Enlarged Prostate, Symptoms, Diagnosis And Treatment Options In Kelina Hospital.
PATIENT INFORMATION AND GENERAL KNOWLEDGE.
Everyone reading this post right now is either a man with a prostate gland, or has a father or brother with a prostate gland. Therefore, the prostate is an important organ everybody needs to know something about. Prostate cancer, for instance, is the commonest cancer affecting black men the world over. We will talk about that at some other time.
The Prostate gland is a male sex organ, and is shaped like the green almond fruit. Imagine a tube running through the centre of the fruit from up to down. That is the urethra, which carries urine from the bladder to the outside. In practice, the prostate lies at the neck of the urinary bladder, and surrounds the beginning of the urethra. It is about 8cm deep from the skin behind the scrotum. It is just in front of the rectum, so a finger inserted into the rectum can actually touch it. This is how Digital Rectal Examination (DRE) is done by the Urologist to feel the consistency and size of the prostate. It feels firm in consistency like hard muscle. It feels very hard like bone and nodular when it is cancerous. The prostate weighs about 20g. When enlarged, it could actually become as big as a small tangerine, guava or actually as big as an orange fruit. We once removed a prostate in Kelina Hospital that weighed 720g.
The prostate contains glands, which produce some of the liquid that mixes with semen during ejaculation(most of that liquid comes from the seminal vesicles). It also contains fibrous tissue, like the type of tissue you find attaching muscle to bones, which is whitish in colour and very hard. Finally, the prostate contains some smooth muscle. Smooth muscle also tends to be whitish in colour, like the muscle you find in the stomach or intestine of animals, as distinct from skeletal muscle, which is reddish, found in the laps, back and shoulders. The proportion of these 3 components, namely, smooth muscle, glands, and fibrous tissue (collagen) varies from one individual to another, and these proportions determine how big the gland can get before it begins to obstruct the urine flow. Glands that are made up predominantly of glands and smooth muscle tend to be very huge, yet urine could still pass. Glands that are made up mostly of collagen tend to block urine even when the prostate is not bigger than normal size.
Enlarged Prostate, seen on endoscopy of the urinary tract (urethrocystoscopy) inKelina Hospital. Note the 2 sides coming together at the middle of the urethra, blocking urine.
It is easy to see, from the above, that the degree to which the prostate can disturb urine is not entirely due to the size of the gland. Some people would request for medications that could “shrink” the prostate. Those medications work mostly on glandular component. Therefore, prostates that are small and obstructing (that is, prostates that are made up predominantly of fibrous tissue) do not respond well to these medications. Second, those medications have a lot of side effects, because they work mostly on glands, by blocking the hormones that stimulate those glands. Therefore, they could interfere with erection and also interfere with production of PSA, which equally comes from those glands. When PSA production is disturbed, the level of PSA you see when you measure it is no more reliable. People who are on these medications could, therefore, develop prostate cancer without knowing this, because the common screening test for cancer, PSA, is no more reliable. Finally, people who are on these medications tend to present with prostate cancer that is already advanced. Such medications should never be used for more than 3 to 6 months.
Common problems that could affect the prostate are cancer, ordinary enlargement (benign prostatic hyperplasia, BPH) that is not due to cancer but is obstructing the urine flow nonetheless, and infection in the prostate, called prostatitis. There are several other problems that could show up in the prostate, but these 3 are the commonest. When the prostate begins to disturb urine flow, there are often symptoms or signs to the patient. Some people do not have symptoms. They just notice one day that they could no longer pass urine. Others even develop kidney failure without knowing that the prostate is responsible. Some also develop cancer in the prostate without a single symptom.
The severity of the symptoms does not depend on the size of the prostate. Small prostates that are fibrous, as we saw above, can actually cause more trouble, sometimes, than huge glands. Therefore, treatment does not depend on the size of the prostate. It depends on the severity of the symptoms or the damage caused by the obstruction. Some of these symptoms are actually not due to obstruction. Some are due to irritation of the nerves around the prostate, that also supply the inside of the bladder, or to the pressure the enlarging prostate is exerting on the neck of the bladder, which tends to carry most of the weight of the urine inside the bladder. When there is a lot of urine in the bladder, this part of the bladder detects the weight of the urine and sends a signal that the bladder is full. However, when this part is irritated by anything, whether it is weight of the urine, inflammation, nervous stimuli or the prostate pushing into it, there is a tendency to feel as though the bladder is full, even when it is empty. The individual then feels like passing urine every time. All the symptoms associated with urine are called Lower Urinary Tract Symptoms (LUTS).
Lower Urinary Tract Symptoms include the following:
- Hesitancy, the tendency to wait a little even when you are in the toilet, ready for the urine to flow. The urine does not come immediately, even when you are pressed and you had the urge to go quickly.
- Poor stream. The flow of the urine is weak. It is no longer as fast and jetty as it was when you were a child. It can no longer hit the wall or cross a small stream of water running in a gutter.
- You tend to push hard for the urine to pass. Yet, most times, pushing does not help the urine to flow any better.
- The stream of urine suddenly stops even when you know very well your bladder is not yet empty. When you relax a bit, it starts running again on its own. You just have to wait, because the urine stops and starts by itself irrespective of whatever you do.
- Terminal dribbling. The urine comes drop, drop, drop, when you get to the end of voiding. It does not stop at once. You need to wait. In fact, if you dress up yourself too quickly, you will find urine soaking your pants even when it had already stopped running.
- Feeling of incomplete voiding. You feel as though there is still some urine in your bladder. When you wait for it to pass, it does not pass. You have to dress up, wash your hands and go. But then, you know very well that there is still something in your bladder.
These symptoms are called voiding symptoms, because they are noticed when you are trying to void. Others are called storage symptoms, because they are noticed when you try to hold the urine back. There is a problem storing the urine for a long time. They include the following:
- When you feel like passing urine, you cannot hold it for a long time. You have a tendency to abandon whatever you are doing to go to the bathroom very quickly. Even if you are in a very important meeting, you have to excuse yourself out of the meeting. Once in a while, you find somebody parking his car on the roadside and voiding. This is definitely because he could not reach the next restaurant to come out of the car as a gentleman and go in to void.
- Urge incontinence. If you do not go quickly enough to void, the urine could come out by itself, or drop into your pants or floor when you are getting yourself ready in the bathroom. The urine could no longer wait for you just to unbutton your trouser.
- You cannot wait for more than 2 hours before going to pass urine. You find yourself passing urine more than 4 or 5 times in a day. You know for sure that you are passing urine too frequently.
- The tendency to wake up more than once in one night to pass urine, before daybreak. It could be so bad that even your sleep is disturbed. You find yourself so tired in the daytime because you cannot sleep well at night.
There are other symptoms that do not strictly fall into the above categories. They include:
- Painful urination. The pain could come at the beginning, throughout, or at the end of urination.
- Blood in urine, which could also be at the beginning, throughout and missed evenly with urine or at the end of urination.
- Discoloured urine. If the urine becomes unduly cloudy in appearance, it could mean that there is infection. Infection could easily set in when there is obstruction to urine flow and stagnation.
- Malodorous urine. This is also often due to infection. The urine smell becomes too strong and offensive.
- Spraying of the urine. It becomes more difficult to control the stream of urine. The urine tends to splash around the toilet instead of directed in one stream. This is often a symptom of stricture, narrowing of the urethra from scarring as a result of past injury or infection, not necessarily due enlarged or obstructing prostate.
- Sudden cessation of urination. This is called acute retention. The urine suddenly cannot pass. The bladder is full and painful, but the urine cannot pass. It often starts with extremely frequent urination, almost every 30 minutes. When you go, only a few drops pass. Finally, no single drop is coming. There is pain. But the urine cannot pass. The pain is very terrible, like that of a woman in labour.
- Urinary leakage. In this case, the bladder is distended, like the lower abdomen of a pregnant woman. Urine comes in trickles. You really cannot control it. The trouser is wet and smelling of urine. But the bladder does not really empty. There is no pain as in acute retention. For this reason, you do not see the need to quickly go to the hospital. You cannot perceive the smell of urine around you anymore, but everyone around you is very uncomfortable with the smell, except you, because your nose is no longer sensitive to the smell you have been exposed to for a long time.
Prostate symptoms are not common in men who are less than 45 years of age. Most men who have prostate problems are up to 50 years or older. However, those who have a family history of prostate problems could have symptoms at an earlier age. Women, although they do not have prostate glands, can also have LUTS. In fact, some studies show that both women and men have similar LUTS, age for age.
DIAGNOSIS OF ENLARGED PROSTATE
This is made by listening to the symptoms, examining the patient generally and even doing a DRE, and proving that the symptoms are not due to other problems, several of which also produce similar symptoms. Things that are done to confirm the diagnosis are:
- Digital Rectal Examination(DRE). A gloved finger, lubricated and placed in the rectum could tell in trained hands the size of the prostate, whether or not it is enlarged, and in fact, whether or not it is cancerous. Cancer, if early, cannot be detected by DRE. Most cancers that are easy to detect on DRE are already too advanced.
- Ultrasound Scan. Transrectal ultrasound scan is the best. It can measure the size of the prostate, the peak volume of urine in the bladder when you feel like voiding and can no longer hold it, and the volume left in the bladder after you have passed urine, if anything is left. If the volume left in the bladder is much, there may be obstruction to the urine flow. If the volume is small, we need to find out what else could be responsible for the symptoms.
- Prostate Specific Antigen(PSA) test. PSA tends to be high if there is cancer in the prostate. It is very important to rule out cancer because at the early stage, the symptoms are similar to those of benign prostatic enlargement (BPH) but treatment is very much different.
- Kidney function tests. If there is chronic retention, or a lot of damage from the prostate obstruction, it tends to cause some compromise to the kidneys. The kidney function deteriorates.
- Urine tests. Tests carried out on urine could show if there are chemicals in the urine that could cause or worsen the symptoms the patient has, such as sugar (diabetes). Obstruction to urine flow could also cause infection in the urine.
- Urine is passed through one machine, which is what we do here in Kelina Hospital, and this would show if there is actually obstruction to the urine flow.
- X-ray. Urethrogram, in equivocal cases, can tell whether or not the urethra is obstructed by stricture. If there is no stricture, and the other findings are in keeping with the prostate as the cause of obstruction to urine flow, something has to be done.
- Urethro-cystoscopy can prove almost 100% that the symptoms are due to enlarged prostate.
Enlarged Prostate, obstructing urine flow. This was seen on endocopy we did
THINGS THAT COULD MIMIC PROSTATE ENLARGEMENT.
The doctor tries to prove to himself that the problem is due to the prostate, before commencing treatment. There are so many things that the Urologist would do to satisfy himself that he is dealing with an enlarged prostate.
OPTIONS FOR TREATMENT
- Option 1: nothing active is done. Sometimes it is obvious that the prostate is enlarged, but nothing active needs to be done, because all the parameters assessed are perfect, or at least fairly manageable. Such individuals need to see their Urologist at least once every year, preferably twice yearly.
- Option 2: medical treatment.
There are 3 main groups of medications:
- Medications that relax the tension in the neck of the bladder, allowing urine to pass. These have few side effects and can be taken indefinitely, as recommended by the Urologist.
- Medications that “shrink” the prostate. These are preferably used for only a short time. They have several side effects, including the fact that they could kill libido or even disturb erection. More importantly, they do not stop prostate cancer from developing, but at the same time, they could make prostate cancer more difficult to detect. These medicines are completely ineffective in small, fibrous prostates. Because of their side effects, they should not be taken continuously for more than 3-6 months.
- Medications that relax the bladder. These medicines reduce the irritation on the bladder, which is partially responsible for the frequent urination. Their draw back is that the mouth feels dry, the body feels hot, and they tend to cause constipation. Taken alone without also relaxing the bladder neck significantly, they can stop urine from passing completely, warranting either the passage of a catheter or immediate surgery, which was not even planned. Planned surgeries have better outcome than emergency surgeries.
Catheters are either made of silicone, which the body does not react to much, or latex rubber. Latex catheters are very cheap, but they also cause a lot of reaction around the urethra, and this could predispose to very early infection. Silicone catheters are better, but they are very expensive.
Not all individuals are suitable for medical treatment. In fact, if an individual really needs surgery and is placed on medical treatment or opts for medical treatment instead, his condition may deteriorate. People on medical treatment need to see their Urologist frequently, to ensure that their condition is not deteriorating.
Surgery is a more serious form of treatment but has the best chance of long term relief. Medical treatment is forever. Surgery is usually a one off treatment.
REASONS FOR PROSTATE SURGERY
Surgery could become necessary under the following circumstances or to avoid the following problems:
- Worsened condition of the patient, in spite of medical treatment.
- Damage to the kidneys, causing kidney failure. Nobody survives without the kidneys. The kidneys are vital organs.
- Recurrent infection in the urine.
- Personal distress, including lack of sleep from urinary frequency.
- Disturbance of urine flow affecting social life.
- Leakage of urine causing embarrassment to patient and family.
- Cancer in the prostate could go undetected without surgery, and this is risky.
- The bladder could form stones if the urine flow is severely compromised.
- The prostate could start bleeding spontaneously. This could be life-threatening.
- The bladder could no longer empty effectively, and with time, become very flabby.
- Urine could suddenly stop passing. If this happens in a flight or in a place where there is no reliable hospital, it could be very devastating.
- There is general ill health and a feeling of uncertainty. Vibrancy is lost.
In Kelina Hospital, 85% of all urological surgeries, from the kidney down to the meatus where urine comes out, are done without the surgical scalpel or knife (without cutting the body open). The following Surgical Options for the prostate are available in Kelina Hospital:
- TURP is the gold standard of all prostate surgeries. We do bipolar TURP. Bipolar TURP is better than the older technology, monopolar TURP. In bipolar, the energy that is use to remove the gland does not pass through the patient. It goes in through one arm of the device and comes out through the other. Bipolar TURP uses ordinary drip for flushing so the Surgeon can see well. In monopolar, sometimes ordinary tap water is used. This has a lot of complications and is not safe. TURP removes the prostate in small bits which float into the bladder and are suctioned out at the end of the procedure. These chips are sent to the Pathologist to test and see if they have cancer. Transfusion is not usually required. In Kelina, only one patient in 20 is transfused.
- Transurethral vaporization of the prostate. This is done when there is already a proof that there is no cancer. The prostates are usually small and can be converted to vapor by vaporizing the water inside the prostate cells with a probe.
- Transurethral Incision of the Prostate. This is done when it is unnecessary to remove the entire prostate. The bladder neck is opened up on both sides and the prostate is left behind.
- Laser Vaporization. We have done a few laser vaporizations using the diode laser. The technique is basically similar to TURP. Holmium laser vaporization is not done in Nigeria at the moment. In Kelina, we use the holmium laser for kidney stones at the moment.
There are several other techniques done in several parts of the world. In 2017, Kelina Hospital will also start Holmium laser enucleation(HoLEP) as well as laser vaporization. In HoLEP, The prostate tissue is removed enbloc and pushed into the bladder. It is then removed with a moselator. The Gynaecologists already do moselation for uterine fibroids here in Kelina Hospital, because most of their fibroids are done laparoscopically. They use the moselator to bring out the growths.
All patients who have had prostate surgery in Kelina Hospital are advised to see the Urologist at least once every year. Removing the prostate does not stop an individual from developing prostate cancer. This is because the capsule, which surrounds the adenoma, or the inside of the prostate to be removed, is like the shell of an orange fruit and is left behind when the inside is removed. This shell equally contains prostate cells, and these cells can also undergo a cancerous transformation. The Urologist would definitely want to keep an eye on the prostate to ensure that if it becomes cancerous, the cancer could be detected early, at which time it could still be curable.
Kelina Hospital specializes in Laparoscopic Surgery for Gynaecology and General Surgery; Laser Surgery for Prostate & Kidney Stones and several other modern surgical techniques.