Prostate cancer

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Benign prostatic hyperplasia (BPH)

Benign prostatic hyperplasia (BPH) is an enlargement of the prostate caused by an overgrowth of cells (called hyperplasia) in the transition zone of the prostate (the area around the urethra).

BPH is a non-cancerous (benign) condition of the prostate. Non-cancerous conditions don’t spread (metastasize) to other parts of the body and are not usually life-threatening. BPH doesn’t increase the risk of prostate cancer and it isn’t considered a health problem unless it causes symptoms.

By 70 years of age, almost all men will have some prostate enlargement.

Risk factors

The following risk factors increase your chance of developing BPH:

  • getting older
  • having extra fat on your abdomen (called abdominal obesity)
  • not getting enough physical activity

Symptoms

Men with BPH may not have any signs or symptoms. If signs and symptoms develop, they most often happen in men older than 50 years of age.

Signs and symptoms of BPH start when the enlarged prostate puts pressure on the urethra and bladder. This can narrow (constrict) or block the urethra, which can cause changes in bladder habits and problems urinating.

BPH can cause the following, which are sometimes called lower urinary tract symptoms (LUTS):

  • difficulty passing urine
  • more frequent urination (called urinary frequency), especially at night
  • a strong or sudden urge to urinate (called urinary urgency)
  • weak or slow urine stream
  • being unable to empty the bladder completely, which can lead to urinary tract infections and bladder stones
  • difficulty starting the urine stream (called straining)
  • having difficulty controlling the bladder (called incontinence), which can cause urine to leak and dribble
  • blood in the urine

Diagnosis

If you have symptoms of BPH, your doctor will ask you how bad they are. You may also be asked to complete a questionnaire about your urinary symptoms and bladder habits.

If your doctor thinks you might have BPH, you will be sent for tests to diagnose or rule out BPH as well as other problems, such as urinary tract infections or prostate cancer. They include:

  • a physical exam
  • a digital rectal exam (DRE)
  • urine tests, including urinalysis
  • blood tests, including the prostate-specific antigen (PSA) test

If the above tests are abnormal or the doctor can’t make a diagnosis, you may have the following:

  • cystoscopy
  • test to check the flow rate of the urine followed by an ultrasound to see how much urine is left behind in the bladder after urinating (called flow rate and residual ultrasound)
  • imaging tests, such as an x-ray or ultrasound, to check the kidneys, bladder and prostate
  • a special test called a urodynamic assessment to see how well the bladder and urethra can hold and release urine
  • biopsy of the prostate done through the rectum using an ultrasound to guide the needle (called a transrectal ultrasound-guided biopsy)

Find out more about these tests and procedures.

Treatments

You and your doctor will discuss which treatment is right for you. This decision is usually based on your symptoms, how bad your symptoms are (called severity), how much they bother you, your test results and your preferences. Treatment options for BPH include the following.

Watchful waiting

Watchful waiting means using tests and exams to watch BPH to see if signs or symptoms are getting worse. It is often used for men who have mild symptoms that don’t bother them. Other treatments will be started if BPH causes problems.

Lifestyle changes

If you have mild symptoms, you may want to make some lifestyle changes to help manage them.

Try to limit the fluids you drink, especially before bedtime. Also try to avoid fluids with caffeine (such as coffee or soda) and spicy foods.

Some medicines can make the symptoms of BPH worse. Talk to your doctor if you are taking the following medicines:

  • drugs that increase the amount of urine that the body makes (called diuretics)
  • decongestants
  • antihistamines
  • antidepressants

You may want to try retraining your bladder. Instead of urinating every time you have the urge, try urinating only at certain times of the day or after a certain amount of time (such as every 3 hours).

Talk to your healthcare team about learning pelvic floor exercises. They can strengthen the muscles in the pelvic floor to help control urination.

Constipation can put pressure on the bladder. If you have constipation, talk to your healthcare team about ways you can manage it. They may recommend lifestyle changes, such as getting more fibre and drinking more fluids or taking medicines to help relieve constipation.

Drug therapy

Most doctors begin treating BPH with medicines before using other treatments such as surgery. The following drugs can be used to relieve symptoms. Talk to your doctor about these medicines and their side effects.

 

Alpha-blockers are drugs that relax the muscles near the prostate, which relieves pressure on the urethra and allows urine to flow more easily. They don’t shrink the prostate. Alpha-blockers usually start working within a week. The most common alpha-blockers used for BPH are:

  • terazosin (Hytrin)
  • doxazosin (Cardura)
  • tamsulosin (Flomax)
  • silodosin (Rapaflo)
  • alfuzosin (Xatral)

5-alpha-reductase inhibitors help shrink the prostate to relieve symptoms. These drugs prevent the enzyme 5-alpha-reductase from changing testosterone into dihydrotestosterone, which makes the prostate grow. They work best in men with large prostates. Finasteride (Proscar) and dutasteride (Avodart) are 5-alpha-reductase inhibitors used to treat BPH. It may take 6 months to a year before symptoms get better.

Combination therapy may be an option for a man who has a large prostate and bothersome symptoms. It includes the alpha-blocker tamsulosin and the 5-alpha-reductase inhibitor dutasteride. These drugs are given together in one pill under the brand name Jalyn.

Phosphodiesterase-5 (PDE5) inhibitors relax muscles in the bladder, urethra and prostate. Tadalafil (Cialis) is a PDE5 inhibitor that is used to relieve symptoms of BPH. It is also used to treat erectile dysfunction.

Muscle relaxants can be used to help lessen bladder contractions, reduce leakage and reduce the urge to urinate. Doctors may give the muscle relaxant solifenacin (Vesicare) or mirabegron (Myrbetriq) with an alpha-blocker.

Surgery

Surgery is used to treat BPH when drug therapy stops working or to treat men who can’t urinate at all. It can also be used to relieve severe symptoms.

Transurethral resection of the prostate (TURP)

TURP removes prostate tissue through the urethra. It is the surgery most commonly used to treat BPH. While TURP relieves urinary symptoms in most men, urinary problems can come back over time if the prostate starts to grow again. This is why younger men may need to have this surgery more than once.

This surgery is done in an operating room. The doctor passes a resectoscope through the urethra to reach the prostate. A resectoscope is a type of endoscope. It has a thin wire that carries an electric current. The doctor uses the electric current to cut away prostate tissue around the urethra. The doctor then removes this tissue through the resectoscope.

The most common side effects of TURP include:

  • bleeding
  • infection
  • semen flowing into the bladder instead of out the end of the penis (called retrograde ejaculation)

In rare cases, men may develop erectile dysfunction or incontinence after TURP. But this surgery has a lower risk of these side effects than surgery to remove the prostate (called prostatectomy).

Other surgeries and procedures

The following may also be used to relieve urinary symptoms caused by BPH.

 

Laser prostatectomy uses a laser to destroy prostate tissue. Doctors do this procedure with a laser that is passed through a cystoscope (a lighted magnifying instrument that is used to look at and treat areas inside the urethra and bladder). A laser prostatectomy can be done by holmium laser enucleation or photoselective vaporization (PVP).

Transurethral incision of the prostate (TUIP) uses a special tool on a cystoscope to make small incisions (surgical cuts) in the prostate. TUIP helps to relieve pressure on the urethra but it doesn’t remove any tissue. TUIP is mostly used in men with smaller prostates.

Transurethral electrovaporization (TUEVP) uses an electrode attached to a resectoscope. The electrode delivers electricity to heat prostate tissue until it is destroyed.

 

Prostatic urethral lifts are implants that the doctor places in the prostate to help pull it away from the urethra.

Prostatectomy is surgery to remove the prostate. Prostatectomy is only used in rare cases when other procedures or surgeries can’t be done. It may also be used if the urethra is completely blocked or if the prostate is very large.

pelvic floor

The muscles that make up the lower part of the pelvis. These muscles support the organs inside the pelvis. When pelvic floor muscles don’t work properly, it may cause incontinence.

testosterone

A male sex hormone that causes male sex characteristics to develop (such as deep voice and facial hair) and stimulates the development of the male reproductive system and sexual activity.

Testosterone is made mainly by the testicles. Small amounts of testosterone are also made in the adrenal glands. It may also be produced in the lab to treat certain conditions.

endoscope

A thin, tube-like instrument with a light and lens used to examine or treat organs or structures in the body.

An endoscope can be flexible or rigid. It may have a tool to remove tissue for examination. Specialized endoscopes may have tools designed to examine or treat specific organs or structures in the body.

Specialized endoscopes are named for the organ or structure they are used to examine or treat.

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