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Enlarged prostate: Symptoms and treatments

Dr T Manohar
Thursday, September 7, 2017, 08:00 Hrs  [IST]

Prostate is a walnut-sized gland that forms part of the male reproductive system. It is located in front of rectum, just below urinary bladder. It surrounds urethra, the tube through which urine passes out of body. Its function is to squeeze fluid into urethra as sperms move through during sexual climax.

Prostate enlargement happens to almost all men as they get older. As prostate enlarges, it presses against urethra like a clamp. Narrowing of urethra and partial emptying of bladder result in problems associated with benign prostatic hyperplasia (BPH), commonly called enlarged prostate.

The precise cause of BPH is not known. There is no definite information on risk factors as well. A small prostate enlargement is present in many men aged over 40 years and in more than 90 per cent of them aged over 80. BPH often results in slowing urinary stream, incomplete bladder emptying, frequent urination at night, strain while urinating, continued dribbling of urine or inability to urinate (urinary retention).

Clinical evaluation and tests
Tests can help identify the problem to evaluate if a surgery is required. These include digital rectal exam to feel prostate gland, Uroflowmetry to determine urine flow rate, urodynamic study to measure pressure changes in bladder during urination, prostate-specific antigen blood test to screen for prostate cancer, and ultrasound examination to assess the size of prostate and post-void residue.

The choice of treatment is based on severity of symptoms and presence of other medical conditions. Men with enlarged prostate having minor symptoms need a yearly check-up. Men with an enlarged prostate having only minor symptoms need watchful waiting with regular check up - an yearly exam to monitor the progression of symptoms and to determine if any treatment is necessary.

For minor symptoms: Lifestyle changes - avoid alcohol and caffeine, especially after dinner. Fluid intake -  not to drink a lot of fluid all at once. Spread out fluids throughout the day. Avoid drinking fluids within 2 hours of bedtime. To avoid medication that contains decongestants or antihistamines. These medications can increase BPH symptoms.

Alpha 1 blockers (tamsulosin and alfuzosin) relax muscles of bladder neck and prostate. This allows easier urination. Finasteride and dutasteride lower hormone levels, reduce the size of prostate gland, increase urine flow and reduce symptoms.

Surgical procedures
Surgical intervention is recommended if there is blood in urine, urinary retention, recurrent urinary tract infections, kidney failure, bladder stones or no response to medical management. The choice of a specific surgical procedure is based on severity of symptoms, risk status of a patient and the size and shape of prostate gland. Following are some surgical procedures available.

Trans-Urethral Resection of Prostate (TURP): This is the most common treatment for BPH. A resectoscope is inserted through urethra which has an electrical loop that cuts prostatic tissue and seals blood vessels. The surgery requires anesthesia and staying at hospital for three to four days.

Bipolar TURP: Trans-urethral resection on saline. However, it is safer and has minimal post-op symptoms like burning sensation while urinating or urgency to urinate. The procedure is adopted for those with chronic kidney diseases and high-risk individuals.

Miniature TURP: A patient with small caliber urethra since birth or due to some illness can be offered miniature TURP in which small telescopes are used without damaging urethral passage while performing surgery.

Open prostatectomy: Preferred in cases with large prostate where laser facilities are not available.

Lumenis Pulse 120H Laser surgery: The procedure employs lasers to vaporize, cut or resect and enucleate obstructing prostate tissue. A laser fiber is passed through urethra into prostate using a cystoscope. Various laser technologies are suitable to different clinical conditions of a patient.

Holmium Laser Enucleation of Prostate with Lumenis Pulse 120H (HoLEP): Pulse 120H is used to resect or enucleate prostate in an effective manner. Unlike other laser technologies, the size of prostate gland does not preclude use of Lumenis Pulse 120H laser. HoLEP with Lumenis Pulse 120H is currently the only procedure to treat larger prostates. All lobes are enucleated, moved into bladder and morcellated or fragmented.

The hospital stay is minimal and recurrence rates are low. Surgeries are the only treatment of choice for prostate of larger seizes (more than 80 to 100 grammes). Even prostate up to 475 gram have been done by Dr T. Manohar in Bengaluru using the Pulse 120H laser.

During surgeries, blood loss is minimum. They can be performed on high-risk individuals or on patients who are on blood thinners (irrespective of the prostate size). The procedure ensures removal of 80 to 90 per cent of the gland. The rate of recurrence is less than one per cent in ten years and the hospital stay is less.

Currently, Lumenis Pulse 120H is the most versatile technology available for the prostate enlargement related problems. The Lumenis Pulse 120H has made HoLEP procedures precise, faster & efficient.

Lumenis Pulse 120H machine has the versatility of treating any size of the prostate and any type of high risk. This laser technology possess new laser pulse width which is helpful in controlling the tissue cutting and further helps in controlling the bleeding. One can use appropriate energy depending on the tissue target. It has varying energy and frequency so that appropriate delivery of laser energy (measured in watt) can be applied. This technology can be applied to bladder cancer, kidney stones and strictures of urethra and ureter.

Sexual function after prostate surgery
Most men find little or no difference in the sensation of orgasm, or sexual climax, before and after surgery. Although most men are able to continue having erections after surgery, a prostate procedure frequently causes a condition called retrograde ejaculation or dry climax. This is because Prostate surgery widens the neck of the bladder. Following surgery, the semen takes the path of least resistance and enters the wider opening to the bladder rather than being expelled through the penis. Some young men can undergo apical preserving bipolar TURP – which may prevent this complication in selected patients.

Surgery usually offers relief from BPH for at least 15 years. Only 10 per cent of the men who have surgery for BPH eventually need a second operation for enlargement. But, this statistics does not hold good for large prostates undergoing conventional surgeries. Hole reduces the recurrence to <1 per cent in 10 years.  Usually these are men who had the first surgery at an early age.

(Author is chief urologist, SCUG Laser and
Laparoscopic Centre, Bengaluru)


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