Tabulating the Symptoms
Perform a self-evaluation. Rate the symptoms in Table 1 from 0 to 5 as to how much you are affected by each one. If you rate each of the 7 items at the maximum of 5, you would have a score of 35. If you are anywhere near 35, definitely see your physician. Of course, most men do not need a score card to know whether there is a problem or not. The chart is now used worldwide. It is sometimes referred to as IPSS (International Prostate Symptom Score).

prostate enlargement may also be staged according to symptoms and AUA score. According to Chia et al. (1999), with better understanding of the natural history of prostate enlargement, treatment can be tailored to the severity of the disease. The aims of their study were to determine the feasibility of staging prostate enlargement according to severity, choose the optimal therapeutic treatment for each category, and compare the results of various treatment modalities.

From October 1994 until July 1995, 225 patients with clinical prostate enlargement were seen. Initial assessment included the IPSS, quality of life index, DRE, urinalysis, PSA, uroflow, and residual urine estimation. Patients were then divided into stages:

Stage I: No bothersome symptoms and no significant obstruction; these patients can generally be watched.
Stage II: Bothersome symptoms, but without significant obstruction; these patients can be treated with pharmacotherapy or thermotherapy.
Stage III: Significant obstruction (defined as uroflow of less than 10 mL/sec with persistent residual urine of more than 100 mL; TURP would be recommended for these patients.
Stage IV: Complications of prostate enlargement such as chronic retention of urine and bladder stones; these patients would need TURP.
Note: Stages are sometimes designated with numbers 1-4.
There was complete follow-up data for 159 patients for at least 2 years. Of the 70 patients who were originally in Stage I, 59 (89%) remained in status quo; six patients developed acute retention of urine; and only one required TURP. Of the 38 patients in Stage II, 24 were downstaged to Stage I after medication and thermotherapy; four still remained in Stage II; and the other 10 had worsening of symptoms requiring surgery. Of the 46 patients in Stage III, 30 (65%) had TURP; all except one were downstaged to Stage I. All patients in Stage IV had TURP and improved.

The researchers concluded that "staging of patients with clinical prostate enlargement is feasible. It serves as a useful guide for management and improves cost effectiveness."

prostate enlargement DiagnosIS

DRE
Flow Rate Test
Home Test
Postvoid Residual Urine
Ultrasonic Imaging
Magnetic Resonance Imaging and Computed Tomography
Cystoscopic Examination
Laboratory Tests
Biopsy
Besides the IPSS score, there are several other tests that a physician may perform to determine if you have prostate enlargement and its severity.

DRE
One of the most common tests that a physician performs is the DRE. The examination may be embarrassing, but it is quick and easy and can yield an enormous amount of information. The patient bends over on an examining table and the physician inserts a lubricated gloved finger into the rectum. The posterior and lateral lobes of theprostate can be easily felt through the thin rectal wall. A normal prostate should be about the size of a chestnut and should feel smooth and elastic. A physician can determine if the size of the prostate is larger than normal. Even if it is larger than normal, the prostate should still feel smooth and elastic if enlargement is caused by prostate enlargement. If a physician finds any hard nodules or areas of undue firmness, he may suspect the presence of cancer.

Table 1: AUA IPSS Index
During last month
How often: Not at all Less than
1 time Less than half
the time About half
the time More than
half the time Almost
always
Question
1. Have you had the sensation of not emptying your bladder completely after you have finished urinating? 0 1 2 3 4 5
2. Had to urinate again within 2 hours? 0 1 2 3 4 5
3. Had to stop and start several times? 0 1 2 3 4 5
4. Was difficult to hold back urine; have to go now? 0 1 2 3 4 5
5. Had a weak urinary stream? 0 1 2 3 4 5
6. Had to strain to urinate? 0 1 2 3 4 5
7. Number of times got up at night? 0 1 2 3 4 5
AUA Symptom Score Key 0-7: mild obstruction 8-19: moderate obstruction 20-35: severe obstruction

A physician might not be able to positively determine if a patient has prostate enlargement by a DRE alone. A physician can only feel the two rear lobes of the prostate.

Most cases of prostate cancer occur in the peripheral zone or the portion of the prostate that can be felt through the rectum. Because prostate enlargement originates in the transition zone, the area in the center of the prostate or transit area of the urethra, prostate enlargement cannot be directly felt through the rectum.

Flow Rate Test
If the urethra becomes constricted because of prostate enlargement, there will be a reduction in the amount of urine that can be voided in a given amount of time. The stream may gradually become very small. A man may not even be aware of it. An important test is to check the flow rate.

A physician may request a uroflow test. For this test, the patient will be asked to drink a large amount of water. When urine cannot be held any longer, the physician will have the patient void into a measured container. The container may be part of a very complex computerized test instrument. The instrument can calculate the instant the first drop of urine hits the bottom; it then calculates the time until urine stops. The uroflowmeter measures the volume of urine that is voided and the amount of time that it takes per milliliter. Usually about 200 mL is needed for a valid test (200 mL is about 7 oz). A normal man under 40 years old should be able to fill a 7-oz cup in about 9 seconds or about 22 mL/sec. A normal man between 40 and 60 should require about 11 seconds or about 18 mL/sec. A normal man over 60 will need a little over 15 seconds or about 13 mL/sec. A man who has prostate enlargement may need 20-40 seconds to pass 200 mL, depending on the severity of the urethral constriction.

It can be important for urodynamic tests to be performed before any treatment is begun. Once the physician has a grasp of the scope of your problem, you may begin to have a series of treatments. Every so often the urodynamic tests are repeated and checked against the original test to determine if the treatment is having an effect. If there is no change in the rate of urine flow, then the physician may change the treatment.

Perform Your Own Home Test
You can perform your own test at home by using a measuring cup and a watch with a second hand. Drink a lot of water, then wait as long as you can to urinate. You could use something such as a 7-oz styrofoam or paper cup. If you have prostate enlargement, it will be obvious.

Postvoid Residual Urine
As obstruction of the prostatic urethra becomes greater, a patient may not be able to completely empty his bladder. He may be able to start to void, but the small stream may stop for a few seconds and then start again. He may continue to try to urinate and strain, but there may still be residual urine in the bladder.

There are several ways to detect residual urine. When a physician performs an examination, he may feel your lower abdomen to determine if there is residual urine in your bladder. The physician may have you void as much as you can then use a catheter or a cystoscope to drain the residual urine and measure it. In severe cases, there may be as much as a pint or even more of postvoid residual (PVR) urine. Incomplete voiding causes stress of the bladder walls and predisposes to infection and inflammatory changes in the bladder. In extreme cases, incomplete voiding may cause renal problems.

The doctor may also order an x-ray urogram. The patient is usually injected with a contrast dye that will show up on an x-ray. Several x-rays are taken as the dye-colored liquid is filtered from the blood and collected in the bladder. Finally, the patient is asked to void. Then, another x-ray, which can show any urine left in the bladder, is taken.

Ultrasonic Imaging
A physician can also use an ultrasound machine to determine residual urine. A residual pool of urine can be seen on an ultrasound image. Ultrasound can also be used to view the enlarged prostate. Cancerous tumor images are also seen with ultrasound.

Magnetic Resonance Imaging and Computed Tomography
Magnetic resonance imaging (MRI) or computed tomography (CT) machines are also used. These machines are very expensive and would probably only be used if there were difficulties in the diagnosis or other complications.

Cystoscopic Examination
Your physician may also want to do a cystoscopic examination. The prefix cyst is from the Greek kystis, which means bladder or sac. The cystoscope is a tubular instrument that is used to examine the interior of the bladder and other body cavities. It has thin fiber optics that conduct light and a magnifying lens at the end. A physician inserts this instrument into the urethra and examines any obstruction in the prostate. He can also examine the interior of the bladder for residual urine, muscle irregularities, and bladder stones. There are several different types of cystoscopes. Cystoscopes may be fitted with grasping forceps or with a cutting scalpel. A cystoscope has an eyepiece that the physician can look through, but it may also have provisions to electronically display the image on a television screen.

There are several different diameters for cystoscopes, catheters, probes, and sounds that are measured by the French scale. A Frenchman named Chevrrier devised this scale. The English had difficulty pronouncing and spelling Chevrrier's name, so the scale came to be known simply as the French scale. Each unit is about 1/3 mm, so a 21 French (or 21F) cystoscope is 7 mm in diameter. Because 1 mm is 0.04 inches, 7 mm would be 0.28 inches or a little more than 1/4 inch in diameter. It is not too difficult to insert a 21F cystoscope into the urethra. However, many cystoscopes and probes can be 1/2 inch or more in diameter. Physicians provide anesthesia when using these instruments.

Laboratory Tests
A urine analysis test and a blood test may be ordered to rule out any infection. These tests may include a PSA test, a test for glucose, protein, pH, occult blood, and a white blood cell count.

Biopsy
A physician may perform a biopsy to make sure that the enlarged prostate is benign. A spring-loaded needle through the wall of the rectum may be used to retrieve a sample of the prostate cells. He will take several samples from different areas of the prostate. The procedure is fairly painless. Samples are sent to a pathology laboratory for microscopic inspection.

Treatment for prostate enlargement

Watchful Waiting
Surgical Treatment
Alternatives to Surgery
There are several treatments for prostate enlargement. Many treatments involve surgery, but there are also several nonsurgical treatments. Several drugs and nutrients can be highly effective if properly used. Each treatment has advantages and usually some disadvantages. Many of the treatments may have some side effects.

Prostate cells, both normal cells and cancer cells, produce 5 alpha-reductase that converts testosterone into DHT. DHT is much more potent than testosterone.

One of the treatments for prostate enlargement is finasteride or Proscar, which is a 5 alpha-reductase inhibitor. Unfortunately, finasteride does not completely inhibit the enzyme, so it is not a perfect tool.

Remember that the prostate cells must have androgens in order to survive. Surgical castration (or an orchiectomy) can remove the principal source of tes-tosterone. (The Greek word for testes is orchid. An observation was made that the bulb of the flower looked like a testicle. Orchiectomy is the same as castration.) By using lutenizing hormone-releasing hormone (LH-RH) agonists, a chemical castration can be done using the drugs Lupron or Zoladex. These drugs are often used in men with advanced prostate cancer. The big difference is that surgical castration is permanent, while that resulting from drugs may be reversible upon cessation of the drugs.

LH-RH drugs can definitely cause shrinkage of the prostate and prostate enlargement. However, the drugs are expensive and have some very unpleasant side effects. As a result, they are not used very often for prostate enlargement.

Another drug that is often used with LH-RH drugs is Casodex. Casodex is a drug that appears to be an androgen. Casodex can fill the androgen receptors in normal prostate cells, prostate enlargement, and cancer cells.

Casodex does not suppress the production of tes-tosterone, but if there is enough Casodex circulating, it may be able to fill the androgen receptors before testosterone and DHT can reach them.

Often when a man decides to have seed implants (or brachytherapy) as a treatment for prostate cancer, the prostate might be so large that it would require an excessive number of radioactive seeds. Portions of the prostate might also be hidden and inaccessible behind the pubic bone. In these instances, often the man will be placed on high dose Casodex (150 mg a day) and/or LH-RH agonists for a period of 3-6 months to shrink the prostate.

Watchful Waiting
If prostate enlargement is not severe, only watchful waiting may be considered. The patient should check with his physician to be certain that delay in treatment does not lead to irreversible complications.

Some reasons for watchful waiting may be cost of treatment, reluctance to undergo unpleasant side effects, and inconvenience of doctor visits.

Watchful waiting does not imply that nothing is done. There are several measures that can be taken to lessen the severity of symptoms. Decreasing the intake of fluids, especially before bedtime, might help. Also moderating the intake of alcohol and caffeine might help. However, patients must realize that the natural history of prostate enlargement is progression. Therefore, eventually it may be necessary to have treatments.

These statements have not been evaluated by the FDA. These products are not intended to diagnose, treat, cure, or prevent any disease