Enlarged prostate, also known as benign prostatic hyperplasia (BPH), is a disorder that generally affects men 50 years of age and older. BPH is not the same as prostate cancer.
The prostate is a small, muscular gland (in the shape of a walnut) in the male reproductive system. It surrounds the urethra just below the urinary bladder and adds fluid to semen to allow sperm mobility. With age, the cells of the gland begin to multiply, leading to an enlarged prostate. Although the exact cause is unknown, changes in male sex hormones with age may be a factor.
Other risk factors for prostate gland enlargement are family history, diabetes, heart disease and obesity. It tends to be more common in men of Asian heritage than other races.
Many men with BPH have either no symptoms or very mild symptoms. However, many men have severe symptoms that may even interfere with their quality of life. Some of the symptoms of BPH are a frequent urge to urinate, increased frequency of urination at night, trouble starting a stream of urine, a weak urine stream, continued dribbling of urine, and a feeling of incomplete bladder emptying.
If left untreated, an enlarged prostate can block the flow of urine out of the bladder, leading to other complications like urinary retention, UTIs, bladder stones, and kidney damage.
The prostate gland commonly becomes larger in older men. This prostate gland enlargement is also called benign prostatic hyperplasia (BPH). It can cause problems with passing urine. Symptoms are often mild. Without treatment, symptoms do not always get worse, and may even improve over time. If symptoms become troublesome or distressing they can be improved by medicines or surgery.
What is the prostate gland?
Cross-section diagram of the prostate and nearby organs
The prostate gland (just called prostate from now on) is only found in men. It lies just beneath the bladder. It is normally about the size of a chestnut. The urethra (the tube which passes urine from the bladder) runs through the middle of the prostate. The prostate's main function is to produce fluid which protects and enriches sperm.
The prostate gets bigger (enlarges) gradually after the age of about 50. By the age of 90, about 9 in 10 men have an enlarged prostate.
What are the symptoms of prostate enlargement?
The symptoms of prostate enlargement are called lower urinary tract symptoms (LUTS). See separate leaflet called Lower Urinary Tract Symptoms in Men where these are discussed in more detail. LUTS can also be caused by other conditions.
As the prostate enlarges it may cause narrowing of the first part of the urethra. This may partially obstruct the flow of urine. This can lead to obstructive symptoms such as:
*Poor stream. The flow of urine is weaker, and it takes longer to empty your bladder.
*Hesitancy. You may have to wait at the toilet for a while before urine starts to flow.
*Dribbling. Towards the end of passing urine, the flow becomes a slow dribble.
*Poor emptying. You may have a feeling of not quite emptying your bladder.
The enlarged prostate may also make the bladder irritable, which may cause:
*Frequency (passing urine more often than normal). This can be most irritating if it happens at night. Getting up several times a night is a common symptom and is called nocturia.
*Urgency. This means you have to get to the toilet quickly when you need to go.
Usually the symptoms are mild to begin with. Perhaps a slightly reduced urine flow, or having to wait a few seconds to start passing urine. Over months or years the symptoms may become more troublesome and severe. Complications develop in some cases.
Note 1:
an enlarged prostate does not always cause symptoms. Only a quarter to a half of men with an enlarged prostate will have symptoms. Also, the severity of the symptoms is not always related to the size of the prostate. It depends on how much the prostate obstructs the urethra.
Note 2:
not all urinary symptoms in men are due to an enlarged prostate. In particular, if you pass blood, become incontinent, or have pain, it may be due to bladder, kidney, or other prostate conditions. You should see a doctor if these symptoms occur.
What are the possible complications?
Urinary symptoms do not worsen in everyone. Serious complications are unlikely to occur in most men with an enlarged prostate. Complications that sometimes occur include:
*In some cases, a total blockage of urine occurs so you will no longer be able to pass urine. This is called urinary retention. It can be very uncomfortable and you will need to have a catheter inserted to drain the bladder. It occurs in less than 1 in 100 men with an enlarged prostate each year.
*In some cases, only some of the urine in the bladder is emptied when you pass urine. Some urine remains in the bladder at all times. This ongoing condition is called chronic retention. This may cause repeated (recurring) urine infections, or incontinence (as urine dribbles around the blockage rather than large amounts being passed each time you go to the toilet).
*Note:
the risk of prostate cancer is not increased. Men with a benign prostate enlargement are no more or less likely to develop prostate cancer than those without benign prostate enlargement. Cancer of the prostate is a separate condition and dealt with in a separate leaflet called Prostate Cancer.
Do I need any tests?
Benign prostatic enlargement is usually diagnosed based on the typical symptoms as described earlier. Tests are not always needed to confirm the diagnosis. However, one or more tests may be advised to exclude complications, to rule out other causes of your symptoms, and sometimes to assess the severity of the enlarged prostate. The following tests may be done:
*A doctor may examine your prostate to see how big it is. This is done by inserting a gloved finger into your back passage (through the anus into the rectum) to feel the back of the prostate gland. The size of your bladder may be assessed by examining your abdomen.
*Urine and blood tests may be done to check the function of your kidneys, to exclude a urine infection and to check there is no blood in the urine.
*A referral to a bladder specialist (urologist) may be advised if your symptoms are troublesome or if complications develop. Tests may be done in these more severe cases, particularly if surgery is being considered as a treatment. For example:
-A look inside the bladder with a special telescope (cystoscopy).
-A urine flow test to assess how bad the obstruction has become.
-A scan to see whether much urine remains in the bladder after you pass urine (void).
*Voiding diary. You may be asked to complete a diary over a week or so. This will have information about the number of times during the day and night you void, the amount passed, and also the number and types of drinks you have had.
*A prostate specific antigen (PSA) blood test may be offered, although this test is not done routinely. This can be used as a marker for the size of the prostate. Larger prostates make more PSA.
Note: a high PSA level is also found in people with prostate cancer. It has to be stressed that most men with prostate symptoms do not have prostate cancer.
Is treatment always necessary?
No. In most cases, an enlarged prostate does not do any damage or cause complications. Whether treatment is needed usually depends on how much bother the symptoms cause. For example, you may be glad for some treatment if you are woken six times a night, every night, with an urgent need to go to the toilet. On the other hand, slight hesitancy when you go to the toilet, and getting up once a night to pass urine may cause little problem and not need treatment.
What are the treatment options for prostate enlargement?
No treatment is likely to clear all symptoms totally, although symptoms can usually be greatly improved with treatment. The treatments considered usually depend on how severe and bothersome your symptoms are.
General measures:
The following tips may help if you opt not to have treatment (for example, if symptoms are mild) or if treatment does not fully work:
*Try to anticipate times when urinary frequency and urgency are likely to be most inconvenient, and reduce the amount that you drink beforehand. For example, when you go out, don't drink much for 2-3 hours before you go out. However, do not reduce the total amount of fluid to less than 1.5 litres each day.
*After you have finished passing urine, go back to the toilet again after a few minutes to try to pass some more. (This is called double micturition.) This aims to make sure the bladder is emptied completely.
*Consider reducing or stopping caffeine (commonly found in tea, coffee and cola) and alcohol. These can make the symptoms of frequency, urgency and nocturia worse.
*If hesitancy is a problem - try to relax when standing to pass urine.
*If urgency is a problem - try some distraction techniques such as breathing exercises and mental tricks (for example, counting) to take your mind off the bladder.
*If frequency is a problem - try retraining the bladder by holding on for as long as you can each time before passing urine. The bladder muscle can be trained to expand more in this way. Eventually, the bladder may be trained to hold on for longer each time before you need to go to the toilet.
*If you are a smoker then stopping smoking may significantly improve your symptoms, as nicotine irritates the bladder.
Not treating may be an option (often called watchful waiting)
If symptoms are mild then this may be the best option. You may be happy just to see how things go if the symptoms are not too bothersome and are not affecting your life very much. The situation can be reviewed every year or so, or sooner if there is change in symptoms. Symptoms do not always become worse. They may even improve.
Medicines
The decision to treat with medicines usually depends on how much bother the symptoms are causing you. There are two groups of medicines that may help: alpha-blockers and 5-alpha reductase inhibitors. Medicines do not cure the problem, nor do they usually make symptoms go completely. However, symptoms often ease if you take a medicine.
Alpha-blocker medicines.
These medicines work by by relaxing the smooth muscle of the prostate and bladder neck. This can improve the flow of urine. There are several different types and brands of alpha-blockers which include prazosin, indoramin, tamsulosin, alfuzosin, doxazosin and terazosin. There is no real difference between how effective these medicines are, but some tend to cause side-effects more often than others. In most cases, symptoms improve with taking an alpha-blocker. However, the amount of improvement varies from person to person. Some improvement usually occurs within a few days, but the full effect may take up to six weeks.
Although side-effects are uncommon, they occur in some people. The most common side-effects are slight drowsiness, headaches and dizziness. If you are prescribed an alpha-blocker, read the leaflet that comes with the medicine packet for a full list of possible side-effects and cautions.
5-alpha reductase inhibitor medicines.
These are alternatives to alpha-blockers. There are two: finasteride and dutasteride. These work by blocking the conversion of the hormone testosterone to dihydrotestosterone in the prostate. They do this by blocking a chemical (an enzyme) called 5-alpha-reductase. Dihydrotestosterone is partly responsible for making the prostate enlarge. Therefore, a reduced amount of dihydrotestosterone in the prostate causes it to shrink. These medicines have been shown in studies to improve prostate symptoms, reduce the risk of complications and also reduce the need for surgery. It can take up to six months for you to notice any effect from these medicines, as it takes time for the prostate gradually to shrink.
It is unusual to have side-effects with 5-alpha reductase inhibitor medicines. However, between 1 in 10 and 1 in 100 men may have impotence and reduced sex drive; these side-effects are usually reversible but may continue after the medication is stopped. (Again, read the leaflet in the medicine packet for a full list of possible side-effects.)
Which medicine is chosen?
The severity of symptoms is not always related to the size of the prostate. A small or large enlargement may cause mild or severe symptoms. An alpha-blocker may help, whatever the size of the prostate, as it works by relaxing muscle fibres. Finasteride or dutasteride tend to work best if you have a larger prostate which has more tissue to shrink. Your doctor will advise which medicine may be best in your circumstances. Also, if you develop a problem or side-effect with one type of medicine, then another may be an option.
Combinations of medicines.
In some cases, a combination of an alpha-blocker plus a 5-alpha reductase inhibitor is used. This may give quicker and better relief of symptoms than either alone. Some studies suggest that in men who take a combination of two medicines, about four in five men can stop the alpha-blocker after 6-12 months without their symptoms getting any worse. This is likely to be because the prostate will have shrunk with the 5-alpha reductase inhibitor after this time and the alpha-blocker is no longer then needed.
Herbal remedies
There is currently no strong evidence that herbal remedies improve the symptoms due to an enlarged prostate. More studies are needed in this area.
Surgery
Removal of part of the prostate is an option if symptoms are very bothersome, or if medicines do not help. Around one in four men with an enlarged prostate will have an operation at some stage. In these operations, only the central part of the prostate is removed (creating a wide channel for urine to flow through), leaving the outer part behind. This is different to prostate cancer when, if surgery is carried out for cure, all the prostate is removed.
There are many different types of operation now available that can remove prostate tissue. Your surgeon will discuss the most suitable operation for you in more detail. Some of the more commonly done operations are listed below:
Transurethral resection of the prostate (TURP).
This is the most common operation carried out for an enlarged prostate. Under anaesthetic, either spinal or general, a rigid cystoscope is inserted through the urethra into the bladder. A cystoscope is a narrow tube-like telescope through which small instruments pass to allow the operation to be carried out. A semicircular loop of wire has an electrical current passed through it. It is this loop that sticks out from the end of the cystoscope and cuts out small chips of prostate that are then washed out at the end of the operation. This operation nearly always gives good relief of symptoms. 80-90% of men after this operation will have retrograde ejaculation. This means that semen goes backwards into the bladder at climax producing a 'dry' orgasm. Impotence and incontinence are rare complications after a TURP.
Transurethral incision of the prostate (TUIP).
This may be offered if you only have a slightly enlarged prostate. For this operation, the surgeon makes small cuts in the prostate where the prostate meets the bladder. This then relaxes the opening to the bladder, resulting in there being an improved flow of urine out of the bladder. There is less risk of retrograde ejaculation with this operation.
Open prostatectomy.
This is a more traditional operation which involves cutting the skin to get to the prostate. It is now rarely done. It is only performed when the prostate is very large, and when it would not be practicable to remove an adequate amount of prostate tissue through a narrow cystoscope inserted through the urethra.
Laser prostatectomy.
This is simply the application of newer technologies to achieve the same goal as either TURP or open prostatectomy. It has the advantage of fewer side-effects, a shorter period of having a catheter in, and a shorter stay in hospital (often just one night). There are two types of lasers:
*Green light which vaporises the prostate tissue to create a cavity
*Holmium or thulium lasers that can very effectively core out large pieces (lobes) of prostate which, in turn, are chopped into small pieces in order to be removed from the bladder.
In the hands of experienced laser surgeons, very large prostates, which in the past could only be dealt with by open surgery, can be removed by this technique.
Other methods.
Implants can be used to lift the urethra and improve flow of urine. This procedure has been shown to have fewer problems with sexual function than TURP. Other forms of energy are also being investigated instead of lasers. These include microwaves, radiofrequency waves, high-intensity ultrasound and high-voltage electrical energy. Research continues to find new ways to manage these symptoms and you may be offered a chance to take part in these studies.
There are several effective treatments for enlarged prostate, including medications, therapies and surgery. In addition, certain home remedies and lifestyle changes can help ease the symptoms.
1. Kegel Exercises
Kegel or pelvic-strengthening exercises can help ease some of the discomforts of enlarged prostate as they help tighten and clench specific pelvic muscles to help control urination.
Empty your bladder and lie on the floor with your knees bent and apart. Tighten your pelvic floor muscles for 5 seconds, then relax them for 5 seconds. Repeat 10 to 20 times, 3 or 4 times each day. Pelvic floor muscles are the muscles you use to stop your urine flow.
Another option is to squeeze the muscles in your anus, then relax your pelvic floor muscles. Do it 10 to 20 times, a few times a day.
Regularly perform kegel exercises throughout the day. You can do them after waking up in the morning, at lunchtime, in the evening and before going to bed. Target your pelvic muscles only and avoid tightening the muscles in your stomach, buttocks or thighs. If you are having difficulty locating the pelvic muscles, get help from an expert.
Note: Men who suffer from chronic prostatitis or chronic pelvic pain syndrome must avoid doing kegel exercises.
2. Aerobic and Resistance Exercises
Staying active is good for the prostate as well as overall health. Inactivity contributes to obesity, one of the risk factors for enlarged prostate. Even a small amount of exercise like aerobic and resistance exercises can help reduce urinary problems caused by an enlarged prostate and can even prevent this problem.
Aerobic exercises can help you maintain a healthy weight. Incorporate aerobic exercises like walking, jogging, running, tennis, basketball and rowing in your daily routine.
Resistance exercises help improve strength and muscle tone, while reducing inflammation. Examples of resistance exercises are swimming, push-ups and lifting weights. Do these for 30 minutes, a few times a week.
3. Sitz Bath
A contrast sitz bath is a soothing and effective remedy for enlarged prostate. The hot bath will help relax the pelvic muscles, reduce swelling and promote healing. On the other hand, the cold bath will ease pain.
Fill one bathtub with warm water and add ½ cup of Epsom salt to it.
Fill another bathtub with cold water and add a few drops of lavender essential oil to it.
First, sit in the bathtub with hot water up to your waist for 3 minutes.
Next, sit in the bathtub with cold water up to your waist for 1 minute.
Do this 2 more times. The last bath should always be in the cool water.
Enjoy a sitz bath a few times each week.
Note: Do not follow this remedy if you have acute bacterial prostatitis.
4. Stinging Nettle
Stinging nettle can also lessen BPH symptoms. The root contains essential bioactive phytochemicals that help shrink prostate tissue. Being a natural diuretic, it also encourages the elimination of inflammatory wastes through urination.
Add 1 teaspoon of dried nettle leaves to a cup of hot water. Steep for 10 minutes, then strain it. Drink this tea 2 or 3 times daily.
You can also take a stinging nettle supplement. The usual amount is 300 mg daily. Always consult a doctor before taking a supplement for the correct dosage for your condition.
5. Corn Silk
Corn silk is a time-tested remedy to fight off symptoms of prostate enlargement. It acts as a natural diuretic and even helps relax the urinary muscles and lining. This leads to improved urine flow.
Put the silk of 6 ears of fresh corn in 4 cups of water. Bring it to a boil, then simmer for another 10 minutes. Strain and drink up to 3 cups of this corn silk tea a day.
Another option is to add 15 drops of corn silk extract to 1 cup of water and drink it a few times a day.
6. Apple Cider Vinegar
Raw, unfiltered apple cider vinegar has astringent properties that help shrink swollen prostate glands. It also aids weight loss and helps prevent complications of enlarged prostate like UTIs.
Mix 1 to 2 tablespoons of raw, unfiltered apple cider vinegar and 1 tablespoon of honey in a glass of warm water. Drink it twice daily.
Another option is to add 1 cup of apple cider vinegar to a bathtub of water and soak in it for 10 to 15 minutes. Enjoy this soothing bath a few times a week.
7. Pumpkin Seeds
Pumpkin seeds also help an enlarged prostate shrink in size. The seeds contain diuretic properties that help urine flow. They are also high in zinc. Men with enlarged prostate usually have a zinc deficiency. In addition, the seeds have omega-3 fatty acids that aid prostate functioning.
The best way to enjoy pumpkin seeds is to eat them plain without adding any salt. A handful of seeds per day are enough.
Alternatively, put a handful of crushed fresh pumpkin seeds in a large cup. Add boiling water to the cup and allow it to cool to room temperature. Strain and drink a cup of this tea, a few times a week.
8. Tomatoes
Tomatoes are rich in lycopene that helps ease the symptoms of BPH. Lycopene helps lower the level of prostate-specific antigen (PSA) connected to prostate inflammation and BPH. It helps lower bladder pressure and, in turn, helps shrink the enlarged prostate.
Include tomatoes and tomato products like tomato sauce, puree and juice in your diet.
You can also take a lycopene supplement, after consulting your doctor.
9. Zinc Supplement
To help shrink the prostate gland, start taking a zinc supplement. Zinc is an essential trace mineral that plays an important role in the body’s immune response and cell growth. This mineral is present in prostate cells, where it plays a protective and anti-inflammatory role.
According to a 2007 study, Oregon State University researchers concluded that zinc deficiency might impair the function of zinc-containing proteins in the prostate, leading to abnormalities in prostate function and growth.
Take a zinc supplement, usually a total of 90 mg daily, taken in three 30 mg doses. Before taking the supplement, consult your doctor.
Also, eat zinc-rich foods like oysters, crab, fortified breakfast cereals, beans, cashews and yogurt.
10. Dietary Changes
Eating a healthy diet can also help in controlling and reducing the symptoms of enlarged prostate.
Eat 2 servings a week of fish high in omega-3 oils, such as tuna, mackerel or salmon.
Include soy and soy-based foods in your diet.
Follow a diet that is low in starches and meats.
Include vegetables like red bell peppers, broccoli, cauliflower, kale and Brussels sprouts in your diet.
Use polyunsaturated fat in your cooking. Make sure to use it in moderation.
Additional Tips:-
-Try to empty your bladder as soon as you feel the urge to urinate.
-Make a habit of going to the bathroom to urinate, even when you do not feel the urge.
-Avoid alcohol and caffeine, especially after dinner or 2 hours before your bedtime.
-Avoid drinking a lot of fluid all at once. Instead, take small sips throughout the day.
-Avoid taking any over-the-counter medicine without consulting your doctor.
-Keep yourself warm and, if possible, avoid cold weather.
-Reduce stress and tension as these can lead to the urge to urinate more frequently.
-Limit your intake of fatty foods and red meats.
-If you are overweight, take steps to lose weight. Obesity is associated with enlarged prostate.
-Avoid prolonged sitting in the same position as it may worsen your condition.
-Breathing exercises and postures can help reduce stress and relieve symptoms of BPH.
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