Prostatic hypertrophy, causes, symptoms, diagnosis and treatment

• Prostatic hypertrophy is the abnormal enlargement of the prostate due to age and hormonal changes.
• Prostatic hypertrophy is a very common condition in men over 60 years of age.
• The only definitive solution to relieve the symptoms of prostatic hypertrophy is prostate surgery.

Prostatic hypertrophy is a disease associated with the prostate, obviously, which consists of an abnormal increase in the size of the prostate due to age and the hormonal changes that occur in a man's body. Prostate enlargement is a very common pathology among elderly men, and it is very likely that by the age of 70 they will be suffering from prostatic hypertrophy.

It is also important to mention that prostatic hypertrophy is benign, non-cancerous and can occur in men between the ages of 40 and 80 years and older. The main problem with benign prostatic hypertrophy is that due to the position of the prostate in the human body, which is crossed by the urethra just at the entrance to the bladder and in front of the rectum, as it increases in size it puts pressure on the urethra causing problems when urinating. For definitive relief of these problems, prostate surgery is most likely to be required.

As we have already mentioned, the main cause of benign prostatic hypertrophy is age and the hormonal changes that occur over time, mainly the increase in oestrogen over testosterone. In reality, the prostate does not stop increasing in size throughout life, and this increase is relatively small. 

The only difference is that at certain ages this increase in size accelerates and causes the voiding symptoms discussed below:

Prostatic hypertrophy is benign in nature.

The symptoms of prostatic hypertrophy are directly related to urination (peeing). They include:

• Intermittent urination. Due to the pressure exerted by the hypertrophied prostate on the urethra, urine does not flow easily, causing intermittent urination and even the need to exert effort to do so.
• Retention of urine and difficulty emptying the bladder. In these cases, the patient has so many problems urinating that he or she ends up retaining urine in the bladder during each urination, making it almost impossible to empty the bladder completely.
• Reduction in the size and strength of the urinary stream. As we mentioned, the prostate with prostatic hypertrophy squeezes the urethral duct, reducing the channel through which urine flows, which reduces the size of the urinary stream and even the force with which it comes out.
• Urine infections. Because of the difficulty in emptying the bladder completely, unvoided urine may encourage the development of urinary tract infections.
• Increased urinary frequency. Unable to empty the bladder completely, patients feel the need to urinate more often than normal, especially at night.
• Kidney problems and urinary bleeding. This is one of the most serious complications of benign prostatic hypertrophy and treatment with a urologist is vital.

Patients over the age of 50 are recommended to see a urologist every year for a check-up to detect possible prostate problems, both in terms of benign prostatic hypertrophy and prostate cancer. During the consultation, the urology specialist will perform a series of diagnostic tests to determine whether or not there is an enlarged prostate.

First of all, the surgeon will carry out the IPSS prostate symptom questionnaire. This questionnaire consists of a battery of questions about the patient's urination habits, which the doctor will use to determine whether there are signs of prostatic hypertrophy.

On the other hand, there is the quantification of prostate-specific antigen in the blood, or PSA. This antigen is produced by the prostate to dilute the semen and normally the amount that passes into the blood is very low. A high PSA level in the blood is an indication that there may be an increase in the size of the prostate, either due to prostatitis, prostatic hypertrophy or prostate cancer.

Next comes the well-known digital rectal examination. This diagnostic test is perhaps the most important as it allows the urologist to determine the health of the prostate by touch. With this test, the doctor is able to tell whether the growth of the prostate is abnormal and to differentiate whether this growth is benign, due to benign prostatic hypertrophy; malignant, due to prostate cancer; or due to infection. In addition, the doctor can detect the degree of prostatic hypertrophy by being able to detect the approximate size of the prostate. You can learn more about how to tell the difference by clicking on the following link: How to diagnose benign prostatic hypertrophy?

Digital rectal examination is the most important and effective diagnostic test for detecting prostatic hypertrophy and other prostate pathologies.

Finally, once the urologist has determined that the size of the patient's prostate is large and is causing problems in the patient's quality of life, a prostate ultrasound scan may be requested to determine the size of the prostate and thus determine what type of treatment is most advisable. Depending on the size of the prostate, a pharmacological treatment may be carried out to alleviate the symptoms or it may be necessary to perform a prostate operation. 

Prostate surgery can be performed using different techniques, which we explain in a couple of paragraphs below.

Grades of prostatic hypertrophy

As mentioned in the previous section, the urologist can determine the degree of prostatic hypertrophy by digital rectal examination, which will be confirmed by prostate ultrasound. The usual size of the prostate is 2 x 3 centimetres, with a volume of 20 cubic centimetres and the shape of a chestnut. Depending on the increase in size of the prostate we can differentiate between:

• Grade 1 prostatic hypertrophy: In this case, the size of the prostate has doubled, reaching up to 40 cc. In these cases and depending on each patient, it is possible to treat it with drugs if symptoms are present.
• Grade 2 prostatic hypertrophy: Grade 2 prostatic hypertrophy is considered in cases where the prostate is three times larger than normal.
• Grade 3 prostatic hypertrophy: Benign prostatic hypertrophy grade 3 is when the prostate is four times the usual size.
• Grade 4 prostatic hypertrophy: Finally, if the size of the patient's prostate is so large that the doctor cannot determine the limits of the prostate, it will be considered grade 4 prostatic hypertrophy.

Depending on the size of the prostate and the PSA levels in the blood, additional tests will be carried out, such as a biopsy if the PSA levels in the blood are very high, or some type of treatment will be recommended to the patient. Also, unless the patient has a high PSA level, if the patient has no symptoms or discomfort due to prostatic hypertrophy, no treatment will be necessary, just regular check-ups.

If the benign prostatic hypertrophy presents symptoms that diminish the patient's quality of life, the specialist may recommend pharmacological or surgical treatment.

Based on the size of the prostate, the symptoms suffered by the patient and the deterioration in quality of life caused by these symptoms, the urologist will recommend one or the other treatment. The two most commonly used types of treatment are explained below:

Pharmacological treatment for prostatic hypertrophy

Pharmacological treatment for benign prostatic hyperplasia is aimed solely at relieving the most bothersome symptoms such as irritation and obstruction. This treatment is mainly based on the use of anti-androgens and usually has good results in patients with prostates of a size of little more than 40 cc.

Initially the problem can be solved with medication, but over time the size of the prostate may continue to increase and reduce the effectiveness of this treatment. In these cases, the only solution to eliminate the problems of benign prostatic hypertrophy is prostate surgery.

Surgical treatments for prostatic hypertrophy

Benign prostatic hypertrophy is one of the most common diseases in men, with an estimated 500 million people worldwide suffering from it. This number will increase over the coming years due to the continuous increase in life expectancy, which is why there are numerous surgical techniques for the treatment of benign prostatic hyperplasia. 

The most relevant of these are described below:

Thulium laser prostate surgery

The thulium laser prostate surgery is the most modern and technologically advanced laser procedure currently available.

It consists of the introduction of a laser fibre through the urethra, with the help of a cystoscope, and the subsequent photovaporization of the prostatic adenoma (prostate tissue that has increased in size) allowing the size of the prostate to be reduced and alleviating the symptoms of prostatic hypertrophy.

The main advantage of this operation is the fact that the precision and power of the laser is greater than in its predecessor, the green laser, as well as in the vaporisation technique. Vaporisation of the prostate tissue consists of focusing the laser on the area to be removed by heating the intracellular water to temperatures of over 100 degrees causing it to evaporate along with the rest of the cellular material.

In addition, the heat that is lost to the areas adjacent to the evaporated tissue causes a haemostatic effect (cauterisation of a wound) that minimises intraoperative and postoperative bleeding.

This reduction in bleeding during the thulium laser prostatic hypertrophy surgery allows the patient to reduce the length of hospital stay and recovery time, while reducing possible complications such as urinary incontinence or erectile dysfunction. In order to learn more about this surgery visit the banner below.

Prostate surgery with urethral release (Urolift System)

The urethral release prostate surgery consists of the release of the urethral duct using the urolift system. This system consists of the urolift device and the urolift implants and the steps to be performed are as follows:

• The anaesthetist puts the patient to sleep under light sedation.
• The urologist then applies local anaesthetic to the urethra and introduces a cystoscope through the urethra (which has been previously dilated and lubricated) until it reaches the prostate. Once in the prostate area, the specialist inserts the urolift device through the cystoscope until it reaches the area of the prostatic obstruction.
• The next step is to exert light pressure with the tip of the device towards the side of the prostate and place the implant in the prostate, allowing part of the urethral duct to be freed.
• After this, the surgeon places several implants on each side (usually between 2 and 6, depending on the patient) until the urethral duct is completely free. One of the advantages of this procedure is that at the end the surgeon can immediately check whether the surgery has been successful or not using a flexible endoscope.
• After only 20 minutes of surgery, the patient will only have to wait a couple of hours until he/she is fully awake and will be able to leave the hospital on his/her own feet and will be able to urinate the same day, noticing an automatic relief of the symptoms, an improvement that reaches its peak 15 days after the surgery.

In addition to the short duration of the procedure, the immediate results, the lack of need for regional or general anaesthesia and the fact that it is ambulatory, one of the main advantages of this procedure is that as no tissue is damaged as in conventional operations, the chances of suffering urinary incontinence, erectile dysfunction or retrograde ejaculation are practically nil, being the only one that allows this.

Transurethral resection of the prostate (TURP) surgery

Transurethral resection of the prostate is the most widely used surgery for prostatic hypertrophy in history. This surgical intervention has very good long-term results, although there is a greater chance of complications, such as urinary incontinence or erectile dysfunction, than with modern laser surgeries.

TURP is also one of the most commonly used surgeries for the reduction of prostate size in patients with prostatic hypertrophy. This procedure is performed under regional or general anaesthesia, depending on the patient, and consists of the following:

• A lubricated cystoscope is inserted through the urethra until it reaches the prostate.
• An endoscope with a cutting instrument called a resectoscope and a light is inserted through the cystoscope orifice.
• Once in the prostate area, the surgeon cuts out bits of the prostate adenoma while sealing the blood vessels with small electric shocks from the resectoscope.
• After removing as much of the prostate as necessary, a catheter is placed in the bladder to allow urine to flow during the postoperative period.
• This procedure only takes between 30 and 60 minutes and the hospital stay is approximately 3 days.

Recovery after prostate surgery varies depending on the technique used to treat prostatic hypertrophy:

• Thulium laser: The hospital stay is reduced to a single day, although sometimes the patient can leave the hospital the same day. After this, the patient only has to spend 2 or 3 days at home without excessive physical exertion and can then return to normal daily activities and urinate without any problems. Sexual activities can be resumed from the second or third week post-operatively.
• Urethral release with urolift system: In this case, the patient leaves the hospital a couple of hours after the surgical intervention, can lead a normal life from the beginning and the improvement of symptoms is immediate. It is recommended to wait at least 2 weeks before resuming sexual activities.
• Transurethral resection: In this case, the hospital stay is 3 days and full recovery can vary from 3 to 6 weeks. Sexual intercourse should wait until 3 to 4 weeks after the surgery.