Dr. Emmanuel L. Sta. Cruz

    Despite the advancements in medical science, Prostate Enlargement has remained a dilemma then and until today. This is partly because of the little attention given to understanding the origin of Prostate Enlargement and the penchant to provide medicine for symptom relief, rather than one that addresses the cause of the disease. 

 

 

I. Causes of Prostate Enlargement

​

    The purported normal size of a Prostate Gland is said to be between 10 to 20 grams measured by ultrasound. Usually the measurement of the Prostate Gland done through a Transabdominal Ultrasound is larger than that of a Transrectal Ultrasound (TRUS). 

    An enlargement of the Prostate may be due to different causes. There are at least three conditions that can account for an enlargement: a congestion or an inflammation of the Prostate Gland called "Prostatitis", which may be secondary to an infection. It could also be due to a tumor as a consequent to "Cancer"; then there is also a condition called "Benign Prostate Hyperplasia" (BPH), where there is a non-cancerous proliferation of cells in the Prostate Gland causing  the enlargement.

    Prostate Enlargement is not necessarily part of the normal aging process but it is rather due to a disease process. More recent studies have shown that chronic inflammation (Chronic Prostatitis) promotes the proliferation of cells (BPH) causing the enlargement of the Prostate Gland (Theyer et al., 1992; Blotnik et al., 1994; Freeman et al., 1995; Konig et al., 2004; Kramer et al., 2002; Castro et al., 2004; Wang et al., 2004). Therefore, BPH is not a disease in itself, but merely a product of a disease which is Prostatitis.

 

 

II. Symptoms of Prostate Enlargement

 

    The Urinary Symptoms attributable to BPH and Prostatitis are: 

        1. Frequent scanty urination

        2. Getting up to urinate more than once during 

            sleeping hours (Nocturia)

        3. Weak urinary stream or force

        4. Interrupted flow (Intermittency)

        5. Retention

        6. Difficulty in holding urination (Urgency)

        7. Splitting of urine flow

        8. Acute Urinary Retention (AUR)

    These urinary symptoms are intermingled or confused with one another and are commonly attributed to BPH rather than Prostatitis.

 

 

III. Diagnostic Test for an Enlarged Prostate

 

    The dilemma in Prostate Enlargement is in the diagnosis because most cases of enlargement of the Prostate are presumed to be due to BPH. Prostatitis, which may be the root cause of BPH, has been overlooked. 

    So in most men with an Enlarged Prostate, the prescribed diagnostic test for Prostatitis should be routinely done to determine the root cause of the problem. This would entail the examination of the Expressed Prostatic Secretion (EPS) collected after Prostate Massage with a comprehensive microbiologic examination of the Prostate Fluid such as a Wet Mount, Gram Stain, Culture and Sensitivity Tests including Ureaplasma, Mycoplasma and a Direct Fluorescence Antibody (DFA) for Chlamydia test by Immunofluorescence Microscopy. But sadly, this is not routinely done. 

    Prostate ultrasound, DRE, PSA, IVP, or cystoscopy cannot directly diagnose Prostatitis. Thus, Prostatitis may be the most under-diagnosed and untreated Prostate Disease.

 

 

IV. Traditional Treatment of Prostate Enlargement

 

    Traditionally, treatment is directed towards the signs and symptoms of the disease rather than treating the source of the disease. The focus of treatment, then and until today, is to remedy the enlargement by blocking the conversion of testosterone into its active form, which is DHT, despite the fact that multiple studies (McKeehan et al., 1994; McConnell, 1995; Wang et al., 2004; Marcelli & Cunningham, 1999) have shown that testosterone does not cause the proliferation of cells (BPH) which leads to an Enlargement of the Prostate. Thus medicines marketed today are those directed against the conversion of testosterone into DHT such as Finasteride, Dutasteride and Saw Palmetto. Likewise, Alpha blocker medicines such as Alfuzosin, Tamsulosin, Terazosin and Doxazosin to relax the muscles of the Prostate for a freer flow of urination were propagated. 

    However, none of these medicines could address the chronic infection in the Prostate which increases the number of cells in the Prostate causing enlargement (Theyer et al., 1992; Kramer et al., 2002; Wang et al., 2004). Nor could these medicines clear the infection causing the spasm or contraction of the muscles of the Prostate which causes the weak urinary stream, interrupted urination, splitting and urinary retention. 

    Thus, the infection would sparingly trigger the tightening of the smooth muscles of the Prostate, choking the urinary tract, while the so-called Alpha blocker medicine will try to relax the muscles. As the infection triggers the contraction of the muscles, the medicine tries to relax it. The battle continues, and this could become a never-ending story which could later on result in the worsening of the Prostate problem until Surgery would be deemed  as the only recourse.

 

 

V. Non-Surgical Treatment for Prostate Enlargement

 

    The Treatment of Prostate Enlargement should always be directed towards the real cause of the enlargement and the urinary symptoms. Most of the urinary symptoms of patients I have seen do not happen as a result of an enlargement of the Prostate but were rather due to Prostatitis which could cause irritation or spasm of the smooth muscles of the Prostate and result in Frequency of urination, Weak urinary stream, Intermittent urination, Splitting and Retention.

    Diagnosing Prostatitis is the key to solving the problem, because Prostatitis is treatable medically with culture-based antibiotics combined with thrice weekly Prostate Massage. This is to drain out the infected Prostate fluid or open clogged glands of the Prostate thereby allowing antibiotics to enter these glands as new fluid refills them after the Prostate Massage. Otherwise "there is an inherent failure of the antibiotics to penetrate the prostate" (Stamey & Meares, 1978) without a Prostate Massage. Prostatitis basically does not need surgery.  

    According to a study by Kohnen and Drach in 1979, Prostatitis was seen in 98% of men whose Prostate were operated on due to BPH. Had the diagnostic test for Prostatitis been done before the Surgery, there is a good chance that Prostatitis could have been diagnosed and Surgery would not have been recommended. 

 

 

VI. Prostatitis is not amenable to Surgery

 

    We cannot pass up the chance to save a patient from surgery because using a surgical procedure called Transurethral Resection of the Prostate or TURP, which scrapes or removes part of the urethral section of the Prostate, is seldom effective for Prostatitis, especially since the Peripheral Zone of the Prostate usually contains the bulk of the infection and this area is not effectively removed by this procedure (E. Meares, Smiths General Urology, 1995) (R.S. Kirby, Textbook of Prostatitis, 1999) (J.C. Nickel, Campbell's Urology, 2002). 

    Doing a TURP on patients with Prostatitis is like barking up the wrong tree and could seal off some glands in the back part of the Prostate which could make it worse and could give rise to Prostate Cancer. Thus, Prostatitis should be considered in every case of Prostate Enlargement. The key to every treatment is a proper diagnosis.