus also takes place through the urethra. But instead of an electric loop, a specially shaped electrode (“mushroom”) is used, which produces a flat plasma jet in saline solution. With this plasma jet, doctors can “evaporate” the excess prostate tissue, so to speak. In a first series, the new technology was able to achieve good surgical results. Long-term results and the systematic comparison to other methods are still pending.
Photoselective laser vaporization or KTP laser
Also interventions in which the prostate is virtually evaporated (laser vaporization) take place through the urethra. To remove the excess prostate tissue, laser light of a certain wavelength is used, which is perceived green.
Unlike many previously used laser systems, tissue vaporization immediately removes tissue. The narrowing of the urethra can thus be eliminated immediately. Disadvantage: There is no prostate tissue , which can be examined under the microscope for a possible prostate cancer . For this reason, the procedure should only be used if a prostate carcinoma is unlikely. Another disadvantage of laser vaporization is the frequent occurrence of irritative discomfort after surgery, which often lasts for months. Patients, for example, need to urinate more often or feel urge to urinate.
The results are roughly comparable to the results for a TUR-P. However, less laser can be removed per time by laser. A great advantage of the laser systems: With this technique, a good hemostasis is possible – which is especially important if patients have to take permanent anticoagulant drugs.
Another advantage is the use of physiological saline as a rinsing fluid, so that a TUR syndrome (see above) is excluded. However, the procedure is costly and is therefore reserved in some treatment centers primarily for high-risk patients.
In recent years, holmium laser enucleation of the prostate (HoLEP), in addition to TUR-P, has become the gold standard in the surgical treatment of benign prostate enlargement. The HoLEP is a surgical procedure that also occurs through the urethra. Using a laser, the doctor separates the entire excess prostate tissue very accurately and with virtually no bleeding. With a special instrument, he can still shred this separated tissue in the bladder (“morcellieren”) and then aspirated through the urethra.
The advantage of this surgical technique is that it can be used on almost any prostate size. Thus, even very large prostate glands can be removed with well over 100 ml volume, which used to succeed only by means of an open operation, the adenoma enucleation. The removed tissue can then also be examined for the possible presence of a prostate cancer.
In the long-term results, the HoLEP of TUR-P is at least equal. Complications such as narrowing of the urethra are rare. However, since the surgeon needs a lot of experience in the field of technology, the method is still not widely used and is mainly used by experts.
Before prostate surgery was developed through the urethra, open surgery was the only effective way to eliminate urinary obstruction. The most common route of entry is through the bladder or above the pubic bone. An advantage of access through the bladder is the option to treat sequelae in the bladder like large bladder erosions (diverticula) in the same session. In recent years, minimally invasive procedures (“keyhole technique”) and even robot-assisted operations have been described.
The result regarding the residual urine and the improvement of the maximum urinary flow rate is excellent, since the excess prostate tissue is removed down to the prostate capsule. The rate of complications is low, wound healing disorders are reported at five to six percent. There is no danger for a TUR syndrome.
Due to the increasing prevalence of the significantly less burdensome HoLEP resection, open adenoma enucleation is only a second-line treatment.
An even more recent minimally invasive procedure is the placement of implants intended to hold the urethra open. Under local anesthesia or under general anesthesia, implants are inserted from the urethra, anchored on one side in the prostate tissue and on the other in the urethra. The thin threads stretched between them pull the prostate lobes together, expanding the urethra.
The advantage of this procedure is an improvement in urine flow and symptoms while maintaining normal ejaculation. Not suitable is the method for patients with a so-called middle lobe. Your urologist can give you this information after he has performed a cystoscopy .
Long-term experience will have to show whether this technique can prove itself and persist in the long term.
During operative therapy, the outer zone of the prostate is left in the body. Since malignant prostate tumors (prostate cancers) almost always form in this outer zone, it is of great importance for patients to use regular prostate cancer screening even after such a prostate operation.
Prostate enlargement: early detection
Statutory insured men over the age of 45 are entitled to an examination of the prostate once a year.
There is no reliable protection against the enlargement of the prostate in old age. Early diagnosis is therefore important. This can also be helped by the investigation as part of the cancer screening program. The health insurance companies pay for men over 45 years once a year a corresponding screening test. In addition to a survey of the medical history, this includes an examination of the inguinal region and the external genitalia as well as the palpation of the prostate via the rectum.