Assoc. Prof. Dr. Akif Diri
Urology Specialist
25 Years
Surgical Experience
More than 32 Thousand

Benign Prostate Enlargement

What is Prostate, What Does It Do?

The prostate is a walnut-sized gland that surrounds the urinary canal just at the exit of the urinary bladder in men. Its approximate weight can vary between 15-20 grams. In the area where the prostate surrounds the urinary tract, the semen duct (ejaculatory duct), which is formed by the merging of the duct coming from the testicles (vas deferens) and the duct of the seminal vesicle, which is another gland behind the prostate, opens into the urinary tract.

The function of the prostate gland is to produce an alkaline milky-white secretion. This secretion makes up about 30% of the semen. This alkaline secretion neutralizes the acidic environment of the vaginal environment and ensures that the sperms stay longer.

The secretory glands in the prostate gland contain various substances and are alkaline and enzymes with a protein content of less than 1%. These are proteolytic enzymes, prostatic acid phosphatase, beta-microsaminoprotein, prostate specific antigen (PSA). The cells lining the inside of these glands secrete the prostate fluid they secrete into the cavity forming the inside of the gland, and from there it is emptied into the urethra, that is, the urinary canal, through larger channels opening to the urinary canal through the ducts.

The secretory glands in the prostate gland and the Secretory Epithelial Cells lining it and the Basal Cells on the outside of them.

The relationship between stroma tissue and secretory cells is completely limited by the Basal Membrane. Therefore, while the PSA value in the semen is very high, the PSA value in the blood is very low. Because the Basal Membrane prevents PSA produced by Secretory Cells from mixing into the blood vessel and thus into the blood.

In Prostate Cancer, PSA produced by the uncontrolled and anarchic proliferation of secretory cells and the destruction of the Basal Membrane begins to pass into the blood more. For this reason, it is suspected whether the reason for the high PSA level in the blood is due to a cancer case that destroys the basement membrane, and biopsy is recommended to make a definitive diagnosis. However, there are other factors that can increase the serum PSA value other than cancer.

Benign Prostatic Hyperplasia (Benign Prostate Enlargement, BPH)​

Physiologically, around the age of 25 in men, the prostate gland enters the growth period. The growth in this period results in benign prostatic hyperplasia (benign prostatic hyperplasia, BPH) years later. Although the prostate continues to grow in the life of the man, this enlargement of the prostate does not cause significant problems in most men, except in advanced ages. BPH rarely causes distress under the age of 40. However, BPH impairs quality of life in more than half of men in their 60s and in more than 90% of patients in their 70s.

This enlargement of the prostate gland, which surrounds the urinary canal, presses on the urinary canal, causing obstruction in the urinary canal and inability to pass urine easily. For this reason, over time, thickening and sensitization begins due to strain on the bladder muscle. Even if some urine accumulates in the bladder, it starts to show itself with the feeling of urination. Over time, the bladder muscle gets tired, weak, and urine begins to remain in the bladder with the inability to empty the urine completely.

With the enlargement of the prostate, problems especially in urination and sexual functions cause the person to consult a doctor, increasing with age. With the increase in life expectancy, the incidence of BPH and related complaints also increases.

Why It Occurs?

The mechanism of BPH formation is still not clearly understood. The most important information we know in our time: BPH increases with age in men, BPH does not develop in men who had to have their testicles removed for some reason before puberty. Therefore, factors related to age and testicular function play a role in the development of BPH.

While men produce the male hormone testosterone from the testicles throughout their lives, there is also a small amount of the female hormone estrogen in their bodies. With the advancing age, the level of active testosterone hormone in the blood decreases and this decrease causes an increase in the estrogen ratio. Animal studies show that estrogen hormone, which starts to appear more effectively in the prostate with aging, triggers some basic cell developments in the development of BPH.

Another theory focuses on dihydrotestosterone (DHT), the active form of the testosterone hormone. Some researchers show that DHT levels increase and accumulate in the prostate gland, even though the level of testosterone in the blood may decrease with age. The increased amount of this active hormone is thought to trigger the development of prostate cells. The absence of BPH development in men who do not produce DHT due to an enzyme deficiency also supports this theory.

Some researchers think that chemical and genetic changes occur in the early developmental period that will lead to the development of BPH in the future, and that a developmental awakening occurs again with the advancement of age, triggered by other factors.

What are the Symptoms?

The problems that affect the social life of the person include the need to wake up to urinate during the night and to urinate frequently during the day. In particular, these two problems cause problems such as lack of sleep in the social life of the person, fatigue, and the search for the toilet where he wants to go. In addition, the force and speed of the urine flow may have decreased and slowed down compared to the past. There may be waiting and difficulty in starting to urinate, as well as a drop of urine may still come after urinating after a major part of the urine has flowed. In addition, the person may feel that the bladder is not completely empty after urinating.

7 questions asked to the patient in the international prostate symptom-symptom evaluation and scored according to the severity of the problem are given below.

  • Waiting to urinate, is there any strain?

  • Is the pressure of the urine, the flow strength less than before?

  • Do you urinate intermittently while urinating until you stop?

  • After urinating, is there still a feeling of urine remaining in the bladder, not fully emptied?

  • How many times do you get up to urinate at night?

  • Do you feel the need to urinate every two hours or more throughout the day?

  • When you want to urinate, do you experience incontinence, difficulty in reaching the toilet, compression problems?

Prostate enlargement is usually in the form of an enlargement as a benign tumor. For this reason, people usually consult a doctor when they encounter problems with urination. Occurrence of symptoms may not cause a significant health problem other than affecting social life in benign prostate enlargement. However, the graded complaints are classified as mild, moderate and severe. In prostate enlargement, which is thought to be benign with prostate examination, blood tests and prostate needle biopsy when necessary, it is decided to follow up the patients and treat them with medication or surgery according to the degree of complaints.

However, mild or severe occurrence of the above-mentioned clinical symptoms in prostate cancer (malignant prostate tumor) may mean that the early stage of treatment that will completely control the cancer has passed. For this reason, it is recommended that every man over the age of 50 should go to a doctor’s control (for prostate examination and PSA test in the blood) once a year, regardless of the above-mentioned problems. If the first degree relatives (such as father, brother, etc.) have prostate cancer, it is recommended to start the mentioned annual controls from the age of 45. Those who have prostate cancer in their first degree relatives

According to the age of the relatives, the risk of prostate cancer in cakes increases between 2-6 times compared to the normal population rates.

In summary, diagnostic methods applied in the benign evaluation of the prostate

​ Finger prostate examination
PSA in serum (total and free PSA), creatinine levels
Prostate biopsy (when necessary)
Urine flow rate measurement -uroflowmetry-
Cystoscopy (when necessary)

What are the Treatment Options?

The first step in the treatment of BPH should be medical treatment. If the expected results from the medical treatment cannot be obtained or if the symptoms that have improved despite the treatment recur over time, different treatment alternatives should be considered.

In drug treatment, drugs that relax the muscles in the prostate and provide a passage for the urine flow (alpha-blocker drugs), in addition to this, drugs that cause a decrease in the volume of the prostate (5-alpha reductase inhibitors) and some herbal drugs are used.

Alpha blocker drugs (with active ingredients; Tamsulosin, Alfuzosin, Terzosin, Doxazosin)
5-alpha reductase inhibitor drugs (Finaterid, Dutasteride)
Sabal extract (saw palmetto)

The drugs called alpha-blockers relax the muscles in the neck of the bladder (urinary bladder) and in the prostate, allowing the enlarged and obstructing prostate to relax and reducing the pressure in the urinary canal. Since the effect of the drug in the form of tablets taken orally is 24 hours, it is necessary to take 1 tablet a day continuously to ensure a continuous effect.

The drugs called 5-alpha reductase inhibitors prevent the formation of active testosterone (male hormone), which is effective in the growth of the prostate, and prevent the growth of the prostate as well as shrink the prostate. However, this shrinking effect is evident in prostate volumes over 50 grams. In addition, it is necessary to use the drug continuously for at least 6 months for the minimizing effect.

Sabal extract is a herbal medicine and has a relaxing effect on the prostate by inhibiting inflammation in the prostate and factors in prostate enlargement.

In cases where medical treatment is not sufficient, interventional treatment alternatives should come to the fore. The best alternatives in these are, in order of activity

  • Laser enucleation with Holmium laser

  • Transurethral resection (TUR), with plasmakinetic or monopolar energy

  • Open Prostatectomy

  • Applied with laser vaporization, KTP, Diode, Thulium laser

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