Benign Prostate Enlargement
BPE is the bread and butter of a Urologist’s practice. It is one of the most common urological complaints of elderly men. Almost all elderly men develop an enlarged prostate, the problem often starting after the age of 40 years. Leading a healthy and active lifestyle may decrease the risk for developing BPE symptoms. The symptoms in these cases can either be obstructive in nature, such as hesitancy in starting urination, poor and intermittent urinary stream or straining during micturition. Other patients may have irritative symptoms, such as frequency, urgency with or without urinary incontinence or nocturia (getting up once or more at night to pass urine). In some cases, the patient may get used to these symptoms and the presentation may be in the form of some complication like urinary infection, urinary retention, blood in urine, urinary bladder stones or kidney damage due to chronic urinary obstruction. On your visit to the doctor, he will ask about these symptoms; along with these, he may ask about your fluid intake and dietary habits. He may examine your abdomen for presence of distended urinary bladder or do a finger rectal examination to assess your prostate. You may also be advised urinary and blood tests and an ultrasound of the kidneys, prostate and bladder. A urinary flow test may be advised to assess your urinary flow. Most of these patients are managed with medications. These medications offer relief in the symptoms. It is important to understand that like medications for hypertension or diabetes, these medications are also required to be taken daily and lifelong, as this disease is age related and usually either stabilizes or increases with age. For patients who do not benefit with medications, those who don’t want to take long term medications or those with other indications for surgery (like kidney damage or recurrent urinary retention etc), surgical management is the treatment of choice. Currently, minimally invasive techniques are the surgical options of choice (TURP, Holium laser enucleation of prostate (HoLEP)). The surgery is done by the natural urinary route and there is no external incision. The patient is usually discharged in 1-2 days and the long term success rate is high.
Prostate Cancer
Prostate cancer is the most common urological cancer in males. Most of the times prostate cancer is diagnosed incidentally. Most of these patients present with urinary symptoms due to benign prostate enlargement; during evaluation of which the doctor may prescribe a blood PSA test (prostate specific antigen). A raised PSA or an abnormal digital rectal examination will guide the doctor to perform a prostate biopsy, which is the confirmative test to diagnose prostate cancer. Prostate biopsy is a daycare procedure, usually done under local anesthesia and associated with minimal morbidity. Depending on the biopsy report and your PSA levels, further investigations using either a Bone scan or PET scan may be done to stage the disease and decide the treatment approach. The field of prostate cancer treatment is rapidly advancing, with new drugs being developed and treatment protocols being regularly updated. It is important to understand that prostate cancer diagnosis is not a death sentence. In many cases, the patient may finish his natural lifespan without the disease causing any decrease in the longevity. In other cases, the disease can be treated by minimally invasive surgery or radiation therapy. In case the disease spreads to other parts of the body (metastatic disease), several medical and surgical treatment options are available to effectively control the disease. The most important part of the treatment for metastatic prostate cancer is regular intake of medications and strict follow up with the treating urologist.
Urinary Tract Infections
Young males uncommonly get urinary tract infections, and in those who do, there is usually an underlying urological cause (such as phimosis, urethral strictures, urinary stones, urinary tract abnormalities etc). In other cases, urinary infection may be due to sexually transmitted organisms. However, in older patients with benign prostatic enlargement, urinary tract infections can be quite common and recurrent. Urinary tract infections in males may present with fever, irritative urinary symptoms (frequency, urgency, urge incontinence), burning micturition or suprapubic discomfort. In some cases, urinary infections in males may get complicated in the form of infections of the testicles (epidydimo-orchitis), prostate (prostatitis) or rarely seminal vesicles (seminal vesiculitis). The infection may also spread to the kidneys, where it may cause pathology of increasing severity if untreated (pyelonephritis, pyonephrosis, renal abscess, emphysematous pyelonephritis etc). In milder infections without any obvious underlying cause, the doctor may simply treat the infection with oral or injectable antibiotics. Other cases might need drainage of infected collections (DJ stenting or percutaneous nephrostomies for pyonephrosis, pigtail drainage for renal abscesses, transurethral drainage of prostatic abscess or orchidectomy for testicular abscess). Definitive treatment of any underlying pathology is essential to ensure the infection gets cured and doesn’t recur.
Urethral Stricture Disease
Narrowing in the urethral lumen is called as urethral stricture disease (USD). There are many causes of urethral stricture (previous minor trauma in the form of straddle injury), sexually transmitted infections like gonorrhea (less common nowadays) and chronic skin conditions (Balanitis xerotica obliterans). USD often affects young and middle aged men and usually presents with thin stream (pencil tip like thin) or straining and hesitancy during micturition. Sometimes, these cases may present with urinary tract infections or occasional blood in urine. On visiting the urologist, he will ask your symptoms history and might examine your urinary opening for narrowing. Further investigations are done using a urine routine examination and culture, uroflometry and a urinary dye study to delineate the extent and severity of narrowing. Treatment options include endoscopic incision of the stricture segment (OIU) or open surgery (urethroplasty). OIU has a success rate of around 80-85% in the first sitting, which reduces to ~50% in the second sitting and 0% from the third sitting onwards. OIU is also less successful for longer and tighter strictures. Depending on the severity of the stricture, the urologist may or may not advise self-dilatation by the patient after surgery. For patients with longer strictures or previous OIU failure, open urethroplasty is the treatment for choice. In this procedure, usually an incision is made between the scrotum and the anal opening and the stricture segment is removed and the normal urethral ends joined to each other. In some cases, skin may be taken from the penis or inside the cheeks to increase the lumen of the urethra. The cheek wound is not visible from the outside and usually heals with minimal sequalae. In most cases, this disease is highly treatable with good surgical outcomes. Salvage procedures may be required in complex cases and patients with previous multiple treatment failure.