Urinary symptoms in men

Where is the prostate and what does it do?

The normal prostate is a walnut sized gland in men. During urination urine travels from the bladder to the urethra through a channel in the centre of the prostate. This channel is referred to as the prostatic urethra. The vas tubes carry sperm from the testes, though the prostate to the prostatic urethra.

The prostate is tiny in childhood, grows during puberty and is the only organ that continues to grow throughout life. It the prostate grows inwards it narrows the prostatic urethra and can cause problems with urination.

The main function of the prostate is to produce some of the fluid in semen. This is important for reproduction. Men can live a perfectly healthy life if part or even all of the prostate is removed surgically, although this may have consequences for fertility.

What is the significance of urinary symptoms in men?

Urinary symptoms are the most common symptoms affecting men beyond middle age. There are two main reasons why it is important to report urinary symptoms to your doctor:

  1. Urinary symptoms may be a sign of a significant underlying problem such as a cancer in the urinary system, particularly if associated with blood in the urine. It is important to notify your doctor if you see blood in the urine, and/or develop urinary symptoms that you are concerned about.
  2. Many men, and their partners, suffer significant impairment to their quality of life as a consequence of male lower urinary tract symptoms (LUTS). LUTS may cause anxiety and embarrassment, and prevent men from doing things that they previously enjoyed. It is possible to tailor the treatment of urinary symptoms to suit the individual. This results in successful outcomes for the majority of men. There is no need to endure the bother that urinary symptoms may cause.

What causes urinary symptoms in men?

There are a number of potential causes for urinary symptoms in men. 

By far the most common is Benign Prostatic Hyperplasia (BPH). BPH is essentially a benign tumour growing within the central part of the prostate. It is an almost inevitable part of the male aging process. 

Prostates grow at different rates in different men. Those who grow very large prostates at a young age often have a family history of BPH and have inherited a genetic tendency for abnormal prostate growth .  

When BPH grows inwards it may begin to obstruct the flow of urine through the prostate and cause urinary symptoms.

What symptoms can be caused by BPH?

Obstructive symptoms

  • Urinary symptoms due to BPH can be divided into obstructive (or prostate) and storage (or bladder) symptoms.  When BPH causes a restriction to the flow of urine the following obstructive symptoms may occur:
    • Weak urinary flow 
    • Intermittent flow (stopping and starting during urination)
    • Difficulty initiating urination
    • Incomplete bladder emptying 

Storage symptoms

  • After a while the bladder tries to compensate for the prostate blockage by becoming muscular and more powerful. This initially helps to maintain the urinary flow, but eventually the bladder becomes so unstable that it starts to push too powerfully and frequently, and at inappropriate times. This causes bladder storage symptoms such as:
    • Urinary urgency or difficulty in postponing urination
    • Frequent urination during the day and night

Acute urinary retention

  • In the worst case scenario, BPH may cause a sudden complete obstruction to the flow of urine (acute urinary retention or AUR). 
  • Sudden over distension of the bladder is very painful and requires urgent medical attention to drain urine from the bladder by placement of a catheter or drainage tube. Catheterisation allows instant pain relief. It is often worth removing the catheter after a week to see if the ability to urinate returns. If this fails, HoLEP is an excellent treatment option, and leads to relief of urinary retention and successful return to normal urination in 98% of men. 
  • AUR often occurs without warning, although may be triggered by drinking alcohol, cold weather, constipation, urinary tract infection and surgical procedures such as prostate biopsy, telescopic inspection of the bladder, hernia repair and any other surgery undertaken under general or spinal anaesthetic.

Chronic urinary retention

  • Sometimes BPH causes a gradual over-distension of the bladder (chronic urinary retention or CUR). As opposed to AUR, CUR occurs over weeks, months or years rather than hours and is painless.
  • CUR may not cause any appreciable change in urinary symptoms but it is potentially serious as it can cause pressure from the over full bladder to back up to the kidneys. If untreated this pressure damages the kidneys and can cause kidney failure. 
  • CUR is treated by passage of a catheter in the first instance. Once kidney function returns to normal, HoLEP can be considered to allow safe removal of the catheter. As with AUR, HoLEP is the most effective endoscopic form of treatment for CUR, with a 98%  chance of allowing a return to normal urination.

Haematuria (blood in the urine)

  • Sometimes, as the prostate grows, blood vessels inside the prostate also grow and become prone to bleeding, particularly during/after physical exertion. This causes blood to appear in the urine. If the bleeding is heavy, blood clots may interfere with and block the passage of urine.

Urinary tract infection and bladder stones

  • When BPH causes incomplete bladder emptying, a pool of stagnant urine accumulates in the bladder. This is an ideal environment for urinary tract infection and the formation of bladder stones. HoLEP is very effective at improving bladder emptying, and in virtually all cases, stops infections and prevents bladder stones from recurring. Bladder stones can be fragmented quickly and effectively by the holmium laser, and this can be safely done in combination with HoLEP.

What tests are performed to investigate urinary symptoms in men?

The purposes of tests done to investigate men with urinary symptoms are to:

  1. Rule out cancer.
    This is done by testing a urine sample, performing a blood test (Prostate Specific Antigen- PSA) and examining the prostate by rectal examination.
  2. Look for evidence of prostate obstruction.
    This is done by measuring a urine flow test and checking how well the bladder has emptied by scanning it soon after urination.
  3. Assess the type and severity of urinary symptoms

           The International Prostate Symptom Score (IPSS) questionnaire gives a useful indication of the type and severity of urinary symptoms. 

4. Assess the frequency and volume of urination

The frequency-volume chart gives useful information on the frequency and volume of urination over a 24 hour period. and may help determine whether lifestyle changes could help to improve urinary symptoms.

What are the treatment options for urinary symptoms due to BPH?

  1. Lifestyle changes
    For men with minimal urinary symptoms the impact of these symptoms on their lives can be minimised by decreasing alcohol and caffeine intake and reducing fluid intake in the evening (Drinks for over active bladder information sheet)
  2. Medical treatment
    Two types of tablets are available for treating BPH:
    • Alpha blockers relax the muscle in the prostate and bladder neck to help widen the prostate channel when urinating. Commonly used alpha-blockers include tamsulosin and alfuzocin.
    • 5-alpha reductase inhibitors shrink the prostate. Commonly used 5-ARIs include finasteride and dutasteride.
    • Plant extracts such as saw palmetto are favoured by some men and can improve urinary symptoms
  3. Minimally invasive procedures
  • Urolift and Rezum are suitable for men with bothersome LUTS. They are both currently recommended for men with prostates up to 80cc in volume. In some circumstances, they might be appropriate for men with prostates slightly larger than 80cc. 
  • Urolift does not affect sexual function. Rezum does not affect erectile function but has an 8-10% risk of ejaculatory dysfunction. The risk of urinary incontinence after urolift and Rezum is extremely low.
  • The effectiveness of Urolift and Rezum for treating men with catheter-dependant urinary retention is not yet known. 

4. Surgical treatment (HoLEP)

There are various surgical treatments available for BPH including HoLEP, TURP, greenlight laser vapourisation of the prostate (PVP) and aquablation. HoLEP is the most widely researched modern surgical treatment currently available. It is suitable for men whose urinary symptoms are a nuisance/impair quality of life, with any of the following :

  1. Don’t want to be on longterm medication
  2. Have side effects from the medication
  3. Didn’t respond to the medication
  4. Have recurrent bleeding from the prostate
  5. Have a large prostate ( There is no prostate size limit for HoLEP. The largest prostate Mr Aho has performed HoLEP on was in excess of 600cc)
  6. Have urinary infections due to incomplete bladder emptying secondary to BPH
  7. Have bladder stones
  8. Have urinary retention
  9. Have kidney failure due to their prostate

BPH in numbers

  • Urinary symptoms due to BPH affect 3.2 million men in the UK.
  • Only 400,000 receive treatment despite effective treatments being readily available
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