The prostate is a walnut-sized gland below the bladder present in men only. It makes the fluid that carries and nourishes sperm. The prostate sits in front of the rectum ('back passage'), which is why the prostate can be felt by putting a finger into the rectum. Urine flows from the bladder through the prostate to the urethra and then to the outside world. The prostate is like a ring doughnut or polo mint with a hole in the middle.
There are three main problems that affect the prostate, prostate enlargement (benign prostatic hyperplasia, BPH), prostate cancer and prostatitis.
If the channel through the prostate gets small as the prostate enlarges, urinary symptoms can develop such as getting up at night, passing urine frequently, or a poor urinary stream. However, the prostate is not the only cause for urinary symptoms. Investigations and treatments for these problems can be found operations for the benign prostate enlargement including laser prostatectomy.
In general, prostate cancer does not cause urinary symptoms unless it is very advanced. Therefore, the majority of men with urinary symptoms do NOT have prostate cancer..
Prostate cancer is a growing problem in this country as men live longer (see graph below). When it starts there are no symptoms, but it is now the second commonest cause of death from cancer in men after lung cancer (see graphs below). Prostate cancer can be detected early using the PSA, PCA3 Score, subsequent prostate biopsies and then deciding what treatment options are best for you including observation. PSA testing is controversial and so it is important to understand the advantages, risks and alternatives to PSA testing. Multiple new treatments have arisen for prostate cancer including HIFU (high intensity focused ultrasound), laparoscopic and robotic prostatectomy.
Urinary symptoms can be due to a variety of different causes. When due to the prostate, these symptoms include getting up a night, passing urine frequently by day, and taking a long time to pass urine when in the toilet.
The prostate is a small gland sitting below the bladder. Urine flows the prostate which is like a ring doughnut or polo mint with a hole in it. As the hole gets smaller, urinary symptoms can get progressively worse. However, the prostate is not the only cause for urinary symptoms.
Diagram of Prostate Gland
See the frequently asked questions (FAQ) regarding the enlarged prostate, operations for the benign prostate enlargement including laser prostatectomy that treats the prostate with almost no bleeding and as a day case so that you can get home the same or next day.
How do I work out how serious my cancer is?
There are several considerations:
The underlying risk of the cancer affecting your quality of life
Your general health
The underlying risk of the cancer is determined principally by:
Gleason Score: this is a measure of how aggressive the cancer is. The two commonest patterns of cancer are each graded from 1 to 5. The two grades are summed and the total is known as the Gleason score. Therefore, this ranges from 2 to 10.
Most cancers have a Gleason Score of 6: the most serious is 10 and the best is 2.
Cancer Stage: This refers to how far the cancer has spread and can be determined partially by prostate examination with a finger, and sometimes with transrectal ultrasound at the time of prostate biopsies, a bone scan or magnetic resonance imaging (MRI) scan. If the cancer is confined to the prostate, the stage is 'T1' or 'T2', if it is outside the prostate it is 'T3' or 'T4'. Bone scans indicate whether there is cancer in the bones. Sometimes, the lymph nodes in the pelvis are sampled laparoscopically to determine if cancer is present there.
PSA: the higher the PSA, the more likely the cancer is outside the prostate; the faster the rate of change, the more likely serious cancer is present
Other bits of information can be used and relate often to the information gained from the prostate biopsies: the proportion of positive biopsies, the length of cancer in the biopsies or the percentage of the core with cancer.
It is important to know how the cancer was detected i.e. by screening with a PSA test or because of symptoms. Most of our knowledge is based on prostate cancer detected in patients with urinary symptoms. If the cancer was detected early because of PSA testing, the time between diagnosis and the development of symptoms from the cancer is likely to be much longer than if the cancer was detected because of urinary symptoms.
What additional tests or scans are necessary now I have prostate cancer?
These tests relate mostly to determining if the cancer is confined to the prostate and what chance there is that treatment will fail after a few years. It is possible to combine the information to calculate whether the cancer has spread outside or the chance that the cancer will return after treatment. The information required is:
Clinical stage determined by examination of the prostate by a finger
the proportion of positive biopsies
The following web sites contain 'calculators' enabling you estimate your risk. This information should be interpreted with a doctor who understands prostate cancer.
the Sloane Kettering Nomogram
•The Prostate Calculator
Other investigations, such as magnetic resonance imaging (MRI) can help tell if the cancer is has spread outside the prostate and give information about your anatomy relevant to treatment and side-effects. For this test, you enter a scanning machine, which makes a lot of noise, and produces high quality images of the prostate. It may help determe if the lymph nodes ('lymph glands') contain cancer or not. Sometimes, lymphotropic superparagmagnetic particles are used (this is still under trial). The best way to tell is by laparoscopic lymph node sampling, which is a keyhole procedure for obtaining tissue to examine under the microscope. This is a highly specific test for the identification of cancer in the lymph nodes.
What are my choices?
Depending on your individual situation you might choose
•radical radiotherapy (external beam)
•radical prostatectomy (either open, laparoscopic or robotic)
•high intensity focused ultrasound (HIFU)
The situation is often difficult and experts frequently disagree. A careful decision needs to be made usually in conjunction with consultants in radiotherapy and urology.
Part of the problem is that early prostate cancer grows slowly and so treatments are for problems that will often not present for several years. Having said that, the opportunity for curative treatment is available only when cancer is confined to the prostate and has not spread elsewhere.
What is active monitoring?
The prostate cancer is monitored to determine whether it is progressing or not. The implication is that if the prostate appears to be growing and is at risk of causing problems, then a treatment option will be undertaken. To do this, the tumour should be of loss risk of progression anyway. There are no universally accepted criteria for this and a discussion is necessary with an experienced prostate cancer doctor. In patients less than 70 years of age in good health, few doctors would recommend active monitoring especially if the cancer was detected because of urinary symptoms, the Gleason score was 7 or more, or if the PSA was 15 ng/ml or more, or if both sides of the prostate contained cancer (stage T2b or higher). If these conditions do not apply, then active monitoring may be appropriate.
Active monitoring involves regularly measuring the PSA and seeing how it changes. Some people perform prostate examinations regularly and repeat prostate biopsies annually. The idea is to look for evidence that the disease is advancing. Provided it does not advance too far, curative treatment might still be possible or not be necessary! This is becoming a more acceptable way to manage people with prostate cancer. Probably the best strategy is to incorporate all pieces of information regarding the disease and your overall health.
It is possible to calculate the rate at which PSA changes. The faster the PSA increases, the more likely it will be a problem. More than 2 ng/ml in the year per year is thought to be serious. The slower the PSA doubles, the less likely the tumour will affect the individual with it. Conversely, the faster the PSA doubles, the more likely the prostate cancer will cause problems. Men with low grade cancer rarely develop problems until the PSA is greater than 50 ng/ml. If the cancer is high grade, a long or slow PSA doubling time is unreliable although a short doubling time indicates treatment is probably necessary.
5The advantage of this option is that the prostate is preserved and the side-effects of treatment are avoided. The disadvantages are that the opportunity for curative treatment might be missed and that our ability to make an accurate estimate of whether a cancer is 'safe' or not is not reliable enough on an individual person basis.
Even older men may benefit from intervention, based on recent evidence (Wong 2006 JAMA)
What is a radical prostatectomy?
A radical prostatectomy is the operation to remove the prostate. At the same time the seminal vesicles, which are attached to the prostate, are removed occasionally with the lymph nodes, which are specialised tissue to which the prostate drains. This procedure can be performed by an incision through the lower belly or by key hole techniques ('laparoscopic' or 'endoscopic' or 'robotic'). The advantages are:
•the prostate gland with its cancer and surrounding tissue is removed offering what many doctors believe to be the best chance of preserving length of life. This is believed to be most accurate when the cancer is detected because of 'prostate' (urinary) symptoms, the cancer can be felt with a finger, or the cancer is Gleason score 7 or more.
•the prostate can be examined completely and a more accurate prediction made of the likley outcome
•the PSA should fall to almost unrecordable values making it much easier to determine if the disease has unfortunately recurred
•additional treatment such as radiotherapy can be given with fewer side-effects
•a short hospital stay (3 to 7 days) is necessary rather than regular attendance
•urinary symptoms (weak or slow flow etc) due to the prostate are usually eliminated completely
The disadvantages are
•it is a major operation
•a blood transfusion may occasionally be necessary
•control of urine is less good in some after surgery and pads may be required. About 1 in 20 men have problems with leakage and it is more common in men over 70 years of age
•erections may be weaker or non existent although good sexual activity can be had with Viagra, Cialis or Levitra
•additional treatments may be required if the prostate cancer returns
There is strong evidence that radical prostatectomy reduces the chance of dying from prostate cancer by about 50% compared to watchful waiting and deferred androgen deprivation. The evidence comes from a randomised study published in one of the world's most prestigious medical journals. However, the results are most applicable to men with cancer detected because of symptoms, with a PSA around 12 ng/ml, prostate cancer that can be felt with a finger when examined, and Gleason score 6 or 7. Nowadays, many men have few urinary symptoms, PSA values around 5 to 8, Gleason score 6 and impalpable cancer ie the cancers are detected earlier in their history. This is not to say that surgery is not effective just that to benefit one has to wait longer.
The procedure can be performed through a traditional incision in the lower abdomen or through 5 very small incisions ie endoscopic or laparoscopic surgery. The advantages of laparoscopic surgery include improved view allowing more precise surgery, shorter hospital stay (2-3 days) and earlier return to leisure activities and work. It is technically difficult to and specialised training is required.
What is radiotherapy?
The prostate is treated by radiotherapy given whilst lying in a machine at a special hospital. Usually, one attends on week days for 6 to 7 weeks for a short time for the treatment. This treatment is sometimes accompanied or preceded by hormonal therapy to block the effects of testosterone, which is the male hormone that drives prostate growth. The advantages are:
•the prostate cancer is treated and is less likely to recur or cause symptoms
•there is a much lesser chance of incontinence compared to radical prostatectomy or brachytherapy, but frequency or urgency may be worse
•radiotherapy can be given to the side walls of the pelvis which may be important if the cancer has spread.
•HIFU or cryotherapy can be used if radiotherapy fails
•surgery is avoided
There are disadvantages too:
•many doctors believe that radiotherapy is probably a less effective treatment than surgery when compared over long periods of follow up
•side-effects include diarrhoea, and blood in the stools
•erections become weaker over time
•it is more difficult to use the PSA to determine if the treatment has been successful or not
•if treatment fails, cryotherapy or surgery is associated with more side-effects such as worse incontinence
What is brachytherapy?
Seeds with radiotherapy energy are placed systematically in the prostate under a general anaesthetic. Patients stay in hospital usually overnight. This is done either in one or two stages depending on the set up.
The advantages are:
•this can be a day case procedure so patients can often leave the same day
•it is possible to have additional therapy, usually external beam therapy, if there is disease recurrence
•incontinence of urine is less likely
The disadvantages include
•urinary symptoms often become significantly worse after surgery and sometimes a catheter is required for a period to empty the bladder
•the treatment is probably less effective than surgery regarding cancer cure
•weakness of erections occurs, although possibly less commonly than after surgery or external beam radiotherapy
What is cryotherapy?
The prostate and its cancer can be killed by freezing the cells. To give this therapy, a general anaesthetic is necessary and a catheter needs to be placed for several days.
The main advantage is that it can be given after radiotherapy if it is not effective. It can also be repeated. However, it almost always causes erectile dysfunction. Expertise with its use is limited in the UK.
What is hormonal therapy
This usually refers to reducing testosterone levels in the body and is usually known as androgen deprivation, androgen suppression or castration. Testosterone with its derivative dihydrotestosterone is the male hormone that drives prostate growth. Rather than reduce the levels of testosterone, its action can be blocked by drugs and this is known as androgen blockade.
This form of therapy is usually used with or without radical radiotherapy, and sometimes after radical surgery but not before. The prostate cancer tends to be more advanced than early.
The side effects of this include hot flushes, tiredness, anaemia, and in the long term osteoporosis.
How do I decide what to do?
You have to trade-off the advantages over the disadvantages of each option. It depends on the relative values of each. This is best done by discussing the issues with a doctor and close family. In general, if the thought of having cancer and not doing the most possible to get rid of it dominates your thinking, then you should choose an interventional treatment. There is no caste iron evidence to indicate one treatment is better than another, but many doctors believe that radical prostatectomy offers the best chance of prolonging life. It becomes more important to maximally remove the cancer if it is high risk or there are many years of life possibly ahead. On the other hand, active monitoring may be the best option if quality of life is more important than preserving a few years of life especially if there is uncertainty over the benefit of treatment and the cancer does not seem obviously to be high risk. A second opinion is often helpful.
Several websites offer details and on-line help in making decisions including:
The Prostate Cancer Charity
IPSS Questionnaire for urinary symptoms possibly due to the prostate
A symptom score helps evaluate the severity of your symptoms when due to the benign enlargement of the prostate and quantify how much bother it causes.
The IPSS (International Prostate Symptom Score) is the name for one of these questionnaires. Download here (PDF file).
The symptoms are graded as:
•Mild: score 1 to 8
•Moderate: score 9 to 19
•Severe: score 20 to 35
Urodynamics in men with an enlarged prostate: why, what and what to expect?
What are urodynamics?
This is a one-hour outpatient diagnostic test to help understand why urinary symptoms are present and to help predict the outcome of treatment. The tests aims to determine the activity of the bladder whilst it is filling with fluid, and the pressure and speed at which urine is passed.
To do this, a very narrow tube has to be passed into the bladder through the urethra. Sometimes, it is combined with x-rays and is known as 'videourodynamics'. A gel with local anaesthesia may be used, but not general anaesthesia. Pressures are measured in the rectum (a.k.a. back passage) at the same time through another narrow tube.
Why am I having this test?
The test can determine the cause of urinary symptoms such as:
•slow flow, stopping and starting, and the need to dribble to finish passing urine
•increased frequency of passing urine during the day and night
•urine leakage (incontinence)
It can also help predict whether drugs or surgery are likely to have a good result for:
•urinary symptoms in men due to obstruction of the bladder by the prostate (BPH) or other cause
•overactivity of the bladder (also known as detrusor instability or detrusor overactivity)
What should I do before this test?
If you are taking drugs for your prostate or bladder, you should probably stop these a week before having the test. Check first with the nurses or doctors. These include:
•oxybutynin (Kentera patches, Cystrin, Ditropan, Lyrinel)
It is not necessary to fast the night before or take laxatives. As long as a urine test to test for infection is normal, the study is very safe and can be performed with minimal discomfort. It is important to arrive with an almost full bladder since it may be necessary to do a urinary flow test before the formal urodynamic test. Usually, a nurse will be in the room during the study. Occasionally, a radiographer or doctor may be there also.
What will happen during the test?
You will need to undress and put on a gown. Local anaesthetic jelly will be placed in the urethra. A narrow tube (catheter) will be placed by a doctor or nurse through the urethra into the urinary bladder. In addition, another narrow tube will be placed in the rectum, which improves the accuracy of the test. The study can be performed whilst standing or sitting. A computer will record all of the measurements and a “tracing” will be generated.
Your doctor may be present during the critical parts of the study. He will analyse and interpret the study based on the tracings and x-rays if these are taken.
What happens after the test?
Half an hour after the test, you will be able to go home. You may experience some burning when passing urine for a few days and this is normal. There may be some blood in the urine, but as long as large clots are not formed, the bleeding will settle if you drink plenty of fluid. You can resume regular diet, medications, and normal activity levels after you leave. Often, antibiotics are prescribed for a few days afterwards. Your results will be discussed in outpatients.
For more information, download the following file:
urodynamics patient information
Are there any medicines that can help symptoms due to an enlarged prostate?
Rather than an operation, drugs, such as alpha blockers (e.g. tamsulosin, Flomax, Omnic, alfuzosin, Xatral, Cardura), relieve prostate symptoms by relaxing the muscle of the prostate and are useful in some patients with BPH, especially younger men with milder symptoms.
Finasteride or dutasteride can reduce the size of the prostate, and improve symptoms in about 30 percent of patients who take it. However, drugs have to be taken for the rest of your life in order to remain effective.
Using finasteride and an alpha-blocker together is more effective than either drug alone to relieve symptoms; they prevent BPH getting worse. The two-drug regimen reduced the risk of BPH getting worse in two out of three patients, compared to one-in three for an alpha-blocker alone and one in three for finasteride alone.
Drugs or medicines may not be enough, and more effective treatments such as TUNA, TURP or GreenLight PVP may be necessary.
Should I have an operation?
At one time, BPH was invariably thought to be a progressive disease. That is no longer the case. Only about 40 to 50 percent of all men with BPH actually develop any symptoms due to this condition, and of that number, only a proportion will need prostate surgery.
BPH requires treatment only if the symptoms are severe enough to disrupt your life or threaten your health. If, during your prostate examination, your doctor finds that you have significant symptoms and that your prostate gland is enlarged, you may start a program of medication and changes in life style to improve your symptoms. During this time, your doctor may examine you periodically and ask you to complete questionnaires (e.g. IPSS).
If your urination problems are not adequately relieved by medication or the side effects of the drug are excessive, you might then consider TUNA, a TURP or Greenlight PVP. TUNA is the least invasive of all treatments and Greenlight PVP utilises a laser to remove prostate tissue. With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed; the rest of the prostate is left intact. Removal of the enlarged part of the prostate is the best long-term solution for patients with BPH. Surgery usually relieves the obstruction and incomplete emptying caused by BPH more than any other treatment.
For certain patients with particular signs and symptoms, a TURP or laser prostatectomy is almost always recommended. These signs and symptoms include:
•Total inability to urinate
•Profuse bleeding through the urethra due to prostatic enlargement
•Difficulty emptying the bladder because of prostatic obstruction, which can lead to progressive kidney failure
•Recurrent urine infections
If you decide to have a prostatectomy for reasons of comfort or for a more severe indication, you should know that an operation offers the greatest chance of getting rid of your symptoms.
Are there any alternatives to TURP or laser prostatectomy for BPH?
TUNA is a good minimally invasive treatment for prostate enlargement. It has advantages over traditional surgery in that it is less invasive and does not affect ejaculation. A stent is another alternative, but this is usually reserved for older men for whom a surgical procedure is particularly risky.
What are the risks/benefits of surgery?
Although there are nonsurgical treatments available to treat BPH, an operation offers the highest chance of alleviating prostate problems. However, it also can result in problems either during or after surgery.
After a TURP or laser prostatectomy, some men will find that semen does not go out of the penis during orgasm. Instead, it passes into the bladder and is passed with the urine next time. The feeling of orgasm stays the same. This backwards ejaculation is a problem for couples who want to have a baby.
Some conditions after TURP or laser prostatectomy may require additional treatment including:
•impotence (small risk)
•uncontrolled urine leakage i.e. incontinence (very small risk)
•a constriction of the urethra (stricture); or the necessity of a second operation later, in some patients (10%).
These risks and benefits must be considered by anyone considering a prostate operation, and your doctor can help you make your decision.
What tests are there to help decide what treatment is necessary and appropriate?
These tests include the following, but do not necessarily have to be performed always:
•Urinary symptoms (IPSS) questionnaire: This quantifies the severity of the symptoms and how much bother they cause.
•Blood test: for kidney function and to estimate the size of the prostate, and risk of prostate cancer (PSA)
•Urine Chemical Analysis: to determine the presence of blood or evidence of infection
•Urine Flow Rate: you will be asked to pass urine into a special machine that measures the speed of your urine flow as well as the volume of urine expelled. This test helps in evaluating the function of your bladder and the degree of prostatic obstruction.
•Measurement of the urine left in the bladder after passing urine (postvoid residual): The volume of urine in the bladder after it has been emptied can be measured by an ultrasound scan. If this is increasing over time, then surgery is probably a good idea
•Transrectal ultrasound measure of prostate volume: A probe is inserted in the back passage (rectum) and the size of the prostate is accurately measured. The larger the prostate, the greater the chance of problems in the future.
•Urodynamics: Measuring pressure in the bladder during urination can determine how strongly the bladder contracts, the extent of obstruction by the prostate, and whether the bladder contracts inappropriately when it is filling with urine. This test also is done by placing a small catheter in the bladder and rectum.
•Cystoscopy: To look at the configuration of the prostate and changes in the bladder that may be responsible for urinary symptoms.
How do I decide what treatment is necessary?
You can predict your chance of being completely unable to pass urine or needing surgery over 6 years by going to the following website (www.oncovance.com). If you register, you then need to know your age, IPSS score (also known as AUA SI) and PSA. Further information can be entered, if you have it, to improve the accuracy.
Mild and non bothersome urinary symptoms
If your urinary symptoms are mild (ie IPSS less than or equal to 7 out of 35) and do not cause bother (bother score less than 3 out of 6), then only changes in lifestyle are usually all that is necessary especially if the prostate is small, the PSA is less than 1.5 ng/ml and the bladder empties efficiently. If necessary medication such as an alpha blocker may be given to reduce symptoms. A 5 alpha reductase inhibitor may shrink the prostate over time and reduce the chance of significant problems in the future. Surgery is not usually suggested if the symptoms are mild and respond well to alpha blockers.
If biopsies of the prostate have been taken and inflammation of the prostate was found, there is a greater chance that there may be more problems with either a complete blockage (acute urinary retention) or that surgery may be needed in the future. As such, it is probably sensible to take a 5 alpha reductase inhibitor (e.g. finasteride or dutasteride) as these can reduce the probability of these undesirable outcomes.
Moderate and bothersome urinary symptoms
If the symptoms are more moderate (IPSS between 8 and 19 out of 35) and bothersome (bother score 4 or more out of 6), then treatment by either drugs (alpha blockers), TUNA, laser prostatectomy or traditional TURP is usually effective. If alpha blockers have not worked well or the bladder is emptying less well over time, then surgery is recommended.
When drugs are used, it's better to use a combination of alpha blockers with finasteride or dutasteride especially when the prostate is large or the PSA is greater than 1.5 ng/ml.
Transurethral needle ablation (TUNA) is a minimally invasive procedure performed as an outpatient. There are many advantages of TUNA including the preservation of normal ejaculation and sexual function. However, about 4 in 5 men find the treatment still works after 5 years. There is less long term evidence for its use compared to a traditional TURP.
The GreenLight PVP laser prostatectomy and TURP are more effective than drugs. In general, Greenlight PVP laser prostatectomy and TURP are most likely to be effective if the prostate is causing obstruction of the bladder. This can be determined by the tests listed above.
Severe and bothersome urinary symptoms
For severe urinary symptoms (IPSS 20 or more) that are bothersome (4 or more out of 6), it is important to look in the bladder to make sure there are no other problems. Further tests to determine whether urinary symptoms are due to obstruction by the prostate will often be necessary, especially if a TURP or other surgical procedure is being considered. The biggest improvement in symptoms and quality of life occurs with the GreenLight PVP or TURP, but not everyone wants these procedures. Medicines such as alpha blockers or finasteride/dutasteride also relieve symptoms, but not as much. If drugs are used alone, further treatment is necessary. A poor response to alpha blockers and increasing residual urine or symptoms mean that surgery is almost always necessary.
In addition, if surgery is delayed when the bladder is obstructed by the prostate, the benefit of surgical procedures may be less than when surgery is performed early. This is possibly because the bladder may undergo irreversible changes if it is blocked for a long period of time. With less invasive treatments available now (eg TUNA or GreenLight PVP laser prostatectomy), it may be better to opt for one of these earlier than later.
How do I decide between drugs or surgery?
Conservative treatments and drugs such as alpha blockers work best when symptoms are mild or moderate. TUNA gives symptom relief as a minimally invasive procedure that preserve normal sexual function. If symptoms are severe and the prostate is causing a blockage, then GreenLight PVP or TURP surgery is more effective and lasts longer than TUNA or drugs.
The severity of symptoms is judged best by assessing the symptom score (IPSS). If the symptom score is 20 or more and the symptoms are bothersome (4 or more). A test called urodynamics can determine if there is a blockage or not, and can also tell if the bladder contracts at the wrong time. Sometimes, urinary symptoms such as getting up at night or having to rush urgently to pass urine are not due to the prostate; these symptoms may be due to the bladder contracting inappropriately. Urodynamics can help predict if the GreenLight PVP or TURP may help. The GreenLight PVP or TURP is most effective when there is obstruction present and this is usually proven by urodynamic testing.
Other factors are also important such as general fitness. It may not be safe to have an anaesthetic, which is necessary for a TURP or GreenLight PVP. Drugs may be the only treatment possible. Occasionally, other procedures are also possible such as 'stents'.
What do I do about having to get up at night?
Getting up at night and passing urine becomes more common as one gets older. Surgery on the prostate may help if the bladder is not emptying completely because of obstruction. However, the prostate is not always the cause of getting up at night. Usually, urine production stops at night, but this may not occur resulting in excess urine production at night. To detect this, keep a record of the total amount of urine passed during the day and night. If the amount of urine made at night is more than 25% of the total daily amount, then the following can help, but discuss with your doctor before adopting the advice below:
•stop drinking 4 or more hours before going to bed
•take a nap in the afternoon making sure the legs are elevated and the body is horizontal if possible.
•wear tight compression leg stockings during the day
Your doctor should advise you further.
Drugs such as alpha blockers (eg tamsulosin or alfuzosin) can also be of benefit. These measures can be combined with a tablet to help encourage more urine production in the afternoon (a diuretic) and something to stop urine production at night (DDAVP).
In some cases, the urgent need to pass urine occurs during the day and night. This problem may be due to overactivity of the bladder muscle and can be helped by avoiding caffeine and taking medicines. These medicines include solifenacin (Vesicare), tolterodine (Detrusitol) and oxybutynin (Lyrinel).
Are there any medicines that can help symptoms due to an enlarged prostate?
Rather than an operation, drugs, such as alpha blockers (e.g. tamsulosin, Flomax, Omnic, alfuzosin, Xatral, Cardura), relieve prostate symptoms by relaxing the muscle of the bladder neck and prostate and are useful in some patients with BPH — typically younger men with milder symptoms. The drugs reduce symptoms by about 25% or 4 to 6 points out of a total of 35 (see IPSS questionnaire) in more than half of men who take the drug. Symptoms are reduced within a few days. Side effects include drowsiness and headache in about 15% of men, reduced semen volume, and nasal congestion.
Finasteride or dutasteride can reduce the size of the prostate by about 20%, and improve symptoms in about 30 percent of patients who take it. Symptom scores improve by about 4 or 5 points out of 25. For example, if your symptom score was 16, then the symptom score would be about 11 or 12 out of 35 after 6 months or more of treatment. The chance of needing surgery for the prostate or being completely unable to pass urine ('acute urinary retention') is reduced by about 50%. To remain effective, the drugs need to be taken for the rest of your life. The side effects of finasteride include reduced volume of semen and altered semen quality, impaired erections, reduced libido, and occasional growth of the breast tissue.
Using finasteride and an alpha-blocker together is more effective than either drug alone to relieve symptoms and prevents BPH getting worse. The two-drug regimen reduced the risk of BPH progression in two out of three patients, compared to one-in three for an alpha-blocker alone and one in three for finasteride alone.
Drugs or medicines may not be enough, and more effective treatments such as TUNA, a TURP or the GreenLight PVP, which is a minimally invasive form of prostate treatment using a laser, may be more suitable.
What do I do about having to get up at night?
Getting up at night and passing urine becomes more common as one gets older. Surgery on the prostate may help if the bladder is not emptying completely because of obstruction by the prostate. However, the prostate is not always the cause of getting up at night. Usually, urine production stops at night, but this may not occur resulting in excess urine production at night. To detect this, keep a record of the total amount of urine passed during the day and night. If the amount of urine made at night is more than 25% of the total daily amount, then the following can help, but discuss with your doctor before adopting the advice below:
•stop drinking 4 or more hours before going to bed
•take a nap in the afternoon making sure the legs are elevated and the body is horizontal if possible.
•wear tight compression leg stockings during the day
Your doctor should advise you further.
Drugs such as alpha blockers (eg tamsulosin or alfuzosin) can also be of benefit. These measures can be combined with a tablet to help encourage more urine production in the afternoon (a diuretic) or something to stop urine production at night (DDAVP).
In some cases, the urgent need to pass urine occurs during the day and night. This problem may be due to overactivity of the bladder muscle and can be helped by avoiding caffeine and taking medicines. These medicines include tolterodine (Detrusitol) and oxybutynin (Lyrinel)
What about Saw Palmetto?
Saw palmetto (Serenoa repens) is a type of palm tree, also known as the dwarf palm. Its primary medicinal value lies in the oily compounds found in its berries. Most dietary supplements are composed of an extract from the berries or a berry powder.
Saw palmetto dietary supplements improve urinary flow, and reduce the frequency and urgency of urination in men with prostate enlargement. Saw palmetto is believed to inhibit the actions of testosterone in the prostate that cause prostate enlargement and interference with urinary flow.
Fatty acids and sterols found in Saw palmetto inhibit testosterone in the prostate. Sterols are also present in other herbs (such as pygeum bark, stinging nettle root, and pumpkin seed extract) used in treating symptoms of prostate enlargement.
Saw palmetto is commonly used in Germany and other parts of Europe and the United States, but less commonly in England. There have been concerns about the quantity of active agent in various preparations of Saw palmetto.