What is the prostate?
The prostate gland is a small, solid gland roughly the size of a walnut, located behind the pubic bone. It is situated beneath the bladder, surrounding the first part of the urethra. Approximately 0.5ml of each ejaculate is fluid made by the prostate, containing a number of substances that nourish the sperm and are necessary for fertility. Two small pouches, the seminal vesicles, sit directly behind the prostate, and provide a further 2ml of ejaculatory fluid via small tubes that run through the prostate into the urethra.
What diseases can affect the prostate?
The three most common are benign prostatic hyperplasia (BPH), prostatitis (inflammation), and prostate cancer. Only the first two conditions are discussed in this section.
Benign prostatic hyperplasia (BPH):
This is a gradual enlargement of the central portion of the prostate that compresses the urethra and causes obstruction to urine flow, giving rise to various symptoms including a weak flow of urine, urgency and nocturia (getting up from sleep to urinate). BPH is not cancer, and does not turn into cancer. BPH seems to be a normal part of ageing in men, but the degree of enlargement, as well as the severity of symptoms varies greatly. The most important aspect of BPH and the symptoms it causes is how much it bothers the man. Many men have minor symptoms which are of no concern to them and therefore treatment is not required. However, for those whose quality of life is being affected, there are several highly effective treatment options available. Medications can relax or shrink the prostate, whereas surgical treatments remove the obstructing prostate tissue. The most commonly performed operation for BPH is a TURP (trans-urethral resection of prostate), in which a telescope is passed through the urethra to the prostate, which is then shaved away from the inside.
Sometimes BPH can lead to retention of urine in the bladder, causing more than just bothersome symptoms. Bladder stones, recurrent urine infections and impaired kidney function may all be due to bladder outlet obstruction caused by BPH. In these cases, surgery is required. Alternatives to TURP include laser prostatectomy (link), and open (not radical) prostatectomy, where the inner portion of a very large prostate is removed via an incision in the lower abdomen.
Importantly, BPH is the most common cause of an elevated PSA between 4 and 10. It can therefore be difficult to distinguish it from prostate cancer unless a biopsy of the prostate is performed, as cancer typically raises PSA also.
Prostatitis indicates inflammation of the prostate and covers a whole spectrum of clinical entities. It is not always due to infection and does not always cause symptoms. At one end of the spectrum is acute bacterial prostatitis, which presents with fever, feeling acutely unwell and sudden difficulty urinating. This is a medical emergency, requiring intravenous antibiotics and drainage of the bladder via a catheter. At the other end of the spectrum is chronic non-bacterial prostatitis, characterized by pain in the pelvic area. It is often not certain whether these symptoms are due to prostatitis at all, and is now termed chronic pelvic pain syndrome. Such symptoms may be relieved by treatments such as anti-inflammatory medication or pelvic physiotherapy. In addition, sometimes prostatitis is diagnosed on a prostate biopsy without the patient having any symptoms at all.
Like BPH and prostate cancer, prostatitis can also elevate the PSA, as well as cause it to fluctuate.
Trans Urethral Resection of the Prostate – (TURP)
A TURP is an operation done with a telescope through the water passage to shell out the prostate gland and relieve symptoms of obstruction. The operation takes about 40 minutes – 1 hour.
In most cases the enlargement is benign (not cancer), but occasionally the enlargement may be due to cancer. Your doctor will be able to tell you if cancer is suspected, however the doctor may not be sure until the prostate tissue is examined by the pathologist after the operation.
Laser Prostate Surgery
Similar to traditional transurethral resection of the prostate (TURP), laser prostatectomy is performed when benign prostatic enlargement causes symptomatic partial obstruction of the bladder outlet. Various lasers are used for this purpose but all have the same goal, which is to remove obstructing prostate tissue, thus creating an open channel for urine to pass freely through the remaining prostate. Urologists at AUA are trained and experienced in photovaporisation of the prostate (PVP) using the Greenlight™ laser. Under spinal or general anaesthetic, a telescope is passed into the urethra to the level of the prostate, which sits directly beneath the bladder and surrounds its outlet. In a traditional TURP, an electrified loop of wire is passed through the scope and swept through the prostate, cutting away chips of prostate tissue. Although the loop is able to cauterize tissue as well, there is always some degree of bleeding.
In PVP using the Greenlight™ laser, a laser fibre is instead passed and fired at the obstructing prostate tissue, instantly vaporizing the tissue and simultaneously cauterizing it. PVP results in minimal bleeding which enables patients to undergo the procedure as a day admission or overnight stay. A catheter is left in the urethra to drain the bladder overnight and is removed the next day. Although PVP can be used for most patients with benign enlargement of the prostate, its main advantage lies with patients with cardiovascular disease who require ongoing anticoagulation, or “blood thinning”.