Symptoms of an Enlarged Prostate Include:
How Do You Evaluate A Patient With Prostate Enlargement Symptoms?
It is our responsibility to evaluate your particular medical situation properly and clearly explain your reasonable choices of treatment along with the expected risks, benefits and drawbacks of each. To do this, we need to examine your lower urinary system and prostate. We usually start with a blood test (Prostate Specific Antigen or "PSA") and a digital rectal exam. (For more information about this blood test, turn to the last section of this report which deals with PSA.) We will ask you a standard series of questions concerning your urinary symptoms. Your responses to these questions are given point values and your score is totaled to give us a numerical average of all your urinary symptoms. This is called the AUA Symptom Score. (AUA stands for the American Urological Association which developed the questions and scoring system.) Symptom scores below eight to ten are not generally considered severe enough to warrant treatment. The maximum score possible, which represents the worst of each type of urinary symptom, would be thirty-five.
We will request a flow test, where you will be asked to void into a special machine that measures the urinary flow rate. This will be followed by a painless ultrasound examination to see how completely the bladder has emptied. You should come to the office with a full urinary bladder so we can more easily perform these examinations. If the flow rate is acceptable (usually fifteen cc's per second) and the bladder empties well (fifty cc's or less) then it's unlikely that the prostate disorder or urinary problem is severe enough to require aggressive treatment or surgery. If the symptoms are severe or if one of these examinations is abnormal, a painless telescopic examination of the prostate and bladder will be needed. This is done in the office using a thin, flexible telescope and a local anesthetic.
A special lubricated telescope is gently passed through the penis and directed through the prostate into the bladder. While this may sound unpleasant, it's usually quite painless. Most patients describe it as feeling as though they're voiding. The entire examination usually takes only five to ten minutes. This is the most accurate and reliable way of determining the nature and severity of the prostate problem. Occasionally, other examinations such as a bladder pressure test or kidney X-rays will be needed, especially if a bladder muscle problem is suspected or if unexplained blood in the urine is found. The final results, interpretation and significance of the tests will be shared with you and discussed. We'll review together all the appropriate treatments and try to select the best one for you.
Medications For Prostate Enlargement (Proscar, Hytrin, Cardura and Flomax)
Several drugs are now available to treat the symptoms of prostate blockage and enlargement. They do not permanently cure the underlying problem, so treatment must be continuous and indefinite or the symptoms will return. These medications are best suited for patients with only mild to moderate symptoms who have no sign of permanent bladder or kidney damage and for those who have a high risk of complications with any surgical procedure.
The first of these medications is Proscar (Finasteride). It works by blocking the effects of testosterone, the male sex hormone, on the prostate. Testosterone causes the prostate to grow, eventually resulting in obstruction and blockage of the urinary stream. Proscar is the only available medication that can significantly shrink the prostate and prevent future prostatic growth. It can lower the risk of urinary retention (a dangerous and extremely painful condition in which the patient is unable to urinate) and reduce the need for prostate surgery by over fifty percent. Proscar is most effective in patients with larger prostates. It will only shrink the prostate by about 20% and relief of symptoms is relatively modest. It will take six to twelve months of continuous therapy to achieve the maximum benefit from the medication. The prostate will grow back if Proscar therapy stops, so the medicine must be taken permanently. Proscar will reduce the Prostate Specific Antigen (PSA) level in the blood, making it more difficult to detect early prostate cancers. A careful screening for prostate cancer should therefore be done before patients start on Proscar.
Proscar only needs to be taken once a day and there are relatively few side effects. The main side effects are impotence or erectile dysfunction (8%) and decreased sex drive or libido (6%). Fortunately, these two side effects will generally disappear during the first year of therapy. Only patients with relatively large prostates or those who are poor candidates for prostate surgery should consider Proscar treatment.
Alpha blockers such as Hytrin, Cardura and Flomax can effectively treat the symptoms of prostatic enlargement for most men. They don't actually shrink the prostatic tissue itself, but rather they relax the nerves that tighten or squeeze the prostate's central channel or passage. This has the effect of increasing the urinary flow and improving symptoms. Maximal results are reached quickly so a short trial of medication is quite reasonable for many patients. Alpha blockers need to be taken just once a day which makes them very convenient. Since the prostate will continue to grow, it's reasonable to expect that eventually the enlargement will overcome the beneficial effects of any Alpha blocker type of medicine. Symptoms of prostatic enlargement would then return.
Hytrin and Cardura were originally designed to treat high blood pressure. They reduce pressure in the artery walls the same way they relax tension in the prostate. This may cause a useful drop in blood pressure in those patients who happen to have high blood pressure as well as prostate trouble. About two thirds of patients will notice significant improvement in their urinary symptoms in only three to six weeks. Hytrin and Cardura generally have few side effects in patients with normal blood pressure, but patients with low blood pressure may not be good candidates for either of these medications. Hytrin was the first Alpha blocker to be used for symptoms of prostate enlargement and is the most widely prescribed of these medications. Cardura is the least expensive.
The chief side effect of Hytrin and Cardura is temporary dizziness or lightheadedness which usually occurs in the morning when first getting out of bed. It's due to a sudden drop in blood pressure when rapid changes in body position occur, such as standing up quickly after lying in bed overnight. Normally, an increase in the tension of the arteries quickly restores the blood pressure back to its' previous level. Relaxation of tension in the arteries caused by the medication blocks this normal mechanism for keeping the blood pressure steady and causes temporary dizziness and lightheadedness in some patients.
To avoid this problem, when first getting up in the morning patients taking Hytrin or Cardura should just sit on the side of the bed for 20 - 30 seconds before standing. This gives the body a chance to adjust to the positional change without causing any dizziness. Taking the medication at night just before going to bed will also help minimize this possible side effect.
The newest Alpha blocker, Flomax, was specifically designed to treat only prostate symptoms and has no significant effect on blood pressure or tension in the arteries. Flomax will not cause the dizziness sometimes associated with Hytrin and Cardura. Flomax can be used at full strength right from the beginning unlike Hytrin and Cardura which must be started at a very low dose initially and then increased or adjusted periodically over several weeks. Urinary symptoms often improve significantly after just one week on Flomax. For best results, it's recommended that patients take Flomax with food during the same meal every day.
Transurethral Resection of the Prostate (TURP)
The standard surgical treatment for an enlarged prostate is Transurethral Resection of the Prostate or "TURP". This is sometimes called a scraping or "Roto-Rooter" of the prostate. It is the "gold standard" against which all other prostate remedies are compared. Under a full general or spinal anesthetic, a telescopic instrument with a small wire loop at the end is passed gently through the penis into the prostate. Under direct vision, an electric current passes through the loop, which can then carve out the channel inside the prostate. The chips or pieces of prostate tissue are rinsed out of the bladder with water. After surgery, a soft rubber tube or catheter is left in the bladder for several days to help control bleeding and allow healing to begin.
This is a very effective surgery with little pain or discomfort. However, it requires several days in the hospital, has a prolonged recovery period after surgery and may infrequently have complications such as bleeding, infection, urinary leakage and scar tissue formation. It will cause retrograde ejaculation, which means that during sexual activity there will be no semen expelled from the penis. Instead, any semen produced will go directly into the bladder. This is not dangerous or harmful in any way and it doesn't affect sensation or enjoyment, but it's disturbing to some patients.
Transurethral prostate surgery (TURP) is considered the best permanent treatment for severe prostatic disease, especially if permanent damage to the bladder or kidneys has occurred. It's also appropriate where other treatments have failed to control symptoms adequately or protect the bladder and kidneys. No other treatment is as effective in relieving the blockage from prostatic enlargement.
Interstitial Laser Coagulation of the Prostate
Lorain County is one of the first sites in the United States to offer this newest and most advanced form of laser therapy for benign prostate enlargement. This innovative and unique treatment, called Interstitial Laser Coagulation, requires only a brief outpatient hospital visit lasting several hours. The laser therapy uses a specially designed laser fiber whose tip is temporarily placed within the prostate tissue through a telescope while the patient is under a brief, mild anesthetic. When activated, the laser energy is directed to the prostate tissue surrounding the tip of the fiber. After therapy, the fiber is repositioned and another portion of the prostate is lasered. This process continues until the entire organ has been treated. Patients can return home the same day. A temporary drainage catheter or rubber tube is left in the bladder to allow the urine to drain until the expected brief swelling of the prostate has subsided. This usually takes three to five days after which the catheter is painlessly removed.
Laser prostate therapy affects both the bulky prostate tissue blocking the central channel and the nerves that cause the prostate to clamp down and restrict the urinary flow. In this way, it combines the beneficial aspects of both traditional surgery and drug therapy. Laser treatment of the prostate will not cause retrograde ejaculation, which almost always occurs with standard surgery. Laser prostate therapy is generally safer than traditional surgery because no tissue is removed or cut and the laser procedure is simpler and quicker, requiring less anesthesia. Since no prostate tissue is available for pathological analysis, a careful screening for cancer should be done before laser therapy is performed.
Results of treatment with this new prostate laser therapy have been very encouraging. Bothersome symptoms of prostate blockage and enlargement are reduced 75% and urinary flow rates improve 125% with virtually no side effects or long-term complications. Maximal beneficial results are generally achieved by three months after treatment. There may be some temporary bladder irritability or cramping immediately after the laser therapy in 10-12% of patients, but these symptoms usually disappear rapidly and can be managed by medical treatment until they subside. Results from laser therapy are far better than can be achieved by medications alone and are comparable to the results of traditional prostate surgery without the risk of surgical complications or the need for prolonged hospitalization. Patients who don't respond well to laser therapy can still be offered other treatments such as standard surgery.
Although the new laser therapy may not help every patient, about 85 - 90% of those treated can expect substantial, permanent relief from their symptoms due to prostate enlargement. The treatment is particularly well suited for patients who aren't responding well to medications for prostate blockage, are having side effects from the drugs or have a high risk for complications from traditional prostate surgery. It's also appropriate for those men who just desire a better, more permanent treatment than medications alone can provide without the risks, complications or hospitalization of the standard surgery.
Which Treatment Is Best For Me?
Each therapy previously described has its own advantages and disadvantages. Some treatments may not be appropriate for certain individuals or situations. For example, those patients with very mild symptoms probably don't require any treatment. Others will have excellent results from medications and not need or desire any type of procedure or surgery. Some patients may be too ill to undergo any operative procedure that isn't absolutely essential. For example, a patient who has just suffered a heart attack would not be a good candidate for any surgery until he fully recovered.
The nature of your urinary disorder, the condition of the bladder and the precise size and shape of the prostate itself will help determine the optimal therapy. Some patients will be unacceptable candidates for certain treatments due to other unrelated medical conditions or problems. After reviewing your specific urinary problem and overall medical condition together with the results of the various tests, we can make a specific recommendation for the most appropriate therapy. The final decision regarding treatment is made by you, the patient.
About Prostate Specific Antigen (PSA): The Blood Test For Prostate Cancer
There is considerable confusion about the significance of the Prostate Specific Antigen (PSA) blood test for prostate cancer. This blood test is a very sensitive indicator of medical problems affecting the prostate gland, but unfortunately it cannot distinguish between benign conditions and cancer. The generally accepted normal value is usually four or less. PSA levels greater than four may be considered suspicious for some type of prostatic disease but do not necessarily or even usually mean cancer. The overwhelming majority of men with elevated PSA levels will not have prostate cancer. Abnormally high PSA levels are frequently due to benign prostatic enlargement, infection or inflammation without any cancer being present at all! And some patients with prostate cancer will have totally normal PSA levels.
PSA is most useful as one of several tools your doctor has to monitor your health and identify early prostate disorders. If the PSA is rising quickly or if it seems unusually high based on the estimated size of your prostate and doesn't respond to treatment for infection and inflammation, further examination of the prostate, including a biopsy, will be needed. If you already have prostate cancer, an increase in PSA levels can suggest the need for further therapy.
The best way to detect prostate cancer early is a yearly digital rectal examination and PSA blood test for all men over fifty years of age. Those men at high risk, such as blacks and those with a family history of prostate cancer, should begin these yearly examinations at age forty five. If the PSA blood level is elevated or the rectal examination is abnormal or unusual, the next step will be an ultrasound evaluation of the prostate and a needle biopsy. This prostatic needle biopsy will also be recommended if the PSA is increasing at a rate greater than 0.75 or 25% per year. If the biopsies don't show any cancer, we may recommend that the PSA levels be rechecked frequently, usually every three or four months. Should an unexplained increase in PSA be found, a repeat biopsy will be necessary.
In some cases, a "Free Versus Total" PSA blood test will be requested. A high percentage of "Free PSA" in the blood increases the chances for benign prostate enlargement, infection or inflammation without cancer. A "Free PSA" percentage that is fourteen or less is usually considered suspicious because about two thirds of these patients will have prostate cancer.