Sunday, January 13, 2002		Fitness

Coping with an enlarged prostate
B.K. Sharma

LATER half of 40s and early 50s bring about physiological and hormonal changes in men and women. The female hormone production and reproductive cycle comes to an end with menopause, which is accompanied by flushing, sweating and other physiological changes. Male climacteric is not so well-defined and the hormonal changes are not so marked, although there is a decline in the production of the male hormone (testosterone). Somewhere at this age, the prostate gland makes its presence felt. Actually, the change occurs in most of the males but symptoms may appear only in 20-30 per cent of them due to the enlargement of this gland. Urologists call it benign hypertrophy of the prostate. Prostate is subject to infections known as prostatitis and cancer, which is much more serious in nature. In this write-up we will be focusing on the common benign enlargement of the prostate.

The prostate is a walnut-sized gland located in the pelvis at the bottom of the bladder in front of the rectum and behind the pubic bone. It encircles the urethra, the tube which carries urine from the bladder to outside. In women, the urinary and genital systems, are separated, In men, the two systems are co-joined half way through and the prostate is at the junction of the two systems as apparent in the accompanying figure. The prostate, at birth is hardly 1-2 gm in weight and gradually grows during early childhood. There is a spurt of growth at puberty when the prostate grows to about 20 gm in size. Vas deference, the tube which brings the sperms from the testis and secretion of seminal vessels) opens in the urethra in the prostate. The prostate itself pours its secretion in the urethra. It is thus an anatomical and chemical junction of various contributing glands in the male genital system. The prostate itself secretes enzymes which play an important role in maintaining the normal physiology of sperms.

Around 50 years, there is a second spurt of enlargement of the prostate. The enlargement at puberty under the influence of the male hormone is uniform in size and all the areas of prostate enlarge uniformally. After the second spurt, it goes on increasing. By the age of 80, 90 per cent of the men would show enlargement of the prostate, but symptoms of enlargement are present in not more than one-thirds out of them. For reasons which are not completely understood, the enlargement of the prostate during the second spurt of growth occurs only in the area which surrounds the urethra and thus produces difficulties in the passage of urine. The exact cause of the second spurt in the local area of prostate is not known. But factors include the process of aging and the presence of testis. It has been seen in the experimental animals that castrating dogs prevents the enlargement of the prostate and replacing the hormone once again causes prostate enlargement like that present in non-castrated dogs.

Once enlargement starts various symptoms start appearing. These may be due to irritation of the urethra to begin with, compression of the urethra by the prostate tissue, super-added infection in the urine, irritation of the bladder and, finally, it can cause complete obstruction of the passage of the urine and precipitate an emergency. In a vast majority of the men, the enlargement does cause complete obstruction. Appearance of symptoms is also not sequential and it is not predictable which will progress to this stage. Urologists usually do not advise surgery on the basis of early symptoms to prevent the future development of obstruction.

Symptoms of an enlarged prostate include getting up once or twice in early morning to pass urine which was not occurring earlier. There may be the sensation of not emptying the bladder completely after urinating. There may be a desire to pass urine within two hours or so and the stream of urine may get thinner and weak.

An opposing set of symptoms may also appear. It might be difficult to hold urine when there is an urge (precipitancy). On the other hand there may be delay in starting the process of urinating when the person wants to pass the urine. If there is super-added infection, there may be burning, irritation while passing urine and also accompanying fever. Of course, when the obstruction is complete, this creates an emergency as the bladder gets full and it becomes painful. Certain factors can precipitate complete obstruction rather dramatically. These include drugs like anti-spasmodics, anti-allergic drugs, tranquilisers, alcohol, medical illnesses that require lying in the bed. Although the size of the prostate enlargement is an important factor, there is no complete correlation between the size and the symptoms.

Once some of the symptoms mentioned appear, a visit to an urologist is helpful for making sure about the nature of the illness and assessment of the state of enlargement. Fortunately, the diagnostic capabilities of the urologists have improved and they can make a fairly good assessment of the size and amount of urine which may be left in the bladder after urinating. The simple physical examination by feeling the prostate through the rectum helps in defining its size, consistency and other factors.

An ultrasound examination is very helpful in defining the volume/size of the prostate and the exact amount of urine that is left in the bladder. Under certain circumstances they may look into the bladder area with a scope. If they suspect or want to rule out the chances of cancer of the prostate, they might perform the biopsy of the prostate. But it is not done as a routine in the simple enlargement of the prostate.

The American Urologists Association has made a table based on the symptoms index of the prostate, which helps the urologists in rating the amount of difficulty a person may have. This helps to make a decision regarding the surgical treatment of the enlarged prostate. When the obstruction of the urine occurs, surgery becomes necessary. But frequent infection, bleeding, disturbed sleep or functioning during the day are additional factors which may determine the need of surgery and a good discussion between the patient and the urologist helps.

In the early course of enlargement of the prostate, medical treatment is of some help. The drug finesteride (Fincar) helps in reducing the size of the prostate. It enymatically blocks the effect of the testosterone on the prostate. The efficacy is not uniform. A group of drugs which are used for high blood pressure also help in relieving the symptoms by relaxing the sphincter of the urinary bladder. The earlier mode of surgery was rather a major affair and the prostate used to be taken out after cutting through the bladder. Now that method is reserved only for persons whose size may be rather big.

The operation has become rather simple and safe. Urologists can go through the urethra and cut through the enlarged area of the prostate around urethra and relieve the obstruction. Newer techniques like microwaves, lasers and electro-evaporation are being tried and hopefully the surgery will become even more simple and safe. Prostate problem comes at the age when other systems may not be at their best. Physical evaluation of other systems has to be done before the surgery is performed.