Urinary symptoms in older men are often a sign of a common, normal and benign condition called Benign Prostatic Hyperplasia (BPH).
Every day, patients enter Dr. Michael O’Leary’s office thinking they have prostate cancer. They have urinary symptoms that worry them. They’re assuming the worst.
Dr. Michael O’Leary, a urologist and Director of BWH Men’s Health Center at Brigham and Women’s Faulkner Hospital, listens calmly as his patients explain their symptoms.
“I have to go all the time,” they typically say. “And when I need to pee, I have to get to the bathroom fast. I also get up three times a night to go. It’s not, cancer… is it?”
Dr. O’Leary explains that he will perform a physical evaluation, often including a digital rectum exam, as well as order a blood test that screens for prostate cancer, but he’s quick to reassure a worried patient.
“I’m quite confident you don’t have prostate cancer,” he says.
“How do you know?”
“If these are your symptoms, it’s not prostate cancer,” says Dr. O’Leary. “Prostate cancer is a silent disease.”
Often, the next question is: Then what’s going on?
The Prostate Grows with Age
The prostate, a small walnut-shaped gland that produces seminal fluid, naturally increases in volume with age. It begins growing at puberty and never stops. Once the prostate reaches a certain size, some men develop urinary symptoms, including weak stream of urine, leaking or dribbling of urine, and more frequent urination, especially at night.
“These are normal symptoms of aging, and in the vast majority of people, it’s not cancer. I explain to patients that while these symptoms can sometimes be a nuisance, they are symptoms of a non-cancerous condition called benign prostatic hyperplasia (BPH), a condition every man eventually develops later in life,” says Dr. O’Leary.
About half of all men older than 75-years-old have some symptoms of BPH. The condition does not cause cancer, affect a man’s fertility, or cause erection problems.
Within minutes of meeting with Dr. O’Leary, an anxious patient is relieved.
To Take Medication, To Not Take Medication
Most patients leave Dr. O’Leary’s office accepting their symptoms as a natural part of aging. “This is just a part of getting older,” is a common remark. They go on with their lives, reassured that BPH is common, normal and completely benign.
“However, if urinary symptoms are bothersome or interfere with patient’s quality of life, there are medications,” says Dr. O’Leary. “The main class of drugs is known as alpha blockers, which help relax blood vessels and improve blood flow. There are many of these medications available; they have few side effects and have been used widely for decades. However, if medication doesn’t work there are also potential surgical options.”
Your Doctor Will Still Check for Cancer
It’s a sobering reality, but every man will develop prostate cancer if they live long enough, according to Dr. O’Leary. That is why even men with BPH still receive a full evaluation and blood work. It is important to note that cancers of the prostate are not typically aggressive and are routinely treated. Dr. O’Leary also reminds patients that some small cancers can develop that will never become life-threatening.
The prostate-specific antigen (PSA) test now detects 100% of prostate cancers. Most urologists recommend PSA screening between the ages of 55 and 69. Men with an increased risk of prostate cancer should begin screening at 40. Those at increased risk include men with a first-degree relative with prostate cancer and African Americans who are at higher risk.
Other Non-Cancerous Prostate Problems
In addition to BPH, other inflammatory conditions of the prostate can cause urinary symptoms. One benign condition of the prostate is called prostatitis, which is inflammation of the prostate. Nine percent of visits to urologists are coded as prostatitis, according to Dr. O’Leary.
Dr. O’Leary says the condition is not well understood among healthcare providers, including urologists. If a bacterial culture reveals an infection, the treatment is antibiotics, but in some cases the inflammation does not have an identifiable cause. Alternatively, acute bacterial prostatitis is a rare condition, where patients have an infection and present with a fever and require antibiotics.
It’s not all About the Prostate
Not all urinary symptoms are due to an enlarged prostate. Some men “train” their bladders to go more frequently. “The more you pee, the more you pee,” says Dr. O’Leary. “But patients can learn to re-train their bladders by not going to the bathroom immediately when they feel the urge.”
Another factor to consider is sleep patterns, which change with age. Dr. O’Leary has seen many patients who were told that their prostate was causing their urinary symptoms. The patients saw a sleep specialist who diagnosed them with sleep apnea. They began using a continuous positive airway pressure (CPAP) machine and slept through the night, proving that their symptoms were not related to their prostate.
Another point to consider: “Many men wake up at night and become aware that they have to pee, so they get up and go. However, are they awake because they really have to pee, or are they simply thinking, ‘Since I’m up, I guess I could pee now?’” If you hold it, the bladder will learn to send urges only when it is full.
One other factor involves the pelvic floor muscles, a layer of muscles that support the pelvic organs and span the bottom of the pelvis. “A lot of men who have high pelvic floor tone typically have higher than average urinary symptoms. Many years ago, doctors used to say these men had chronic prostatitis, but it’s not that simple,” says Dr. O’Leary.
A Part of Getting Older
“I’ve been taking care of men a long time, so I know how they think. Most guys think the worst before they think otherwise,” says Dr. O’Leary.
The majority of men leave Dr. O’Leary’s office without a pill, which they would need to take for the rest of their lives. Some patients learn about BPH and make lifestyle changes, such altering their diet, limiting caffeine intake and avoiding fluids before bedtime.
All men of a certain age should remember that the prostate grows larger with age, and this can cause urinary symptoms. It’s not cancer, however. It’s normal, and just a part of getting older.
– Dustin G.