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Prostate symptoms (bladder outlet obstruction)


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What does the prostate gland do?

The prostate gland lies just beneath the bladder and is normally about the size of a chestnut. The urethra (water pipe) runs through the middle of the prostate. The main function of the prostate is during your reproductive life. It produces fluid containing chemicals which nourish sperms to help with fertilisation.

What should I do if I have prostate symptoms?

If you have difficulty starting or stopping your urine flow, a weak stream, a feeling that you do not empty your bladder completely, increased frequency and urgency of urine passage by day or night and a tendency to dribble after you have finished, you should contact your GP for further advice

Your GP will normally review you initially and may supply you with a symptom questionnaire and/or a bladder diary to complete before your appointment. 

Download the International Prostate Symptom Score (IPSS)
Download a bladder diary

Referral to a urologist is only indicated if:

  • your symptoms are severe;
  • your urine flow is very poor;
  • your blood tests (e.g. PSA) are abnormal; or
  • there are any complications of the condition (e.g. chronic retention, urinary infection, bladder stones).

What are the facts about prostate symptoms?

  • By the age of 65 years, 50% of men will experience benign enlargement of the prostate. At the age of 90, 90% of men have prostatic enlargement;
  • An enlarged prostate alone does not always cause symptoms;
  • The severity of the symptoms is not related to the size of the prostate;
  • 1 in 3 men will suffer prostatic symptoms during their life;
  • 1 in 10 men will require surgical treatment for their symptoms;
  • Not all urinary symptoms in men are due to an enlarged prostate - incontinence, pain or blood in the urine may be due to other conditions;
  • The risk of prostate cancer is not increased by having benign enlargement of the prostate. You are no more likely to develop prostate cancer than a man without benign prostatic enlargement;
  • 30-40% of men with prostatic symptoms do not experience worsening of their condition with time and may not require any treatment;
  • If treatment is indicated, this usually involves with drugs which relax the muscle in and around the prostate and/or drugs which shrink the glandular component of the prostate;
  • If symptoms are severe, if there is no response to medical treatment or if there are complications of prostatic enlargement, surgical treatment may be indicated; and
  • The risk of acute, painful retention of urine is small (approximately 1 in 100) and it is not always preceded by prostatic symptoms. Acute retention usually requires surgical treatment.

What should I expect when I visit my GP?

Your GP should work through a recommended scheme of assessment for men with prostatic symptoms. This will normally include some or all of the following:

1. A full history

Your GP will take a general history and a more detailed urological history. Using the symptom score and voiding dairy (see above), this will allow your GP to understand the severity of your symptoms and, in particular, how much they affect your daily activities. You may also be asked about your erections because reduced erections and prostatic symptoms often go together.

Some drugs can affect your bladder function and it is important that your GP is aware of all the drugs you are taking.

In younger men (less than 45), "prostate-like" symptoms are often due to other problems such as a stricture in the urethra (water pipe); Your GP will ask about previous injuries, diseases or operations in this area which may cause a stricture to develop.

 

2. A physical examination

A full physical examination is normally performed, including measurement of your blood pressure. Your GP will perform a rectal examination (pictured) to assess the size and texture of the prostate gland. Your abdomen may also be examined to feel for an enlarged bladder. Your reflexes will normally be tested to ensure that your symptoms are not due to a neurological problem.

 

3. Additional tests

a. General blood tests

The actual blood tests performed will be left your your GP's discretion. It is essential to measure kidney function and to check the blood for anaemia or other problems.

b. PSA (prostate-specific antigen) measurement

It is usual to measure PSA levels in the blood in men with prostatic symptoms. If you are concerned about this, you should download and read the leaflet on PSA measurement ,and discuss the test with your GP.

Download the leaflet on PSA measurement

If your PSA is measured and is found to be raised above normal levels, or if your prostate feels abnormal on rectal examination, your GP will normally refer you urgently to see a urologist with a view to further tests to exclude prostate cancer.

Having a raised PSA does not mean you have prostate cancer. 50-60% of men with benign enlargement of the prostate have a raised PSA level. The only way to exclude prostate cancer is to see a urologist for further tests.

c. Urine tests

Your urine will be tested for any abnormality and a sample will normally be sent to the laboratory to exclude infection.

d. Other specific tests

Other tests are not always necessary at this stage but your GP may wish to have a more detailed assessment by arranging:

These tests will normally be performed in the urology clinic if your GP feels that a referral is needed.

 

What could have caused my prostate to enlarge?

In general terms, we know very little about why the prostate gland enlarges with increasing age but hormone imbalance within the gland itself probably plays a part as well as certain genetic factors

There is some evidence that hormones and certain growth factors may work together to cause the prostate gland to enlarge. There also seems to be an inherited tendency in approximately 10% of men (1 in 10).

What treatments are available for this problem?

No treatment is likely to clear all your symptoms completely but they can be greatly improved so that the degree of "bother" is minimal; your symptoms can then be monitored regularly to see whether changes in treatment are needed

Treatment options include:

General measures ("watchful waiting")

If you and your GP decide treatment is not necessary initially, some simple, self-help measures can improve your quality of life:

  • limit your fluid intake when you know you will be out of the house;
  • try emptying your bladder twice each time by returning to the toilet after a few minutes for another attempt at emptying;
  • reduce your caffeine, alcohol & nicotine intake which all cause you to make more urine;
  • if you suffer from urgency, try distraction techniques (e.g. by using breathing exercises or counting) to take your mind off the urge to pass urine;
  • if your stream is slow to start, try relaxation measures when standing to pass urine; and
  • try "holding on" as long as possible to improve your bladder capacity.

Your symptoms may improve significantly with these measures. If they do not, you should go back to see your GP and get further advice.

Download the leaflet about self-help measures in male LUTS

Drugs

Alpha-blockers (e.g. tamsulosin, terazosin, alfuzosin, doxazosin) will normally be the first type of drug your GP prescribes. They relax the muscles in and around the prostate/bladder neck area to make the passage of urine easier. They may cause low blood pressure, a stuffy nose, skin rashes and impaired ejaculation.  They should not be taken if you are due to undergo cataract surgery because they cause floppiness of the iris; this can result in complications after cataract surgery.

5-alpha-reductase inhibitors (e.g. finasteride, dutasteride) shrink large prostate glands (>40 grams) and may be used together with alpha-blockers if your PSA is more than 1.5 (an indication that your prostate is significantly enlarged). They can cause ejaculatory problems. They take at least 6 months to have maximum effect and do not work well if your prostate is small. They also reduce your PSA level by up to 50%.

With larger prostates, a combination of both types of drug has been shown to be better than either type used alone, to reduce the risk of complications (especially retention) and the need for surgery.

Herbal Remedies

Some herbal & plant extracts (e.g. saw palmetto, pictured right) are effective in relieving symptoms without the risk of side-effects. They probably work because the extracts contain plant hormones which alter the abnormal hormone balance within the prostate. These extracts are not usually available on prescription from your GP.

Surgery

Surgical treatment is usually recommended if symptoms are severe, medical treatment has failed or if there are complications (e.g. a large residual urine,. retention of urine, infection, bladder stones).

Open surgery on the prostate is rarely performed nowadays but may be necessary if the prostate is very large.

Conventional telescopic surgery (TURP) involves resecting the central part of the prostate using a telescope passed into the bladder through the penis (transurethral resection or TURP). There are risks to this procedure so other techniques, such as electrical vaporisation and laser surgery, have been developed which also give good results with less risk.

Sometimes, when the prostate is small, the muscle at the neck of the bladder can be cut telescopically without actually removing the prostate (bladder neck incision or prostatotomy); normally, the surgeon can only decide if this is appropriate after looking inside the bladder.

Download a leaflet about laser prostate surgery
Download a leaflet about bladder neck incision

Less invasive alternatives to surgery

Microwave treatment, stretching with a balloon, radio-frequency needle ablation and freezing (cryotherapy) have all been tried. They are less effective than conventional surgery and often not long-lasting. An indwelling catheter or intermittent self-catheterisation relieve symptoms but should be regarded as temporary measures.  

More recently, the UroLift® procedure has proved promising; this is performed by inserting two to four "tags" through the prostate to pull the obstructing prostate lobes away from the urethra. The advantage of this procedure is that it has little or no adverse effects on your sexual function (ejaculation & erection) but it is not suitable for everyone.

Download a leaflet about simple bladder catheterisation
Download a leaflet about male intermittent self-catheterisation
Download a leaflet about the Urolift® procedure

Video summary

This video was prepared by Mr Mark Speakman, Consultant Urological Surgeon in Taunton, and it summarises the current thinking about how lower urinary tract symptoms (LUTS) due to benign prostatic enlargement should be investigated and managed.

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