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Prostate disease

NHS Direct Online Health Encyclopaedia

Introduction
The prostate gland is roughly the size and shape of a walnut and lies immediately under the bladder, surrounding the first two or three centimetres of the urine outlet tube (the urethra) in males. The front of the wall of the rectum is immediately behind the prostate, so it can easily be felt in the course of a rectal examination.

The function of the prostate gland is uncertain. It secretes a thin, milky, slightly alkaline fluid that constitutes about 10% of the seminal fluid, and makes the sperm more active. The fluid contains various substances such as citric acid, zinc, acid phosphatase and prostaglandins, but the need for most of these substances in this location is not known.

The prostate gland is involved in three main conditions prostatitis, benign enlargement and prostate cancer.

The effects of prostate enlargement usually begin to appear about the age of 55. About a quarter of men over 65 have moderate to severe symptoms from this cause.

Prostate enlargement is both a hyperplasia and a hypertrophy. In hyperplasia there is an actual increase in the number of cells in the organ. Hypertrophy means that cells themselves have got bigger. In benign enlargement the connective tissue and gland cells increase in number (hyperplasia) and the smooth muscle cells enlarge (hypertrophy).

The most important enlargement occurs mainly in the part of the gland surrounding the urethra, so that its effect is to compress and narrow the tube. As the gland gets bigger, the volume and force of the urine stream is reduced, so that it takes longer to empty the bladder.

In addition, the force required to push out the urine increases steadily. Eventually a point is reached at which the muscular wall of the bladder is not strong enough to achieve complete emptying. Because some urine is always left in the bladder, it means that it fills up again more quickly.

Bacterial prostatitis is an inflammation of the prostate gland. The inflammation can be severe and happen at once (acute prostatitis), or less severe, but never quite clear up (chronic prostatitis). Symptoms include pain, mainly at the base of the penis and around the anus.

Non-bacterial prostatitis, sometimes-called Chronic pelvic pain syndrome (CPPS) causes ongoing pain in the lower pelvic region. The cause is unknown.

Symptoms
Prostate enlargement produces a range of signs and symptoms. These include:

slowness and difficulty in starting to urinate (hesitancy),
dribbling or a poor urine stream,
sudden strong desire to urinate (urgency),
leakage associated with this (urge incontinence),
a feeling of incomplete emptying owing to residual urine in the bladder,
inability to empty the bladder (acute or chronic urinary retention),
excessive number of visits to the toilet (frequency), and
getting up at night to urinate (nocturia).
Symptoms of bacterial prostatitis include:

pain felt mainly at the base of the penis and around the anus and lower back. Pain may spread to the penis and testes,
symptoms of a urine infection - pain on passing urine, frequency, urgency and, sometimes, blood in the urine,
fever and general aches and pains, and
a slight discharge from the penis
Symptoms of non-bacterial prostatitis include:

pain or discomfort at the base of the penis and around the anus. Ejaculation may be painful. The pain may vary in severity and lasts for several months,
mild urinary urgency, poor urinary stream and mild pain on passing urine, and
general tiredness with aches and pains.
Prostate cancer (see Prostate cancer) is the second most common cancer in men. Symptoms are similar to those of prostate enlargement, and on rectal examination the gland is felt to be very hard and irregular. There may even be indications that the tumour has already spread to other parts of the body, often to the bones.

Causes
Bacterial prostatitis is caused by bacterial infection. The cause of non-bacterial prostatitis is unknown.

The causes of benign enlargement and prostate cancer are also not clear.

Diagnosis
Prostate enlargement is confirmed by a rectal examination with a finger. Enlargement of the prostate gland is usually a benign condition, but is sometimes due to cancer, so this should be checked by a doctor.

Rectal examination reveals any enlargement of the prostate gland. The enlargement may be smooth and even, or it may be rough and irregular. Smooth enlargement suggests benign hyperplasia; roughness and irregularity suggest the possibility of cancer.

An important diagnostic test for prostate enlargement is the prostate-specific antigen (PSA) test. The prostate-specific antigen is an enzyme produced by the lining (epithelial) cells of the prostate gland.

The amounts produced are proportional to the size of the gland, whether this is increased benignly or by prostate cancer. Small quantities of PSA enter the bloodstream and their levels can be accurately measured.

Raised levels imply an increase in the bulk of prostate tissue. High levels do not necessarily imply cancer, but indicate the need for a fuller investigation.

The rate of urine can be measured. This is a useful guide to the actual degree of urethral compression. A maximum flow rate of less than 10ml per second, for a total of about 200ml, suggests that the outflow is obstructed.

Ultrasound examination can show the size of the prostate gland, the presence of residual urine after a full urination, abnormal widening of the urethra and the kidney outlets, indicating backpressure and the presence of bladder stones.

Bacterial prostatitis is diagnosed by a rectal examination, which reveals the acute tenderness of the gland. Pressure on the prostate may cause a discharge of pus from the penis.

A urine sample will detect bacteria after the prostate has been gently massaged.

Non- bacterial prostatitis will not show test abnormalities, however the above tests may be done to rule out other conditions.

Treatment
In benign prostate enlargement, if symptoms are mild to moderate then no treatment and watchful waiting may be the best option.

Medication does not cure the problem, although it might help to ease some of the problems:

Alpha-blockers these relax the muscle tissue of the prostate and the outlet of the bladder.
Finasteride - blocks the conversion of the hormone testosterone to dihydrotestosterone in the prostate.
Surgical treatment involves part or complete removal of the gland.This is most commonly done through the urethra, using a special viewing and cutting instrument called a resectoscope.

The procedure is called a trans-urethral resection of prostate, or TURP. This operation gives good improvement in symptoms in most cases. If the enlargement is considerable, a direct surgical approach through the lower part of the wall of the abdomen and the wall of the bladder may be necessary.

There are various alternatives to TURP.

The urethral part of the gland can be stretched with a balloon catheter.
The gland can be treated with Cryotherapy (freezing), a microwave heat method, or a laser.
Bladder neck incisions can be made in the bladder neck to reduce the outflow resistance.
A permanent widening device called a stent can be inserted.
To date, TURP still appears to be the most reliable form of surgery. A simpler alternative is intermittent catheterisation. This relieves the obstruction to the flow of urine by passing a urinary catheter to empty the bladder. Men with urinary-outflow difficulties can be trained to perform the procedure themselves.

In an emergency, when prostate enlargement has completely blocked urinary outflow, a procedure known as suprapubic catheterisation may be necessary. Suprapubic catheters are inserted directly into the bladder through an incision in the lower abdomen.

Treatments for bacterial prostatitis are:

Antibiotics - a 4-6 week course is needed. The bacteria present can be identified from the urine test so the most suitable antibiotic can be used.
Painkillers- Paracetamol or ibuprofen to ease the pain and reduce fever. Stronger painkillers are sometimes needed.
Treatments for non- bacterial prostatitis are:

Painkillers - paracetamol or ibuprofen to ease the pain
Antibiotics - a 4-6 week course of antibiotics may be advised. To be sure that no infection is present even though urine tests for infection are negative.
Complications
In benign prostate enlargement:

Sometimes acute retention occurs where there is a sudden total blockage of urine. Emergency treatment is needed.
Sometimes chronic retention occurs where there is partial emptying of the bladder. Some urine remains in the bladder all the time, this may lead to recurring urine infections or incontinence.
References
Health Technology Assessment 1997; Vol. 1: No. 2 Diagnosis, management and screening of early localised prostate cancer. Selley S et al. http://www.ncchta.org/execsumm/summ103.htm

Maximal androgen blockade for advanced prostate cancer (Cochrane Review) Schmitt B, Bennett C, Seidenfeld. From The Cochrane Library, Issue 1, 2002. Prepared and published by Update Software Ltd. All rights reserved. http://www.update-software.com/abstracts/ab001526.htm

Anonymous (1995) Benign Prostatic Hyperplasia: Treatment for Lower Urinary Tract Symptoms in Older Men. Effective Health Care Bulletin 2, 2. http://www.york.ac.uk/inst/crd/ehc22.htm

Anonymous (1998) Benign prostatic hyperplasia. Medicines Resource 49, 191-194.

Anonymous (1995) Finasteride and benign prostatic hyperplasia. Drug & Therapeutics Bulletin 33, 19-21.

Anonymous (1998) Management of benign prostatic hyperplasia. MeReC Bulletin 9, 1-4.

Cockett, A.T.K. and et.al., (Eds.) Jun 27, 1993. The 2nd international conference on benign prostatic hyperplasia 27-30 June, 1993. 553 p. Scientific Comm. Int. Ltd. (1993)

Cockett, A.T.K. and et.al., (Eds.) Jun 27, 1993. The 2nd international conference on benign prostatic hyperplasia 27-30 June, 1993. 427 p. Scientific Comm. Int. Ltd. (1993)

Cockett, A.T.K. and et.al., (Eds.) Jun 27, 1993. The 2nd international conference on benign prostatic hyperplasia 27-30 June, 1993. 276 p. Scientific Comm. Int. Ltd. (1993)

Andersen, J.T., Ekman, P., Wolf, H., Beisland, H.O., Johansson, J.E., Kontturi, M., Lehtonen, T. and Tveter, K. (1995) Can finasteride reverse the progress of benign prostatic hyperplasia? A two-year placebo-controlled study. The Scandinavian BPH Study Group. Urology 46, 631-637.

Bandolier (1998) Benign prostatic hyperplasia outcomes. Bandolier 5, 4

Bandolier (1997) BPH and finasteride - more results. Bandolier 4, 5

Boyle, P., Gould, A.L. and Roehrborn, C.G. (1996) Prostate volume predicts outcome of treatment of benign prostatic hyperplasia with finasteride: meta-analysis of randomized clinical trials see comments]. Urology 48, 398-405.

Chair: McConnell, J.D. (1994) Benign Prostatic Hyperplasia: diagnosis and treatment. Clinical practice guideline. AHCPR.

Coffey, D.S. (1998) Controversies in the management of lower urinary tract symptoms: an overview. Review] 36 refs]. British Journal of Urology 81 Suppl 1, 1-5.

DoH (2000) Referral Guidelines for Suspected Cancer. Chapter 6, Urological Cancers.

Eri, L.M. and Tveter, K.J. (1995) alpha-blockade in the treatment of symptomatic benign prostatic hyperplasia see comments]. Review] 131 refs]. Journal of Urology 154, 923-934.

Lepor, H., Williford, W.O., Barry, M.J., Brawer, M.K., Dixon, C.M., Gormley, G., Haakenson, C., Machi, M., Narayan, P. and Padley, R.J. (1996) The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group see comments]. New England Journal of Medicine 335, 533-539.

Lepor, H. (1998) The pathophysiology of lower urinary tract symptoms in the ageing male population. Review] 24 refs]. British Journal of Urology 81 Suppl 1, 29-33.

McConnell, J.D., Bruskewitz, R., Walsh, P., Andriole, G., Lieber, M., Holtgrewe, H.L., Albertsen, P., Roehrborn, C.G., Nickel, J.C., Wang, D.Z., Taylor, A.M. and Waldstreicher (1998) The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group see comments]. New England Journal of Medicine 338, 557-563.

OLeary, M.P. (1995) Epidemiology of benign prostatic hyperplasia. Review] 14 refs]. British Journal of Urology 76 Suppl 1, 1-3.

Simpson, R.J. (1997) Benign prostatic hyperplasia see comments]. Review] 114 refs]. British Journal of General Practice 47, 235-240.

Suzuki, H. (1998) Treatment of benign prostatic hyperplasia and hypertension in elderly hypertensive patients. BRIT J UROL SUPPL 81, 51-55.

UK British Prostate Group ., Carne, S.J., Fitzpatrick, J.M., George, N.J., Gingell, J.C., Keen, J.W., Kirby, R.S., Kirk, D., ODonoghue, E.P., Peeling, W.B. and Chisholm, G.D. (1995) Prostate disease: management options for the primary healthcare team. Report of a working party of the British Prostate Group. Postgraduate Medical Journal 71, 136-142.

Wasson, J.H., Reda, D.J., Bruskewitz, R.C., Elinson, J., Keller, A.M. and Henderson, W.G. (1995) A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate see comments]. New England Journal of Medicine 332, 75-79.

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