Miss Kate Warren
Consultant Urological Surgeon, Bristol Urological Institute, Southmead Hospital
Benign prostate enlargement is a normal condition of growing old for most men, with half of over 60s expected to suffer from symptoms such as poor flow and more frequent urination.
Symptoms such as difficulty starting to urinate, not emptying fully or frequently going to the toilet in the day or night are all signs of possible benign prostate enlargement (BPE). This is a normal physiological process, which may not always occur with symptoms.
An enlarged prostate can be indicated by bladder problems
The prostate sits around the urethra at the base of the bladder; its function is to contribute to secretions in the ejaculate, but this gland can enlarge as men get older. This can result in slowing of urinary flow and it being increasingly hard to empty the bladder.
For most men, this results in bothersome urinary symptoms such as taking a long time to wee and needing to go more frequently and during the night. For a small proportion of patients, the failure to empty the bladder properly can result in urinary tract infections, bladder stones or potentially reduction in kidney function if the pressure in the bladder rises.
Men generally present to their GP if their symptoms are irritating them or if they are concerned about prostate cancer. The GP would review the patient’s symptoms and examine them, as well as sending off a blood test (prostate specific antigen) before referring on a fast track pathway if there was a concern about prostate cancer. For those patients with symptoms consistent with benign prostatic enlargement, patients would be offered lifestyle and drug medications to help improve their flow.
Treatment options for those with BPE
Men whose symptoms do not improve with medication alone may be offered surgery on their prostate. The most common procedure performed is a transurethral resection of the prostate (TURP) procedure.
Miss Kate Warren is a consultant urological surgeon at Bristol Urological Institute, Southmead Hospital. She explains: “There are a number of options to relieve bladder outflow obstruction caused by benign prostatic enlargement – a TURP is where you resect the central part of the prostate to relieve the obstruction. This was an alternative to removing the whole prostate as an open procedure, which used to be the standard treatment. More recently, there have been other procedures developed to treat BPE – bipolar TURP (PLASMA), prostatic artery embolisation, Urolift, Holep and rezum steam treatment. Each patient should be offered alternatives and be counselled about the risks and benefits to them of each treatment.”
Bipolar TURP uses irrigation fluid, which is isotonic to the body’s fluids, meaning there is less risk of absorbing hypotonic fluids, which used to cause a condition called TUR syndrome. It also allows better coagulation of vessels so the risk of bleeding and needing a urinary catheter for a prolonged period of time is reduced.
Miss Warren adds: “The prostate is a vascular structure and the risk of bleeding used to keep patients in hospital for a couple of days after the operation. With the PLASMA system, the risk of bleeding is much less, so patients can often go home on the day of surgery. This currently is desirable considering the ongoing coronavirus pandemic; ensuring patients are in elective hospital settings for the shortest time possible.”
How successful is the procedure? Most symptoms of poor flow will improve in the vast majority of patients. Around 2-10% of patients may still not empty their bladder fully, rely on a catheter or have to self-catheterise. There is also a small risk of incontinence (approximately 2-10%).
What is the risk of erectile dysfunction? Most men experience retrograde ejaculation after a TURP, where the semen goes back into their bladder instead of going forward, and may alter the sensation of orgasm. This isn’t harmful and the semen will mix with urine to empty naturally. The risk of reduced quality erections would be around 2-10%.