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Prostate Surgery
A surgical procedure involving the partial or complete removal of the prostate gland is known as prostatectomy or prostate surgery.
Prostate surgery is generally performed in cases of prostate cancer, or benign prostatic hyperplasia or BPH (non-cancerous, age-associated enlargement of the prostate gland that leads to difficulty in urination).
Prostate cancer may metastasize and spread to other parts of the body like the lymph nodes and bones. Prostate removal will prevent this from happening.
Purpose: Prostate surgery may be recommended in the following cases:
- Prostate cancer, to prevent cancer from spreading outside the prostate gland
- Benign prostatic hyperplasia (BPH)
Symptoms: The following are the symptoms of prostate cancer, which may indicate the need for prostate surgery:
- Frequent urination
- Painful urination
- Burning sensation during urination
- Difficulty in urinating
- Increased urination at night
- Blood in urine
- Painful ejaculation
- Difficulty in having an ejaculation
- Blood in semen
- Pain in the pelvic area (area below the stomach) and legs
- Bone pain
Diagnosis:
- Physical examination: The doctor evaluates the physical health status of the patient. The symptoms and medical history of the patient are also noted.
- Cystoscopy: A visual scope is used to look inside the bladder and urethra (the tube that allows urine to be expelled from the body). It helps the doctor to check the size of the prostate and examine the urinary system.
- Digital rectal exam: The doctor inserts his/her gloved, lubricated finger into the rectum to examine the prostate. If the doctor finds any abnormalities, further tests may be required.
- Prostate-specific antigen (PSA) test: It is a type of blood test done to check the level of PSA in blood. A high level may indicate prostate infection, enlargement, inflammation, or cancer.
- Ultrasound: This is an imaging test performed to obtain a clear image of the prostate gland.
- MRI scan: This is also an imaging test done to obtain clear pictures of the prostate gland and its surrounding structures.
- Biopsy: The doctor may collect a sample of cells from the prostate gland and send it to the laboratory for evaluation and check for the presence of cancer cells.
- Blood and urine tests: These are routine tests performed before surgery to check for any underlying infections.
- Chest x-ray: It helps in evaluating the condition of the heart and lungs of the patient.
- Electrocardiogram (ECG): It helps in recording the electrical activity of the heart and checking for any heart problems.
Prostate surgery is primarily of two types:
- Open approach Radical Prostatectomy- open prostatectomy refers to the traditional form of surgery wherein the prostate is removed by making a single long incision (cut) in the skin. Open prostatectomy can be done in two different ways.
- Radical retropubic prostatectomy- this type of surgery involves making an incision from the lower belly to the pubic bone. The prostate is removed to through this incision. This type of surgery also gives the surgeon access to nearby tissue and lymph nodes which might be affected.
- Radical perineal prostatectomy- here, the incision is made between the anus and the scrotum (perineum). This type of surgery is performed when a retropubic surgery may pose complications. It lasts for a shorter duration than a retropubic surgery and recovery may be faster and less painful.
- Laparoscopic approach to radical prostatectomy- this procedure is comparatively less invasive and is carried out by making several small incisions to remove the prostate with the help of special tools.
- Laparoscopic radical prostatectomy- multiple small surgical instruments along with a small tube, with a camera on one end, are inserted through small cuts to remove the prostate.
- Robotic-assisted laparoscopic radical prostatectomy- uses a robotic interface which is connected to the instruments and camera. The robotic arms are controlled and monitored by the surgeon sitting in the operating room.
- Endoscopic surgery:
- This procedure also does not involve making any incisions.
- A long, flexible tube with a light and camera on one end goes through the tip of the penis to remove the parts of the prostate gland.
- Widening the urethra: This can be done in the following ways:
- Transurethral resection of the prostate (TURP): This is the standard procedure for BPH. The urologist cuts pieces of the enlarged prostate tissue using a wire loop. The tissue pieces go into the bladder and flush out after the completion of the procedure.
- Transurethral incision of the prostate (TUIP): This procedure involves making small cuts in the prostate and bladder neck for widening the urethra.
The following complications are associated with prostate surgery:
- Bleeding
- Infection
- Blood clot formation
- Allergic reaction to anesthesia
- Damage to the nearby organs
- Painful urination
- Difficulty in urinating
- Urinary incontinence (involuntary urine leakage)
- Erectile dysfunction
- Loss of libido
- Loss in fertility
- Lymphedema (accumulation of fluid in the lymph nodes in the legs or genital area)
- Groin hernia (a condition in which the soft tissues bulge through a weak point in the muscles of the abdomen)
- The patient will stay in the hospital for two to five days after the surgery, depending on the type of procedure performed.
- The doctor will prescribe pain-relieving medications to relieve the pain and discomfort of the patient after the procedure.
- Antibiotics will be prescribed to reduce the chances of infection.
- Take adequate rest after surgery.
- It is normal to have some blood in urine, urinary irritation, urinary tract infections, difficulty in holding urine, and prostate inflammation for a few days after the procedure.
- A drain tube comes out of the abdomen. This drain tube is generally removed a day or two after the surgery.
- A catheter (small tube) is fitted to the penis to drain the urine into an attached bag or bottle. This catheter is removed one to three weeks after the surgery. The patient is instructed on how to care for the catheter at home.
- The patient is instructed on how to keep the surgical wound clean.
- Driving should be avoided for one week after the procedure.
- Avoid strenuous activities and heavy lifting for six weeks after the procedure.
- Avoid soaking in bathtubs, hot tubs, and swimming pools.
- Avoid sitting in one position for a long time.
- Avoid sexual activities till the doctor permits the same.
- Drink plenty of fluids, exercise regularly, and eat a fiber-rich diet to prevent constipation after the procedure.
- The patient may be given laxatives if there are no bowel movements within a day or two of the surgery.
- If there is swelling in the scrotum after the surgery, a rolled towel may be placed under the scrotum while the patient is sitting or lying down. The ends of the rolled towel are looped over the legs to provide support. The doctor should be contacted if the swelling does not reduce after a week.
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Prostate Surgery
A surgical procedure involving the partial or complete removal of the prostate gland is known as prostatectomy or prostate surgery.
Prostate surgery is generally performed in cases of prostate cancer, or benign prostatic hyperplasia or BPH (non-cancerous, age-associated enlargement of the prostate gland that leads to difficulty in urination).
Prostate cancer may metastasize and spread to other parts of the body like the lymph nodes and bones. Prostate removal will prevent this from happening.
The prostate is a gland present in males. It is located underneath the bladder (where urine is stored before being expelled), and in front of the rectum (where stools are stored before being excreted). The prostate plays an important role in making semen, which is a fluid containing the male sperm.
Symptoms
Purpose: Prostate surgery may be recommended in the following cases:
- Prostate cancer, to prevent cancer from spreading outside the prostate gland
- Benign prostatic hyperplasia (BPH)
Symptoms: The following are the symptoms of prostate cancer, which may indicate the need for prostate surgery:
- Frequent urination
- Painful urination
- Burning sensation during urination
- Difficulty in urinating
- Increased urination at night
- Blood in urine
- Painful ejaculation
- Difficulty in having an ejaculation
- Blood in semen
- Pain in the pelvic area (area below the stomach) and legs
- Bone pain
Diagnosis
Diagnosis:
- Physical examination: The doctor evaluates the physical health status of the patient. The symptoms and medical history of the patient are also noted.
- Cystoscopy: A visual scope is used to look inside the bladder and urethra (the tube that allows urine to be expelled from the body). It helps the doctor to check the size of the prostate and examine the urinary system.
- Digital rectal exam: The doctor inserts his/her gloved, lubricated finger into the rectum to examine the prostate. If the doctor finds any abnormalities, further tests may be required.
- Prostate-specific antigen (PSA) test: It is a type of blood test done to check the level of PSA in blood. A high level may indicate prostate infection, enlargement, inflammation, or cancer.
- Ultrasound: This is an imaging test performed to obtain a clear image of the prostate gland.
- MRI scan: This is also an imaging test done to obtain clear pictures of the prostate gland and its surrounding structures.
- Biopsy: The doctor may collect a sample of cells from the prostate gland and send it to the laboratory for evaluation and check for the presence of cancer cells.
- Blood and urine tests: These are routine tests performed before surgery to check for any underlying infections.
- Chest x-ray: It helps in evaluating the condition of the heart and lungs of the patient.
- Electrocardiogram (ECG): It helps in recording the electrical activity of the heart and checking for any heart problems.
Treatment
Prostate surgery is primarily of two types:
- Open approach Radical Prostatectomy- open prostatectomy refers to the traditional form of surgery wherein the prostate is removed by making a single long incision (cut) in the skin. Open prostatectomy can be done in two different ways.
- Radical retropubic prostatectomy- this type of surgery involves making an incision from the lower belly to the pubic bone. The prostate is removed to through this incision. This type of surgery also gives the surgeon access to nearby tissue and lymph nodes which might be affected.
- Radical perineal prostatectomy- here, the incision is made between the anus and the scrotum (perineum). This type of surgery is performed when a retropubic surgery may pose complications. It lasts for a shorter duration than a retropubic surgery and recovery may be faster and less painful.
- Laparoscopic approach to radical prostatectomy- this procedure is comparatively less invasive and is carried out by making several small incisions to remove the prostate with the help of special tools.
- Laparoscopic radical prostatectomy- multiple small surgical instruments along with a small tube, with a camera on one end, are inserted through small cuts to remove the prostate.
- Robotic-assisted laparoscopic radical prostatectomy- uses a robotic interface which is connected to the instruments and camera. The robotic arms are controlled and monitored by the surgeon sitting in the operating room.
- Endoscopic surgery:
- This procedure also does not involve making any incisions.
- A long, flexible tube with a light and camera on one end goes through the tip of the penis to remove the parts of the prostate gland.
- Widening the urethra: This can be done in the following ways:
- Transurethral resection of the prostate (TURP): This is the standard procedure for BPH. The urologist cuts pieces of the enlarged prostate tissue using a wire loop. The tissue pieces go into the bladder and flush out after the completion of the procedure.
- Transurethral incision of the prostate (TUIP): This procedure involves making small cuts in the prostate and bladder neck for widening the urethra.
Risks
The following complications are associated with prostate surgery:
- Bleeding
- Infection
- Blood clot formation
- Allergic reaction to anesthesia
- Damage to the nearby organs
- Painful urination
- Difficulty in urinating
- Urinary incontinence (involuntary urine leakage)
- Erectile dysfunction
- Loss of libido
- Loss in fertility
- Lymphedema (accumulation of fluid in the lymph nodes in the legs or genital area)
- Groin hernia (a condition in which the soft tissues bulge through a weak point in the muscles of the abdomen)
After Procedure
- The patient will stay in the hospital for two to five days after the surgery, depending on the type of procedure performed.
- The doctor will prescribe pain-relieving medications to relieve the pain and discomfort of the patient after the procedure.
- Antibiotics will be prescribed to reduce the chances of infection.
- Take adequate rest after surgery.
- It is normal to have some blood in urine, urinary irritation, urinary tract infections, difficulty in holding urine, and prostate inflammation for a few days after the procedure.
- A drain tube comes out of the abdomen. This drain tube is generally removed a day or two after the surgery.
- A catheter (small tube) is fitted to the penis to drain the urine into an attached bag or bottle. This catheter is removed one to three weeks after the surgery. The patient is instructed on how to care for the catheter at home.
- The patient is instructed on how to keep the surgical wound clean.
- Driving should be avoided for one week after the procedure.
- Avoid strenuous activities and heavy lifting for six weeks after the procedure.
- Avoid soaking in bathtubs, hot tubs, and swimming pools.
- Avoid sitting in one position for a long time.
- Avoid sexual activities till the doctor permits the same.
- Drink plenty of fluids, exercise regularly, and eat a fiber-rich diet to prevent constipation after the procedure.
- The patient may be given laxatives if there are no bowel movements within a day or two of the surgery.
- If there is swelling in the scrotum after the surgery, a rolled towel may be placed under the scrotum while the patient is sitting or lying down. The ends of the rolled towel are looped over the legs to provide support. The doctor should be contacted if the swelling does not reduce after a week.
FAQ Section
Prostate Cancer Surgery, also known as Radical prostatectomy, is a surgical procedure which involves the removal of the prostate gland when it is affected by cancer. A localized surgery is performed if the cancer cells haven’t spread from the prostate gland and are restricted. However, if the spread of cancer is towards the surrounding tissues around the prostate gland, then a locally advanced surgery will be performed.
This surgery may be conducted in combination with radiotherapy or chemotherapy based on the stage and type of cancer. The main downfall of this procedure is that it can lead to impotence due to the removal of the entire prostate gland. A nerve-sparing prostatectomy tries to prevent erection issues. This is a major operation and is not suitable for patients suffering from heart attacks, thereby increasing the complications.
One may need to undergo a Prostate Cancer Surgery for several reasons out of which few include the following:
- Surgery for removal of the prostate gland
- Surgery for removal of inner part of the prostate to relieve symptoms
- Surgery for removal of testicles to prevent the growth of the cancer
- Surgery for reducing the risks of prostate cancer.
Prostate Cancer Surgery is a major and complex surgery for the treatment of Prostate Cancer. It is an extremely sensitive procedure, due to the huge network of blood vessels and nerves running around the prostate gland, thus demanding to be performed with extreme precision and expertise.
However, it is not void of risks and complications. The two major possible risk factors associated with this procedure are urinary incontinence, which is the inability to control urine and the other is erectile dysfunction, also known as impotence. Some of the other commonly observed risks are:
- bleeding during or soon after the operation
- injury to nearby tissues, like bowel, blood vessels, nerves, pelvic floor muscles etc.
- Blood clots in the lower leg
- infections
Your oncologist will brief you about any possible risks and will advise you the best treatment to undergo based upon your condition.
Prostate Cancer is the weakest when detected at an early stage as it is localized and has not spread to the nearby tissues. Studies have shown that surgeries performed during this time period have a cure rate of 95.5% for intermediate-risk prostate cancer and 91.3% for high-risk prostate cancer. It has been statistically proved that the five-year survival rate is about 98.8% overall.
The success rate of the surgery is highly dependent on the skill set, knowledge, experience and expertise of the surgeon performing the surgery.
The best time for a Prostate Cancer Surgery is as early as possible. The cancerous cells must be eliminated from the body before it spread to the rest of the body. Since the procedure is quite complex, any symptoms of prostate cancer must be diagnosed immediately at the earliest and suitable treatment procedure, either surgery or radiation therapy must be undergone for normal recovery. Once the cancer is diagnosed and confirmed, there must be no delay in following up with the treatment.
Prostate Cancer can be avoided through a well-balanced diet and a healthy lifestyle. It has been observed that men of age 50 and above are usually diagnosed with prostate cancer. Therefore, preventive surgeries can be performed to eliminate the risk of cancer. However, once diagnosed with cancer, surgery is usually unavoidable. If detected at its primary stage, radiotherapy and chemotherapy can help in reducing the size of the tumour and preventing its recurrence, but if detected at an advanced stage, prostate cancer surgery is unavoidable.
Some of the pre-diagnostic measures taken by your health care provider are as follows.
- Biopsy
- CT scan
- Ultrasound
- Lab tests,
- PSA tests
- Bone scan
- Digital rectal exam
- MRI scan
- Prosta-scint scan
Your doctor or oncologist will recommend you the above tests to determine the type and stage of your cancer and the treatment process that needs to be followed to minimize the risk factors and to prevent the return of cancer.
A Prostate Cancer Surgery is performed for the removal of the prostate glands and seminal vesicles affected by the tumour. Some of the nearby lymph nodes may also be removed in order to prevent the spread of cancer.
The surgery is conducted in two ways, open surgery or keyhole surgery. Both the techniques have proved to be equally effective and pose the same amount of risk factors.
1. Open Surgery
In this procedure, the surgeon will make an incision from the belly button to the pubic bone. This is followed by the removal of the affected organs, i.e. pelvic lymph nodes, prostate glands, and the surrounding structures.
2. Laparotomy, Keyhole Surgery or Robot-Assisted Prostatectomy
This procedure involves making of two to three small incisions. A laparoscope is inserted through one of the incisions, and gas is used to expand the stomach. The other required surgical instruments are inserted through the other incisions and the surgery is performed by operating the laparoscope from the outside performed by a specialist surgeon.
This is followed with a combined therapy of radiation therapy and chemotherapy. Your doctor will recommend the appropriate procedure to go with based on your condition.
A Robot-Assisted Prostate Cancer Surgery will take around two and a half hours to three hours to complete the procedure, which is the average time taken to perform open surgery.
The components used in Prostate Cancer Surgery are the basic surgical tools used for the operation. This process involves the removal of the prostate gland, therefore, there is no necessity of any additional components as such. In case, need arises for any additional components, your doctor will inform you of the same.
A slight amount of pain will be experienced following the surgery which includes:
- Abdominal pain around the incisions
- Gastric pain
- Pain in any other part of your body, like back and shoulders
- Rectal pains, with the urge of bowel movements which will eventually reduce with time.
The duration of the recovery time span is about two weeks. The catheter is usually removed after a period of seven to ten days, i.e. once the incision site has healed.
After your surgery, the doctor will recommend a certain period of rest based on your physical health and your type of cancer. However, after discharge, normal day to day activities can be resumed at a slow and gradual pace. Activities like driving, sitting, walking can be performed. In fact, short walks and slight exercises are recommended for speedy recovery. Avoid alcohol consumption and lifting of heavy objects unless you have completely recovered.
The cost of a Prostate Cancer Surgery in India is quite cheap when compared to some of the globally advanced countries and the treatment available in India is at par with these countries. The major advantage is that the best treatment is available at a nominal cost of around four lakh rupees for the entire procedure. Apart from this, there are several financial assistance provided by various health insurance companies.
Yes, a huge population of prostate cancer patients comes to India for their treatment as India is one of the leading cancer treatment providers in the healthcare sector. The cost of treatment is highly economical and reliable due to the state-of-the-art facilities and advanced medical technologies. It has a set of some of the finest and highly qualified doctors providing their services to cancer patients all around the world.
This decision relies on a variety of factors, such as affordability, the physical condition of the patient, financial stability, stage of cancer etc. With the suggestions of your doctor and family, and taking all the parameters into consideration, make the right choice which suits your condition.
The partial or complete surgical removal of the prostate gland is called prostatectomy or prostate surgery.
The prostate is a gland present in men. The prostate is present under the bladder (where urine is stored before being removed from the body) and in front of the rectum (where feces is stored before being excreted).
The prostate plays an important role in making the semen, which is a fluid that contains the male sperm.
A prostate surgery is recommended in the following cases:
- In the case of prostate cancer, to prevent cancer from spreading to the other parts of the body, known as metastasis
- Benign prostatic hyperplasia (BPH), which is a non-cancerous, age-associated prostate gland enlargement that causes difficulty in urination
The following symptoms may indicate the need for prostate surgery:
- Painful urination
- Burning on urination
- Increased frequency of urination
- Difficulty in urinating
- Increase in urination at night
- Blood in urine
- Blood in semen
- Painful ejaculation
- Difficulty in having an ejaculation
- Pain in the pelvic area (area below the stomach)
- Leg pain
- Bone pain
The following diagnostic tests are performed before prostate surgery:
- Physical examination: The doctor checks the physical health of the patient. The symptoms and medical history of the patient are noted.
- Cystoscopy: A visual scope, known as a cystoscope, is used to view inside the bladder and urethra (a tube through which urine is expelled from the body). It helps the doctor to check the prostate size and examine the urinary system.
- Digital rectal exam: The doctor inserts his/her gloved, lubricated finger into the rectum for examining the prostate. If any abnormalities are detected, further tests may be needed.
- Prostate-specific antigen (PSA) test: It is a type of blood test performed to check the level of PSA in blood. A high level could mean a prostate infection, enlargement, cancer, or inflammation.
- Ultrasound: This is an imaging test that helps the doctor to get a clear picture of the prostate gland.
- MRI scan: It is a type of imaging test done to obtain clear images of the prostate gland and its surrounding structures.
- Biopsy: The doctor collects a sample of cells from the prostate gland and then sends it to the laboratory to check for the presence of cancer cells.
- Blood and urine tests: These tests are done before surgery to check for any underlying infections.
- Chest x-ray: It helps in evaluating the lungs and heart of the patient before surgery.
- Electrocardiogram (ECG): It helps in measuring the electrical activity of the heart and checking for any heart disorders.
The following preparation may be needed before a prostate surgery:
- Tell the doctor about any medical diseases that the patient has.
- If the patient is taking any herbs, supplements, or medications, tell the doctor about the same.
- Tell the doctor if the patient is allergic to any medicines, anesthetics, contrast dyes, latex, tape, or iodine.
- The patient should stop smoking at least 15 days before the procedure.
- The patient will be told to stop taking blood-thinning medications like warfarin and aspirin a few days before the surgery.
- The patient may be given a laxative or enema the evening before the procedure to clear his/her bowels.
- The patient is told to not eat or drink anything after midnight, the day before the surgery.
The type of prostate surgery done depends on the condition that is present and the purpose of the surgery. The goal of prostate cancer surgery is to remove the cancerous tissue, whereas, the goal of BPH surgery is to remove the prostate tissue to restore the normal flow of urine.
Prostatectomy can be performed in any of the following ways:
Open prostatectomy: The surgeon makes a large cut or incision on the skin. The prostate and nearby tissues can be removed using this procedure. The procedure is generally done under general anesthesia (the patient is put to sleep during the procedure) or epidural anesthesia (a numbing agent is given in the spinal area to block the sensation from the spine downwards).
Open surgery can be done by any of the following two approaches:
- Radical retropubic approach: The surgeon makes an incision from the belly button to the pubic bone in this approach. The surgeon then removes only the prostate and a few lymph nodes for further testing and evaluation.
- Radical perineal approach: An incision is made by the surgeon in the space between the rectum and scrotum (a bag of skin that holds and helps in protecting the testes). The time taken to perform this surgery is less than retropubic surgery, but it has a higher risk of erectile dysfunction in men.
Laparoscopic approach: This is a minimally-invasive surgery. The procedure causes lesser pain, has a quicker recovery time, and a shorter hospital stay than open surgery. It can be performed using any of the following approaches:
- Laparoscopic radical prostatectomy: Many small incisions are made by the surgeon to insert small surgical instruments. A thin tube with a camera, called a laparoscope, is used to view the images of the inside of the body and perform the procedure.
- Robotic-assisted laparoscopic radical prostatectomy: This procedure is performed by robotic arms that are guided by the surgeon while viewing the images on a computer monitor. The procedure provides more precision and maneuverability than other treatment approaches.
There are different types of prostate surgeries that help with urine flow. These surgeries may include:
Prostate laser surgery:
This procedure helps in the treatment of BPH without making any incisions.
A fiber-optic scope is inserted through the tip of the penis into the urethra.
The prostate tissue blocking the urine flow is later removed.
Endoscopic surgery:
No incisions are made in this procedure.
A long, flexible tube with a light and camera on one end, known as an endoscope, then goes through the tip of the penis to remove certain parts of the prostate gland.
Widening the urethra:
This can be done in the following ways:
Transurethral resection of the prostate (TURP): This is a common procedure done for BPH. The urologist cuts some pieces of the enlarged prostate tissue using a wire loop. The tissue pieces then go into the bladder and are later flushed out after the procedure is complete.
Transurethral incision of the prostate (TUIP): This procedure involves making small incisions in the prostate and bladder neck to widen the urethra.
The following are the post-procedure steps following prostate surgery:
- The patient usually stays in the hospital for two to five days after the procedure, depending on the type of procedure done.
- The doctor prescribes pain-relieving medications to relieve the pain and discomfort of the patient after the surgery.
- The doctor recommends antibiotics to reduce the risk of infection.
- The patient needs to take adequate rest after the procedure.
- It is normal to have some urinary irritation, blood in urine, urinary tract infections, difficulty in holding urine, and prostate inflammation for a couple of days after the procedure.
- A drain tube comes out of the stomach to remove the excess fluids. This tube is usually removed a day or two after the surgery.
- A catheter (small tube) is fitted to the penis of the patient to drain the urine into an attached bottle or bag. This catheter is removed one to three weeks after the procedure. The patient will be instructed on how to care for the catheter at home.
- The patient will be instructed on how to keep the surgical wound clean.
- Driving should be avoided by the patient for a week after the surgery.
- Avoid strenuous activities and heavy lifting for at least six weeks after the surgery.
- Avoid soaking in hot tubs, bathtubs, and swimming pools.
- Avoid sitting in a single position for a prolonged time.
- Avoid sexual intercourse till the doctor allows for the same.
- Drink lots of fluids, exercise regularly, and consume a fiber-rich diet to prevent constipation after the surgery.
- The patient is given laxatives if there are no bowel movements a day or two after the surgery.
- If there is swelling in the scrotum following surgery, a rolled towel has to be placed under the scrotum while the patient is lying down or sitting. The ends of the rolled towel are then looped over the legs to provide support. If the swelling does not reduce after a week, contact the doctor.