Health and Prostate

As we have already mentioned, many men with BPH don’t have symptoms or their symptoms can be managed with lifestyle changes. About half of men of any age who have benign prostatic hypertrophy will have symptoms that require attention and treatment that may involve taking one of the drugs we evaluate in this post. The percentage of men requiring treatment increases with age:

• One in four men in their late 50s can expect to have symptoms that are bothersome enough to seek medical attention or treatment;
• One in three men in their late 60s can expect to have symptoms that are bothersome enough for them to seek medical attention or treatment, and
• One in two men in their late 70s and beyond can expect to have symptoms bothersome enough to seek medical attention or treatment.

This means that millions of men are regularly taking drugs or using other treatment options to ease the symptoms of benign prostatic hypertrophy.

The first advice we’d give to any man bothered by problems when urinating is to see a doctor. Many men are reluctant to talk about urination problems with their doctor, but it’s important to get these issues evaluated as early as possible to prevent any complications that may be present, whether or not the patient is aware of them. It’s important to note that some men don’t notice any symptoms of BPH and their enlarged prostate is only discovered by their physician during a routine examination.

Getting a diagnosis

Doctors should regularly ask all men over age 50 about urination problems. But if you are experiencing problems, you should bring them to your physician’s attention even if he doesn’t specifically ask you about them.

It’s important to note that the size of your prostate does not always correlate with the severity of BPH symptoms. That is, some men with only slightly enlarged prostates can have quite bothersome symptoms, while others with substantially enlarged prostates may have few or no symptoms.

To gauge the severity of your symptoms, your doctor will likely ask you several questions about your urination problems (See Table 2). Those questions will include how often you feel the urge to go, how many times per night you wake up to use the restroom, and how much your urination problems affect the quality of your life. Your doctor will use your answers to these questions to determine how severe your problems are and the most appropriate treatment.

In addition, your doctor will also take your medical history, including whether you have any other conditions that may worsen your symptoms or that might affect your treatment options.

Your doctor might also perform a digital rectal exam (the insertion of a finger in the rectum to feel the prostate) to assess the firmness and size of your prostate. The American Cancer Society recommends that all men undergo a digital rectal exam starting at age 50 to screen for prostate cancer, but you should know that there is considerable disagreement about whether this procedure is useful and whether it should be performed at all. In fact, some medical organizations, including the American College of Preventive Medicine, do not recommend the digital rectal exam as a screening tool for prostate cancer. The procedure alone might not detect infection, kidney problems, or prostate cancer, or discern between a prostate that is enlarged due to benign prostatic hypertrophy or cancer.

Most likely your doctor will also do some simple tests to check for infection and make sure your kidneys are fine.

Your doctor should then discuss the blood test for prostate cancer, called the prostate-specific antigen, or PSA, test. There are pros and cons of administering this test, especially if you have any signs of infection. In that case your infection should be treated and further testing delayed.

It is important to understand the pros and cons before you have a PSA test. The test is not as accurate as we would like it to be. Although it was initially thought that elevated prostate-specific antigen levels indicated prostate cancer, in fact, many men with the cancer have low PSA levels, while those who do not have prostate cancer can have elevated prostate-specific antigen levels. Recent large-scale studies have shown that while prostate-specific antigen tests might detect prostate cancer early, this has little, if any, reduction on a man’s chances of dying from the disease. This is worrisome, because a positive PSA test can lead to more aggressive prostate-cancer treatments, which can have significant side effects, such as difficulty getting erections and trouble controlling urination. And as men grow older, especially over 75, detecting prostate cancer early is less important, since the cancer grows more slowly at older ages and often does not affect life span. The American Urological Association now recommends prostate-specific antigen testing for all men starting at age 40 who are in good health. But this is a controversial guidance that contradicts the recommendations of other organizations. Given these uncertainties, we advise the current recommendations from the U.S. Preventive Services Task Force, which are that doctors should discuss the benefits and risks of the PSA test and prostate-cancer treatment with men under the age of 75 before ordering the test. The task force also recommends against prostate-cancer screening for men over 75 because there is little, if any, benefit.

In some cases of urination problems, your doctor may want to do additional tests to establish the diagnosis. One is called a post-void residual volume test, which measures how much urine is left in the bladder after urinating. Ultrasound techniques can also be used to check the size and structure of the prostate.

Treatment options

If your doctor diagnoses BPH and you have only mild symptoms or they are not too bothersome, he or she is likely to suggest “watchful waiting” and some lifestyle adjustments. The term “watchful waiting” means that you won’t be offered any specific treatments, but that you and your doctor commit to closely monitoring your symptoms over time to see if they worsen. That may include keeping a diary of symptoms and urination patterns or problems.

Lifestyle adjustments aren’t a treatment per se but they have been shown to be highly effective at both reducing symptoms and improving one’s quality of life. Table 3 lists commonly used measures. They include going to the bathroom when you first feel the urge rather than waiting, and reducing or eliminating your intake of alcohol and caffeine. It’s also a good idea not to drink a lot of fluids in a short time-span or two hours before bedtime.

Getting regular exercise is promoted as helpful for reducing benign prostatic hypertrophy, but there’s no good evidence that this works consistently. Kegel exercises — contracting the muscles that regulate urine flow — are known to help build control over urination. While good evidence showing this improves urination problems due to BPH is lacking, it can be worth trying. If possible, you should avoid over-the-counter cold and sinus medications containing decongestants or antihista-mines, since those drugs can worsen the symptoms of prostate enlargement.

If you’re taking diuretic drugs, you should ask your doctor whether the dose can be reduced or if you can take a different medication, since either could improve your symptoms. Men with diabetes should work with their doctor to make sure their blood sugar levels are kept in control because if they aren’t, it can lead to increased urination.

If your symptoms don’t improve with lifestyle changes or if they worsen, medication is typically the next step.

Other treatments

Various herbal supplements are touted as a treatment for urination problems due to BPH. These include saw palmetto, beta-sitosterol, rye-grass pollen, and Pygeum africanum. Some studies have suggested that those herbs may be effective, but many of the studies were small and not well done. That makes the results unreliable. Also, most of the studies followed men for less than six months, so it’s not clear if the benefits of these products last longer than that.

We would urge caution in using any herbal supplements and advise you to discuss them with your doctor to make sure they are not interacting with any other medicines you take.

Surgery and other procedures

Surgery is typically reserved for men with complications, including recurrent blood in the urine, recurrent urinary-tract infections, kidney failure, and bladder stones. Surgery will likely be necessary if your benign prostatic hypertrophy becomes so bad that you cannot urinate at all. Surgery can also be an option for men who can’t take medications for other health reasons or in cases where prescription medications haven’t worked well.

A number of surgical procedures are used to reduce prostate enlargement and the associated symptoms. These techniques remove tissue from the prostate that may be blocking urine flow. Your doctor will review the risks and benefits of the different procedures if you need surgery.

There are also nonsurgical procedures, such as microwave therapy, that shrink or kill obstructing prostate tissue. Again, your doctor can give you more information about those options if they are right for your situation.