Prostate, Bladder and Urinary Incontinence – By Dr. Gnana Sankaralingam
Prostate is a gland located at the neck of the bladder surrounding the urethra in men. It starts enlarging after the age of 50, obstructing the outflow of urine by compressing, and distorting the urethra to produce symptoms. It produces fluid which mixed with sperms produced by testicle, makes up the semen, which is passed into the urethra by the action of muscles of the prostate. It also converts Testestorone into biologically active form.
Prostate enlargement occurs in the elderly males, probably due to diminishing hormonal (androgen) effect. It presses urethra producing symptoms like difficulty to initiate urination, increased frequency, weak stream, stopping and starting (intermittency) several times during passing urine, dribbling at the end of urination and difficulty to empty bladder. Enlarged prostate does not always cause problem. Severity of symptoms depends on extent of obstruction of the urethra. It is diagnosed by performing rectal finger examination, and if necessary ultrasound using rectal probe and direct views through urethra using cystoscope. It is managed initially using medicines to shrink the enlarged gland, and to relax the neck of bladder to ease the flow. Problems do not worsen in everyone and severe complications are rare in many. Complications include sudden blockage (Acute retention) where the person is in extreme discomfort unable to pass urine, requiring insertion of a tube (catheter) to drain the bladder, or urine filling up the bladder slowly due to inability to empty the bladder fully (Chronic retention) which could result in infection of bladder and incontinence where urine dribbles around the blockage. Surgery is done on those with recurrent complications or not responding to drug therapy. These are transurethral resection of prostate (TURP) performed using a cystoscope, Holmium laser treatment using a fibre passed through urethra and open transvesical prostatectomy done through abdominal incission using a laparoscope.
Prostate cancer is frequently slow growing making survival rate quite high with symptoms often absent in the early stages. About 15% of men get prostate cancer, and It is linked to genetic factors, where one is more than twice likely to get it if his father or brother had suffered from prostate cancer. It can spread locally to tissues near or other parts of the body particularly lower back. Common presentation are blood in the urine or low back pain. If detected early, can often be removed in its entirety. It is diagnosed by feeling the gland at per rectal examination, ultrasound with rectal probe for imaging of the prostate and taking samples using needle for studies and blood tests for PSA levels. X-Ray of back is done to find out any bone deposit and CT scan is done to detect spread elsewhere in the body. For those which are confined to the gland, total removal of prostate is done. For localised one in early stages, radiotherapy is given lasting for few minutes and repeated after six weeks. If it had spread to other parts of the body, options are either chemotherapy or hormone therapy or combination of both. Even for advanced cancer, prognosis is good with treatment.
Prostate Specific Antigen (PSA) test measures the level of this protein in blood, which is produced by the prostate. It is recommended if one has symptoms of enlargement of prostate. Since early stages of prostate cancer often show no symptoms, PSA screening is helpful in detecting cancer before it has advanced. High levels of PSA do not definitely prove its presence (false positive), and normal levels do not guarantee its absence (false negative). PSA can be raised in old age due to enlargement of prostate, inflammation (Prostatitis) and procedures such as per rectal examination, catheterisation and instrumentation of urethra. It can also go up in urinary tract infections and ejaculation. PSA can be bound to protein or circulate free, which if high is likely to be benign, and if low there is risk of cancer.
Bladder functions as a reservoir for urine produced by the kidneys, and empties it through urethra by muscle action, when the need arises. Leakage of urine is prevented by the bladder neck and the urethral sphincter. Often when volume builds to 600 ml, feeling to void urine comes, but bladder could hold much more without causing any discomfort to the person. Obstruction to its outflow would result in retention of urine in the bladder. Types of obstruction such as enlarged prostate, large stone in ureters or narrowed urethra (stricture) creates back pressure on kidneys, causing dilatation of draining system (calyx), and damage to filtration mechanism (nephron), which if not relieved may end in kidney failure.
Bladder can get infected due to obstruction to the flow causing stasis of urine, by bacterial organisms which present with burning on passing urine, increased frequency of urinatioin and fever. This is treated with appropriate antibiotics recommended by urine test. Rarely infection can be by tuberculosis secondary to kidney infection where bladder shrinks called thimble bladder, and by blood flukes which cause bleeding from bladder. Bladder can be the site of stones either passed down from kidneys or originating in it. Cancerous growth can occur in bladder, which presents with blood in the urine and other symptoms mimicking urinary infection. Investigations include cystoscopy to view the growth and take samples for examination and CT scan to detect any spread. Most tumours are confined to the inner wall of the bladder, which need surgical removal through cystoscopy and post surgery instillation of chemotherapy retained inside bladder for one hour and drained. If the risk of recurrence is high, six doses of chemotherapy are given and second cystoscopy and resection is done in six weeks time. If the tumour had spread to the wall, bladder is removed and post surgery radiotherapy is given. Artificial bladder is created using segment of small intestine, ureters implanted on it, one end closed and the other end brought out to drain into a bag.
Incontinence occurs when one is unable to control the bladder as a result of the disruption of normal process of storing and passing of urine. This could happen either due to distortion of the bladder neck or malfunctioning of urethral sphincter. Stress incontinence is leaking out due to weakening of pelvic floor muscles when bladder is under pressure such as coughing or laughing. This happens in womb prolapse. Urge incontinence is leaking out due to overactivity of bladder muscles, where one feels a sudden intense urge to pass urine. This happens in bladder infection. Overflow incontinence is leaking out due to inability to empty the bladder fully, resulting in overfilling. This happens in prostate enlargement and diabetes. Total incontinence is leaking out constantly, due to inability to contain urine by the bladder.This happens when sphincter control is defective as in old age or after spinal injury.
