My enlarged prostate, not caused by cancer, creates urinary problems for me. I will describe my enlarged prostate journey and share with you what I learned along the way. One or two items of this information might help you cope with your urinary problems.

About Me   oooooooo

If you need to know more about me to help you decide if you should continue reading, here is some biographical information: I am a former clinical psychologist (retired) who was diagnosed in November of 2000, at the age of 70, as having prostate cancer. If you need even more information about me, Lawrence J. Bookbinder, Ph.D., go to the second page of this two-page website.

[If you like the information you read, emailing me your thanks will reward me for creating this website and help sustain my motivation to keep it going for future readers.]

About this Website   oooooooo

In telling my enlarged prostate story, I translated the medical terms into plain English and tried to make the medical information easy to understand.

Although this website contains many sections, it does not cover all aspects of noncancerous prostate enlargement. Instead it presents only my experiences and what I learned.

I present both basic and advanced information. Below are the links to the remaining sections of this first page of this two-page website:

• Words that Describe the Prostate
• More Attention for Prostate Cancer than for BPH
• BPH-Caused Misery in the United States
• Three Basic Facts about BPH
• The Doctor Who is a Urologist
• Symptoms of BPH
• Dangers of BPH
• Normal Prostate, Urethra, Kidneys, and Bladder
• Abnormal Growth of the Prostate
• Effect of BPH on the Bladder
• My Postvoid Residual Urine Volume
• Effect of BPH on the Kidneys
• My Inability-to-Urinate Episode
• Catheterization and Terrfying PSA Rise
• Cold Medications and the Prostate
• Measuring Prostate Volume
• My Prostate Volume
• Digital Rectal Exam
• Lifestyle Changes for Alleviating BPH Symptoms
• Nonprescription Substances for BPH
• Medications for BPH: Alpha Blockers
• Medications for BPH: 5-Alpha-Reductase Inhibitors
• Alpha Blocker + 5-Alpha-Reductase Inhibitor
• Going Beyond Medication Treatment
• Learning About Cystoscopes
• Invasive Treatment for My BPH?

Some people misspell the word "prostate" as "prostrate," one definition of which is to position oneself facedown on the floor. To help me remember the difference between the two words, I think of inside versus outside--something inside the body versus the outside of the body on the floor.

Doctors label my noncancerous enlarged prostate as "benign prostatic hyperplasia." However, they usually call it "BPH."

"Benign" means noncancerous. "Hyperplasia" means enlargement of a body part caused by an abnormal increase of the number of its cells.¹

A less frequently used label for a noncancerous enlarged prostate is "benign prostatic hypertrophy." "Hypertrophy" means excessive growth or an abnormal enlargement of a body part caused by an increase in the size of its cells.¹

Other words will be defined when they are first mentioned.

More Attention for Prostate Cancer than for BPH   oooooooo

I have noticed that prostate cancer receives vastly more coverage in newspapers, in magazines, and on television.

There are more than a few books devoted to prostate cancer and others devoted to the three common prostate diseases (the third being prostatitis--an infected or inflamed prostate). I know of no book devoted to BPH.

I have also noticed that there are vastly more exchanges of information on the internet about prostate cancer than about BPH. These exchanges occur via "discussion boards," also called "discussion forums" or "mailing lists." For example, I know of nineteen internet prostate cancer discussion boards but only one BPH board.

I have participated in prostate cancer support groups in four different locations in my county. I know of a fifth one in which I have not participated. I know that there are prostate cancer support groups throughout the United States but I know of no BPH support group in the United States.

One likely reason for vastly more information and support for prostate cancer patients is that BPH rarely kills you. Although BPH is far less deadly than prostate cancer, its many inconveniences and worries add up to make many of us miserable. BPH is a quality-of-life killer. Examples from my life:

• Since 1995 or thereabouts, I buy only dark-colored pants so that if I dribble after urinating, it would not show as much as it would, say, on a beige pair of pants. I would love to wear a wider variety of colors.
• If I am eating a leisurely dinner with a group in a restaurant, I often have to excuse myself during the meal to go to the restroom and urinate.
• After urinating, I stand for three or four minutes holding a Kleenex to the tip of my penis until my dribbling stops. I am embarrassed to do this while standing at a urinal so I prefer to urinate into a toilet in an enclosed stall.
• If I am in a hurry and do not urinate before I leave my home for, say, a one-hour drive, I worry I will lose control and wet my pants, which has, fortunately, never happened.
• When I go to bed without having had a bowel movement that day, I begin worrying that the next day I might be unable to urinate and have to rush to a hospital emergency room to have a catheter (thin flexible tube) threaded through my penis and into my bladder to drain my bladder.
• I usually awaken two times in the middle of the night to urinate, which causes my sleep to be less restful. After the second urination, I sometimes cannot get back to sleep. The result is that on too many days I am tired and drag myself through the day.

Now I will move from me to all men in the United States. About 50% of men age 51 to 60 develop BPH. This percentage increases with age so that by age 80, about 90% have BPH.² By contrast, 16% of males born in 2006 will have prostate cancer at some point in their lives.³ My guesstimate is that at least three times as many men are suffering from BPH as compared with men suffering from prostate cancer.

The numbers above justify my belief that we BPH patients are entitled to as much help as prostate cancer patients receive! Inadequate or no medical care for BPH patients may lead to severe pain, intense anxiety, or permanent damage to the bladder and kidneys.

• only men have this abnormality because females do not have a prostate
• a man can have both BPH and prostate cancer (I'm an example)
• having BPH does not increase a man's chances of developing prostate cancer⁴

Most men know little about the prostate--what it does or where it is.⁵ I was one of them until I was diagnosed as having prostate cancer and began:

• reading books, printed and website articles, and discussion boards
• learning from other patients, especially during prostate cancer support group meetings
• consulting different types of doctors who diagnose and/or treat prostate disorders

This type of doctor is a specialist in urinary problems of males and females and in reproductive problems of males. Some specialize even further. Examples are the urologist who:

• only treats men unable to have erections (erectile dysfunction);
• has a subspecialty in implanting a device in women to help them control their leaking of urine (urinary incontinence);
• never works with BPH patients because he limits his practice to children
• specializes in kidney-transplant surgery.

I consult a medical oncologist (treats all types of cancers with medications) who specializes in prostate cancer and a urologist with expertise in urinary problems of men and women. At both of their offices, I completed an International Prostate Symptom Score questionnaire, developed by the American Urological Association,^6,7,8 which evaluates the severity of BPH symptoms.

I rated, on a zero to five-point scale, seven urinary problems. The only one of the following problems I do not have is the sixth one:

• sometimes feel I have not emptied my bladder after urinating
• often urinate again less than two hours after urinating
• often stop and start more than once before I finish urinating
• occasionally find it difficult to postpone urination
• often have a weak urinary stream
• have to push or strain to begin urination
• interrupting my sleep to urinate

The total scores, which help decide on a BPH treatment, are categorized as follows:

•  1 to  7 is Mild. Usually no treatment is advised. This option is often called "watchful waiting."
•  8 to 19 is Moderate. Often medication is advised or sometimes invasive treatment, such as prostate surgery.
• 20 to 35 is Severe. Usually invasive treatment is advised.⁹

In the Summer of 2005, at least 14 years after I was diagnosed with BPH, I became aware of three serious problems it can cause. I wish I had the information in this website when I learned I had BPH and hope that this website will help you protect yourself from these problems, which are:

• inability to pass even a drop of urine
• damage of the bladder
• damage of the kidneys

To help you understand why an enlarged prostate can cause problems, I will begin by presenting a little information about the normal:

• prostate
• urethra
• kidney
• bladder

The urethra is a tube one end of which is at the tip of the penis. It tunnels through the penis, through the "cored apple" (prostate), and attaches to the bladder.

The kidneys filter waste products from the blood to produce urine. Attached to each kidney is a tube (ureter) which goes down to the bladder. Urine flows from each kidney through the ureter into the bladder.

The bladder is a "...big bag. Stretched to its fullest, this muscular tank can hold about a pint of urine."¹³ When the brain signals the bladder to urinate, it opens its "valve" (internal sphincter) and squeezes out the urine into the urethra.¹⁴ Urine then flows through the urethra and out the tip of the penis.

The prostate can grow outward and/or inward. When it grows inward, it squeezes the urethra, which reduces the force of the urinary stream.

Usually the prostate grows both outward and inward¹⁵. With a few men, the prostate grows only outward. Thus, it will not squeeze the urethra, which leads to the situation of a large prostate but no urinary problems. Also, with a few men, the prostate grows only inward. Thus, it will squeeze the urethra, which leads to the situation of a small prostate with urinary problems. Therefore, the size of the prostate does not always predict urinary problems¹⁶ but most of the time it does.

If the prostate is growing inward and continues to grow inward, it eventually will squeeze the urethra to the point that urine can no longer flow through it, an emergency medical situation, which the doctors call "acute urinary retention."

What are the effects of a squeezed urethra on the bladder? It empties itself by contracting its musculature to push urine out of it and into the urethra. If the urethra has been narrowed, the bladder has to work harder, which over the years results in it becoming muscle bound, a permanent disorder. A muscle-bound bladder has a thickened wall and less elasticity, which leads to, for example:

• less capacity to store urine
• filling up more quickly than a normal bladder
• less ability to push out urine¹⁷
• not emptying completely (see next section)

Other names for this term are "residual urine volume" or simply "residual urine." This measurement, similar to a man's score on the American Urological Association's questionnaire, helps evaluate the seriousness of a BPH disorder.

I have had mine measured by two different machines: a simple ultrasound machine which used a device placed against the skin of my lower abdomen¹⁸ and a color doppler ultrasound which used a lubricated probe inserted into my rectum.

My measurements were:

05/15/01: 132 cc
09/19/02:   70 cc
10/22/03:   68 cc
04/28/05:   61 cc
10/26/05:   29 cc

If you have a residual urine which goes beyond the 100 to 150 cc range, ¹⁹ this is one of the factors which helps a urologist decide to recommend treatment for BPH.

Effect of BPH on the Kidneys   oooooooo

What are the effects of a squeezed urethra on the kidneys? When the bladder cannot empty completely, over the years it holds back a larger and larger volume of urine ("urinary retention"), which can eventually block the flow of urine from the kidneys, which in turn impairs the kidneys' ability to filter waste products. This rare problem results in uremic poisoning which can cause "coma and death."²⁰

Speaking of BPH, coma, and death, I will present relevant information about the death of the third president of the United States, Thomas Jefferson. Here is the best information I could find on whether he died from BPH: "Racked with pain from rheumatism and an enlarged prostate, Jefferson could barely move when invited to attend ... the 1826 Fourth of July festivities...." He did not attend because of his illnesses. On July 4, 1826, he "lapsed into a coma and died....²¹"

The following research finding about the kidneys and BPH disturbed me: Longstanding urinary retention doubled the risk of a man developing chronic kidney disease. Moderate to severe BPH symptoms tripled the risk. An enlarged prostate which did not cause urinary obstruction did not pose a kidney risk.²²

Before I tell you about my episode, you will need to know what is a catheter. It is a thin flexible tube. One type of catheter, called a Foley catheter (sometimes called a "balloon catheter"), has a small deflated balloon at the end which is inserted into the urethra and threaded through the urethra into the bladder. The balloon is then inflated, which prevents the catheter from slipping out of the bladder.²³

After three days of not having a bowel movement, I found myself, on 10/05/02 at about 11:45 pm, completely unable to urinate, in pain, and intensely anxious. My wife hurriedly drove me to the urgent care department of a large and respected clinic. The physician who saw me, who was not a urologist, immediately ordered a Foley catheter inserted and then left the examining room.

A staff member who looked about 25 years of age came into the room carrying a plastic-encased Foley kit. His nametag did not indicate he was a registered nurse (R.N.). As he ripped open the plastic wrapping, I asked "How many Foleys have you done?" "About 5 or 10," he replied. I then said "I'd prefer to have someone who has done at least 50 do the Foley." He cheerfully responded with "I'll try to get someone for you."

Three minutes later, a woman who looked about 40 years of age came into the room. Her nametag indicated she was an R.N. She looked at the kit the young man had left and exclaimed "It's the wrong one!" She returned with the right Foley kit and installed it. After the installation, I immediately passed a huge volume of urine and felt greatly relieved.

Nine days later, a nurse who assisted my urologist removed my catheter. After its removal, I was able to urinate without its aid.

My urologist agreed with my belief that constipation combined with my enlarged prostate caused me to be unable to urinate.

Later I began taking a prescription medication, a 4-teaspoons daily dose of a 10gm/15 ml solution of Lactulose, which helps me avoid constipation. It is a stool softener which uses a different method to soften stools than over-the-counter docusate sodium (one brand is Colace), which helped me less than Lactulose.

Eighteen days after my catheter was removed, my PSA (a blood test used to help diagnose and monitor prostate cancer), which was 5.22 on 08/28/02, skyrocketed to 18.2 on 11/01/02. I immediately thought that my cancer had escaped my prostate (metastasized). The urologist with whom I had discussed this disturbing finding ordered another PSA in the event it was a laboratory error.

The next day I talked about this finding and my panic about it during a prostate cancer support group meeting. The urologist who served as a regular consultant to this group (a rare activity for a prostate cancer doctor) told me that the PSA jump could have been caused by the catheter insertion traumatizing my prostate, and, if so, that my PSA would probably soon return to its pre-catheterization level. This information brought my panic down to the level of anxiety. Unfortunately, my other urologist had not mentioned this possibility.

The consultant's prediction turned out to be correct, as indicated by the following trend: My PSA dropped from 18.2 (on 11/01/02) to 12.7 (11/22/02) to 6.76 (12/13/02) and remained in the 5 to 7 zone without any upward or downward trend. (For example, it was 5.45 on 06/11/03).

Even if you do not have prostate cancer, learning that you have a PSA of more than 18 will likely make you think you suddenly developed a case of prostate cancer.

Some urologists advise BPH patients not to use over-the-counter decongestants or antihistamines.²⁴ I learned this from reading, not from any of the urologists I consulted. An example of the importance of this advice follows:

I was sitting in the waiting area of the urology department in a large clinic and started talking with a woman who was waiting for her husband to finish his visit with his urologist. She informed me that her husband, who had prostate cancer and an enlarged prostate, once suffered an inability-to-urinate episode after taking some cold medication.

My prostate size has been measured by three different methods, only one of which was used during a particular evaluation or monitoring visit. These were:

• black-and-white transrectal ultrasonography;
• color doppler transrectal ultrasonography (a combination of black-and-white and color doppler ultrasonography);
• magnetic resonance imaging combined with magnetic resonance spectroscopy, sometimes called "spectroscopic MRI."

My guesstimate is that as of June of 2006, no more than 5% of prostate ultrasounds are done with color doppler equipment and no more than 5% of prostate MRIs are done with spectroscopic MRI equipment. One reason for this infrequent useage is the cost of the equipment. An example is that in 2002, the cost of a color doppler machine was about $250,000. This is unfortunate because these tests yield much more prostate cancer information than black-and-white ultrasounds and plain MRIs.

From my participation in prostate cancer suppport groups, I learned that many men newly diagnosed with prostate cancer did not know the volume of their prostate. I was one of them. One reason that volume is important is that it sometimes influences the choice of treatment for both prostate cancer and BPH.

For purposes of comparison, the volume of a normal prostate is similar to that of a walnut, about 20 cubic centimeters (cc). Prostate volume is also measured by weight in grams (gm). The two methods of reporting volume are roughly equivalent, that is, a 20 cc prostate is about the same volume as a 20 gm prostate. (I remember reading this cc-and-gm statement but I do not remember where.)

Here's the record of my prostate volume measurements as measured by black-and-white ultrasound (BWUS), color doppler ultrasound (CDUS), or spectroscopic MRI (SMRI):

11/09/00:  68 cc (BWUS)
04/02/01:  67 cc (SMRI)
05/15/01:   68 cc (BWUS)
04/03/02:   68 cc (SMRI)
09/19/02: 109 cc (CDUS)
04/03/03:   87 cc (SMRI)
10/22/03: 116 cc (CDUS)
04/28/05:   85 cc (CDUS)
10/26/05:   80 cc (CDUS)
02/03/06:   84 cc (CDUS)

The doctor who did my 02/03/06 CDUS said that the downward trend in my prostate volume beginning with the last five CDUS measurements was caused by my taking Avodart, which can shrink the prostate.

The doctor inserts a gloved, lubricated finger into the rectum and presses on the prostate to determine if there are abnormalities, such as lumps or enlargement. This exam, often called a DRE, can only feel part of the prostate.

To prepare for a DRE, doctors would instruct me as to how I should position my body. Each chose one of two ways:

• bending over an examining table, placing my forearms on the table, and placing my feet about two feet apart
• lying on my side on the examining table and placing my knees about nine inches apart

I have had DREs by a physicians assistant, primary care doctors, urologists, and medical oncologists specializing in prostate cancer. The DREs done by the urologists and my medical oncologist impressed me as being more skillful.

Lifestyle Changes for Alleviating BPH Symptoms   oooooooo

Unfortunately, none of the urologists I consulted recommended these changes. I learned about them from a book²⁵ about three years after I received my prostate cancer diagnosis. These changes may control the symptoms of BPH and might stop your problem from getting worse:

Limit fluids at bedtime. Stop drinking fluids a few hours before going to sleep to reduce the number of times you have to wake up to go to the toilet. I have difficulty following this recommendation, which contributes, as of May, 2006, to interrupting my sleep two times a night.

In about 2004, during a prostate cancer support group meeting, one of the men, who also had BPH, startled me when he disclosed that he does not eat or drink anything after 3:00 PM.

Empty your bladder When you urinate, try to release as much urine as you can. What helps me do this is to sit on the toilet whenever one is available. After my first round of urination, I wait but do not try to force urine out; often I will then experience a second round of urination.

Limit alcoholic beverages. When you drink alcohol, you produce more urine and you can cause your prostate to become congested.

Limit over-the-counter decongestants. They can cause your urethral sphincter (think of a valve) to tighten, causing urination to be more difficult.

Exercise. Being inactive leads to urinary retention. Only a minimal amount of exercise can ease this problem.

Keep warm. If you feel cold, you will experience urinary retention.

Avoid delaying urination.²⁴

Avoid caffeine. Also limit spicy or salty foods.²⁶

Nonprescription Substances for BPH   oooooooo

Men use one or more substances derived from plants to alleviate urinary problems. Some of these substances are:

• Saw palmetto (serenoa repens).²⁷
• Rye grass (secale cereale).²⁷ I used a brand named Cernilton.
• Pygeum (pygeum africanum).²⁷
• African wild potato, also known as South African star grass (hypoxis rooperi).²⁷ A third name for this substance is beta sitosterols.²⁸
• Stinging nettle made from above-ground parts (urtica dioica and urtica urens). Another name is common nettle.²⁷

I was using all of these substances (except for beta sitosterols) at one point in my BPH journey but gradually discontinued them after being prescribed Flomax and Avodart.

Nine days after after I had my Foley catheter removed (see my Inability-to-Urinate Episode), my urologist prescribed 0.8 mg of Flomax. I then consulted another urologist, who reduced the dose to 0.4 mg. Later, when my urinary symptoms worsened, he doubled the dose. Typical daily dosages are either 0.4 or 0.8 mg.³¹

Flomax (also known as tamsulosin) is an alpha blocker, which is designed to relax the urethral sphincter (a valve), sometimes causing a reduction in urinary problems. Other alpha blockers used are:

• Hytrin (terazosin)
• Uroxatral (alfuzosin)
• Cardura (doxazosin).³²

Medications for BPH: 5-Alpha-Reductase Inhibitors   oooooooo

My medical oncologist, who monitors my prostate cancer, initially prescribed 0.5 mg of Avodart for two reasons: to slow the progression of my prostate cancer and to reduce my urinary problems. Several months later, he recommended I double the dose because it was not sufficiently lowering my dihydrotestosterone (DHT), measured by a blood test.

Avodart (dutasteride) is a 5-alpha-reductase inhibitor, which reduces BPH symptoms by shrinking the prostate. An older 5-alpha-reductase inhibitor, Proscar (finasteride), also shrinks the prostate. Both are much more effective with a large prostate, such as mine.

An important caution: Either Avodart or Proscar will lower PSA by 40 to 50 percent. For example, my PSA went from 5.0 to 2.6. However, this was a masking effect, not an indication of a significant reduction of my prostate cancer.³¹

A 5-alpha-reductase inhibitor is not always effective. If it is effective, improvement of urinary symptoms will be seen within 3 months and even better results within 12 months³³.

Although both Avodart and Proscar were designed to treat BPH, they are sometimes prescribed to treat prostate cancer³⁴ (called "off-label" usage). Their use for prostate cancer treatment is controversial.

Alpha Blocker + 5-Alpha-Reductase Inhibitor   oooooooo

Some men take either an alpha blocker or a 5-alpha-reductase inhibitor for their BPH. Others, such as me, take both. A research study showed that taking both of these medication types produces better results than taking only one type.³⁵

The study used the alpha blocker Cardura and and the 5-alpha-reductase inhibitor Proscar, neither of which I am taking. However, since I am taking medications in the same categories, I believe that I am getting better results than if I used only one of my medications.

My medications alleviated my urinary problems for the first few years but beginning around January of 2006, these problems began to get worse.

Going Beyond Medication Treatment   oooooooo

There have been great advances in treatments that are more powerful than medications with the result that in 2006 men have many choices. The prostate tissue that squeezes the urethra is now eliminated by cutting it out or destroying it with electricity, radiofrequency energy, lasers, or microwave energy. Below is a list of the treatment names:³⁶

• transurethral resection of the prostate (TURP)
• open prostatectomy (different from radical prostatectomy)
• transurethral electrovaporization of the prostate ((TUEVP)
• transurethral incision of the prostate (TUIP)
• holmium laser prostatectomy
• potassium-titanyl-phosphate (green light) laser vaporization, also called photoselective vaporization of the prostate (PVP)
• transurethral microwave thermotherapy (TUMT)
• transurethral needle ablation (TUNA)
• interstitial laser coagulation (ILC)
• water-induced thermotherapy (WIT)
• stents in the urethra
• botulin toxin, also known as Botox (experimental)³⁷

Learning About Cystoscopes   oooooooo

The reason I became motivated to learn about cystoscopy in explained in the next section. What I learned is that urology patients are sometimes examined with an instrument called a cystoscope, a thin tube which has "a light and lens on one end and a viewing lens on the other."³⁸ There are two versions, an older one with a rigid tube, sometimes called a standard cystoscope, and a flexible one, which "may be less uncomfortable for the patient."³⁹

Before the examination, the urethra is numbed by squirting anesthetic jelly into the urethral opening at the tip of the penis.⁴⁰ Then the light-and-lens end of the cystoscope is inserted into the urethra, through the penis, through the prostate, and finally into the bladder. The cystoscope's path of travel allows the doctor to see inside the urethra and bladder, which enables him or her to diagnose abnormalities such as:⁴¹

• prostate enlargement
• urethral obstruction (blockage)
• bladder stones

Invasive Treatment for My BPH?   oooooooo

My urologist, during my 05/15/06 visit, startled me by raising the issue of an invasive BPH treatment for me, possibly transurethral microwave thermotherapy (TUMT). He recommended a cystoscopic examination to help him determine which type of treatment would be most suitable. I became upset about possibly having invasive treatment and also upset about possibly having a cystoscopy, which would be my first.

When my wife and I left his office, I was shaking inside. Fortunately, I became less disappointed in myself for being anxious after I read that it was normal for a man to become intensely anxious after he is advised to undergo cystoscopy.⁴²

After I calmed down, three days later, I began seriously thinking about having an invasive treatment. On 06/11/06, I thought:

• I need to have an invasive treatment before my prostate, measured on 02/03/06 as 84 cc, grows to 100 cc, at which point my treatment options would be reduced. I have no doubt it will eventually reach 100 cc, despite my being on Avodart, a prostate-shrinking medication.
• My chronic inability to empty my bladder completely (urinary retention) is slowly destroying my kidneys. The sooner I stop this process, the better.

The next and final page of this two-page website contains the following four sections:

• Sources of Information and Notes
• Recommended Reading
• BPH Discussion Board Link
• Information about Me

DISCLAIMER: The purpose of this website is to educate you about BPH, not to give you medical advice. Therefore, before you use any of the information in this website, discuss it with your physician(s) and/or healthcare practitioner(s). I am not responsible for any negative effects you may experience from reading and/or using the information in this website and/or the resources to which it guides you.