PROSTATE ENLARGEMENT

Prostate enlargement is a problem that men may face as they grow older. Surgical treatment of an enlarged prostate depends on the stage of the disease.

THE prostate is a fibro-musculo glandular organ present in men in the pelvis, below the urinary bladder and surrounds the upper part of the urethra. It is a part of the male reproductive system. In a normal man, in each of its three dimensions, it is about three to four centimetres big and is walnut shaped. It is quite small in children and grows till the time of sexual maturity.

It secretes the fluid that transports the sperms and makes up for the volume of the semen. It energises sperms and helps in their survival in the vaginal canal after ejaculation.

It starts enlarging after 50 years in about 70 per cent of men. This is called benign hyperplasia of the prostate (BHP). This is not cancer or infection. The exact cause of enlargement is not known, but is related to the levels of the circulating male hormone testosterone.

As the gland starts enlarging, it compresses the urethra traversing through it and causing difficulty in passing urine. It can result in retention of urine, necessitating emergency treatment.

Common symptoms will be:

# Frequency of urine due to bladder instability.

# Slow stream due to mechanical obstruction.

# Hesitancy or delay in starting the act of micturation.

# Precipitancy unable to control the urination.

# Incomplete emptying of the bladder.

# Haematuria due to rupture of blood vessels during straining to pass urine.

Other effects of straining to pass urine will be

# Passing flatus at the time of urination.

# Development of piles.

# Development of inguinal hernia.

The size of the prostate has no relationship to the symptoms it can produce. Sometimes a big gland can be totally symptom free and a small gland can produce agonising symptoms.

Enlargement of the prostate can be diagnosed by the symptoms and digital rectal examination. The most objective test is ultrasonography, which gives the size of the prostate, the amount of residual urine in the bladder (i.e. post void residue) and other complications of obstruction like stone formation and dilatation of the upper urinary tracts. Uroflowmetry is another test for objective assessment.

Cases not treated in time can produce complications like urinary tract infection, stone formation, large capacity and a weak urinary bladder, dilations of the upper urinary tracts and, ultimately, renal failure. But these can be prevented by timely treatment. Treatment of the enlarged prostate can be by medical or surgical means. Mild enlargements and, more importantly, those producing mild symptoms without many complications can be treated medically. The main drugs are blocking agents, which help to reduce the toxicity of the smooth muscle of the prostate and open up the urethral passage for better voiding.

Non-steroidal anti-androgen, which diminishes the effect of the male hormone on the prostate,helps to reduce the size of the prostate if given for a longer time.

Surgical treatment is indicated when the symptoms are severe and when the complications are manifested.

Surgical treatment is mostly the endoscopic method [TUR(P)] in which a special instrument with a telescope and a metal loop is passed through the urethra. Using electricity as its energy source and under vision, the prostate gland is resected and a channel is made to help a person pass urine better. There could be bleeding during this procedure which is controlled by electro-cautery and catheter drainage is likely during the immediate post-operative period. In laser prostatectomy, a laser is used as the energy source.

The other type of surgery is open prostatectomy where the enlargement is quite big and when there are associated complications like stone formation and diverticulum. This is also a major procedure necessitating blood transfusion and prolonged hospital stay.

Enlarged prostate — or BHP as it is commonly called — is not synonymous with cancer of the prostate, which is a different condition requiring different type of treatment. Cancer of the prostate develops mostly in people above 70 years. Often it is diagnosed by digital rectal examination (DRE), Trans-rectal ultrasound (TRUS) and blood PSA studies. The latter are quite specific for cancer of the prostate and the diagnosis should be made by a needle biopsy of the prostate.

Treatment options depend on the stage of the disease and it can be radical surgery, radiotherapy or chemotherapy.

Most cases of cancer of the prostate are very slow growing and these patients tend to live longer when compared to other malignancies.

Prostatitis is an inflammatory condition of the prostate, which can be bacterial or abacterial depending on the type of infection and is mostly prevalent during the sexually active age and in diabetics. It produces bizarre symptoms like bladder irritation, urethral or penile pain, perineal pain, lower abdominal pain and low-grade fevers.

It is best diagnosed by culture of the semen or prostatic secretions. If the organisms can be identified, the problem can be treated with antibiotics and periodic drainage of the prostatic secretions. In chronic cases the partner will also have to be examined for genital infections and treated simultaneously.

Many cases of prostatitis are difficult to treat successfully and take a long time to cure, as it requires good cooperation and perseverance on the part of patients.

Even though the prostate is a boon during the reproductive age, it may become a nuisance as one grows older.