Diagnosis and Treatment of Prostate Enlargement: A Guide for Africans

 

By Oluwasola Samuel, Freelance Writer. With medical review and editorial support by the DLHA Team

An Elderly African Man

 

 

Takeaway

• Not everyone with benign prostatic hyperplasia (BHP) will always have symptoms. In situations where this happens, treatment may not be required and a “wait and watch” position may be adopted following discussions with your healthcare provider.

• Before treatment commences, your healthcare provider will discuss options that you can choose from based on your age, the size of your prostate, and your health condition. This helps you to pick the best treatment procedure for your overall circumstances.

• In the absence of widespread health insurance in most African countries, financial hardship and out-of-pocket spending for BPH care often restrict care options for many African men especially in the rural communities. Hence, there is a need for the institution of health insurance generally in Africa.

 

 

Introduction

 

Benign prostatic hyperplasia (BPH) is also known as an enlarged prostate. It is a common urological condition that affects older men above 50. People who have this condition experience narrowing or sometimes blockage of their urethra (a tube that transports urine from the bladder out of the body). When the urethra is narrowed or blocked, it causes difficulty emptying the bladder.

If you have an enlarged prostate, you may experience no symptoms. Sometimes, symptoms could also be mild or severe. Furthermore, if you have an enlarged prostate, there is a possibility you may begin to experience symptoms like difficulty voiding urine, lower abdominal pain, a weak urine stream, or pain while urinating.

In this article, you will learn how benign prostatic hyperplasia (enlarged prostate) is diagnosed and the treatment options available to you.

 

 

How is BPH Diagnosed? 

 

Early diagnosis of benign prostatic hyperplasia is important to avoid life-threatening complications. Some people with an enlarged prostate may be asymptomatic (experience no symptoms). If you are at risk for prostate enlargement, it's crucial to go for a checkup even if you don't feel any symptoms. Going for a checkup puts you in a better position to diagnose the condition early.

There are several diagnostic tests for benign prostatic hyperplasia; they include:
 

1. Digital rectal examination

 

This test is carried out to find out the size, texture, and if there is a lump or bump on your prostate. Before the test, your healthcare provider wears and lubricates a clean glove on the examining hand or finger. The lubricated gloved finger is inserted into your back body (rectum), while you bend on a couch with your back body to the healthcare provider. This is done to have a feel of your prostate while checking the size, and the texture.

 

2. Urine flow test

 

This test is also known as uroflowmetry. [1] It's done to measure the volume of urine released from your body, urine speed, and how long urination lasts.  This test aims to know how serious your prostate enlargement is or whether the condition is improving or not. 

 

3. Transrectal Ultrasound

 

Your healthcare professional conducts this invasive imaging test with a device that is inserted into your rectum (back body). This device uses a sound wave to scan and create a detailed image of your prostate. The image helps your healthcare professional get a clear view of the size, shape, and internal structure of your prostate.

 

4. Transabdominal Ultrasound

 

This is a non-invasive imaging test that uses sound waves that are applied with a device placed on your lower abdominal wall to scan and create a detailed image of your bladder and prostate. This test is carried out to check the size of your prostate, possible obstruction, and the amount of urine left in your bladder after urinating. 

 

5. Prostate magnetic resonance imaging (MRI)

 

This imaging technique helps to differentiate between prostate cancer and BPH. The test also checks for complications and severity of your BPH. 

The MRI is done using strong magnetic fields and radio waves to scan and create a detailed image of your prostate. The images that the MRI provides are far superior when compared to other imaging techniques.

 

6. Prostate-specific antigen (PSA) blood test

 

The epithelial cells in the prostate produce a protein that is called Prostate Specific Antigen or PSA. When your prostate is enlarged, PSA increases. Also, when PSA is higher than normal, it could be a sign of prostate cancer.  

 

7. Cystoscopy

 

For this test, your healthcare professional inserts a cystoscope (a flexible, thin tube) through your urethra. [2] This thin tube has a small light and camera attached to it. The light and camera provide a clear picture of your urethra, bladder, and prostate.

 

8. Filling out questionnaires

 

This is the first line of tests conducted to help find out if you have an enlarged prostate or not.

Questionnaires are helpful tools. The questionnaire contains questions that help to understand your medical history, lifestyle, and symptoms. It's important to note that it doesn't diagnose benign prostatic hyperplasia.

 

 

How is BPH Treated?

 

When symptoms begin to cause complications, treatment will be required. At first, it may not be necessary to receive treatment if your condition is mild. Your healthcare professional may recommend observing your condition (the “wait and watch” approach. Scheduled regular checkups will be required to see if your condition worsens or improves.

But, if symptoms become severe or life-threatening, treatment may be recommended. Before treatment commences, your healthcare professional will discuss a treatment plan with you. The treatment plan will be based on several factors.

These factors include:

• Your age

• The size of your prostate

• The severity of your symptoms

• Your overall health condition

• Other medical conditions.

 

 

Treatment Options Available for Benign Prostatic Hyperplasia

 

If you have symptomatic benign prostatic hyperplasia, the good news is that there are several treatment options available to you. These treatment options include: 

• Lifestyle changes

• Medications

• Surgery (Minimally invasive and Open). 

 

The urologist is better placed to advise you about the best treatment option. A combination of the above-listed treatment options may be advised for the management of your BPH.

  

Lifestyle changes 

 

If you have a mild symptom, your healthcare professional may recommend lifestyle changes. At this stage, you will be monitored and advised to visit your urologist for regular checkups and proper monitoring.

The lifestyle changes are advised to help you reduce the risk factors associated with this condition include: 
 

• Dieting

• Avoiding or staying away from alcohol

• Avoiding consumption of liquid a few hours before going to bed

• Avoiding or staying away from caffeinated drinks

• Engaging in physical activities or exercise, especially pelvic floor exercise

• Bladder training to hold up urine for a longer period

 

Medications

 

If your condition worsens, or there is no significant improvement after adopting lifestyle changes, medication may be included along with lifestyle changes.

 

Some of these medications include:
 

1. Alpha-1 adrenergic blocker

Alpha-1 blockers act on your prostate to relax the smooth muscles of the gland. It then allows urine to flow freely through the urethra. The effect relieves the symptoms of BPH but does not cure the condition. Examples of this class of drugs include Alfuzosin and Tamsulosin. 

 

2. Phosphodiesterase-5 inhibitors

Originally, this medication was used to treat erectile dysfunction. But urologists can now prescribe it to help relieve benign prostatic hyperplasia symptoms.

Once administered, it reduces the symptoms in your lower urinary tract. It relaxes the fine muscles in your lower urinary tract. Once this is achieved, it improves symptoms and the flow of your urine.

More research is needed to be sure if phosphodiesterase is a safe treatment option for BPH.

Examples of this class of drugs include Tadalafil and Sildenafil. 

 

3. 5- alpha-reductase inhibitor

This medication targets an enzyme called 5-alpha-reductase. This enzyme plays a vital role in the conversion of testosterone, a male sex hormone. It converts it into a more potent form called dihydrotestosterone (DHT). DHT is crucial for prostate growth. When the 5-alpha-reductase inhibitor is administered, it blocks the conversion of testosterone to DHT. This then leads to the shrinking of the prostate. As the prostate shrinks, symptoms begin to improve, ensuring you live a normal life.

Examples of 5-alpha-reductase inhibitors include Finasteride and Dutasteride.

 

4. Combination of Medication

Your healthcare professional may prescribe to you a combination of drugs.

Several studies, such as the Medical Therapy of Prostate Symptoms (MTOPS) study, show how combinations of drugs like finasteride and doxazosin can prove to be quite effective. [3] The study found that combinations of both medications were more effective. They prevented the progression of prostate growth and symptoms compared to when used alone.

Other drugs that could also be combined are:

• Dutasteride and Tamsulosin [4]

• Alpha-blockers and antimuscarinics.

 

Surgery: Minimal invasive procedures

 

Minimally invasive procedures are surgical treatment options you would want to consider. These procedures are carried out when lifestyle and medication have failed to improve the symptoms of your BPH.

The procedures require less cutting and offer a faster recovery period. They involve the use of needles, tubes, devices, or scopes.

 

The procedures include:
 

1. Transurethral microwave thermotherapy (TUMT)

One way to tackle benign prostatic hyperplasia is through TUMT. Here, the procedure targets enlarged tissues in your prostate, destroying them using a heat wave.

Here is how it is done:

Your urologist inserts a special microwave urinary catheter (a thin, flexible tube) through your urethra. The aim is to get it close to your prostate gland. This catheter has a special tip that emits heat waves. When on-site, the catheter heats your enlarged prostate tissue. The heated tissues die off, and the prostate shrinks. This gives more room for urine to flow easily through your urethra.

 

2. Transurethral Needle Ablation (TUNA)

This procedure uses radiofrequency energy to destroy enlarged prostate tissues.

Here is how it's done:

Your urologist inserts a cystoscope (a syringe-like device that has a flexible end) through your urethra to your prostate gland. Needles are then inserted through the cystoscope. Once the inserted needles reach your prostate, a high-frequency radio wave is sent through these needles. The heat then destroys the targeted excess prostate tissues. This eventually makes more room in your urethra to ensure you urinate with ease.

 

3. Water Vapour Thermotherapy

This type of procedure uses heat water to heat overgrown parts in your prostate.

Here is how it's done:

Your urologist inserts a catheter (a tiny flexible tube) into your urethra. The tip of the catheter has a balloon which is made to rest on your prostate. Heated water is run through the catheter into the balloon. The balloon becomes hot and gradually heats the overgrown tissues of your prostate. Your body absorbs the dead excess part. This gives more space in the urethra for easy urine flow. 

 

4. Prostate Lift

This procedure is like when a water hose in your garden is blocked due to something resting on it. As a result, the flow of water is blocked. If you want water to flow properly, you have to lift off the obstruction.

Here is how it's done:

Your urologist inserts an anchor-like pin through your urethra into a specific location of your prostate. This pin lifts and pegs your prostate backward, leaving enough space for urine to flow through your urethra easily. 

 

5. Prostatic stent insertion

This procedure is like scaffolding, a structure for temporary or permanent support.

Here is how it's done:

Your urologist inserts a stent (a flexible tube made of silicon or flexible metal) through your urethra. The stent is guided to the location where your urethra is blocked by the enlarged prostate. Once at the site, the prostatic stent is carefully placed at the location, and it expands like a spring. It pushes back the overgrown tissue. This in turn widens your urethra and makes more room for the free flow of urine through your urethra.

 

Surgery: Invasive/Open

 

Surgery will be required for BPH treatment when medication or minimally invasive procedures aren't effective.

There are many types of invasive/open surgeries. These include:

 

1. Transurethral resection of the prostate (TURP)

 

This is the most common surgery for treating benign prostatic hyperplasia. It is considered the gold standard treatment for treating benign prostatic hyperplasia.

Here is how it's done:

Your urologist uses a resectoscope (a thin lighted tube with a loop) to safely cut excess prostate tissue. The resectoscope is powered by an electric current, while the loop at the end of the resectoscope cuts through excess tissues. This gives room to the urethra for the free flow of urine. After the procedure, your urologist flushes out the excess prostate tissue cut-off.
 

2. Transurethral microwave thermotherapy (TUMT)

 

This procedure requires your urologist to insert a catheter through your urethra. Once the catheter reaches your prostate, the tip of the catheter sends out microwave energy. The microwave energy destroys the inner part of your enlarged prostate. As a result, your prostate shrinks and there is less pressure on your urethra. This creates enough space for the free flow of urine.  
 

3. Transurethral incision of the prostate (TUIP)

 

This surgery is carried out on people who may be at risk if other surgeries are done.

Here is how it is done:

In this surgery, your urologist makes use of two devices. The first is a cystoscope (a syringe-like device with a flexible end), and the other is a resectoscope (a thin lighted tube). These two devices are guided through your urethra to reach your prostate. The thin lighted device is then used to make small cuts in your prostate. This makes it easier for urine to pass freely through your urethra.

 

4. Laser Surgery

This procedure involves using a high-energy laser to kill enlarged tissue in your prostate.

Here is how it is done:

Your urologist uses a cystoscope to pass a laser fiber through your urethra. The aim is to guide it to your prostate. Once on site, the high-energy laser is used to cut off enlarged prostate tissues. Afterward, blood vessels are sealed off to ensure bleeding doesn't occur. After surgery, you will be able to urinate freely because your urethra is free.

 

5. Open prostatectomy 

This surgery is different from others. This is because your urologist will have to make one or two cuts around the lower part of your abdomen. The cuts are required to gain access to your prostate. At this point, your prostate is either cut off partly or completely. This procedure allows the free flow of urine through your urethra.

 

This surgery is carried out only in severe cases. If you have an overgrown prostate, complications, or liver damage, this procedure may be required.

 

 

What are the Challenges of Treatment of BPH in Africa?

 

Some of the challenges of BPH treatment in Africa will be considered in three sections for your understanding..

 

Healthcare Provider Factors

 

• There are no guidelines on treatment

 

In developed countries, there are laid down professional treatment guidelines for BPH. However, in Africa, there are little to no treatment guidelines on how BPH should be treated. [5] Because of this, the treatment of BPH varies amongst urologists and general practitioners. 

 

• Ignorance of BPH by general practitioners

 

There aren't enough available urologists in many countries of sub-Saharan Africa to treat BPH patients. As a result of this, many patients are being treated by general practitioners who may not have the all-round knowledge or skill to treat BPH. This leads to variable outcomes and sometimes sub-standard care.  

 

Patient factors

 

• Poverty

 

Africa is one of the poorest continents in the world. According to the World Bank, sub-Saharan Africa accounts for almost 60% of the world’s extremely poor with 40% of the poor living in countries like the Democratic Republic of the Congo, Madagascar, Nigeria, and Tanzania. [6]

In the absence of widespread health insurance, these statistics paint a clear picture of how poverty impacts healthcare delivery in the continent.

The cost of surgery can be a heavy burden for an average African. This can hinder access to appropriate care and how BPH is managed. Furthermore, the average African may not be able to afford the cost of diagnosis and drugs.

 

• Low Health Literacy

 

Due to low health literacy and the influence of belief systems, some African men with an enlarged prostate associate it with a spiritual attack, a curse, or strange beliefs. These beliefs in turn dictate or influence the time and place where they seek help. Many prefer to visit spiritual leaders or other strange places for treatment options.

 

• Late reporting of the condition

 

Another major stumbling block is the late reporting of the condition to the hospital. Low awareness of this condition contributes to its late reporting. Furthermore, lack of trust in the healthcare system and low purchasing power (money) are also contributory factors. Delays in  accessing professional care leds to complications and poor tretament outcomes. 

 

Infrastructural factors

 

• Poor healthcare facilities

 

Many sub-Saharan African nations have persistent challenges with access to healthcare delivery, healthcare facilities, and electricity. Many of the available healthcare facilities are either too old, functioning poorly; while the ones functioning are poorly maintained and poorly funded. All these infrastructural challenges negatively impact the diagnosis and outcome of treatment of BPH in Africa, especially in rural communities.

 

• Inadequate manpower

 

The shortage of qualified and adequate healthcare professionals imposes limitations to the delivering of quality healthcare services to people in Africa.

According to the World Health Organization (WHO), it's projected that in 2030, the shortage of African healthcare workers will reach a staggering 6.1 million. [7] That will be a 45% increase from the 2013 estimate.  If many skilled health workers continue to leave for greener pastures, it could cripple the healthcare system.

 

• Acceptance of alternative medication

 

In Nigeria for example, many unregistered and substandard drugs and medicaments are thriving. These products are aggressively advertised and are accepted by the public. As many Africans for various reasons prefer self-medication to visits with healtcare professionals, their exposure to substandard drugs and the harm associated with them are quite high.  

 

• Poor data availability and management

 

The availability and management of data is a big issue in many countries of sub-Saharan Africa. Because of the paucity of data about the burden, characteristics of patient presentations and challenges of BPH care, etc., public health and professional policies for broad care improvements are lacking.

 

 

Recommendations

 

• Public health managers and other stakeholders in health in sub-Saharan African countries should improve mass literacy campaigns and health education about prostate disorders. This will encourage early presentation of the condition.

 

• Improved quality staffing is needed in both rural and urban centres for quality healthcare provision to people with BHP.

 

• Research and training institutes of excellence in urology should be set up in countries of sub-Saharan Africa. This will enable medical graduates to get optimal training to meet up with the demand in each country and more especially in their rural areas.

 

• Universal health coverage and public and private health insurance should be promoted to reduce out-of-pocket spending and the burden of healthcare cost on the citizenry. These will in turn boost access to care and improve the quality of life of patients with prostate disorders among many other health issues.

 

• Treatment and management guidelines should be formulated to standardise effective BPH care across rural and urban health facilities. This may serve to streamline care coordination and facilitate efficient resource utilisation between the various centres of care. 

 

• Support for more research is needed to drive the collection of data for public health and professional decision making that will improve access and care quality for BPH sufferers.

 

 

Frequently Asked Questions (FAQ)

 

How do I perform a prostate self-examination to know if I have enlargement or not? 

 

Regular self-examination of your prostate can help detect any abnormalities or signs of potential prostate issues. While self-examination is not an adequate substitute for professional medical care, it can serve as an early detection tool.

 

Self-examination steps:

• Preparation: Start by emptying your bladder and ensuring you are in a relaxed state of mind.

 

• Positioning: Choose a comfortable area in your home where you can bend forward while standing and that provides privacy and unhurried access to your rectal area (back body).

 

• Glove up: Wear a clean or sterile non-latex glove on the examining hand.

 

• Lubrication: Apply water-based lubricant or unscented petroleum jelly to the finger after your thumb (the index finger).

 

• Insertion: Gently insert your lubricated and gloved index finger into your back body (rectum) to feel your prostate.

 

• Examination: Examine the texture and size, and check for any irregularities like lumps.

 

• Repeat: Perform this exercise once a month or as advised by your healthcare professional. 

 

Can BPH damage my kidney?

 

Yes, Benign Prostatic Hyperplasis or BPH can damage your kidney if left untreated for a long period. Kidney problem is a rare condition that only occurs in severe cases. When BPH is severe, chronic kidney disease can result in kidney failure. At this point, your kidney won't be able to filter waste products out of your body. It's crucial to report any urinary symptoms you may have to your healthcare professional.

 

What's the best treatment for an enlarged prostate?

 

Transurethral resection of the prostate (TURP) is considered the “gold standard” for the treatment of prostate enlargement. It is the most effective treatment for BPH cases especially in resource limited countries where professional skills and facilities for more sophisticated minimally invasive procedures are in short supply. TURP has fewer side effects and faster recovery time compared to open surgical option. However, medication is recommended for adults around 65 years or older.

 

 

Conclusion

 

Benign prostatic hyperplasia is a condition that affects only men. Not only can its symptoms be mild, they can also be severe. Furthermore, BPH can result in life-threatening complications that require invasive procedures or other surgical options to manage.

 

Policymakers should work with health professionals to create policies and programs that will raise awareness for early presentation of BPH cases and improve the efficiency of healthcare delivery in Africa generally.

 

 

References

1. Urology Care Foundation. What is uroflowmetry? [Internet. N.d.]. Cited 2024 Mar 4. Available from: https://www.urologyhealth.org/urology-a-z/u/uroflowmetry.

2. Gleason JL. Cystoscopy and Other Urogynecologic Procedure. Obstetrics and Gynecology Clinics of North America, 40(4) 2013, 773-785, doi.org/10.1016/j.ogc.2013.09.003. Available from: https://www.sciencedirect.com/science/article/pii/S0889854513000855.

3. Lee J. Medical therapy of prostatic symptoms (V2) [Dataset]. NIDDK Central Repository. 2023. https://doi.org/10.58020/b3ns-nq56. Cited 2024 Mar 4. Available from: https://repository.niddk.nih.gov/studies/mtops.

4. Mayo Clinic. Dutasteride and Tamsulosin (Oral route). [Internet. Last updated March 1, 2024]. [Cited 2024 Mar 4]. Available from: https://www.mayoclinic.org/drugs-supplements/dutasteride-and-tamsulosin-oral-route/side-effects/drg-20074350?p=1

5. Lerner LB, McVary KT, Barry MJ, Bixler BR, Dahm P, Das AK, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA Guideline Part 1—initial work-up and medical management. J Urol. 2021. 206(4) 806-817.  doi.org/10.1097/JU.0000000000002183. Available from: http://www.auajournals.org/doi/10.1097/JU.0000000000002183.

6. Dabalen, A. Africa still can: A call to create more and better jobs to end poverty [Internet. Published Oct. 17, 2023]. [Cited 2024 Mar 4[]. Available from: https://blogs.worldbank.org/africacan/africa-still-can-call-create-more-and-better-jobs-end-poverty.

7. World Health Organization. Chronic staff shortfalls stifle Africa’s health systems: WHO study [Internet. [Published Oct. 17, 2021]. WHO | Regional Office for Africa. [Cited 2024 Mar 4]. Available from: https://www.afro.who.int/news/chronic-staff-shortfalls-stifle-africas-health-systems-who-study

 

Related: 

Prostate Enlargement in African men: Causes, Symptoms and Complications

 

 

Published: March 7, 2024

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