Enlarged Prostate

The prostate is a small gland, usually about the size of a walnut, that is situated just below the bladder and above the penis. 1 The urethra passes through the prostate, which produces fluid that is mixed with sperm to create semen. When the prostate enlarges, it places pressure on the bladder and the urethra, which can cause urinary problems.

The prostate is a small gland, usually about the size of a walnut, that is situated just below the bladder and above the penis. 1 The urethra passes through the prostate, which produces fluid that is mixed with sperm to create semen. When the prostate enlarges, it places pressure on the bladder and the urethra, which can cause urinary problems.

The prostate is made up of four zones: 2

1. Peripheral zone. The area most easily felt during the standard digital rectal exam and the zone from which prostate cancer tends to develop.
2. Transition zone. This surrounds the part of the urethra that passes through the prostate. It enlarges as men age, causing benign prostatic hyperplasia and consequent urinary symptoms.
3. Central zone
4. Anterior fibromuscular stroma

The prostate can become enlarged for a variety of reasons. The most common are: 3

• Prostatitis. Inflammation of the prostate that can occur in men of any age. There are several types of prostatitis, including infectious acute or chronic bacterial prostatitis, nonbacterial prostatitis, also known as chronic pelvic pain syndrome (CPPS), and asymptomatic inflammatory prostatitis in which an affected person will not show any symptoms.
• Benign prostate hyperplasia (BPH). Benign prostate hyperplasia is a benign, non-cancerous enlargement of the prostate, usually found in men older than 50 years of age. ‘Hyperplasia’ means that the number of cells increases.
• Prostate cancer. Cancer of the prostate, mostly originating in the peripheral zone. Prostate cancer can spread to other areas of the body.

Because the prostate is positioned so close to the bladder, penis and rectum, most disorders which cause enlargement of the prostate share several basic symptoms. These include: 1 3 4 5 6

• An urgent, at times uncontrollable, need to urinate, which may lead to incontinence if the person can’t make it to the bathroom in time
• Trouble urinating
• Frequent urination
• Urinary hesitancy, i.e. slow start till urine streams out
• Weak flow of urine
• Frequent need to urinate at night, known as nocturia
• Intermittent flow, i.e. stopping and starting
• Leaking or dribbling urine

In addition, prostatitis may also have some or all of the following symptoms: 7

• Hematuria (blood in the urine) or blood in semen
• Pain in the penis and testicles
• Burning or painful sensation during urination
• Painful or difficult ejaculation
• Urethral discharge
• Pain and/or pressure in the rectum
• Painful defecation (painful bowel movements)
• Discomfort and/or pain in the genitals, groin, lower back and/or lower abdomen
• Recurring urinary tract infections (UTIs)
• Sexual problems and loss of sex drive
• Postcoital pain (pain after having sex)

In the case of prostate cancer, there may be no immediate symptoms, or there may be urinary symptoms like those listed above. In addition, there may be symptoms such as:

• Hematuria (blood in the urine) or blood in semen
• New onset of erectile dysfunction
• Back, especially lower back, hip, or pelvic pain
• Unexplained weight loss

A variety of different conditions and biological processes can cause the prostate to become enlarged. These include:

Prostatitis is the painful inflammation of the prostate and can affect men of any age. There are several types of prostatitis: 8

• Bacterial prostatitis
• Acute bacterial prostatitis
• Nonbacterial prostatitis, also known as chronic pelvic pain syndrome
• Asymptomatic inflammatory prostatitis

Bacterial prostatitis, the most common type of prostatitis, can affect all adult men and sometimes accompanies recurring urinary tract infections. 9 It can occur when bacteria from the bowel transfer to the skin, to the urethra and then up into the urinary tract. Another cause is urinary retention, caused by an enlarged prostate, bladder or kidney stones, causing a urinary tract infection that then spreads to the prostate.

Factors that put individuals at risk of prostatitis, other than UTIs, include prostate surgery or any complications of prostate surgery, catheterisation (using a thin, flexible tube called a catheter to drain urine from the bladder, e.g. when healing after surgery), and infections spreading from other parts of the body. For prostatitis to be considered chronic, symptoms have to recur for at least three months. Recurrence is possible because the prostate can harbor infection. Symptoms can come and go. Chronic prostatitis tends not to cause fevers.

Acute prostatitis is caused by infection and manifests with chills, fever and muscle pain, in addition to the multitude of urinary symptoms mentioned above, often along with cloudy-appearing urine. It often causes intense/severe abdominal and/or pelvic pain. It is relatively rare compared to chronic prostatitis, but must be treated promptly. Complications can include developing a prostate abscess and also urinary retention, where the patient is unable to pass urine due to pain, and which requires catheterisation. A prostate abscess requires surgical intervention. 8

Nonbacterial prostatitis or chronic pelvic pain syndrome can cause persistent discomfort and/or pain in the lower pelvic region, mainly around the anus and the base of the penis. The causes of CPPS are not well understood and may involve autoimmune responses, nerve problems, inflammation, or another, yet unidentified cause.

In asymptomatic inflammatory prostatitis, there are no symptoms. The condition is usually diagnosed in the course of a prostate examination for other conditions or as part of a urologic routine check-up. It can cause elevated PSA-values - this is an enzyme produced by the prostate, often looked at during routine urologic check-ups of men over 50 and which can be detected in the blood.

Prostatitis is not a sexually-transmitted infection, although it can be caused by one. Prostatitis itself cannot be passed on via sexual activity, but sexually-transmitted infections that cause prostatitis can be.

Prostatitis is not prostate cancer, and there is currently no evidence to suggest that getting prostatitis increases the risk of prostate cancer. 8

Benign prostatic hyperplasia is a common problem affecting men over the age of 40. By the time men turn 50 or older, an average of 40 percent have BPH to some degree. In BPH, the transition zone of the prostate enlarges, constricting the urethra, hindering, in some cases, the bladder’s ability to empty by throttling the flow of urine, which would normally move through the urethra and out of the bladder.

Benign prostatic hyperplasia is not cancer, but it can affect a person’s quality of life due to the urinary problems it causes, especially the increased need to urinate at night, which disrupts sleep.

If left untreated, BPH can cause complications such as kidney damage, urinary retention (the bladder not fully emptying anymore), bladder or kidney stones and urinary tract infections (UTIs), all due to disrupted urination. As it is largely an age-related disorder, BPH can worsen as it progresses if left unaddressed.

This is the second most common kind of cancer affecting men, after skin cancer. Men who are at particular risk are:

• Men older than 50 years of age
• Men with a family history of prostate cancer
• Men affected by obesity and/or who consume a diet high in animal fat
• Men of African descent, e.g. African-American men

Prostate cancer can remain in the prostate and spread to closely located surrounding areas/tissues of the body - this is known as locally advanced prostate cancer; or it may spread to other parts of the body - this is known as advanced prostate cancer or metastatic prostate cancer.

Prostate cancer has a good survival rate. This is because it progresses slowly and may be found and treated before it has a chance to spread too far and become life-limiting.

In order to establish the possible underlying causes for an enlarged prostate, doctors will perform a variety of tests.

Tests which are commonly used to find the cause of an enlarged prostate include:

• A digital rectal exam. A physician or nurse will insert a gloved finger into the patient’s rectum to digitally examine the prostate for swelling and/or enlargement.
• Swab tests for urethral discharge or urine. To determine underlying conditions such as STIs/STDs (sexually transmitted infections/diseases) and urinary tract infections. A swab of discharge or urine is taken and sent to a medical laboratory for culturing, so that any microorganisms are identified.
• Urinalysis. A urine sample is sent to a medical laboratory for analysis and may be tested for urea nitrogen or creatinine, among other things.
• Blood tests. A sample of blood is sent to a medical laboratory for analysis, which may include tests for creatinine or blood urea nitrogen, as well as antibodies and infectious agents.
• Prostate-specific antigen test. A blood sample is sent to a medical laboratory to be tested for prostate-specific antigen (PSA), an enzyme produced by cells in the prostate. A change in PSA levels can indicate that there is a problem with the prostate.

If patients are referred to a urologist, they may have further tests, including:

• Ultrasounds to check the kidneys, the amount of urine left in bladder and the prostate itself.
• Urine flow studies, which involve urinating into a specialised device that measures the speed/rate of urine flow. A flow that is slower than normal may indicate an enlarged prostate.
• A cystoscopy, in which a tiny camera is threaded up the urethra at the end of the very thin, flexible tube. This can pick up damage, inflammation or changes in the bladder and is usually done if there are symptoms such as blood in the urine, painful urination, or a urinary tract infection.
• Bladder pressure (urodynamic) tests, in which tube sensors are placed in the bladder and sometimes also the rectum to measure pressure in the urethra, bladder and possibly rectum. An enlarged prostate can cause pressure in any of those places to increase, because it presses on the bladder and rectum.
• The International Prostate Symptom Score, a questionnaire formulated to determine the severity and duration of prostate symptoms.

Before referring the patient for tests, the physician may also ask questions in order to determine the possible causes of the discomfort, their severity, and their duration. Such questions may cover:

• Medications used, prescribed and over-the-counter medication
• Other medical conditions, such as diabetes
• Medical conditions in other family members
• Lifestyle and diet
• Existing symptoms: their duration, whether they are getting worse and how they are affecting quality of life.

Treatment for an enlarged prostate will depend on the condition which has caused the prostate to enlarge. No one treatment is best for every patient, and there are a number of treatment options available. Some may be as minor as lifestyle changes, and others may involve a hospital stay and surgery.

Treatment for prostatitis includes:

• Antibiotics to kill the infectious agent
• Alpha-blockers, which relax the muscles near the prostate and relieve pressure on the urethra
• Other medications, such as finasteride or quercetin
• Muscle relaxants
• Painkillers to manage general discomfort/pain
• Laxatives to manage bowel discomfort caused by constipation

In rare cases, prostatectomy (prostate surgery) may be necessary. Read more about Prostatectomy »

Treatment for benign prostate hyperplasia can involve: 10 11

• Lifestyle changes, such as limiting a night-time consumption of liquids, avoiding caffeine and alcohol, avoiding medication such as diuretics, decongestants and antihistamines and getting more exercise, as well as dietary improvements, such as eating more fibre, avoiding artificial sweeteners and sweetened beverages.
• Medication, such as alpha-blockers or 5-alpha-reductase inhibitors.
• Interventions, such as the Urolift](https://urolift.com/urolift-system/)® system, a non-surgical proprietary device that uses tiny implants to lift the prostate away from the urethra and thereby relieve BPH symptoms that result from pressure on the urethra. 12
• Surgical procedures, such as a prostatectomy (removal of the prostate), transurethral microwave thermotherapy (TUMT) (using heat/microwaves), 13 14 prostate laser, and Transurethral Resection of the Prostate (TURP).
• Herbal prostate treatments, such as saw palmetto extract. Saw palmetto extract is made from the fruit of the saw palmetto, which is native to the southeast and Gulf coasts of North America and may potentially assist in reducing urinary frequency and increasing urinary flow.

Treatment of prostate cancer can involve: 15 16 17 18

• Prostatectomy. The surgical removal of all or part of the prostate gland, which can be done as open surgery or laparoscopically (keyhole surgery). There are several different types of prostatectomy.
• External beam radiotherapy. This involves x-ray beams, which are focused on the prostate to destroy cancer cells. This is a non-surgical option.
• Permanent seed brachytherapy. This involves implanting small radioactive pellets into the prostate gland to destroy cancer cells.
• Hormone therapy. This may be used instead of radiation therapy or if the cancer has spread too far to be susceptible to prostatectomy or radiation treatment; it involves orchiectomy (surgical castration) and/or various treatments to lower androgen levels (chemical castration). 19
• Cryotherapy. This is an option for cases where the cancer is still within the prostate or is locally advanced. It is non-invasive and involves the insertion of cryotherapy needles into the prostate, through which a certain gas is then passed in order to freeze the tissue and thereby also ideally killing the cancer cells. 20
• Focused ultrasound therapy. This is a non-invasive method of treating prostate cancer using focused beams of ultrasound energy to heat and destroy cancer locations in the prostate. 21

Q: Can an enlarged prostate affect my sexual function?
A: Whether or not an enlarged prostate affects sexual function depends on the underlying cause.

Prostatitis can cause erectile dysfunction because of pain. 22 It can also result in painful ejaculation, which can lead to problems with sexual pleasure and indirectly cause problems with sexual function. 23 This is likely to be temporary, and matters will improve along with the condition.

Benign prostatic hyperplasia itself does not cause erectile dysfunction, but some treatments for it, for example the drug finasteride, can. However, there are other drugs available, such as terazosin, tamsulosin and doxazosin, that are less likely to cause this side effect. Likewise, Transurethral Resection of the Prostate (TURP) can cause erectile dysfunction in some men.

Prostate cancer can cause problems such as erectile dysfunction, and if there is a sudden onset of such problems where no problems have existed before, a physician should be consulted. Some treatments for prostate cancer can affect sexual performance, e.g. by causing erectile dysfunction, due to the side-effects of hormone therapy, damage to erectile tissue resulting from radiation or brachytherapy or severed nerves and muscles after prostate surgery.

Q: Can an enlarged prostate affect my fertility?
A: Prostate problems, such as those resulting from pain and prostate cancer treatments, can lead to problems with getting and maintaining an erection and with ejaculation, which then affects successful conception.

However, any very enlarged prostate may also cause problems with sperm transport. If the prostate is enlarged, it can press on the ejaculatory ducts and prevent the adequate formulation of semen. 24

Treatments for prostate cancer, especially radiation treatment and hormone treatment, can affect male fertility, owing to their effects on sperm production. Prostatectomy, when it involves the removal of the entire prostate and seminal vesicles, can render men unable to ejaculate. Radiation treatment causes a decline in sperm production and/or sperm quality, and the same is true of many chemotherapy treatments.

Inflammation of the prostate (prostatitis) can affect sperm motility, i.e. the way sperms move around, and fertility problems might result. Inflammation of the prostate can also cause bladder problems that lead to retrograde ejaculation, which is when semen enters the bladder rather than leaving the body. 25