Treatment of Benign Prostatic Enlargement

Once the diagnosis of prostatic enlargement is established and prostate cancer is ruled out, various treatment modalities are available. The treatment depends upon the size of the prostate, the severity of symptoms, age, and overall health of the patient.

Medical therapy

Medical therapy is for patients having mild urinary symptoms due to prostate enlargement. For small prostate size alpha-blockers (Silodosin, Tamsulosin, Alfuzosin, etc) are the most commonly used drugs. Side effects may include dizziness and retrograde ejaculation (semen going into the bladder rather than coming out while intercourse). For patients with large prostate size having only mild symptoms, a combination of alpha-blocker and 5- alpha-reductase inhibitor (Dutasteride) is used. Patients having simultaneous erectile dysfunction & urinary symptoms may be started with 5-PDE inhibitors such as Tadalafil which benefits alleviating both symptoms. Besides these for patients having purely irritative symptoms (frequency, urgency ) may be started with anticholinergics (Solifenacin, Darifenacin, Tolterodine, etc) and Beta-3 agonists (Mirabegron).

Surgical therapy

Surgical therapy is recommended for patients with

  • Moderate – severe symptoms
  • Evidence of kidney damage
  • Having refractory urinary retention
  • Failed medical therapy
  • Very large sized prostate

Various surgical modalities exist for prostate surgery and depend upon the size of the prostate. These surgeries are done almost exclusively transurethrally (through normal urethral orifice) and rarely if ever open surgery is required for isolated benign prostate enlargement.

Transurethral incision of the prostate (TUIP) – In this surgery, one or two small cuts are given in the prostate gland and are done for patients having small-sized prostate.

Transurethral resection of the prostate (TURP) – This surgery is for moderate-sized prostates and large prostate may need more than one session. A scope is inserted into the urethra and the enlarged prostate except its outer part is resected into small chips and removed. A catheter is placed after surgery ends and irrigation generally required for a day. The catheter is removed after 3-4 days as decided by the doctor.

Laser Prostatectomy – High energy lasers such as Holmium, Thulium are available which remove the prostate tissues and provide symptoms relief early after surgery. Laser surgery is associated with fewer side effects as compared to TURP as there is less bleeding and safe for patients on blood thinners. Large-sized prostate can be conveniently removed in less time compared to TURP. HoLEP is the most commonly performed laser prostatectomy procedure which removes the majority of the prostate gland as a whole. As in TURP, the procedure done transurethral, and a catheter is placed after surgery which is removed after 2-3 days.

Embolization – In this procedure which is generally done for patients who are not fit for surgery, the blood supply of the prostate is blocked which then causes prostate size to decrease. The symptoms relief takes months and effectiveness is not well documented.

Open/ Robotic Prostatectomy – Open prostatectomy is reserved for patients having either very large-sized prostate or associated with other complicating factors such as bladder stones, bladder diverticula, etc. Robotic surgery similarly may be required for a very large-sized prostate and the whole prostate is removed.

Follow up Follow-up care is decided based on specific techniques used to treat the enlarged prostate. Improvement in urinary symptoms is checked after 4-6 weeks of catheter removal. Straining exercises and limiting heavy lifting are prohibited for up to 2-3 weeks after laser ablation, transurethral resection of the prostate. If you have open or robot-assisted prostatectomy, you might need to restrict activity for six weeks

BPH (Enlarged prostate) Symptoms

The prostate is a small gland present in men just below the urinary bladder. Urethra make its way through it. The prostate does not grow until about 40 years when usually it starts enlarging.  Prostate enlargement occurs in every male though the rate of increase in size may vary with race, familial factors, etc. Although an increase in the size of the prostate is associated with the chances of having urinary symptoms, it may not always be true. Enlarged prostate may cause none to little symptoms and minimal enlarged prostate may cause severe bothersome urinary symptoms. The enlarged prostate ( or BPH) may affect by irritative or obstructive voiding symptoms.

Irritative symptoms of enlarged prostate

  • Frequency – passing urine too frequently
  • Urgency – Inability to hold and postpone passing urine and need to rush for passing urine at first thought
  • Nocturia – getting up at night for more than once for passing urine
  • Dysuria – burning sensation while passing urine

Obstructing symptoms of enlarged prostate

  • Poor flow – having weak urinary stream
  • Intermittency – urine flow interrupts many times while voiding
  • Incomplete evacuation – a feeling of residual urine in bladder and persistent urge to pass urine even after finished voiding 
  • Straining – passing urine with the push or need to strain for passing urine
  • Hesitancy – taking a long time to initiate the urinary flow
  • Post void dribbling – the continuous passage of urine in drops at end phase of passing urine

The presence of the these symptoms points towards something wrong in the urinary system and most commonly due to prostate once age crosses 50-60 years. The symptoms are then graded in each person to place each patient in certain risk groups by the physician and subsequent treatment of enlarged prostate are initiated for each risk group. Not all patients require surgery for enlarged prostate and medicine is appropriate for patients with minimal symptoms. Passing blood in urine is the ominous sign after 60 years and may point towards something more serious happening inside and need to be evaluated promptly.

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Care of indwelling foley’s catheter

•Keep pericatheter area clean with saline or clean water and keep it dry.

•Secure catheter to prevent movement in urethra.

•Do not disconnect catheter from drainage bag unless absolutely necessary.

•Keep bag below the level of bladder.

•Empty the bag every 6-8 hourly or earlier if full.

•Never let collection bag touch the floor.

•Always wash hand or sanitise with alcohol handrub before and after opening tap of collection bag.

•Do not instill disinfectant/antiseptic into the collection bag.

•In case of fecal incontinence, clean and dry the area and change catheter.

•Plan of catheter removal when no longer required.

Hematospermia (Blood in semen)

•Presence of gross or microscopic blood in seminal fluid.

•It may occur only once or may be sporadic and chronic.

•The exact etiology is unknown in upto 20% of cases even after extensive workup.

•Causes include – prostate infection, STDs, prostate cancer, urethral stricture, seminal vesicle infections and cancer, Genitourinary tuberculosis, testes cancer, deviant sexual practices, after prostate biopsy etc.

•Diagnosis is made after comprehensive evaluation with medical history, clinical examination, semen culture and analysis, urine culture, urethral swab, blood tests including PSA, imaging with TRUS and ultrasound scrotum and MRI pelvis and rarely cystoscopy.

Mostly it is self limiting; treatment is based on the cause found and may include antibiotics, surgery or just reassurance if no identifiable cause found.

•Men with recurrent hematospermia and age >40 years need exhaustive workup in search for its cause and to rule out prostate malignancy. Those with single episode and age <40 years need basic workup.

Things to know about ‘Dhat’ syndrome (Nocturnal emission/Nightfall)

What is meant by nightfall or nocturnal emission or wet dreams?

Spontaneous involuntary loss of semen while the person is in sleep is called as nightfall or nocturnal emission. It is most common in young boys (adolescent age group).

Is there any side effects of night fall ?

There is no evidence that nightfall (wet dreams/nocturnal emission) cause any bodily side effect in men.

What is Dhat disease or Dhat Syndrome ?

Dhat syndrome is the clinical entity seen primarily in Indian subcontinent and present with a features of depression, anxiety, multiple nonspecific body symptoms, sexual dysfunction, fatigability, and impairment of concentration, which are attributable to semen loss. Loss of semen irrespective of the mechanism (during urination, defecation, masturbation, nightfall or nocturnal emission, and even sexual intercourse) is considered worrisome by patients suffering from Dhat syndrome.  

Which age group are mainly affected with Dhat syndrome ?

Patients with Dhat syndrome are often young males in second to third decade of life. Majority of the patients belong to south east Asia continent and belong to low socio-economic groups with orthodox culture. Families with poor education have higher chances of having this entity.

What are the symptoms of Dhat syndrome ?  

The most common presenting symptoms in patients with Dhat syndrome are weakness of the body, tiredness, low energy, low mood and mental stress. It can also be described as the abnormal illness behavior and bodily symptoms due to semen loss, as well as heightened emotional (depression and anxiety) response. These symptoms often get amplified with the stress.

How the symptoms of Dhat syndrome develop ?

At the time of onset of Dhat syndrome, these people get excessively worried with having nightfall or semen discharge and gives lot of significance to this semen loss. Every time they loss semen, they experience stress (as it is not acceptable in their culture). This abnormal thinking leads to stress response which further gets amplified with each time person have semen loss and hence this vicious cycle goes on. Further exaggeration of this stress response leads to the symptoms of anxiety, depression and other body (somatic) symptoms. This anxiety feature can lead to sexual dysfunction seen in few men with Dhat syndrome. Nearly 20% of patients diagnosed with Dhat syndrome do harbour some underlying depression, anxiety disorder.

How to treat Dhat syndrome ?

The patient with Dhat syndrome approach a variety of medical practitioners and specialists with their complaints. Since this culture originated disease entity is rare in western countries, the presentation and management knowledge is deficient in western medical practitioners. Patients with Dhat syndrome require comprehensive assessment to assess clinical severity. Integration of various medical specialities such as Urology, Psychiatry, Psychologists, general medicine, psychiatric nurses, alternative medicine (Ayurvedic/Siddha) can lead to better patient management. Psychosocial therapy, cognitive behavior therapy (imparting sex education and resolving sexual myths is very important), antianxiety and antidepressant therapy are helpful. Educating the traditional healers may help in resolving the sexual myths that they carry and dissipate to the people in the society.