PROSTATE

PROSTATE: a Public Service Article for Men

Dear Men,

Do NOT ignore urinary problems. They creep up slowly, starting maybe at age 50, maybe at 60 or later, but your urination may not be what it used to be. The stream doesn’t start immediately. It’s thinner. It stops, then starts when you push. You don’t feel you’ve emptied completely, evidenced by your need to go again soon. And maybe the classical waking up to pee every few hours.

If you can relate to the above, your prostate may be enlarging, reducing the flow. Your bladder may not be emptying completely. Perhaps your kidney function is not optimal.

So, go to your family doctor and start looking for answers. But don’t count on your doctor to offer you solutions. Family doctors are not supposed to know everything about every medical condition, but they are required to know enough to send you for testing or to an expert. That doesn’t always happen, and you may go for years while your prostate enlarges. First, to beyond the point where drugs and/or supplements can be effective. Then, beyond where non-invasive interventions are possible, and you need surgery.

The following case is illustrative:

H’ went to his family doctor in the year 2017 at age 65 for routine blood tests and general consultation. For several years, he had slowly increasing edema (fluid retention and spongy swelling) in his legs, and some mild symptoms urinary problems. The doctor was not alarmed and told him that these were totally normal at his age and don’t worry.

Three years later, in 2020, he again went to the family doctor. H’ had read that edema could be a sign of developing problems with his heart or kidneys. Again, the doctor calmed him and said that the edema was simply the veins getting tired. However, H’ requested kidney function tests (eGFR, which is the estimated kidney filtration rate, and creatinine), which showed suboptimal kidney function. Still, the doctor did not send him for further testing.

Finally, in July 2024, H’ switched to a different family doctor. She immediately sent him for an ultrasound of the lower abdomen. The results were shocking:

1. His prostate was 100 cm³, which is severe BPH (benign prostatic hyperplasia).
2. He had 500 mL of urine left in his bladder after “emptying”. This is a severe level of urinary retention. Normal for his age group is less than 100 mL. Urinary retention happens when the enlarged prostate does not allow free flow of the urine.

H’ made an appointment with a urologist, for which he had to wait a month. The urologist told him he must have a prostate operation, but because of the very poor way the doctor related to him, H’ scheduled an appointment with a different urologist for a second opinion.

H’ admits the mistake of acting too slowly, mostly for fear of the operation. In mid-November, his belly became swollen and hard, and he couldn’t urinate more than a few drops. He went to the hospital emergency room where he was administered a catheter, and 2.2 liters of urine were released.

While making the necessary arrangements for a prostate operation, H’ wore a catheter for 5 unpleasant weeks. The operation, using a laser (HoLEP) was a success, and H’s urination is more or less what it was 20 years ago.

During the four years before his ultrasound, H’s prostate grew to 100 cm3 from an estimate of about 60 cm3, according to standard estimates of prostate growth. If diagnosed back then, it could have been treated with a significantly less invasive procedure, such as Rezum or iTIND (see below).

MORE INFORMATION ABOUT PROSTATE DIAGNOSIS AND CARE

1. The most important thing you can do is get an ultrasound of your lower abdomen. This will measure your prostate size, how much urine is left in your bladder, kidney size, and any irregularities in the shape of those three organs.

1. Non-cancerous enlarged prostate is called BPH (Benign Prostatic Hyperplasia).

• Normal Prostate: ~20–30 mL (similar to a walnut)
• Mild BPH: 30–40 mL
• Moderate BPH: 40–80 mL
• Severe BPH: >80 mL

1. As to urinary retention, you may use the following values:

• Normal: ≤50 mL (minimal retention, no concern)
• Borderline: 50–100 mL (may require monitoring, especially in older adults)
• Abnormal: >100 mL (suggests incomplete emptying; further evaluation needed)
• Severe Retention: >200 mL (significant issue, may indicate bladder dysfunction or obstruction)

If your ultrasound shows any irregularities, make an appointment with a urologist, and do your own research about your condition.

PROCEDURES

This is a partial list of prostate procedures, meant to supply some information so you can have an educated discussion with your physician to decide what is best for you.

1. Medications (For Mild to Moderate BPH, Any Size)

• Alpha-blockers (e.g., Tamsulosin, Alfuzosin) – Relax prostate muscles to ease urination.
• 5-alpha reductase inhibitors (e.g., Finasteride, Dutasteride) – Shrink the prostate, slightly and maybe, over time.
• If testosterone levels are low, use of testosterone and possibly natural progesterone may be helpful. This is based on my examination of scientific literature, and your doctor will most likely be opposed.
• Supplements which may be helpful, and for which there is reasonable research support include: Saw Palmetto, Zinc, Lycopene, Beta Sitosterol, Pygeum, Stinging Nettle (Urtica dioica) and others.

2. Minimally Invasive Procedures (For Small to Medium Prostates, ~30-80g)

• Rezūm (Water Vapor Therapy) – Uses steam to ablate prostate tissue, effective for prostates up to ~80g.
• iTind (Temporarily Implanted Nitinol Device) – Relieves obstruction by reshaping the prostate, suitable for small-to-medium prostates (~30-80g).

3. Surgical Procedures (For Medium to Large Prostates, ~80-150g+)

• Transurethral Resection of the Prostate (TURP) – Gold standard for prostate surgery.
• Holmium Laser Enucleation of the Prostate (HoLEP) – Can be used for any prostate size, including very large prostates >100g. This is considerably better than TURP, as there are less adverse effects and recovery is quicker. TURP is more common, because few doctors have the expertise for this laser procedure. Find one.

4. Open & Robotic Surgery (For Very Large Prostates, 100-300g+)

• Simple Prostatectomy (Open or Robotic-Assisted) – For very large prostates (>100-300g), usually when other procedures aren’t effective.
• Robot-Assisted Laparoscopic Prostatectomy (RALP) – Mainly for prostate cancer removal but sometimes used for extreme BPH cases.

NOTE: I did not mention the PSA (prostate specific antigen) blood test, which is routinely done for men as they age. It may reveal cancer but has a high level of false negatives and false positives. For example, at least 70% of men with elevated PSA do not have prostate cancer and may be subject to biopsies and other worthless treatment. A friend of mine had 10 worrisome years of biopsies and other treatments before it was clear he didn’t have cancer. Do your own research and discuss with your doctor whether it’s worth getting this PSA test.