Enlarged Prostate Gland

Prostate Gland Enlargement

PKGhatak,MD

Prostate gland enlargement is due to excessive growth of normal prostate tissue. It is a common problem in elderly men. About 90% of elderly over 80 years of age will have some degree of prostatic enlargement. In the same population cancer of the prostate gland is also common.

Some doctors are gentle with patients when examining the prostate. Your gentle doctor will ask you to lie on your side on the examination table, ask you to pull your knees to your chest. Then he will put on a pair of gloves, gently insert a finger in your anal canal and feel the prostate gland. You may be embarrassed but will not feel any pain. Others are rough, ask you to drop your pants and bend over the examination table and then insert a gloved finger and do the examination. It is not only a crude way to examine but very much unnecessary. Ask for a gentle prostate examination when you go for an examination next time.

Why prostate enlarges:

It grows in proportion to the general growth since birth. At puberty, it grows rapidly and then returns to the usual growth pattern until men reach age 45. Then it starts to grow again. The reason for the second growth is not precisely known. It is postulated that when the blood levels of testosterone begin to fall at age 45, the gland begins to grow again. Others have suggested that the blood levels of testosterone might be below but in the prostate tissue the concentration of Dihydrotestosterone (DHT), derived from testosterone, a more potent agent for prostate growth, remains high and that causes prostate enlargement.

Cancer of the prostate is another cause of prostate enlargement.

Symptoms of Prostate enlargement or Benign Prostatic Hyperplasia (BPH):

Going to the toilet frequently, getting up at night multiple times to go to the toilet, cannot wait when has to go and then wetting underpants, feeling that the bladder did not empty fully, having difficulty in initiating urination, standing too long for starting urination, urine comes in drips and drops, blood in urine and painful urination from infection are symptoms of BPH

Cancer of the prostate usually produces the same symptoms and the two conditions may present at the same time.

How doctors know an enlargement is cancer:

There are no symptoms that are specific to cancer, but fresh blood in the urine and pain and discomfort in the genital area are more common in cancer.

Going to the doctor:

After an examination, the doctor may say the gland is not only large but hard and has lumps. But that is not diagnostic of cancer. A blood test – PSA level may be elevated but that is not enough. An ultrasound test through the rectum may show the irregular pattern of growth and nodules in the gland. But ultrasound test is not diagnostic either. An MRI of the prostate provides better information. A needle biopsy of the prostate is necessary for the diagnosis of cancer.

PSA test:

A protein secreted by the prostate cells known as Prostate Specific Antigen (PSA), is present in blood in free and bound forms.

The PSA test was introduced as a surveillance tool for detecting the recurrence of cancer in patients treated successfully. PSA levels fall to zero and remain zero following cancer treatment; the reappearance of PSA in the blood is an indication of cancer recurrence. Subsequently, it was used as a screening tool for prostate cancer. Later studies showed many patients were unnecessarily subjected to prostate biopsies and treatment on the basis of elevated levels of PSA. PSA is present in blood in free and bound forms. When total PSA is over the normal limits - 25 % or more of free PSA in relation to total PSA is associated with a low probability of cancer; whereas, a 10% or lower ratio of free PSA/ bound PSA is considered as positive for cancer. A rising level of PSA over time, a high ratio of PSA in relation to the prostate volume, and a sharp rise in the level over the previous year were considered as the presence of cancer. But none of these tests are not full proof, both false positive and false negative results are common.

A normal level of PSA is age specific. Blood levels of  2 to 4 ng/ml are generally accepted as normal for people between 45 and 79 years of age. For people 80 or over, a level up to 5.5 ng/ml is taken as normal.

At present, a routine PSA test for people over 80 years of age is not recommended.

Besides BPH and cancer, other causes of elevated PSA levels are - prostate infection, injury to the prostate, prostate examination, recent sexual activities, and urinary tract infection.

Prostate Biopsy:

The prostate gland is accessed through the wall of the rectum. Local or general anesthesia is used. It is still a painful procedure. 6 to 12 pieces of tissue are obtained during the biopsy. Prostate cancer grows at different rates at different sites and varies in the degree of abnormality from one side to the other, that is why multiple tissue samples are taken from different sites.

Based on the degree of abnormality of cells and the distortion of architecture of the glands, when examined under a microscope, a biopsy report is given a score from 2 to 10 on the Gleason score. A score of 10, being the most aggressive, and a core of 2 is atypical growth but not cancer.

 All 12 biopsy samples are individually assessed and graded on a 1 to 5 scale based on the degree of cancerous changes and architectural distortions. Only two samples with the highest grade are selected and reported and this is the basis of reporting on Gleason's score.

Like the interpretation of PSA tests, the prostate biopsy reports and interpretations are confusing. Quite often, Pathologists disagree among themselves when examining the same tissue sample.

If digital examination of the prostate gland, PSA, and ultrasound are indicative of a low chance of cancer, the doctor may recommend regular follow up with PSA tests before suggesting a biopsy or on the other hand, if the possibility of cancer is high then a biopsy will be recommended.

For treatment of BPH, the doctor may prescribe one of the two types of medications: 

One that decreases the frequency of urination and urgency:

They are called alpha-blockers. Urinary bladder contracts in response to alpha stimulation of the sympathetic nervous system. The neck of the bladder is rich in alpha receptors and alpha blockers block receptors and thereby interfere with bladder contraction and help relaxation of the bladder.

The other group of drugs is called 5- alpha reductase inhibitors.
These drugs block the action of 5-alpha reductase on testosterone and prevent the formation of Dihydrotestosterone (DHT), thus preventing prostate cell proliferation and gland growth. And when used on a long term it actually reduces cell volume and prostate size.

A combination of these two groups of drugs is available as tablets and is often prescribed.

Complications and surgery:

Common complications are- infection of urine and the prostate, acute urinary retention and backpressure in the bladder leading to a decrease in renal function.

Infections of the prostate and urinary bladder are treated with antibiotics and are followed by preventive therapy that includes surgery of the prostate.
Acute retention is relieved by inserting a catheter into the urinary bladder and may require to drain the bladder for a prolonged period by Foley catheters.

To relieve obstruction at the bladder neck by the enlarged prostate, the extra gland tissue is shaved off by instruments inserted through the urinary passage. The procedure is called Transurethral Resection of the Prostate (TURP), a modified version is called Transurethral Incision of the Prostate (TUIP), and by Open Prostatectomy

Other modalities like Laser, Radiofrequency Ablation, Microwave, Hyperthermia are also used. Still, other methods are in the developmental stages.

Health food stores sell herbal products claiming these promote “prostate health” and prevent BPH. It may be true for some of these products but the potency of these pills varies according to country of origin, seasonal variation of plant growth producing a different concentration of active ingredients and may be contaminated with pesticides. There are no federal regulations certifying the safety of these products.

Other tests and procedures at the time of evaluating BPH are:

Cystoscopy of the urinary bladder, MRI. IVP, urinalysis, urine culture, cystometrogram, and urodynamic profile, etc. are not required to make a diagnosis of BPH but to detect associated complications.

It is important to note: BPH does not cause cancer, but cancer may coexist with an enlarged gland.

 

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