The Beat on Big Prostates

Get the inside scoop on prostate size. Learn about BPH diagnosis, treatments, and potential implications for prostate cancer. If your last PSA test come back elevated or you’re having symptoms such as frequent, urgent, urination一are you now convinced you have prostate cancer?

Before you get too worked up, listen to this episode. Join us and hear a few answers from Dr. Richard Lam this month on PROSTATE PROS.

Your problem may simply be a large prostate!

Liz: [00:00] We're going to talk about what qualifies as a big prostate, the implications of big prostates and how they can be managed. Hey, Dr. Lam, what's the biggest prostate size you've ever seen?

Dr. Scholz: [00:20] Welcome to the PROSTATE PROS podcast. We're guiding you to treatment success and avoiding prostate cancer pitfalls. I'm your host, Dr. Mark Scholz here with my cohost Liz Graves.

Dr. Lam: [00:12] 300 cc's, which is 10 fluid ounces.

Liz: [00:32] Okay, let's expand a little more on the 300 cc prostate. Can you give me some insight onto why it was that big?

Dr. Lam: [00:40] Prostate size varies but everyone's prostate grows as they age and some people just grow to these enormous sizes, whether or not we need to do anything about it depends on their symptoms and their ability to empty their bladder.

Liz: [01:00] So I'm assuming patients will come in with high PSA and maybe some urinary symptoms. What kind of tests do you conduct to figure out if they have big prostates?

Dr. Lam: [01:09] So one could get a good idea about the size of the prostate with a simple digital rectal prostate exam. If one wants to measure, get a better measurement of the true gland volume one could have the patient undergo a color Doppler ultrasound or a multiparametric MRI.

Liz: [01:28] I know it varies patient to patient, but what's your typical approach or recommendation for men with BPH?

Dr. Lam: [01:35] There's two approaches. One is to improve one's urinary symptoms and that involves taking medications to help a patient empty his bladder better. The medications could include alpha blockers such as Flomax, Alfuzosin, or Rapaflo and also low dose, daily Cialis also helps people urinate better. Sometimes if despite these medications, the patient still has urinary problems, then we use medicines such as Proscar and Avodart to shrink the prostate.

Liz: [02:10] Thank you for the insight, Dr. Lam. Dr. Scholz, how big is a big prostate?

Dr. Scholz: [02:18] Prostates, as you know, are hiding down in the pelvis. And many men will go to their graves and never know what size prostate they have, but when problems occur, some men will go through an ultrasound procedure and they'll measure the gland size and that's described in cc's, cubic centimeters, and that average for patients that come see me who are in their sixties is around 40 cubic centimeters. So a big prostate would be something 50 and a higher or as high as a 150 cc's, quite, quite a bit larger than normal.

Liz: [02:57] So prostates grow with age. Do men need to be concerned if they have a large prostate?

Dr. Scholz: [03:04] Yeah, it seems like kind of a basic assumption that having a big prostate is a bad thing. And I think that prostates get maligned for every urinary problem that seems to develop with age. In my experience, only a minority of these urinary problems are actually due to the enlarged prostate. There's other problems like hyperirritable bladders, prostatitis and other factors that we don't really understand well that can cause men to have problems with getting up at night or running to the bathroom frequently, or a slow urinary stream. Well, a large prostate can contribute, it's oftentimes not the main problem.

Liz: [03:44] So a lot of the urinary symptoms that come with BPH are what people incorrectly attribute to prostate cancer.

Dr. Scholz: [03:52] Yeah. You know, that's another thing I mentioned already that big prostates get blamed for urinary symptoms and you're correct, prostate cancer can be blamed for urinary symptoms.  In this modern era, if you're checking your PSA levels and being monitored, as all men over age 40 or 45 should, that chances that urinary symptoms are coming from prostate cancer are really negligible.  Prostate cancer is a silent process and when PSA came along, we finally started to get some insight into the early stages of prostate cancer. But at its early stages, prostate cancer really causes no urinary symptoms whatsoever.  If men are having urinary symptoms, they should of course have a PSA, but if the PSA is in the normal range, we can be assured that it's not a problem related to prostate cancer.

Liz: [04:42] Okay, so you mentioned PSA and as the prostates grow, the PSA naturally rises.

Dr. Scholz: [04:49] Absolutely correct. So one of the things that I've seen, and I saw a little more frequently earlier in my career is men consulting me because their PSA is were high and they'd had numerous biopsies over and over. I've had men who've gone through random biopsies annually for five or 10 years straight from coming from other practices.  And the fear of course is that the high PSA is an indication of occult prostate cancer. The doctors are nervously searching for the presumed, underlying prostate cancer when in reality it's just a big prostate. There's the rule of 10 in the PSA world and that is that for the prostate's size, if you have a 40 cc prostate, a normal PSA is around four. And if the prostate is much larger, say a hundred cc's, a normal PSA would be around 10.  Just an elevated PSA by itself is not necessarily a strong argument for a prostate cancer problem.

Liz: [05:53] So you've previously talked about imaging. Is that one way that you're using to tell if a prostate or if a PSA is registering as high because the prostate is large or if it's actually prostate cancer?

Dr. Scholz: [06:06] Absolutely. So the two popular types of imaging or ultrasound and MRI, or we call it multiparametric MRI. And ultrasound provides an accurate indication and it's an easy office procedure.  MRI, you have to go to an imaging facility. But studies now indicate that if you go to a center of excellence, the MRIs are very accurate for the detection of prostate cancer. So the question about trying to determine if a high PSA is coming from prostate cancer or perhaps from a large prostate can be answered quite successfully with these different imaging procedures.

Liz: [06:42] We have a lot of patients who come to us with high PSA or are concerned they have symptoms. What do you tell these men?

Dr. Scholz: [06:50] Well, once we confirm that there's no underlying prostate cancer, that's always the first order of business. Then it's on to trying to help people have a better quality of life.  The waking up at night frequently, which is disruptive to sleep or sense of urinary urgency where men are always looking around to make sure a bathroom is close, can really mess up the quality of life. And there's a number of medications and procedures that can help alleviate these symptoms.  One of the popular types of treatments, and I always lead in with medicines before I think about different procedures to be done to the gland itself.  And the reason I like to use medicines first is because the side effects are almost always reversible. You can sometimes get wonderful relief with a pill and then not have to face the risk of a procedure.  Procedures can have dramatic and wonderful benefits, but there's always a small percentage of people that have negative outcomes and sometimes those outcomes are permanent so the pills are popular because they can alleviate symptoms and you don't risk permanent damage from some treatment that's gone awry. The medication list is long.  There's things like Flomax and Rapaflo, Myrbetriq, Noctiva, Proscar, Avodart.  All these different medicines have their pros and cons and potential side effects as I mentioned, which are reversible and they all need to be used sequentially and sometimes even in combination. It's a trial and error process trying a medicine for a few weeks or a month and then switching to another product if that's ineffective as a very logical first step to try and help people that are being troubled by these types of symptoms.

Liz: [08:35] I know you were recently interviewed by routers about potential side effects of Finasteride. Could you further comment on that?

Dr. Scholz: [08:42] Concern with Finasteride and Avodart, Dutasteride and Proscar.  Those are the four names for two different pills that shrink the prostate pretty effectively, actually. But they have known side effects because they block a type of testosterone called DHT, dihydrotestosterone. And the issue is that some men lose their sex drive, their libido.  I'm not talking about potency, the capacity to get an erection, I'm talking about the interest in participating in sexual activity. If the medicine is stopped in a timely fashion, this effect wears off.  But there are questions about what happens if this medicine has continued for a year or longer, and is it possible that the impact on Libido could be permanent?  That question is not completely answered, but I think it is a concern and people need to be vigilant about the possibility of low libido when they're taking this type of medicine.

Liz: [09:38] So I've researched about this topic and I've ran across UroLift.

Dr. Scholz: [09:42] UroLift is a new type of procedure that kind of pins the prostate open and allows better urinary flow. It's an attractive procedure.  And of course now we're entering into talking about procedures because there's a bunch of different kinds and it's attractive because the UroLift can be reversed, unlike many of the others. So it's not going to be effective for everyone.  And some men with really, really large prostates aren't going to be candidates, but as an intervention, when pills no longer seem to be effective, UroLift is a logical choice.

Liz: [10:20] We mentioned UroLift, what other procedures are there?

Dr. Scholz: [10:25] Well, there's a lot of them. Historically, the Transurethral Resection, a surgical procedure where the urologist goes up the penis with a knife and carves the core out of the prostate gland called the TURP or the Roto-rooter job has been the old standby for many years. This has become more and more replaced by using a laser to accomplish the same thing. So a laser TURP where they burn away the anterior portion of the prostate to try and aid with urinary flow.  But beyond those procedures, there are some other newer approaches with microwave therapy, with a pressured steam, hydrotherapy, all these different methods to try and open up the urinary passage. Of all the things that I've listed besides the Urolift, I would probably try and go with one of the milder approaches if it's feasible, such as the Rezum that seems less likely to cause retrograde ejaculation, which is a frequent problem with things like laser TURP and standard Transurethral Resections.

Liz: [11:31] Do men ever just get their prostate taken out? Like that all seems kind of difficult.  And if it's just causing a problem do people ever just say, well, I'll just get it removed?

Dr. Scholz: [11:43] Yes, indeed. There's a procedure that's usually reserved for the men that have the largest prostates that might not be amenable to these other procedures we've been talking about and kind of ironically, it's called a simple prostatectomy. A simple prostatectomy is only simple compared to a radical prostatectomy.  Simple prostatectomy is done through an incision in the lower abdomen and the lion's share of the prostate is surgically removed.  They call it a simple prostatectomy because they preserve the lateral portion of the gland, which is where the nerves for erections run and so erectile dysfunction thankfully is a lot less common than it is compared to the radical prostatectomy, which is the type of surgery performed for men that need to undergo surgery to get rid of prostate cancer.

Liz: [12:32] It seems like there might be similarities between treating BPH in this way and treating prostate cancer with surgery.

Dr. Scholz: [12:41] You're absolutely right. It's a connected issue because surgeons, urologists are in charge of both these issues. Treating prostate cancer and treating enlarged prostates.  The approach of a surgeon is going to lean towards doing a procedure, not that they're poorly trained and giving these types of pills. They certainly do that as well, but because the procedure mentality is pervasive in the urology world, there is going to be a tendency to move that type of treatment up the priority list and you're going to find a lot more enthusiasm for those procedures than what I would normally a harbor myself. For me personally, I'd like to avoid procedures if at all possible and only use them if the different types of medical therapy are ineffective.

Liz: [13:32] Okay, so bringing this back to prostate cancer, are men with big prostates at risk for prostate cancer?

Dr. Scholz: [13:41] Men with big prostates get high PSA days and unfortunately because random biopsies are done in over a million men annually, they get biopsied more frequently. And guess what?  A lot of these men are diagnosed with low grade, grade 6 prostate cancers, so big prostates to lead to a more frequent diagnosis of an innocuous condition that's present in almost 50% of men over age 50 but that's not really prostate cancer. And we're going to have much more discussion about that in a subsequent podcast.

Liz: [14:14] You wrote a blog post about the 10 Myths of Prostate Cancer. You mentioned that big prostates actually have a less aggressive prostate cancer.

Dr. Scholz: [14:23] That's right. So even though men with big prostates are diagnosed more frequently with grade six, the innocuous type of prostate cancer, they less frequently have higher grade cancers. That's not known exactly why that is or may be a protective effect, when the prostate is larger, it may be more difficult for the little cancers to get out of the gland.

Liz: [14:44] So having a big prostate isn't necessarily a bad thing in terms of prostate cancer.

Dr. Scholz: [14:49] Not a bad thing at all. And the men with smaller prostates have a somewhat more worrisome prognosis.

Liz: [14:56] Well, big prostates might not mean higher stage prostate cancer, they do tend to have symptoms and that can frighten a lot of men into believing they have prostate cancer.

Dr. Scholz: [15:06] Yeah, that's a sad thing. That's also all over the Internet that people are motivated by the word cancer and they're going to click, out of their anxiety and fear, on things that suggest that cancer related symptoms may be underlying their problems. Thankfully, we know that this is actually not true at all, that prostate cancer is a silent process and that symptoms come either from a large prostate for benign reasons or possibly some other unrelated problem like prostatitis. So BPH is an incredibly common thing, as men get older and there's so much confusion since everything is related to the prostate and many men don't even know what a prostate is and all this information seems to get rolled into a confusing mishmash of high PSA and big prostates and prostate cancer. But it can all be sorted out and if you have an imaging study to see how big the gland is, that'll help put the PSA in perspective and make sure that there's no cancer lurking in the gland. Once that's been accomplished, you can move on to some sort of medical therapy to improve the quality of life so you don't wake up at night so much so you don't have to urinate so frequently and there are so many effective ways to help in that regard.

Liz: [16:26] If you Google Prostate Size Matters by Dr. Scholz, you can get a nice recap of what we're talking about today. There's still time to register for the PCI conference, which is taking place September 6th through 8th, you can register on PCRI.org

[MISC. Soundclips]

[16:43] This is my fifth time, I've learned something every year. That was my first conference. This is my fourth. I think this is my sixth and I love it, it's part of my treatment plan. I've come to quite a few of these PCRI conferences and enjoyed all of them. I've been to probably nine PCRI conferences, everyone there is something different, so I keep coming every year.

PRCI 2019 PROSTATE CANCER PATIENT CONFERENCE PROMO @youtube.com/thepcri

Liz: [17:18] As we end today, I wanted to remind you to visit our website, podcast.prostateoncology.com you can find us online. If there's something you'd like to hear about, let us know. Please rate, review and subscribe on Apple Podcasts and share with friends and family. Dr. Scholz , what should we talk about next time?

Dr. Scholz: [17:37] Well, we're going to have to cover at Gleason 6 prostate cancer. The cancer that's not really a cancer.