Prostate: benign enlargement and PSA

What is the prostate and what does enlargement do?

The prostate is a small gland below the bladder that makes part of the semen fluid. When it grows, it can press on the urethra and make urinating harder. The NHS considers this very common and says it is seen mostly in men over 50. The cause is probably a change in hormones with age, and a family history raises the risk.

The EAU keeps the term “benign prostatic enlargement” for the tissue diagnosis and speaks of “lower urinary tract symptoms” when talking about the patient. In other words, what matters for treatment is how bothersome the symptoms are, not just the size of the gland.

Symptoms

According to the NHS: a slow start to urination or straining, a weak or stop-start stream, a feeling that the bladder has not emptied, dribbling after urinating, and frequent or urgent urination, including waking at night. They usually develop slowly and may get worse. If urination wakes you at night or your stream has weakened, it is not yet an emergency, but it needs to be assessed.

What needs to be seen urgently?

The NHS says that if you see blood in your urine, urinating is painful, or you cannot urinate at all, get urgent help. NIDDK adds that a sudden stop in urine can be life-threatening. So if you cannot urinate at all, or you are confused or very unwell, call 115 (Iran’s emergency number), or your local emergency number if you are outside Iran, or go to an emergency department. The full list is in urgent signs. Blood in the urine is a separate topic explained in the article Blood in the urine.

How is it assessed?

For a start, the NHS lists: questions about your symptoms, an examination of the abdomen and genitals, a rectal examination to judge the size of the prostate, a diary of drinking and urination for at least three days, a urine test and a PSA test. If you are referred, the urine flow may be measured, and a bladder ultrasound or cystoscopy may be done.

The EAU recommends using a standard symptom questionnaire, a bladder diary (at least three days, especially for night-time urination), a urine test, and a measurement of the urine left in the bladder. The EAU writes that PSA should be measured when a diagnosis of prostate cancer would change the treatment decision, and that the patient should be counselled on what a high PSA means. Preparing for a urine sample and PSA is covered in the test preparation guide.

Treatment

The NHS stresses that treatment is not always needed and depends on how much the symptoms affect your life. The EAU also writes that for most men whose symptoms do not bother them, follow-up without treatment is a reasonable option, and only a few of them go on to urinary retention or other complications.

Changing habits. For mild symptoms this is the first step. The NHS and EAU say: drink less in the hours when urination is most troublesome (for example in the evening), cut down on caffeine and alcohol, treat constipation, keep a reasonable weight, and check whether a medicine you take (especially a water tablet) is making the symptoms worse. After you urinate, wait a moment and try again (double voiding). Do not reduce or stop any medicine yourself.

Medicines. The NHS names three groups: medicines that relax the muscles around the bladder outlet, medicines for urgency and frequency, and medicines that shrink the prostate by changing hormones, for people at higher risk of getting worse. All have side effects and need regular check-ups. The EAU is more precise about the sexual effects:

• The first group (alpha-blockers) can mainly reduce ejaculation. The EAU says this is more a matter of less semen fluid than of it going back into the bladder, and a systematic review found no bad effect on sexual desire or erections.
• For the prostate-shrinking group, the most common effects are reduced desire and erection problems; ejaculation problems are less common.
• If these two groups are taken together, the risk of an ejaculation problem is about three times that of either one alone.
• PDE5 inhibitors are used for both urinary symptoms and erection problems, according to the EAU.

The EAU also says alpha-blockers do not prevent urinary retention and the need for surgery, but the prostate-shrinking group lowers the long-term risk of both. Which medicine suits you, and how much, is your doctor’s decision.

Surgery. The NHS says that if medicines do not work or symptoms are severe, the most common option is TURP: removing part of the gland through the urethra. Other options are laser, electrical energy, steam or pressurised water, an implant that holds the prostate open, a small cut around the bladder neck, and open surgery. The EAU says the choice of method depends mostly on the size of the prostate. After TURP, backward ejaculation and erection problems are recorded long-term effects. Other methods may carry different chances. Which method is available at which centre is something to ask your doctor.

If you cannot empty your bladder, the NHS says a urinary catheter is an option. Living with a catheter is covered in the stent and catheter guide.

PSA and screening

PSA is a protein made by the prostate; a small amount of it in the blood is normal. MedlinePlus says there is no single definite “normal” or “abnormal” PSA number, and a high level only makes cancer more likely. The NHS writes that benign prostate enlargement and a recent urinary infection also raise it. The EAU adds that prostate inflammation, acute urinary retention and a recent biopsy can also have an effect, and that medicines that shrink the prostate roughly halve the PSA, so it has to be adjusted.

If the PSA is between 3 and 10, the EAU recommends repeating the test before further work-up. For a man with no symptoms whose PSA is between 3 and 20, a prostate MRI helps decide about a biopsy. The NHS says that if the PSA stays high, the doctor may suggest referral for a biopsy and an MRI.

Screening is a shared decision, because it has both benefits and harms. According to the EAU, the Cochrane review saw more diagnoses but no better prostate-cancer-specific survival, and overtreatment of low-risk cancers eats into part of the benefit. For a well-informed man with a life expectancy of at least 15 years, the EAU suggests an individual, risk-based strategy. The NHS says routine testing is not offered to everyone, except in men with a faulty BRCA2 gene. These are the guidance of other countries and, for Iran, should be weighed with your treating doctor. A fuller explanation is in the article PSA explained.

A reminder

This page is for general information and does not replace an examination and tests. The decision about medicines, surgery or PSA testing is made with your doctor.