Urinary symptoms are extremely common in men over fifty, and the immediate fear is always cancer. In the large majority the cause is benign prostatic enlargement, which is a normal part of ageing.
Distinguishing the two, and understanding what PSA testing can actually tell you, removes a great deal of unnecessary anxiety.
Why the Prostate Causes Symptoms
The prostate sits below the bladder and surrounds the urethra. As it enlarges with age, it compresses that channel and obstructs urine flow.
The bladder then has to work harder, and its muscle thickens and becomes irritable. That explains why symptoms fall into two groups: obstructive symptoms from the narrowing, and storage symptoms from the irritable bladder.
Importantly, symptom severity correlates poorly with prostate size. A modestly enlarged prostate can cause severe symptoms and a large one can cause few.
The Symptoms
Recognising both groups helps in describing them accurately.
Obstructive symptoms: weak or interrupted stream, hesitancy before starting, straining to pass urine, dribbling at the end, and a sensation of incomplete emptying.
Storage symptoms: passing urine frequently, urgency, waking at night to urinate, and occasionally urge incontinence.
Waking two or more times nightly is one of the most disruptive symptoms and the one that most often brings men to clinic, since it fragments sleep and causes daytime fatigue.
Symptoms That Are Not Simply Enlargement
Certain features suggest something other than benign obstruction and warrant prompt assessment.
- Blood in the urine or semen
- Complete inability to pass urine, which is an emergency
- Bone pain, particularly in the back or pelvis
- Unexplained weight loss
- New erectile difficulty alongside urinary symptoms
- A hard irregular prostate on examination
- Recurrent urinary infections
- Rapidly worsening symptoms
Acute urinary retention, being unable to pass urine at all with a painful full bladder, requires immediate catheterisation. Our emergency department manages this at any hour.
Understanding PSA
Prostate specific antigen is produced by prostate tissue, both normal and cancerous. It is prostate specific, not cancer specific, and that distinction is the source of most confusion.
PSA rises with: benign enlargement, urinary infection, prostatitis, recent ejaculation, cycling, catheterisation, and prostate examination.
PSA can be falsely low with: drugs used to shrink the prostate, which roughly halve the value and require the result to be doubled for interpretation.
A raised PSA does not mean cancer, and a normal PSA does not exclude it. Trend over time is more informative than a single value, and the rate of rise matters more than the absolute number.
Should You Have a PSA Test?
This is genuinely a decision to discuss rather than a straightforward yes.
The case for: it can detect cancer early, when it is curable, and prostate cancer is common.
The case against: it detects many cancers that would never have caused harm during a man's lifetime. Investigating them leads to biopsies with their own risks, and treating them can cause incontinence and erectile dysfunction for no benefit.
Testing is more clearly worthwhile in men with a family history of prostate cancer, particularly in a father or brother diagnosed young, in men of African ancestry, and in those with symptoms.
It is generally not recommended in men with a life expectancy under ten years, since any cancer found would be unlikely to affect them.
Have the conversation with a doctor before testing rather than adding it to a health package without discussion. It is included in some of our health check packages, and that inclusion should follow a discussion.
Treatment for Benign Enlargement
Treatment is guided by how much the symptoms bother you, not by prostate size.
- Watchful waiting with lifestyle measures, for mild symptoms
- Alpha blockers: relax the muscle at the bladder neck, working within days. Can cause dizziness on standing and retrograde ejaculation
- 5 alpha reductase inhibitors: shrink the prostate over three to six months. Reduce PSA by half, which must be accounted for. Can affect libido
- Combination therapy for larger prostates with significant symptoms
- Surgery: transurethral resection or newer laser techniques, for those failing medication or with complications
Surgery becomes necessary for recurrent retention, recurrent infections, bladder stones, kidney impairment from back pressure, or persistent bleeding. Our urology department assesses these.
Practical Measures That Help
Several simple changes reduce symptoms noticeably, particularly night time waking.
- Reduce fluid intake in the three hours before bed, while maintaining total daily intake
- Limit caffeine and alcohol, both of which irritate the bladder and increase urine production
- Empty the bladder before going to bed, then wait a few minutes and try again
- Avoid decongestants and some antihistamines, which worsen obstruction
- Treat constipation, since a loaded rectum compresses the bladder
- Stay physically active, which is associated with fewer symptoms
- Do not delay urinating when the urge comes
Over the counter cold remedies containing decongestants are a recognised trigger for acute urinary retention in men with prostatic enlargement, and this is rarely mentioned on the packet.
If Cancer Is Found
Prostate cancer covers a wide spectrum, from slow growing tumours that never cause harm to aggressive disease requiring prompt treatment.
Modern assessment uses MRI before biopsy, which reduces unnecessary biopsies and improves targeting. Grading using the Gleason score and staging determine risk category.
For low risk disease, active surveillance is often appropriate: monitoring with PSA, MRI and repeat biopsy rather than immediate treatment. This avoids the side effects of treatment in men whose cancer may never progress.
For higher risk disease, surgery, radiotherapy and hormone treatment are used, alone or in combination, and outcomes are generally good when treated appropriately.
The important message is that a prostate cancer diagnosis does not automatically mean immediate radical treatment, and asking about risk category and surveillance is entirely reasonable.
Urinary symptoms after fifty usually reflect benign enlargement and respond well to simple measures and medication. Discuss PSA testing rather than simply having it, and act promptly on blood in the urine or inability to pass urine.
Our urology department at T. Nagar assesses prostate symptoms and provides treatment.
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