Enlarged Prostate Gland (Benign Prostate Hyperplasia, BPH)

The prostate gland is part of the male reproductive system. It produces the fluid that carries semen — a function that is important to a man’s fertility. It is about the size of a walnut and surrounds the urethra, a tube that carries urine to the outside of the body and moves semen through the penis. The prostate gland is in front of a man’s rectum, just below the bladder.

The prostate gland doubles in size in puberty and continuing growing throughout a man’s life. That growth is a normal process.

As men get older, the prostate gland can grow too large. This condition, benign prostatic hyperplasia (BPH) — also known as prostate gland enlargement — is common. It affects around half of men ages 51 to 60, and most men older than age 80 (up to 90%) have an enlarged prostate gland. One report estimates that BPH is responsible for 4.5 million doctor visits each year because of symptoms that go along with an enlarged prostate.

Causes and Risk Factors for an Enlarged Prostate Gland

Men who are more likely to experience BPH include those who:

• Are older than age 40
• Have erectile dysfunction
• Are sedentary
• Have a family history of enlarged prostate
• Have medical conditions like type 2 diabetes, obesity and heart and vascular disease

BPH Symptoms 

As the prostate gland grows, it can pinch the urethra it surrounds and the bladder can start working too hard, trying to move urine through the blocked urinary tube. Some men don’t have symptoms or have few symptoms. However, an enlarged prostate gland can cause many disruptive problems that affect a man’s quality of life, including:

• Incontinence
• Having to urinate often — eight or more times per day
• Having to urinate often at night
• Urgency — not being able to delay urinating
• Problems starting to urinate
• Weak urine stream or interrupted urine stream
• Dribbling when done with urinating
• Pain when urinating
• Urine that has an unusual color or odor
• Retaining urine in the bladder
• Pain after ejaculating

It is important to see your doctor if you have symptoms of BPH. Although complications of BPH don’t affect most men, serious conditions can happen, including:

• Inability to pass urine (also called acute urinary retention)
• Frequent urinary tract infections
• Blood in the urine
• Long-lasting or chronic retention of urine
• Damage to the bladder or kidneys
• Development of stones in the bladder

Diagnosing Benign Prostatic Hyperplasia

Your doctor will talk with you about your personal medical history and family medical history and will do a physical exam, including a digital rectal exam of the prostate. This exam tells your doctor if your prostate gland is enlarged, feels tender or has abnormal areas (lumps and bumps). You may be referred to a specialist, such as a urologist, to rule out other conditions such as prostatitis or cancer. Tests for BPH can include:

• Analyzing the urine for infection
• Ultrasound
• Cystoscopy — a test that looks inside the urethra and bladder
• Urodynamics — a test to see how well urine gets stored in your bladder and released through the urethra
• A blood test called prostate-specific antigen
• Biopsy of the prostate gland to test tissue for prostate cancer — if the doctor thinks it is needed

Treatment for Enlarged Prostate

There are a number of treatments for BPH depending on the size of the enlarged prostate gland and severity of symptoms. Treatment ranges from lifestyle changes, to medications, minimally invasive procedures or surgery to reduce the prostate’s size and BPH symptoms.

Lifestyle Changes

• Exercises to strengthen muscles in the pelvic floor
• Avoiding or treating constipation
• Drinking less liquid before bedtime
• Avoiding caffeinated drinks and alcohol
• Bladder training to hold urine in the bladder longer
• Avoiding or carefully monitoring certain medications like diuretics, antihistamines, decongestants and drugs that treat depression

Medications for Enlarged Prostate

• Drugs that stop the growth of or shrink the prostate gland
• Medications that improve urine flow by relaxing muscles in the prostate gland and neck of the bladder

Minimally Invasive Treatment for BPH

Holmium Laser Enucleation of the Prostate (HoLEP)

HoLEP is done by a urologist, who uses a high-energy laser to remove prostate tissue that is blocking the urethra. It doesn’t require large incisions. It can be used to treat BPH in prostate glands of any size and is appropriate for men who are taking medications to thin the blood. By avoiding nerves and muscle, erectile function is maintained.

HoLEP provides a lasting solution for men of any age who have obstructed urinary flow caused by an enlarged prostate, especially those with prostate glands larger than 60 grams.

Advantages of Treating BPH with HoLEP

• HoLep can be used to treat enlarged prostate glands of any size without a skin incision.
• Symptom relief typically happens within three to four weeks.
• There is less bleeding than after a transurethral resection of the prostate (TURP) procedure
• Less than 1% of men experience tissue regrowth that would need more surgery
• Risk for permanent urinary incontinence is very low; less than 2% of patients experience permanent problems with incontinence.
• There can be temporary loss of urinary control until the pelvic floor muscles recover. Pelvic floor exercises before and after the procedure can help this problem.

What to Expect During the HoLEP Procedure

The HoLEP procedure requires general or spinal anesthesia and usually involves a one to two day hospital stay. During the surgery:

• The surgeon inserts a rectoscope, a thin tube with a camera and laser at the end, into the urethra. The camera gives the surgeon a view of the inside of the prostate gland.
• The surgeons passes a laser through the rectoscope. With the laser, the surgeon removes all of the tissue blocking urine flow.
• Tissue fragments are moved to the bladder.
• A tool called a morcellator cuts the tissue into easily removable tissue fragments.
• The prostate tissue that was removed is examined after surgery to make sure there are no serious conditions like prostate cancer.

What to Expect During Recovery After HoLep

HoLEP recovery requires limiting activities for about one to two weeks and avoiding sexual activity for three to four weeks. Most men can return to normal activities in three to four weeks. You may experience:

• Initial discomfort (typically improves over a few days)
• Blood in the urine for one to two weeks
• Changes in how often you have to urinate and urgency to urinate (typically last several days, but can last several months)
• Getting up at night to urinate
• Temporary incontinence while pelvic floor muscles recover
• Retrograde ejaculation — lack of fluid with ejaculation during sexual activity

Prostate Arterial Embolization (PAE) to Treat BPH

PAE is an option for some men who have moderate to severe BPH. This low-risk procedure is successful for most of the men who have it. It is not the right choice for every man who has BPH, and patients should try conservative measures like lifestyle changes and medications first. However, when symptoms persist or become unbearable, PAE is a safe and effective alternative.

Within two or three weeks after PAE, 80% to 90% of men experience improvement in their symptoms. While PAE is usually successful, patients can still have surgery if necessary.

The best results occur when men have a larger gland — greater than 100 grams measured from imaging scans. Key to the effectiveness of PAE is identifying the right candidates by confirming the BPH diagnosis and ruling out other causes such as muscle or bladder dysfunction, prostatitis or prostate cancer.

The doctor will measure the size of the prostate gland and examine blood vessel anatomy, which can be very different for every man. An imaging scan helps establish prostate gland size, which determines if the procedure will be effective. MRI or CT angiography is used to make sure the system of blood vessels don’t have unusual twist and turns that make it difficult or unsafe for catheterization. A prostate-specific antigen blood test (PSA) is done to rule out any indications of cancer.

What to Expect During the PAE Procedure

PAE can take from one-and-a-half to four hours, depending on a man’s anatomy. It requires only mild sedation, and the procedure is done by a vascular and intervention radiologist.

• A very small catheter is threaded into the arteries of the prostate gland.
• Tiny particles of polyvinyl alcohol or other embolization agents are injected through the catheter into the prostate arteries
• The particles significantly diminish blood flow, causing the prostate gland to shrink
• Macrophages, a type of white blood cell in the immune system, reabsorb the dead prostate tissue and replace it with scar tissue, which contracts to open up the central part of the gland.

What to Expect During PAE Recovery

Patients can go home the same day after two to three hours’ recovery in the Vascular and Interventional suites. They are given antibiotics to minimize the risk of infection and medication to reduce bladder inflammation. Men may have some soreness at the puncture site and will need to limit activities. Normal activities can resume after five to seven days.

High-Intensity Focused Ultrasound (HIFU)

HIFU delivers sound waves to a targeted area of the prostate gland. This energy creates heat, which destroys enough prostate tissue to reduce the size of the enlarged prostate gland. The procedure does not require incisions, causes almost no bleeding, and is safe with a very low risk of complications. HIFU only requires one treatment session.

HIFU significantly reduces BPH symptoms and slightly increases free flow of urine.

What to Expect During the HIFU Procedure

HIFU takes about three hours when delivered to the entire prostate gland; less time is needed, around 40 minutes, when HIFU is delivered only to targeted areas.

• Light or general anesthesia is given to the patient
• The urologist uses imaging to determine the exact location of tissue to be targeted.
• A slender ultrasound probe is inserted through the rectum.
• A test dose of ultrasound beams will be applied first, and the urologist may adjust the power of the beams if needed
• Short bursts of ultrasound energy are delivered to the prostate tissue.
• An imaging scan is done to make sure all the targeted tissue has been destroyed.

What to Expect During HIFU Recovery

• Patients will stay in the hospital for a brief time
• A catheter will remain in place for three to four days.

Surgery for Enlarged Prostate

Transurethral Resection of the Prostate (TURP or TUIP)

TURP is has been considered the gold standard of surgical treatment for BPH for decades. It does not involve external incisions; the procedure is performed internally to remove excess prostate tissue blocking the urethra. TURP is very effective and can relieve prostate symptoms permanently. Studies show that about nine months after TURP, most men (75 of 100) will have only mild symptoms.

Before considering TURP for your BPH, your doctor will have you try lifestyle modifications or medications to relieve your symptoms. If these choices don’t work, and your symptom become unmanageable, TURP can be considered.

TUIP, or transurethral incision of the prostate, is a variation of TURP but it is not recommended unless the prostate gland size is less than or equal to 30 cc. Unlike TURP, TUIP doesn’t remove tissue; instead, it makes the urethra wider. This involves small cuts in the neck of the bladder where the urethra joins it, as well as cuts in the prostate gland.

What to Expect During the TURP Procedure

You will receive general anesthesia so you are asleep during the operation or spinal anesthesia, during which you are awake but numb from the waist down. The surgery takes 60 to 90 minutes to complete.

• The urologist inserts a resectoscope through the urethra.
• The resectoscope includes a light, valves for turning irrigating fluid on and off, and an electrical loop that cuts away excess tissue that blocks the urethra and seals blood vessels.
• Pieces of tissue move into the bladder
• When the procedure is done, tissue pieces are flushed out with fluid

What to Expect During TURP recovery

After your TURP procedure, you will stay in the hospital for one to three days. A catheter is left in place temporarily until urethra swelling goes down, which may cause some discomfort and bladder spasms. Water will be flushed through catheter to remove any remaining tissue debris. The catheter will be removed to see if you can urinate before going home. If you can’t, the catheter will be inserted again, and you may need it for a few days or weeks.

Common Post-TURP Symptoms

• Discomfort (but not severe pain) when urinating
• Urinating is hard to control for a few days
• Blood in the urine, which could increase after a week or two
• Fatigue that lasts a week or two

After You Go Home

You’ll need three or four weeks to rest and recover after the TURP. Avoid sex during that time, as you allow your body to heal. Your doctor will tell you when it’s safe for you to resume normal activities, to drive again and return to work.

• Drink plenty of water to avoid a urinary tract infection and to clear any small amounts of blood from the bladder
• Don’t lift anything heavy
• Limit activities. When you feel up to it, do some slow-paced walking to avoid the risk of blood clots in the legs.
• Do recommended pelvic floor exercises to improve bladder control
• As recommended by your doctor, take ibuprofen or Tylenol for pain

Call your doctor immediately if you experience:

• High fever
• Inability to urinate
• Severe pain when urinating
• A lot of blood in your urine
• Blood clots in your urine