Enlarged Prostate & Prostate Cancer

A common part of aging in men is the enlargement of the prostate gland, frequently referred to as benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy. The prostate naturally grows as the man matures, however, the enlargement does not typically cause discomfort until later in life.

The prostate is located right below the bladder (as depicted below) while partially wrapping around the urethra. As the prostate enlarges, it applies pressure onto the bladder while constricting or narrowing the urethra, causing an obstruction of urine flow from the bladder through the urethra. Naturally, when any passageway is hindered, we apply more strength or force to push our object through. As we continue to use this energy, we begin to lose the strength we initially occupied and eventually require the same level of energy to apply on now much smaller objects. Gradually, the bladder becomes stronger and thicker, though making it less flexible and elastic; resulting in an over sensitive bladder that will contract when it contains just small amounts of urine causing you to urinate more frequently. The bladder is now working more often than it used to; in time, it is unable to overcome the effect of the restricted urethra becoming incapable of emptying out entirely (incomplete bladder emptying) and leaving behind urine (residual urine). The remaining urine leaves you at great risk for developing urinary tract infections, amongst other urological conditions.

• Weak or slow urinary stream
• Urinary Retention
• Incomplete Bladder Emptying
• Urinary Incontinence
• Urinary Frequency
• Urgency to urinate (strong and sudden)
• Nocturia (needing to urinate at night)
• Pain/burn with urination
• Hematuria (blood in the urine)
• Delayed start of urination

The following exams and tests are performed for diagnosis:

• **Digital Rectal Exam (DRE).  To feel the prostate gland.
• Uroflow.  Checks the urine flow rate.
• Urocuff.  Measures internal bladder pressure as you urinate.
• Bladder Scan.  Measures post-void residual (PVR) or how much urine is left in the bladder after urinating.
• **Transrectal Ultrasound of the Prostate (TRUS).  Small, lubricated probe placed into rectum to capture video and pictures of the prostate.
• Urinalysis.  Checks for blood and screens for bacteria (infection) in the urine.
• Urine Culture.  Indicates the type of bacteria growth and lists the antibiotics sensitive to it.
• **Prostate-Specific Antigen (PSA).   Blood test to screen for Prostate Cancer (see below for more information regarding correlation to Prostate Cancer).
• Cystoscopy.  Flexible catheter with camera inserted through the urethra into the bladder to check for any abnormalities within the bladder.
• Urodynamic Study (UDS).  Study that measures bladder capacity, flow rate and bladder muscles (essentially measures how your bladder functions or works).

Once diagnosed, choice of treatment is relative to the severity of symptoms and any contraindication of other medical conditions.

Natural Products:

• Saw Palmetto.  Recommended as an alternative to medication for symptom relief.

Medications:

• Alpha 1-blockers.  Relax the bladder neck muscle and prostate allowing for easier urination.
• Antibiotic.  Primarily used for chronic prostatitis (prostatic infection causing inflammation) which may not be linked to BPH, however, have been noted to aid in short term relief of BPH symptoms.

Surgery:

• Transurethral Microwave Thermotherapy (TUMT).  A catheter is inserted through the urethra where an antenna is extended to the prostate emitting microwaves.  The microwave energy heats up and destroys excess prostate tissue blocking urine flow.  Essentially, this procedure shrinks the prostate and increases the passageway allowing for easier urination.
• Greenlight Laser of the Prostate.  A minimally invasive therapy that vaporizes prostate tissue which is blocking the flow of urine from the bladder. It uses a unique high power laser energy which is selectively absorbed by blood within the prostate tissue which leads to vaporization and removal of the tissue, leading to an open channel for passage of urine.
• Transurethral Resection of the Prostate (TURP).  A surgical telescope is used to core out the inside of the prostate (surrounding the urethra) creating a larger channel making the passage of urine easier.
• Transurethral Needle Ablation (TUNA).  Using a cystoscope, tiny needles are placed into your prostate where radiowaves are then passed through the needles creating scar tissue. This tissue then shrinks the prostate tissue to create a larger urinary channel so the passage of urine is easier.

BPH is a non-cancerous enlargement of the prostate that does not result in Prostate Cancer. The tumor causes the prostate gland to swell or enlarge, thus, the symptoms for Prostate Cancer are parallel to those of BPH.  Due to the similarities, when a patient arrives to the office with the above symptoms, further testing is performed to rule out the possibility of malignancy.

Along with the symptoms listed for BPH, below is a list of further symptoms related to Prostate Cancer but not direct indications:

• Hematospermia (blood in the semen)
• Painful or burning sensation during urination or ejaculation

As mentioned, BPH and Prostate Cancer symptoms are parallel. When a patient’s primary complaint involves any of the symptoms mentioned under BPH, the workup includes tests to rule out malignancy:

• **Digital Rectal Exam (DRE).  Check for any abnormalities in the texture, shape or size by feeling the prostate gland.
• **Prostate-Specific Antigen (PSA).  Measures the antigen levels produced by the prostate.  Small amounts are usually secreted into the blood stream; however, the secretion of larger amounts indicates that the gland is enlarged, infected, or malignant.
• **Transrectal Ultrasound of the Prostate (TRUS).  A small, lubricated probe placed into rectum to capture video and pictures of the prostate. Checks for any abnormalities not detected by a DRE as well as estimates the size of the gland.  This aids us in finding the patient’s PSA density which helps strongly distinguish between BPH from Prostate Cancer. If PSAD indicates prostate cancer, the patient will undergo a Prostate Needle Biopsy.
• Prostate Needle Biopsy.  In-office surgical procedure in which several small samples of tissue are removed from the prostate and examined by a pathologist for malignancy.

• Cyberknife.  A robotic radio-surgery system, which is used to treat a variety of benign and malignant tumors. It is composed of a compact linear accelerator (a source of radiation), which is mounted on a computer-controlled arm. The CyberKnifeSystem uses real-time continuous image guidance during each treatment session. It delivers multiple beams of high-energy radiation to the tumor from many different directions, and constantly adjusts for any movement of the target organ. The net result is a high dose of radiation delivered to the cancer, in the most precise way currently possible. Radiation treatments are accurately delivered to the prostate and a small amount of tissue surrounding the prostate, minimizing the amount of radiation received by sensitive nearby structures (such as the bladder, rectum, and penis).

• Radioactive Seed Implantation. Also known as prostate seed implantation or radioactive seed implantation involves placing tiny radioactive pellets (“seeds”) directly inside the prostate tumor. Low-dose seeds are implanted permanently and give off radiation for several months before losing their radioactivity. High-dose, or high-energy, seeds are implanted for less than a day and deliver a concentrated dose of radiation to the tumor.

• Robotic Prostatectomy.  Robotic prostatectomy, also known as robot-assisted laparoscopic prostatectomy, is the most advanced treatment option for patients who are candidates for surgery. Operating through five or six tiny holes in the abdomen, surgeons remove the cancerous tissue while preserving the vital nerves and arteries that control bladder and sexual function. This nerve sparing prostatectomy approach helps men retain their urinary control and sexual function.

• Hormone Therapy.  Hormone therapy is designed to reduce the levels of the male hormones (androgens) that fuel the growth of prostate cancer cells. Doctors reduce hormone levels by using drugs that lower or suppress testosterone levels.

• Watchful waiting.  Observation and monitoring of cancer without immediate active treatment.