The prostate is a walnut-sized organ that is part of the male reproductive system. It sits in front the bladder and above the rectum. The prostate is responsible for the production and supply of fluid that helps nourish sperm in the ejaculate. The urethra, where urine travels from the bladder to the penis, runs through the prostate.
As a result of family history, lifestyle, diet, and natural hormonal changes, the prostate begins to grow in size as men age, starting in their mid-30s. When the prostate becomes more enlarged over time, it might press against the urethra and block urine flow (usually around age 50). This condition is called benign prostatic hyperplasia, or BPH.
Enlarged prostates differ in size. The size can be estimated on digital rectal exam or prostate imaging like an ultrasound. People with very enlarged prostates (over 80 grams) have several treatment options. However, size is not the only factor used to choose a treatment.
When doctors evaluate the prostate, symptoms are just as important as size. In addition, size and symptoms don't always correspond. For example, one person might have a mildly enlarged prostate with noticeable symptoms, while another person could have a very large prostate with no symptoms.
To learn about patients' symptoms, doctors ask a lot of questions about what they feel and see when they urinate. Based on the answers, doctors classify BPH as mild, moderate or severe. During the exam, doctors assess the prostate's size, and they might order lab tests to assess kidney function and screen for prostate cancer.
All of this information is the basis of a personalized treatment plan. Here are the options for patients with very enlarged prostates, with or without symptoms.
Large Prostate with Few Symptoms
Patients with very enlarged prostates may have few symptoms or mild symptoms. Doctors verify that there are no problems with kidney or bladder function. If not, they know that the enlarged prostate is not harming the body. In this case, doctors may recommend just watching the prostate or doing non-surgical treatments. Options include changing certain eating and drinking habits and urinating less often. Patients can take medications that relax the prostate, such as tamsulosin, or shrink the prostate, such as finasteride or dutasteride. Patients also may try supplements like saw palmetto to help their symptoms.
Large Prostate with Significant Symptoms
For patients who have moderate or severe symptoms that have failed medical therapy from very enlarged prostates, the optimal treatment is often surgery. For very enlarged prostates, there are four main surgical options:
- Open prostatectomy - The surgeon makes an incision and removes some of the enlarged prostate. This is done rarely today because less invasive surgeries through the urethra work well with fewer side effects.
- Transurethral resection of the prostate (TURP) - Going in through the urethra, with the aid of a small camera, the surgeon removes tissue to open up the channel, which can help the urine flow and take some of the pressure off the bladder. Tissue is removed with bipolar energy that shaves off pieces of the prostate. While this method is less invasive than open prostatectomy, it still can have side affects, such as bleeding, infection, need for repeat resection, erectile dysfunction, and scarring.
- Transurethral laser ablation of the prostate (HoLAP) - This is where the urine channel is opened up using a high-powered holmium laser to vaporize the prostate tissue. Like TURP, the procedure can help urine flow and symptoms from enlarged prostate. The use of the laser may decrease the need for a catheter or reduce bleeding after the procedure. A high-powered laser that uses "Moses effect" pulses has the potential to remove the tissue more efficiently, so the procedure time can be shortened.
- Holmium laser enucleation of the prostate (HoLEP) - Like TURP, HoLEP is also minimally invasive. Prostate tissue is removed in large blocks using a high-powered holmium laser and a second instrument. The benefits are similar to the previously mentioned procedures. Some doctors are comfortable using the laser on patients who cannot stop their blood thinning medications for surgery. Also here, the use of a high-powered laser may have some added benefits.
Enlarged prostate is a common problem. If you find yourself waking up more at night and experiencing any changes in the way you urinate, such as a weaker stream or increased frequency it's a good time to tell your doctor. There are excellent medical and surgical options for enlarged prostate that can get you flowing better and worrying less.
Jamin V. Brahmbhatt, MD, is Co-Director of the Personalized Urology and Robotics (PUR) Clinic, Orlando Health South Lake Hospital, Clermont, Florida. He is also Assistant Professor of Urology at UCF College of Medicine, and co-founder of Drive for Men's Health.