Enlarged Prostate
Management of benign prostate enlargement that causes urinary difficulty, frequency or incomplete bladder emptying
What is enlarged prostate?
The prostate sits below the bladder and the urethra runs through the middle of it. From about the age of forty the inner zone begins to enlarge, and by seventy most men have some enlargement. It is a normal ageing change and has no relationship to cancer, which grows in a different zone of the gland.
What causes trouble is not the size of the gland but how much it obstructs. A modest prostate with a middle lobe pushing up into the bladder can obstruct more than a large one growing outwards, so the measured flow tells you more than the measured volume.
The bladder responds to years of pushing against resistance by thickening and becoming irritable, and later by tiring. Treatment is more straightforward, and the result better, before the bladder has spent a long time working against obstruction.
What you might notice
- A urine stream that has weakened
- Unable to pass urine at all, with a painful lower belly
- A PSA reading that has risen
- A urine stream that stops halfway and starts again
- A urine stream that sprays or splits
- Getting up at night to pass urine
- Blood in urine
How it is diagnosed
The assessment is a scored questionnaire, a flow rate, and an ultrasound measurement of what is left in the bladder after passing urine. Those three together say how obstructed the outflow actually is.
A digital examination gives the size and consistency of the gland. A PSA blood test is offered with an explanation of what a raised result would and would not mean, since enlargement raises it by itself. Urine is tested to exclude infection and kidney function is checked.
Pressure flow studies are added where the picture is confusing, particularly in men whose bladder may have weakened instead of being obstructed, because the two need opposite treatment.
Recovery
Medication is judged over four to twelve weeks and is then taken for as long as it keeps working. The two main classes act on different timescales, one within days and one over months.
After treatment through the urethra a catheter stays one to three days, the urine is blood-stained for a week or two, and the bladder settles over four to six weeks. Most men return to desk work in one to two weeks and avoid heavy lifting and cycling for four.
Flow improves as soon as the catheter is out. The bladder itself takes longer, sometimes months, because it has to recover from years of overwork. Retrograde ejaculation, where semen passes back into the bladder, follows most tissue-removing treatment and is worth discussing before the day.
If it is left untreated
Mild enlargement that is not bothering you needs no treatment, and watchful waiting with an annual review is a recognised plan that many men follow for years.
Left to progress, obstruction can produce a bladder that never empties fully, repeated infections, stones forming in the residual urine, and eventually back pressure reaching the kidneys. Acute retention, where the bladder cannot be emptied at all, needs relief the same day and is more likely the larger the gland and the larger the residual volume.
The bladder muscle can also decompensate. Once it has, restoring the outflow helps less than it would have done earlier, and that is the argument for acting while the obstruction is still measurable and the muscle still strong.
Questions about enlarged prostate
Does an enlarged prostate mean I have cancer?
No. Benign enlargement grows in the inner transition zone of the gland, while cancer usually arises in the outer peripheral zone, and one does not lead to the other. The two can coexist simply because both are common with age, so a PSA test and a digital examination are part of the assessment. Enlargement itself raises PSA, so a mildly raised result in a man with a large gland is often explained by the size alone, and your urologist interprets the number against the volume before deciding whether anything further is needed.
Do I have to have an operation, or will tablets do?
Tablets are the usual starting point and many men stay on them for years. Alpha blockers relax the muscle in the prostate and work within days; five alpha reductase inhibitors shrink the gland over three to six months and suit larger prostates. Surgery becomes the recommendation when tablets have not restored an acceptable flow, when you cannot tolerate them, or when there are hard indications such as retention needing a catheter, recurrent infection, bladder stones, or kidney function affected by back pressure. Waiting until the bladder has decompensated makes any treatment work less well.
Will treatment affect sex or ejaculation?
Erections are generally unaffected by treatments that remove or vaporise prostate tissue, including TURP and HoLEP. Ejaculation usually is affected: most tissue-removing procedures leave semen passing backwards into the bladder, which is harmless but permanent, and matters if you still want to father children. UroLift and Aquablation are chosen specifically when preserving ejaculation is the priority. Among tablets, alpha blockers can reduce ejaculatory volume and finasteride and dutasteride can lower libido in a minority of men. Say at the outset if this is important to you, because it changes which option is offered.
Other urology treatments
Treatment of kidney and urinary tract stones based on their size, location, symptoms and likelihood of passing naturally
Day CareRemoval of the foreskin for selected medical, hygiene or personal reasons after appropriate consultation
Day CareTalk to a care coordinator about enlarged prostate
Leave a number and a care coordinator calls you back with what the treatment involves and which hospital it would be at. They book a consult only if you want one