An enlarged prostate means the gland has grown bigger. Prostate enlargement happens to almost all men as they get older. As the gland grows, it can press on the urethra and cause urination and bladder problems.

An enlarged prostate is often called benign prostatic hyperplasia (BPH) or benign prostatic hypertrophy. It is not cancer, and it does not raise your risk for prostate cancer.

Causes

The actual cause of prostate enlargement is unknown. Factors linked to aging and the testicles themselves may play a role in the growth of the gland. Men who have had their testicles removed at a young age (for example, as a result of testicular cancer) do not develop BPH.

Similarly, if the testicles are removed after a man develops BPH, the prostate begins to shrink in size.

Some facts about prostate enlargement:

The likelihood of developing an enlarged prostate increases with age. BPH is so common that it has been said all men will have an enlarged prostate if they live long enough.
A small amount of prostate enlargement is present in many men over age 40 and more than 90% of men over age 80.
No risk factors have been identified other than having normally functioning testicles.

Symptoms

Less than half of all men with BPH have symptoms of the disease, which include:

• Dribbling at the end of urinating
• Inability to urinate (urinary retention)
• Incomplete emptying of your bladder
• Incontinence
• Needing to urinate two or more times per night
• Pain with urination or bloody urine (these may indicate infection)
• Slowed or delayed start of the urinary stream
• Straining to urinate
• Strong and sudden urge to urinate
• Weak urine stream

Exams and Tests

After taking a complete medical history, your doctor will perform a rectal exam to feel the prostate gland. The following tests may also be performed:

• Urine flow rate
• Post-void residual urine test to see how much urine is left in your bladder after urination
• Pressure flow studies to measure the pressure in the bladder as you urinate
• Urinalysis to check for blood or infection
• Urine culture to check for infection
• Prostate-specific antigen (PSA) blood test to screen for prostate cancer
• Cystoscopy

Treatment

The choice of a treatment is based on the severity of your symptoms, the extent to which they affect your daily life, and the presence of any other medical conditions. Treatment options include “watchful waiting,” lifestyle changes, medication, or surgery.

If you are over 60, you are more likely to have symptoms. But many men with an enlarged prostate have only minor symptoms. Self-care steps are often enough to make you feel better.

If you have BPH, you should have a yearly exam to monitor the progression of your symptoms and determine if any changes in treatment are necessary.

Even though it may seem awkward to talk with your doctor about erectile dysfunction, go in for an evaluation. Problems getting or keeping an erection can be a sign of a health condition that needs treatment, such as heart disease or poorly controlled diabetes. Treating an underlying problem may be enough to reverse your erectile dysfunction.

If treating an underlying condition doesn’t help your erectile dysfunction, medications or other direct treatments may work.

Erectile dysfunction is the inability to maintain an erection firm enough for sex, on an ongoing basis. Symptoms related to erectile dysfunction may include:

• Trouble getting an erection
• Trouble keeping an erection
• Reduced sexual desire
• When to see a doctor

A family doctor is a good place to start when you have erectile problems. See your doctor if:

• Erectile or other sexual problems are an issue for you or your partner
• You have diabetes, heart disease or another known health problem that may be linked to erectile dysfunction
• You have other symptoms along with erectile dysfunction that may not seem related

IMRT treats difficult-to-reach tumors in the prostate with greater precision than conventional radiation. As a result, doctors are able to use higher radiation doses and minimize damage to the surrounding healthy tissue.

There are several ways IMRT differs from conventional radiation therapy:

• Employs a powerful, advanced software to plan a precise dose of radiation, based on tumor size, shape and location.
• Delivers prostate cancer radiation in sculpted doses that match the exact 3D geometrical shape of the tumor, including concave and complex shapes.
• Adjusts the intensity of radiation beams across the treatment area as needed with laser accuracy.

Because of its greater degree of accuracy, IMRT may be a treatment option if you have reached the maximum allowable dose of prostate cancer radiation therapy and have a recurrent tumor in the treated area.

Hope for Infertile couples

Approximately 15 – 20% of couples have difficulty initiating a pregnancy. These numbers are increasing as couples defer parenthood until later in life. While much emphasis is placed on the evaluation and treatment of the female partner, male factors impact fertility in 50% of infertile couples.

Early evaluation of the man allows timely treatment and limits the necessity for expensive testing of his partner. This also permits any serious underlying disorders to be detected and treated appropriately. Treatments focus on improving the quality of sperm, and may be as easy as avoiding certain environmental exposures or optimizing the timing of intercourse.

Most subfertile men can be helped after a proper evaluation with a male infertility specialist. Even men with no sperm in their ejaculate can often initiate a pregnancy.

Do I need an infertility specialist?

While most urologists receive some instruction concerning the evaluation of subfertile men, the vast majority of urology training programs do not emphasize infertility in their curriculum. In addition, the microsurgical skills necessary to treat many urological conditions associated with infertility require intensive and meticulous training. For this reason several male infertility fellowships have been established around the country. Candidates who are accepted into these programs receive a year or two of additional training specifically in the evaluation and treatment of subfertile men. Due to the relatively few physicians who complete male infertility fellowship training, these specialists represent a small, tightly knit medical community. Active participation in the infertility community ensures state of the art care for patients in the rapidly changing world of infertility evaluation and treatment.

How will I be evaluated?

Upon making an appointment, you will receive an information packet and detailed questionnaire. Answering the questionnaire helps direct your office evaluation. Men are encouraged to bring their partners with them to their appointment. This facilitates the evaluation and permits any female fertility factors to be addressed. Once the history and physical examination are complete, a semen sample is often requested. Men who have had recent, properly performed semen analyses may not need to supply another sample. The initial appointment usually takes about one hour. Further evaluation, often with hormonal or genetic testing, is the then initiated as indicated.

Semen Analysis

The semen analysis is the cornerstone of the male infertility evaluation. While it only takes one sperm to fertilize the egg, millions of sperm are necessary for proper sperm functioning. Semen samples can vary extensively from one time to another. To accurately assess the quality of semen, at least two samples separated by several weeks are required.

I Have Low Sperm Counts

Many subfertile men have low sperm counts. Sometimes this is only transient, or an artifact due to improper semen analysis. When low counts (called oligospermia) are truly present, they are often associated with dilated veins in the scrotum, called varicoceles. Varicoceles are present in about 30% of all men undergoing infertility evaluations. Varicoceles appear to impair sperm production and function by increasing the temperature of the testicles. The vast majority of well-performed studies have demonstrated significant improvement in semen quality and pregnancy rates after varicocele repair. Varicocele repair is performed as an outpatient procedure. While there are many methods of varicocele repair, our specialists utilize the microsurgical technique. This technique has a better success rate and a lower complication rate than the standard techniques for varicocele repair. In addition, it is performed through a one to two inch incision and there is no need to cut across muscle. This allows much quicker recovery and less post-procedural discomfort.

Low sperm counts can also be caused by subtle hormonal abnormalities or environmental exposures such as medications, tobacco, pesticides or solvents. Identification of these abnormalities/exposures and proper treatment can help to improve sperm counts

Finally, very low counts may be due to underlying subtle genetic abnormalities. Accurate diagnosis is made with genetic testing from cells obtained with a swab of the inner cheek. These men often require advanced techniques such as in vitro fertilization (test tube baby) to father children. However, with proper testing the success rates and risks of passing any genetic abnormalities on to their offspring can be determined.

I Have Low Sperm Motility

Decreased sperm motility (asthenospermia) is common. As is the case with low sperm counts, low motility is often a transient phenomena, or due to an improperly performed semen analysis. However, among men with true low motility, many will have dilated veins in scrotum called varicoceles. Please refer to the I have low sperm counts section for more information about varicoceles.

Low motility can also be due to various environmental exposures such as tobacco, pesticides and solvents. Sometimes, antisperm antibodies cause low motility. Antibodies normally fight infection in the body; however, in some men these antibodies attack their own sperm. If this is suspected, special testing for antibodies is performed. When sperm counts are normal, the antibodies can be washed off the sperm and the sperm used to inseminate their partners.

Finally, white blood cells in the semen can impair motility. Like antibodies, white blood cells usually fight infection. When they are in the semen, however, they often damage sperm. Treatment can be as simple as a short course of antibiotics.

I Have No Sperm in my Semen

The most common cause of having semen containing no sperm is vasectomy. Vasectomies can be reversed with very high success rates. For more information, please see the Vasectomy Reversal section.

About 10% of all infertile men have no sperm in their semen (azoospermia). Many of these men have normally functioning testicles, but the ducts which transport the sperm from the testicles are blocked. Using microsurgical techniques, these ducts can be unblocked and couples can then have children naturally.

Occasionally, men are born with healthy testicles, but without the ducts that transport sperm from the testicles. This is diagnosed on physical examination. For such men, hormonal and genetic testing is usually performed to rule out any underlying abnormalities. Then, sperm can be obtained from the testicles with a minimally invasive procedure performed in the office. The sperm are then used together with in vitro fertilization techniques (test tube baby) to obtain a pregnancy.

Men with no sperm in their semen who do not have a blockage require hormonal testing. Occasionally, hormone replacement will return sperm to the semen. Other men simply do not make enough sperm to reach the semen. Genetic testing can reveal any underlying causes. Even though these men have no sperm in their semen, with careful microscopic testicular dissection, small islands of sperm can often be found. These sperm are then used together with in vitro fertilization techniques (test tube baby) to obtain a pregnancy.

A vaginal prolapse is a condition in which structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself may begin to prolapse, or fall out of their normal positions. Without medical treatment or surgery, these structures may eventually prolapse farther and farther into the vagina or even through the vaginal opening if their supports weaken enough.

The symptoms that result from vaginal prolapse commonly affect sexual function as well as bodily functions such as urination and defecation. Pelvic pressure and discomfort are also common symptoms.

The following are types of vaginal prolapse:

• Rectocele (prolapse of the rectum)
• Cystocele (prolapse of the bladder, bladder drop)
• Enterocele (herniated small bowel)
• Prolapsed uterus (womb)
• Vaginal vault prolapse

Approximately 30%-40% of women develop some presentation of vaginal prolapse in their lifetime, usually following menopause, childbirth, or a hysterectomy. Most women who develop this condition are older than 40 years of age.

Symptoms of prolapse can include: difficulty voiding, incontinence, urinary tract infections, constipation, pelvic pain, feeling a bulge, pain with intercourse, and others.

Robotic Prostatectomy

Robotic prostatectomy or robotic-assisted laparoscopic prostatectomy is the complete surgical removal of the prostate gland and seminal vesicles. The procedure is performed laparoscopically using the da Vinci Surgical System. The da Vinci Surgical System provides the surgeon with better vision and better ‘hands’ through the use of advanced optics and computer and robotic technology.

A look at the Da Vinci Medical Robot

How Is a Robotic Prostatectomy Performed?

The procedure is begun by inflating the abdomen with carbon dioxide gas in order to provide the surgeon with “working room”. Next, six small incisions, 1/4 to 1/2 inch in length, are made in the abdomen and plastic or metal ports are installed to keep the incisions open. Seated at the da Vinci System console nearby and using both the laparoscopic surgical instruments and a pencil-sized video camera, the surgeon directs the da Vinci’s robotic arms to dissect the prostate gland and adjacent tissue. The video camera’s 12X magnification and 3D view enable the surgeon to identify the many delicate nerves, tiny blood vessels, and other structures surrounding the prostate gland. Once the procedure is completed and the prostate is removed, the patient awakens, is ambulating later that day and typically is discharged within 24 hours.

Patient Benefits

For qualified candidates, the robotic prostatectomy offers numerous potential benefits over the traditional open prostatectomy, including:

• Shorter hospital stay
• Less post-operative pain and pain medication
• Less anesthesia
• Less blood loss and transfusions
• No blood donation necessary from patient
• Less scarring
• Fewer postoperative complications than open surgery including fewer post operative infections
• Faster and more complete recovery of our patients, 97% go home the morning after surgery
• By comparison, time in the hospital for patients treated with open radical prostatectomy is two to four days. Quicker return to normal daily activites
• Most patients return to work two to three weeks after the procedure and resume exercising or golf in 3-4 weeks, recovery time for patients treated with radical open prostatectomy is six to eight weeks
• The catheter that drains the bladder is removed after seven days in robotic surgeries. In open radical prostatectomies, the catheter is removed after two to three weeks
• Covered by almost all insurances
• Costs the same as traditional open surgery

Surgeon Benefits

The da Vinci© Surgical System used by our surgeons for robotic prostatectomy extends the surgeon’s capabilities to provide these significant benefits:

• 3-D Visualization: Provides the surgeon with a true 3-dimensional view of the operating field. This direct and natural hand-eye instrument alignment is similar to open surgery with “all-around” vision and the ability to zoom-in and zoom-out.
• Dexterity: Provides the surgeon with instinctive operative controls that make complex minimally invasive surgery procedures feel more like open surgery than laparoscopic surgery.
• Surgical Precision: Permits the surgeon to move instruments with such accuracy that the current definition of surgical precision is exceeded.
• Access: Surgeons perform complex surgical maneuvers through 9-mm ports, eliminating the need for large traumatic incisions.
• Range of Motion: EndoWrist© Instruments restore full range of motion and ability to rotate instruments more than 360 degrees through tiny incisions.
• Reproducibility: Enchances the surgeon’s ability to repetitively perform technically precise maneuvers such as endoscopic suturing and dissetion

What Are the Side Effects of Robotic Prostatectomy?

The side effects associated with robotic prostatectomy, which are similar to those associated with open radical prostatectomy, include:

• Urinary incontinence
  Stress incontinence is the term given to the leakage of urine that can occurs when a patient coughs, sneezes, or lifts a heavy object after the procedure. All patients wear urinary pads after the procedure; 70% of patients are able to discontinue the pads by three months; 85% by six months; and 95% by one year.
• Erectile dysfunction
  Recovery of erectile function is dependent upon the pre-operative state of each patient. However, a nerve-sparing procedure can be performed better with “the robot” than with the open radical prostatectomy. Because of the precision and gentleness of the robotic prostatectomy procedure, these side effects are less common than they are with open radical prostatectomy. Patients also recover from the robotic procedure in a shorter time than from the open radical procedure.

If urinary incontinence affects your day-to-day activities, don’t hesitate to see your doctor. In most cases, simple lifestyle changes or medical treatment can ease your discomfort or stop urinary incontinence.

Types of urinary incontinence include:

• Stress incontinence: This is loss of urine when you exert pressure – stress – on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy. Stress incontinence occurs when the sphincter muscle of the bladder is weakened. In women, physical changes resulting from pregnancy, childbirth and menopause can cause stress incontinence. In men, removal of the prostate gland can lead to this type of incontinence.
• Urge incontinence: This is a sudden, intense urge to urinate, followed by an involuntary loss of urine. Your bladder muscle contracts and may give you a warning of only a few seconds to a minute to reach a toilet. With urge incontinence, you may need to urinate often, including throughout the night. Urge incontinence may be caused by urinary tract infections, bladder irritants, bowel problems, Parkinson’s disease, Alzheimer’s disease, stroke, injury or nervous system damage associated with multiple sclerosis. If there’s no known cause, urge incontinence is also called overactive bladder.
• Overflow incontinence: If you frequently or constantly dribble urine, you may have overflow incontinence, which is an inability to empty your bladder. Sometimes you may feel as if you never completely empty your bladder. When you try to urinate, you may produce only a weak stream of urine. This type of incontinence may occur in people with a damaged bladder, blocked urethra or nerve damage from diabetes and in men with prostate gland problems.
• Mixed incontinence: If you experience symptoms of more than one type of urinary incontinence, such as stress incontinence and urge incontinence, you have mixed incontinence.
• Functional incontinence: Many older adults, especially people in nursing homes, experience incontinence simply because a physical or mental impairment keeps them from making it to the toilet in time. For example, a person with severe arthritis may not be able to unbutton his or her pants quickly enough. This is called functional incontinence.
• Gross total incontinence: This term is sometimes used to describe continuous leaking of urine, day and night, or the periodic uncontrollable leaking of large volumes of urine. In such cases, the bladder has no storage capacity. Some people have this type of incontinence because they were born with an anatomical defect. This type of incontinence can be caused by injuries to the spinal cord or urinary system or by an abnormal opening (fistula) between the bladder and an adjacent structure, such as the vagina.

When to see a doctor

You may feel uncomfortable discussing incontinence with your doctor. But if incontinence is frequent or is affecting your quality of life, seeking medical advice is important for several reasons:

• Urinary incontinence may indicate a more serious underlying condition, especially if it’s associated with blood in your urine.
• Urinary incontinence may be causing you to restrict your activities and limit your social interactions to avoid embarrassment.
• Urinary incontinence may increase the risk of falls in older adults as they rush to make it to the toilet.

Urologists at Arizona Urology Specialists offer the latest vasectomy techniques. The most common of which is the No-Scalpel vasectomy. We were also among the first urologists in Arizona to use No-Needle anesthesia for the procedure.

Studies evaluating microsurgical vasectomy reversal techniques have demonstrated decreased success rates as the interval between vasectomy and vasectomy reversal increases. The most highly regarded study involved over 1,400 men at five different centers. This demonstrated that among men undergoing microsurgical reversals within 3 years of their vasectomy, 97% will have sperm return to their semen, and 76% will initiate a pregnancy. At 3-8 years, 88% have sperm and 53% initiate a pregnancy. From 9-14 years, 79% have sperm and 44% get pregnant. Finally, among men undergoing vasectomy reversal 15 years or more after their vasectomy, 71% have sperm return to their ejaculate and 30% initiate a pregnancy.

The success rates with vasectomy reversal compare very favorably to in vitro fertilization (test tube baby) pregnancy rates, which are typically around 40%. In addition, vasectomy reversal is less expensive than in vitro fertilization, and eliminates female complications from hormonal manipulation which can occur during in vitro fertilization. Finally, the twin or triplet birth rate (around 40% with in vitro fertilization) is not increased with vasectomy reversal.

Vasectomy reversal is performed as an outpatient surgical procedure using an operative microscope and extremely small sutures (9-0 and 10-0). This allows a water-tight connection between the two previously cut ends of the vas deferens. The procedure usually takes about 3-4 hours. During the procedure, fluid from the vas deferens is examined under the microscope to confirm that no additional blockages are present. When an additional blockage is present, it usually occurs in the epididymis. The epididymis is an extremely small and delicate tube that transports sperm from the testicle to the vas deferens. If the epididymis is blocked, the surgeon connects the vas directly to the unblocked portion of the epididymis, thereby bypassing the blockage. This procedure requires additional operative time and microsurgical skill, but success rates still remain around 70% when the vas is connected to the epididymis.

Although microsurgical vasectomy reversal success rates are very high, occasionally a reversal is not successful. In such cases, it is helpful to have preserved sperm available. Our fellowship trained male infertility specialists, possess honed microsurgical skills, and work closely with embryologists located in central Phoenix, Scottsdale, and the West and East Valley. Sperm obtained during the vasectomy reversal can be preserved by the embryologist and used in the future if necessary.