With the increasing lifespan in Turkey and the world, benign prostatic hyperplasia and prostate cancer are becoming more common.
However, 150 years ago, these diseases were treated solely by removing the testicles (ovaries) and inserting a catheter. We now have very modern treatment methods.
The prostate gland is an accessory sex gland weighing 15-20 grams that surrounds the urethra at the base of the bladder. Surgical removal of the prostate doesn't disrupt sexual function. The reason it surrounds the urethra and passes through the prostate gland is because the prostate gland provides 40-50% of the fluid portion of semen. The prostate gland, which produces this fluid, opens into the posterior upper portion of the urethra, which surrounds the prostate, via 25 main ducts. The prostate gland is composed of two lateral lobes, one each of the anterior, posterior, and middle lobes, and another group of glands, known as inner and outer lobes.
Benign prostatic hyperplasia begins as microscopic hyperplasia in the periurethral glands of the prostatic urethra after the age of 30-40. However, it doesn't cause immediate symptoms. The adenoma, which develops as a result of the growth and coalescence of these foci, narrows the bladder outlet, causing difficulty urinating, obstructing the urethra, and inability to urinate, usually after the age of 60. While the exact cause of prostate enlargement is unknown, it is thought to be hormonal, resulting from an imbalance between male and female hormones in men. Evidence of this is the relief provided by the removal of two testicles in the 1850s for the treatment of prostate enlargement.
The disease is usually caused by enlargement of the two lateral and middle lobes (trilobe hyperplasia), and sometimes by enlargement of both lateral lobes. The urinary tract (posterior urethra) within the narrowed prostate gland lengthens. The bladder neck shifts, deviating from the midline. To overcome urethral resistance to pass urine through this narrowed channel, the bladder muscle works harder and thickens. Residual urine begins to accumulate in the bladder. If the patient doesn't undergo surgery over the years, the bladder muscle will become exhausted and fail, making it impossible for the patient to urinate. The urine inflates the bladder like a balloon. This is called a "vesical globe." These patients have elevated urea levels. A catheter is immediately inserted, the bladder is emptied, and the catheter is left in place. The patient is encouraged to drink plenty of water to produce 1.5-2 liters of urine per day, which returns the urea level to normal within a week. These patients then undergo prostate surgery. Infections and bladder stones due to residual urine are common.
The most significant and distressing complaint of patients is the need to urinate frequently after going to bed at night (nocturia). While a normal person does not wake up to urinate at night, those with prostate disease may wake up 2-3 or even 8-10 times a night. However, these patients do not urinate as frequently during the day. This is because the edema that accumulates in the legs of older patients is filtered through the kidneys at night, producing a large amount of urine. This is due to the decreased release of anti-diuretic hormone (ADH) from the pituitary gland, which absorbs water from the kidneys at night, in aging men, increasing the amount of urine (volume). Furthermore, the conscious urination reflex decreases during sleep. The second most important complaint is the thinning of the thickness (diameter) of the urine produced and the decreased urine flow rate (projection). These complaints increase as prostate obstruction increases.
Other complaints include waiting to urinate, not being able to start urination immediately, feeling a little more urine remaining after urinating, and urinating again immediately after using the toilet. All of these complaints usually worsen at night. This is because most bad things, such as births, deaths, and urgent illnesses, usually occur at night. This is why Arabic songs are often based on the theme of "ya leyl-gece."
A burning sensation during urination can indicate a urinary tract infection or bladder stones. Blood in the urine is caused by a rupture of a dilated vein in the bladder wall.
If the patient's urea level is elevated, they will feel lethargic and have a very dry tongue. Nausea, vomiting, and loss of appetite may occur.
Urine from the bladder may be palpable in the abdomen during the examination. In a globular vesical examination, the lower abdomen appears swollen. A digital rectal prostate examination is the most important examination. This examination assesses the size, shape, and consistency of the prostate gland. Benign prostatic hyperplasia is rubbery and homogeneous. This examination is 65-70% helpful in distinguishing normal prostate enlargement from prostate cancer. In prostate cancer, the prostate gland appears as hard areas or is completely hard. However, a definitive diagnosis requires a prostate biopsy to assess normal prostate enlargement or prostate cancer.It's important to check for prostate cancer.
A large prostate gland on rectal digital examination may not require surgery. Prostate surgery requires the patient to either have an obstruction and a catheter, frequent urination that prevents them from sleeping at night, or additional bladder stones or frequent urinary tract infections. A small prostate can cause frequent urination and even obstruction, while a significantly enlarged prostate can cause minor symptoms. Therefore, prostate size alone is not a reason for surgery.
The patient's symptoms, urinalysis, PSA, and an abdominal ultrasound are sufficient for diagnosis. The ultrasound shows all abdominal organs, the condition of the kidneys, bladder, and prostate, the bladder volume when full, and the amount of residual urine remaining in the bladder after urination. If the residual urine exceeds 100 cc and the patient's symptoms are severe, it's time for medical treatment or surgery. Measuring urine flow rate helps determine the timing and type of treatment. A normal man urinates at a rate of 20-25 cc per second. Below 15 cc may require medical treatment, while below 10 cc may require surgery. It is advisable to repeat this test several times, as the patient may not be able to urinate comfortably in the presence of others or in unfamiliar environments. In benign prostatic hyperplasia, the PSA level is below 4 ngr/ml. However, in cases of suspicion, a prostate biopsy should be performed to rule out prostate cancer in patients with a PSA level above 2.5 ngr/ml.
To determine whether surgery is appropriate, seven questions are asked about the patient's symptoms, and each question is scored between 0 and 5. This is called the International Prostate Symptom Score (IPSS). If the score is below 7, the patient is advised to wait and take general precautions. These include avoiding spicy foods, avoiding colds, avoiding prolonged sitting, avoiding horseback riding, avoiding alcohol, and having sexual intercourse once or twice a week. If the score is between 8 and 20, medical treatment is first applied. Any urinary tract infection is treated during medical treatment. Alpha-adrenergic blocking drugs are used to reduce the prostate gland's resistance to urine flow. There are 6-7 of these. They can be very beneficial. Resistance can develop after 5-6 years of use, and switching is necessary. These drugs do not shrink the prostate gland. 5-Alpha reductase inhibitors, which slightly shrink the prostate gland, are used for prostates larger than 40 grams. They can be very beneficial, but should be given to patients over 70-75 years of age because they can cause impotence. Six months of use can halve PSA levels, potentially leading to a doctor's suspicion of prostate cancer. A phytotherapeutic drug derived from palm tree leaves, which shrinks the prostate without causing frigidity, may have the same effect.
If the patient experiences relief with medical treatment, treatment can be continued for years. If symptoms worsen or the patient experiences obstruction despite medical treatment, surgical treatment is performed. Surgical treatment is performed in two forms: endoscopic (using instruments - closed) and open surgery.
Companies have produced a wide variety of instruments for closed surgeries. These include balloon dilation of the prostate, prostate stent placement, ultrasound-assisted prostate thawing (HIFU), hyperthermia, and prostate vaporization. These are not very effective surgical methods. They have many medical uses. The most commonly used and beneficial closed procedures are Transurethral Prostatectomy (TUR-P) and Holmium Laser Prostatectomy (HOLEP), performed by skilled professionals.
Open prostate surgery is the most effective method, especially for prostates larger than 60 cc. Although first performed in the 1890s, it remains relevant. It does not require expensive instruments or endoscopes, can be performed by any urologist, and, most importantly, it provides the most comfort to the patient.
Wishing you healthy days.
Prof. İbrahim Bozkırlı, M.D., Urology