When should I be concerned about an enlarged prostate?

When to Be Concerned About an Enlarged Prostate

Men should be concerned about an enlarged prostate when experiencing bothersome lower urinary tract symptoms (LUTS), particularly if symptoms are moderate to severe, or when complications such as urinary retention, recurrent infections, bladder stones, or renal insufficiency develop. 1

Understanding Prostate Enlargement and LUTS

Benign prostatic hyperplasia (BPH) is extremely common in aging men:

• 60% of men have BPH by age 60
• 80% of men have BPH by age 80 2

The prevalence of moderate-to-severe LUTS increases with age, reaching nearly 50% by the eighth decade of life 1. However, not all men with enlarged prostates develop symptoms or complications.

Warning Signs That Require Medical Attention

Immediate Medical Attention Required:

• Inability to urinate (acute urinary retention)
• Painful urination with fever
• Blood in urine (hematuria)
• Renal insufficiency secondary to BPH
• Recurrent urinary tract infections
• Bladder stones 1

Concerning Symptoms That Warrant Evaluation:

Storage Symptoms:

• Frequent urination (especially at night/nocturia)
• Urgency (sudden, compelling desire to urinate)
• Urge incontinence 1

Voiding Symptoms:

• Weak urinary stream
• Hesitancy (difficulty starting urination)
• Intermittency (stopping and starting)
• Straining to urinate
• Incomplete emptying sensation 1

When to Seek Medical Evaluation

1. Symptom Severity: When symptoms become bothersome enough to affect quality of life 1

2. Symptom Progression: When symptoms worsen over time, particularly if they're interfering with daily activities or sleep 1

3. Abnormal Findings:

   • A walnut-sized prostate in an 80-year-old man is unusual and warrants evaluation, as most men this age have some degree of prostatic enlargement 2
   • If LUTS are present despite a small prostate, other causes should be investigated 2

4. Risk Factors for Progression:

   • Prostate volume >30cc
   • PSA >1.5 ng/mL
   • Age >60 years 3, 4

Evaluation Process

When concerned about prostate enlargement, the following evaluations are recommended:

1. Medical History and Symptom Assessment:

   • Use validated questionnaires (AUA-SI/IPSS) to assess symptom severity 1, 2
   • Assess how bothersome symptoms are (bother score) 1

2. Basic Tests:

   • Urinalysis to rule out infection or hematuria 1, 2
   • Digital rectal examination (DRE) to assess prostate size and rule out suspicious findings 1
   • PSA measurement in men with at least a 10-year life expectancy 1
   • Post-void residual measurement 2

Risk of Complications

Without treatment, men with significant BPH are at risk for:

• Acute urinary retention (6.8 episodes per 1,000 patient-years overall, increasing to 34.7 episodes in men aged 70 and older) 1
• Need for BPH-related surgery (10.1% risk in placebo groups over 4 years) 3
• Urinary tract infections 1
• Bladder stones 1
• Renal insufficiency (rare) 1

Treatment Considerations

When symptoms are bothersome enough to warrant treatment:

• For prostates >30-40 mL: Consider combination therapy with an alpha-1 blocker and a 5-alpha-reductase inhibitor 4
• For smaller prostates: Alpha-1 blockers are typically first-line therapy 4
• For predominant storage symptoms: Consider adding antimuscarinic medications 5
• For significant nocturia: Consider desmopressin 1

Common Pitfalls to Avoid

1. Ignoring symptoms: Many men consider LUTS a normal part of aging and delay seeking care until complications develop.

2. Focusing only on prostate size: Not all men with enlarged prostates have symptoms, and not all men with LUTS have significantly enlarged prostates 6.

3. Overlooking other causes: LUTS may be caused by conditions other than BPH, including bladder dysfunction, neurological conditions, or medication side effects 1.

4. Delaying treatment: Early intervention in high-risk patients (large prostate, elevated PSA) can prevent complications like acute urinary retention and need for surgery 3.

Remember that the degree to which symptoms bother the patient is more important than objective measures in determining the need for treatment 6.