Prostate enlargement: Exploring your treatment options

Prostate enlargement, also known as benign prostatic hyperplasia, is a common condition that can affect men as they age. As the prostate gradually increases in size, it can lead to a range of urinary symptoms that significantly impact quality of life.

Mr Sudhanshu Chitale, renowned urologist, explores the nature of prostate enlargement, delve into its causes, and discuss the various treatment options available.

What is prostate enlargement?

The prostate (meaning “one who stands before” in Greek) is a reproductive gland involved in the male sexual and ejaculatory function, contributing 20% to the volume of ejaculate or semen. The prostate is located beneath the bladder, deep inside the pelvic cavity, in front of the rectum. Looking up from below, it surrounds the urethra (windpipe) as it leaves the bladder and traverses through the prostate gland.

The prostate gland has two distinct parts: the fibromuscular and the glandular.

In the early years, the fibromuscular part enlarges, creating a tight muscular ring around the urethra and causing symptoms similar to those caused by prostate enlargement, without an actual increase in the size of the prostate. This condition is referred to as prostatism sans prostate.

From the age of 30, the prostate gland gradually increases in size under the influence of testosterone, the male hormone produced by the testes. When testosterone from the blood circulation enters the prostate, it is converted by the enzyme 5 alpha reductase (5AR) in the prostate into a biologically active product called dihydrotestosterone (DHT), which fuels the growth of the prostate from the age of 30. In other words, no testes: no prostate enlargement, no enzyme (5AR): no prostate enlargement.

With the enlargement of the glandular part of the prostate at or around 40 years of age, the physical size of the enlarging prostate strangles the urethra as it leaves the bladder, causing symptoms termed as prostatism or prostate-related symptoms.

There are three types of prostate enlargement-related symptoms:

• Storage type: Needing to urinate too often during both day and night, an inability to hold urine for long, and urine leakage.
• Voiding/micturition type: Taking a long time to start, taking a long time to finish, and a slow and intermittent flow.
• Post micturition type: Feeling that the bladder hasn’t fully emptied, with dribbling of urine after finishing.

In addition, in a significant majority of cases, patients may also suffer from sexual dysfunction (erectile dysfunction) alongside urinary symptoms, which they may hesitate to report and as such needs to be considered in their initial assessment and individual, case-based treatment plan.

What treatment options are available to patients with prostate enlargement?

Depending on the severity of symptoms (mild, moderate, severe), initial treatment options may include:

• Lifestyle changes, such as reducing caffeine and alcohol intake.
• Education, such as guiding patients on fluid restriction, dietary changes, and establishing healthy bowel habits.

The next line of therapy involves various types of medications based on:

• The predominant type of symptoms, such as storage, voiding, mixed.
• The size of the prostate, either less than 30cc (fibromuscular) or greater than 30cc (glandular).
• The presence of sexual dysfunction in conjunction with prostate symptoms.

It’s only after these conservative and medical treatment options fail to address or improve prostate-related symptoms that surgical or invasive interventional options should be explored and discussed with patients who are in urgent need of a solution for symptoms that have been refractory to treatment thus far and who remain significantly bothered by their symptoms, adversely affecting their overall quality of life.

In your opinion, what is the most effective option?

There is no such thing as the "most effective" treatment option for addressing prostate enlargement. A treatment plan is very much an individual plan based on the specific needs of each patient, primarily determined by the type and severity of symptoms experienced and their impact on the patient’s quality of life, as well as his expectations regarding the treatment he has been offered or accepted.

Therefore, it’s essential for the patient to be involved from the outset in exploring all available options, from non-invasive to minimally invasive to ultimately the most invasive treatments. Urologists play an important role in facilitating the process of “informed decision-making” that the patient makes regarding his chosen treatment option.

If the initial or first line treatment plan fails to yield the desired results, the patient then has the option of moving on to the next best option available in the treatment hierarchy. At this stage, it’s crucial to emphasise the importance of “patient choice”, as the most important and relevant factor in selecting a treatment. We, as urologists, should thus make it clear that we are committed to upholding patients’ rights.

How will suitability be decided upon in terms of which treatment option to opt for?

A patient’s symptoms are stratified into mild, moderate, and severe as per a symptom scoring questionnaire called the International Prostate Symptom Score (IPSS).

Patients with mild symptoms (IPSS: 0-7) should be offered lifestyle advice and dietary/fluid changes for symptom management, and perhaps medications at the 6-week review, as appropriate.

Patients with moderate symptoms (IPSS: 8-19) should be considered for lifestyle changes and medications, either as a single agent or in combination, depending on the size of the prostate based on physical assessment and/or prostate scanning.

Patients with severe symptoms (IPSS: 20-35) should be considered for combinations of medications for a few weeks, in addition to lifestyle measures. If they fail to respond to this approach or indeed have already exhausted these options, then they should be offered various surgical options. The urologist should carefully guide the patient through the maze of treatment modalities available (some of which the patient may already be aware of from reading about them in newspapers or researching on Google).

The surgical options are again to be tailor-made to the patient’s circumstances and expectations. Here is a list of factors that need to be given due consideration before helping the patient make an informed decision regarding surgical options better suited for his index individual scenario:

• Age: For example, under 60 years old, between 60 and 80 years old, and over 80 years old.
• Risk status/co-morbidities.
• Size of the prostate: For example, less than 80cc, greater than 80cc, greater than 200cc, etc.

Prostate-related coexisting conditions and complications, namely, can include urinary retention with a catheter in situ, bladder stones, high pressure on the kidneys with large bladder residue (greater than 500 cc), and recurrent bleeding from the prostate. Additionally, a patient’s desire to preserve sexual function, including normal ejaculation and erections, is a critical consideration in managing these conditions.

It must be made clear to patients throughout the assessment process that treatment for prostate enlargement isn’t based on a “one size fits all” principle; on the contrary, “one size doesn’t fit all”.

There is a list of surgical options, from minimally invasive to invasive, readily available and it’s the urologist’s responsibility to skilfully guide the patient through all these options. This includes explaining the pros and cons, as well as the risks and complications associated with each procedure, and ultimately facilitating an informed decision-making process for the patient. The urologist should also be prepared to answer the commonly-expected question from the patient: “What would you choose if you were in my position?”.

The surgical options available include: UroLift® (staples), Rezūm (steam), TPLA (laser through the skin), iTind (stent), Aquablation (water jet), TURP (rebore surgery, the gold standard), HoLap (laser vaporisation), HoLEP (laser enucleation/removal), PAE (artery blockade to cut off blood supply), TUNA (needle ablation), and TUMT (microwave treatment).

For patients who are too old or unfit for any surgical intervention, long-term urethral or suprapubic catheter placement may be considered as a last resort.

If you would like to book an appointment with Mr Sudhanshu Chitale, head on over to his Top Doctors profile today.