The prostate is a small, almond-shaped gland that sits at the base of the bladder. Its main function is to produce the majority of fluid that a man ejaculates, but it is not essential for life. It enlarges throughout a man’s life, and can commonly cause problems with a man’s “waterworks”. As can be seen from the diagram the urethra passes through the middle of the prostate, and as it grows it compresses this tubular structure. This compression in turns leads to the difficulty men often experience in passing urine as they get older.
Condition – Benign Prostatic Hyperplasia
Symptoms and Signs
Symptoms caused by problems with the prostate are often known collectively as “lower urinary tract symptoms” or LUTS.
Symptoms and signs of prostate problems include:
- a delay before starting to pass urine – hesitancy
- poor stream – slow, may stop & start
- the need to strain to keep urine flowing
- passing urine often – frequency
- needing to pass urine at night – nocturia
- the need to rush to pass urine urgently – urgency
- dribbling urine onto underpants after finishing urination – post-micturition dribbling
- the feeling the bladder is not empty
- burning pain when passing urine – dysuria
LUTS are rarely caused by cancer, though when you are investigated the Urologist will often seek to exclude this possibility (more later). The most common prostate problem that causes these symptoms is BPH (Benign Prostatic Hyperplasia).
BPH occurs in all men – prostates enlarge throughout adult life. The size of the prostate does not correlate well with the occurrence of symptoms. Many men with large prostate have few symptoms, whilst conversely some men with small prostates may experience quite severe LUTS.
The prostate can block the bladder (BOO = Bladder Outlet Obstruction) as it enlarges. Treating the prostate for enlargement does not result in incontinence, as the prostate sits above the urinary sphincter and is separate from that structure.
You will find that some or all of the following may be required to make an accurate diagnosis of LUTS caused by your prostate:
- History – your medical history, including medications, past problems or previous surgery.
- Symptom Score – a simple questionnaire that can help in judging the severity of your symptoms and your response to any treatments.
- Examination – especially a digital rectal examination (DRE) of the prostate. Abdomen & genitals are often examined as well.
The DRE should not cause you any anxiety. It is not painful (though perhaps a little embarrassing) and is performed with you laying on your left side or standing whilst bending over. This examination allows the doctor to obtain an indication of the size of your prostate as well as the presence of any lumps or nodules, etc.
- Urine tests: to look for infection, blood, sugar, etc.
- Blood tests: general blood count and kidney function tests.
- PSA – Prostate Specific Antigen: this is a blood test that is designed to assist in the diagnosis of prostate cancer. It is not always required but you should feel free to discuss this test with your doctor.
You may be required to have one or all of the following tests as well:
- Ultrasound (US) – to image the kidneys & bladder
- Post-void Residual (PVR) – usually performed at the same time as the US
- Cystoscopy – a telescopic inspection of the bladder
- Urodynamic Study – a computer-based test of your bladder function
The main risk men face when suffering from LUTS due to prostatic enlargement is acute urinary retention. This is the medical term for when a person cannot urinate – they usually suffer severe pain and need to go to hospital to have a catheter inserted in the bladder.
Treatment – Benign Prostatic Hyperplasia (BPH)
There are many treatment options for BPH that do not involve surgery. Once “dangerous” conditions such as prostate cancer, bladder cancer, kidney disease, bladder stones etc have been excluded, the need for any treatment depends on how bothered you are by your LUTS.
You will have noticed the so-called bother score you provided if you completed an IPSS -International Prostate Symptom Score – a simple questionnaire about your symptoms. Some of the treatment options are listed below.
What you can do for yourself – lifestyle changes
You may decide you do not wish any specific medical treatment at this point in time. Some of the following tips may help make some of your symptoms more bearable.
- Drink a little less fluid in the evening
- some drinks such as tea, coffee and alcohol can exacerbate the symptoms
- some medications (such as diuretics) make you pass more urine – a consultation with your local doctor may enable these drugs to be taken in the morning
- “urethral milking” – after passing urine run your finger from behind the scrotum forward to push out those last few drops of urine that often stain the underwear
- “herbal” remedies that can be bought over the counter can often improve symptoms e.g. Saw palmetto & Trinovan
- sometimes pelvic floor exercises help
You should have an annual prostate check as back-up to ensure you are not developing any hidden problems.
These drugs block the nerves to the muscles of the prostate. This relaxes the prostate and allows easier passing of the urine. Symptoms improve 2-4 weeks after commencing the drugs.
Prazosin (Minipress or Pressin) is relatively nonspecific and in larger doses is used as a blood pressure tablet. Its big advantage is that it a PBS listed drug.
Tamsulosin (Flomaxtra) and Alfuzosin (Xatral) are prostate-specific alpha-blocker that works more rapidly and often with more effect, but at this time is only on the Repatriation PBS scheme – therefore for most people it costs about $50 per script.
5 Alpha-Reductase Inhibitors
These drugs – the one available in Australia is Finasteride = Proscar – reduce some of the hormonal activities of testosterone in the prostate causing it to shrink. It is not commonly used in Australia as it is very expensive and less than 30% of men who try it find it provides them any relief of their symptoms.
Minimally invasive surgical options
A/Prof Cozzi has the largest single surgeon experience to date of implantation of the UroLift device for men with mild to moderate symptoms who wish to avoid the side effects of drugs or traditional prostate surgery. Dr Cozzi has implanted more men than any other surgeon in the world with almost 500 cases performed between 2013 through 2017.
The aim of this novel device is to-
- Compress encroaching lateral lobe
- Deliver UroLift® implant to hold in place
- Typically ~4 implants delivered
The procedure is performed as day surgery without a catheter and with no reports of loss of ejaculation, impotence or incontinence.
The Rezum System
Rezum is a transurethral RF thermal therapy to treat benign prostatic hyperplasia (BPH) that can be performed in a clinic or out-patient setting. Using a hand-held device, Rezum delivers radiofrequency generated thermal therapy, in the form of water vapor, directly to the extra prostate tissue that is causing symptoms such as frequency, urgency, irregular flow, weak stream, straining and getting up at night to urinate. There are minimal side effects with preservation of ejaculation in more than 94% of patients undergoing this new minimally invasive treatment.
A/Prof Cozzi was the first surgeon in Australia to be fully credentialed (in March 2018) to perform the Rezum procedure independently and currently offers the procedure to suitable patients each week with timely availability and no “out of pocket” expenses both for the surgery and the anaesthesia.
A/Prof Cozzi and his colleagues were integral to the deployment of the technology in Australia including arranging a local distributor, organising re-imbursement from health funds and obtaining TGA approval.
The three year follow up data from US studies has recently been released which demonstrates durable, reproducible and highly effective improvement is symptom scores, urinary flow rates and quality of life with no major side effects on urinary and sexual function.
For more information please visit the Rezum website at www.rezum.com
Rezum instructional video 1: A short explanation of Rezum procedure and the suprapubic catheter.
Rezum instructional video 2: Why it is beneficial to have a suprapubic catheter after Rezum procedure.
Rezum instructional video 3: An explanation of how to perform a trial of void (urinate through the penis) prior to the removal of your suprapublic catheter.
Post by A/Prof Cozzi ‘Rezum needle ablation of the prostate for BPH now available’ – read blog here
Channel Nine News interviews A/Prof Cozzi about Rezum, the breakthrough new treatment for enlarged prostate! – watch news article here