Enlarged Prostate Diagnosis

  • Diagnosis

    An enlargement of the prostate gland that is not cancerous (malignant) is called benign prostatic hyperplasia (BPH). Recently, the term LUTS, an acronym for "lower urinary tract symptoms," has been introduced as an alternative term for BPH, since many patients with typical symptoms of BPH have small prostates Figure 01. The prostate gland, found in men only, surrounds the tube through which urine leaves the bladder (the urethra). BPH is usually progressive because the prostate tends to enlarge as a man ages. Such enlargement may lead to obstruction of the urethra and interfere with urine flow. In patients with small prostates, increased tone of the smooth muscle in the bladder neck, rather than enlargement of the prostate, causes symptoms. Symptoms, whether from a large or a small prostate, are divided into three stages: mild, moderate, or severe.

    BPH is not life-threatening, but it is important that it be diagnosed early. Severe BPH causes significant amounts of urine to be retained in the bladder after voiding. Severe BPH may also reflect a major obstruction that could lead to repeated urinary tract infections along with bladder and/or kidney damage. Early detection along with treatment greatly reduces the risk for these complications.

    BPH is common in men after age 50; in fact, it affects two-thirds of men over 55 years of age. A specialist is not usually required to treat BPH. A general physician can treat an uncomplicated case. Many patients with BPH live with their symptoms and do not seek medical help, although this is not recommended.

    Click to enlarge: The prostate gland

    Figure 01. The prostate gland

    Increasing age and the presence of normal male hormones (testosterone and dihydrotestosterone [DHT]) are the best-known factors that contribute to BPH. A hormone known as 5α-reductase converts testosterone into DHT in the prostate gland, which results in prostate enlargement. DHT concentrations in BPH tissue have been shown to be increased when compared with normal prostate tissue. Of great interest is the fact that BPH does not occur in males who are castrated before age 40, indicating the great importance of the male hormone in this disorder.

    BPH occurs with nearly equal frequency in all races and cultures with the exception of Asians, in whom it occurs much less often. The cause for this is suspected to be environmental, since Asians who migrated to the U.S. developed an equal frequency of BPH. The average age for detection is somewhat earlier in African-Americans (60 years) than in whites (65 years).

    The symptoms of BPH can be classified as obstructive and irritative Table 01. Obstructive symptoms include straining to initiate urination, hesitancy in starting the stream, intermittency of urination, dribbling after urination, a weak urine stream, and a sensation of incomplete bladder emptying. Irritative symptoms include frequent urination during the daytime and nighttime, and a strong sense of urgency to urinate.

    Table 1.  Symptoms of BPH

    Obstructive symptoms Irritative symptoms
    Hesitancy Frequency of urination during the day
    Straining to start the stream Frequency of urination at night
    Weak urine stream Urgency to urinate at all times
    Terminal dribbling after urinating
    Intermittency of urination

    Some BPH symptoms are also symptoms of bladder or prostate cancer and bladder infection. Patients with symptoms of BPH must have these other possible disorders ruled out by a series of simple diagnostic tests, including a urine test for red cells and white cells, a serum prostate-specific antigen (PSA) test, and, of course, a digital rectal exam. Another disorder the doctor will check for, although it is somewhat less common than the aforementioned disorders, is prostatitis. Prostatitis may raise the serum PSA in the absence of prostate cancer. Therefore, to rule this disorder out, a patient should have a prostatic massage followed by collection of either a seminal fluid specimen to be examined for white blood cells, or a first-voided urine sample to be examined for white blood cells and possibly for organisms.

    Your doctor may give you the international prostate symptom scale (ISPS) test Table 02. Your score on the International Prostate Symptom Scale (ISPS) test can be helpful in gauging the severity of the condition. This scale was recently published by the American Urological Association (AUA). Scores of 8 or less indicate mild disease, 9 to 19 indicate moderate disease, and 20 and above indicate severe disease. The symptom score is a good guide for initiation of therapy, since patients with mild disease are usually just monitored carefully and not treated, whereas patients with moderate disease usually begin treatment. Patients with severe disease are almost always treated.

    Table 2.  International Prostate Symptom Score

    ? Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always
    Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 0 1 2 3 4 5
    Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? 0 1 2 3 4 5
    Over the past month, how often have you found you stopped and started again several times when you urinated? 0 1 2 3 4 5
    Over the past month, how often have you found it difficult to postpone urination? 0 1 2 3 4 5
    Over the past month, how often have you had a weak urinary stream? 0 1 2 3 4 5
    Over the past month, how often have you had to push or strain to begin urination? 0 1 2 3 4 5
    Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? 0 1 2 3 4 5
    Total international prostate symptom score ? ? ? ? ? ?
    Quality of life resulting from urinary symptoms Delighted Pleased Mostly satisfied Mixed?about equally satisfied and dissatisfied Mostly dissatisfied Unhappy
    If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? 0 1 2 3 4 5

    Adapted from Berry SJ, Coffey DS, Walsh PC: The development of human benign prostatic hyperplasia with age. J Urol 1984, 132: 474-479.

    Risk factors for this condition are unclear. BPH is equally prevalent in all races except for Asians, in whom it is less common. Asians, including Indians, Chinese, and Japanese, may be protected from the factors resulting in BPH by their dietary habits, which are largely vegetarian with much lower fat intake. The Asians also consume a large quantity of soy products, which have been thought to have factors such as isoflavones, which may inhibit growth of the prostate. No study has found a clear connection between BPH and smoking, obesity, alcohol consumption, liver dysfunction, or vasectomy. Evidence is beginning to suggest that BPH has a genetic component.

    Your doctor will take a medical history and conduct a physical examination and urinalysis to learn about your condition. The history will focus on the urinary tract and general health issues, such as high blood pressure and diabetes. The physical examination will include a digital rectal examination and an examination of your genitals. If hard areas, nodules, or asymmetry are present, the doctor may suspect cancer and do further testing. Dipstick urinalysis and microscopic examination of urinary sediment should be done to rule out blood in the urine and urinary tract infection.

    Testing urinary flow rates is also helpful. Maximal flow rates of less than 10 mL/sec indicate severe disease; rates above 10 mL/sec indicate moderate to mild disease. Your doctor can also estimate the amount of residual urine with straight catheterization or bladder ultrasonography. Values over 200 mL indicate significant long-standing outlet obstruction and early bladder failure, and point to advanced disease.

    Your doctor may give you a prostate-specific antigen (PSA) test. Once you reach age 50, your doctor should give you a PSA test after discussing the risks and benefits of early detection of prostate cancer. If you have a family history of prostate cancer or are African-American, your doctor will begin PSA testing at age 40 to 45. Patients with PSA levels above normal (4 µg/L) should be referred to a urologist for further testing. African-American males with a PSA level above 2.5 µg/L, and all men whose PSA level has increased substantially in 12 months should also be referred to a specialist. PSA testing can also help your doctor estimate the size of your prostate, which helps determine a course of treatment for BPH.

    There is no proven way to prevent BPH. However, according to the National Cancer Institute and the American Cancer Society, all men over 50 should have a digital rectal examination once a year to screen for prostate cancer. Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to urinate at all. This condition, called acute urinary retention, may be triggered by taking over-the-counter cold or allergy medicines. Such medicines contain a decongestant drug known as a sympathomimetic. A potential side effect of this drug may be to prevent the bladder opening from relaxing and allowing urine to empty. When partial obstruction is present, urinary retention also can be brought on by alcohol, cold temperatures, or a long period of immobility.

  • Prevention and Screening

    There is no proven way to prevent BPH. However, according to the National Cancer Institute and the American Cancer Society, all men over 50 should have a digital rectal examination once a year to screen for prostate cancer. Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to urinate at all. This condition, called acute urinary retention, may be triggered by taking over-the-counter cold or allergy medicines. Such medicines contain a decongestant drug known as a sympathomimetic. A potential side effect of this drug may be to prevent the bladder opening from relaxing and allowing urine to empty. When partial obstruction is present, urinary retention also can be brought on by alcohol, cold temperatures, or a long period of immobility.

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