What is Your Prostate?

The prostate makes some of the milky fluid (semen) that carries sperm. The gland is the size of a walnut and is found just below the bladder, which stores urine. The prostate wraps around a tube (the urethra) that carries urine from the bladder out through the tip of the penis (Figure 1). During a man's orgasm (sexual climax), muscles squeeze the prostate's fluid into the urethra. Sperm, which are made in the testicles, also go into the urethra during orgasm. The milky fluid carries the sperm through the penis during orgasm.

Figure

Figure 1: Male Urinary System and Prostate .

Purpose of This Booklet

This booklet can help you understand benign prostatic hyperplasia (BPH) and how it can be treated. BPH is an enlarged but otherwise normal prostate. It is common in older men and may cause no problems at all. If you want or need to choose a treatment, however, this booklet describes both benefits and risks of all treatments.

Understanding the Problem

When Should You See a Doctor?

If you have symptoms that bother you, see a doctor. He or she can find out if BPH -- or another disease -- is the cause. If you do have BPH, your doctor can also see if it has caused other problems.

How is BPH Diagnosed?

During your visit, the doctor will most likely:

• Give you a list of questions about your symptoms. These questions are important. Your answers will help the doctor decide if your symptoms are mild, moderate, or severe.

• Take your medical history. Your doctor will ask you about past and current medical problems.

• Examine your prostate gland by inserting a gloved, lubricated finger into your rectum.

• Do a physical exam to see if other medical problems may be causing your symptoms.

• Check your urine for blood or signs of infection (a urinalysis).

• Test your blood to see if the prostate has affected your kidneys. Your doctor may also recommend a blood test to help detect prostate cancer.

These tests are not painful or costly. They are done to help confirm that you have BPH and to find any problems it has caused. But tests used to diagnose your condition cannot predict if BPH will cause problems later if not treated now.

Your doctor may also recommend other tests. They may help find if BPH has affected your bladder or kidneys and make sure your problems are not caused by cancer. These tests may help some patients but not everyone:

• Uroflowmetry measures how fast your urine flows and how much you pass. This test can help find how much the urine is blocked.

• Residual urine measurement shows how much urine is left in your bladder after you urinate. This test can help find ow much your bladder has been affected by BPH. The test can be done several ways. You and your doctor should talk about the method used.

• Pressure-flow studies measure the pressure in your bladder as you urinate. Some doctors feel this test is the best way to find out how much your urine is blocked. The test can help most if results of other tests are confusing or if your doctor thinks you have bladder problems. In the test, a small tube called a catheter is inserted into the penis, through the urethra, and into the bladder. The test may cause discomfort for a short time. In a few men, it may cause a urinary tract infection.

• Prostate-specific antigen (PSA) is a blood test that can help find prostate cancer. BPH does not cause cancer. But some men do have BPH and cancer at the same time.

• The PSA test is not always accurate. PSA test results can suggest cancer in BPH patients who do not have prostate cancer. The results can also sometimes suggest no cancer in men who do have cancer.

• Not all doctors agree that being tested for PSA levels lowers a patient's chance of dying from prostate cancer. Each man with BPH is different. You and your doctor may want to discuss this test.

Your doctor may also suggest other tests such as x-rays, cystoscopy, and ultrasound. Many men do not need these tests. They are costly and not very helpful for most men with BPH. Also, cystoscopy and x-rays can cause discomfort or problems for some men. But the tests can help patients with some BPH problems or men with other problems such as blood in the urine.

• Cystoscopy lets the doctor look directly at the prostate and bladder. This test helps the doctor find the best method in men who choose invasive treatments (such as surgery). In cystoscopy, a small tube is inserted into the penis, through the urethra, and into the bladder. Some men may have discomfort during and after the test. A few may get urinary infections or blood in the urine; a few may not be able to urinate for a short time after the test.

• An x-ray called a urogram lets the doctor see blockage in the urinary tract. A dye injected into a vein makes the urine show up on the x-ray. Some men are allergic to the dye.

• Ultrasound lets the doctor see the prostate, kidneys, and bladder without a catheter or x-rays. A probe put on the skin sends sound waves (ultrasound) into the body. The echoes result in pictures of the prostate, kidneys, or bladder on a TV screen. This test is not harmful or painful. A special probe put in the rectum can give a better view of the prostate when the doctor wants to check for prostate cancer.

When Should BPH Be Treated?

BPH needs to be treated only if:

• The symptoms are severe enough tobother you.

• Your urinary tract is seriously affected.

An enlarged prostate alone is not reason enough to get treatment. Your prostate may not get bigger than it is now, and your symptoms may not get worse.

Ask yourself how much your symptoms really bother you:

• Do they keep you from doing the things you enjoy, such as fishing or going to sports events?

• Would you be a lot happier or do more if the symptoms went away?

• Do you want treatment now?

• Are you willing to accept some risks to try to get rid of your symptoms?

• Do you understand the risks?

Your answers to these questions can help you choose a treatment that is right for you.

What Are Your Treatment Choices?

Currently, the five ways of treating BPH are:

• Watchful waiting.

• Alpha blocker drug treatment.

• Finasteride drug treatment.

• Balloon dilation.

• Surgery.

Surgery will do the best job of relieving your urinary symptoms, but it also has more risk than the other treatments. Unless you have a serious complication of BPH that makes surgery the only good choice, you can choose from a range of treatments. Which one you choose if any depends on how much your symptoms bother you. Your choice also depends on how much risk you are willing to take to improve your symptoms. You and your doctor will decide together.

What Are the Benefits and Risks?

Each treatment may improve your symptoms. But each treatment has different chances of success. All treatments, even watchful waiting, have some risks.

Ask your doctor these questions about each treatment:

• What is my chance of getting better?

• How much better will I get?

• What are the chances that the treatment will cause problems?=

• How long will the treatment work?

Both benefits and risks are given below for each treatment. This can help you and your doctor make the best choice for you.

Figure 2 shows that the chance your symptoms will improve after TURP surgery is greater than if you simply watch and wait.

Figure

Figure 2: Chances Symptoms Will Improve With Treatment .

But even with TURP, your chances for improvement are somewhat uncertain. This is because doctors do not know the exact chances that each patient's symptoms will improve. In general, the worse your symptoms are before treatment, the more they will improve if the treatment works. The success of TUIP and open prostatectomy is similar to TURP.

Figure 3 shows the amount of symptom improvement for each treatment. Again, TURP gives the greatest amount of improvement and watchful waiting gives the least.

Figure

Figure 3: Amount of Improvement .

Figure 4 shows the chances of having problems during or soon after treatment.

Figure

Figure 4: Chance of Problems Right Away With Treatment .

Most of the time, treatments do not cause problems. Most problems are not serious, but some are. TURP can cause serious problems such as urinary infection, bleeding that requires transfusion, or blocked urine flow. Few patients have these serious problems after surgery (see Balance Sheet on pages 20-21 for benefits and risks).

Table

Balance Sheet: Outcomes of BPH Treatments.

For patients taking alpha blocker drugs, the most common side effects are feeling dizzy and tired and having headaches.

With finasteride, about 5 out of 100 patients have some kind of sexual problem such as a lower sex drive or trouble getting an erection.

With watchful waiting, there is no active treatment and no added chance of problems right away. But over time, the BPH itself can cause symptoms to grow worse or cause other problems. Only TURP clearly reduces that risk. Doctors do not know if alpha blocker drugs, finasteride, or balloon dilation lower the risk of future BPH problems.

Figure 5 shows the chance of dying from treatment. There are probably no added chances of dying from watchful waiting, alpha blocker drugs, and finasteride. There is now no information for balloon dilation.

Figure

Figure 5: Chance of Dying Within 3 Months After Treatment .

Some BPH treatments can make it hard to control urine, leading to leakage (urinary incontinence). Over time, BPH itself can cause incontinence. Also, men treated with alpha blocker drugs, finasteride, or balloon dilation may have some risk of incontinence from BPH in the future.

Although it is rare, some men have severe uncontrollable incontinence after treatment ( Figure 6). About 7 to 14 out of 1,000 men have this problem after TURP. Men in a program of watchful waiting have no immediate risk of uncontrollable incontinence.

Figure

Figure 6: Uncontrollable Urine Leakage After Treatment .

The chance of needing surgery in the future differs for each treatment. Some men who at first choose watchful waiting or nonsurgical treatment may later decide to have surgery to relieve bothersome symptoms. Also, some men who have surgery may need to have surgery again. One reason is that the prostate may grow back. Another is that a scar may form and block the urinary tract.

Within 8 years after TURP, 5 to 15 out of every 100 men will need another operation. Doctors are uncertain if treatment with alpha blocker drugs, finasteride, or balloon dilation lowers the chance that surgery will be needed in the future.

Figure 7 shows the chance of becoming impotent (not being able to get an erection) because of BPH treatment. Each year, about 2 out of every 100 men 67 years old will become impotent without BPH treatment.

Figure

Figure 7: Chance of Impotence (loss of Erection) .

There is probably no added risk of impotence with watchful waiting and alpha blocker drugs. Finasteride has a small added risk of impotence, but the problem should stop when the drug is stopped. The risk with balloon dilation is unknown, but probably low. With TURP, the risk of impotence ranges from 3 to 35 out of 100 patients. If your erections are normal before surgery, however, the risk of impotence after surgery may be no higher than with watchful waiting.

Figure 8 shows about how many days you can expect to lose from work or from what you normally do over the first year. Time at the doctor's office and in the hospital is included.

Figure

Figure 8: Loss of Work and Activity Time, First Year .

One other problem -- retrograde ejaculation -- can result. It is common with surgery and rare with alpha blocker drug treatment. Retrograde ejaculation means that during sexual climax, semen flows back into the bladder rather than out of the penis.

Men with this problem may not be able to father children. But it does not affect the ability to get an erection or have sex, and it does not cause any other problems. You may want to talk to your doctor about retrograde ejaculation.

Between 40 and 70 out of 100 patients have this problem after surgery. About 7 out of 100 patients have the problem while taking alpha blocker drugs. Retrograde ejaculation does not occur with watchful waiting or finasteride. Some men who take finasteride do notice that they make less semen.

The Balance Sheet on pages 20-21 lists the benefits and risks for each treatment. You can use this table to compare treatments. For example, treatment with either alpha blocker drugs or TURP can result in problems, but some are minor and others are serious.

What Is the Next Step?

Before choosing a treatment, ask yourself these two important questions:

1. If my BPH is not likely to cause me serious harm, do I want any treatment other than watchful waiting?

2. If I do want treatment, which is best for me based on the benefits and risks of each?

No matter what you decide, talk it over with your doctor. Take this booklet with you to your visits. Ask questions. Together, you and your doctor can choose the treatment best for you.

Learning More About BPH

Several national groups can provide more information on BPH and its treatment. They include:

• Prostate Health Council

• American Foundation for Urologic Disease, Inc.

• 300 West Pratt Street

• Baltimore, MD 21201

• (800) 242-2383

• National Kidney and Urologic Diseases Information Clearinghouse

• Box NKUDIC

• Bethesda, MD 20892

• (301) 468-6345

For More Information

The information in this booklet was based on the Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline. The guideline was developed by an expert panel sponsored by the Agency for Health Care Policy and Research (AHCPR), an agency of the U.S. Public Health Service. Other guidelines on common health problems are available, and more are being developed to be released in the near future.

For more information on guidelines and to receive additional copies of this booklet, call toll free (800) 358-9295 or write to:

AHCPR Publications Clearinghouse P.O. Box 8547 Silver Spring, MD 20907

AHCPR Publication No. 94-0584.