This is definitely one of those male-only health issues, if only for one reason – women don’t have one. Yes, boys, we’re on our own on this one. This is definitely one of those male-only health issues, if only for one reason – women don’t have one. Yes, boys, we’re on our own on this one.
What Is the Prostate?
The prostate is a small male sex gland, about the size and shape of a walnut. However, for such a small gland it packs one hell of a punch. This is because of where it is located in the body. The prostate is found at the bottom of the bladder between the bladder and the penis. It is wrapped around the waterworks tube (known as the urethra).
What Does It Do?
The prostate gland plays an important role in both urinary function and sexual function. The prostate is part of the male reproductive apparatus. It plays a supporting role during sex by producing fluid that mixes with sperm at the time of ejaculation. This fluid accounts for most of the milky semen you ejaculate every time you experience an orgasm. This prostate fluid is thought to help nourish sperm and help them reach their target. Prostate fluid also contains a protein known as prostate specific antigen or PSA. The role of PSA is to help liquefy semen, aiding the fertility process. However, some PSA also escapes into the bloodstream. This is the basis of the PSA blood test. It can be a marker of prostate health in that raised levels of PSA in the blood can indicate prostate problems.
The Waterworks System
Understanding the process of urination can help you to understand diseases of the prostate and how they can affect us. When men attempt to urinate, urine passes from the bladder and out of the body through the urethra, a tube that runs from the bladder through the prostate and the penis. The prostate completely surrounds the first part of the urethra. Changes in the prostate, including an increase in size, can put pressure on the urethra, which can then cause symptoms such as needing to urinate more often, difficulty starting to pee, poor stream and dribbling at the end. These are known as ‘prostatic symptoms’.
Disorders of the Prostate
There are three main types of prostate disorders:
Prostatitis
Prostatitis is one of several benign (non-cancerous) conditions causing inflammation of the prostate gland. The prostate is prone to become inflamed and sometimes infected, as it is connected to the processes of both sex and urination. Prostatitis is common and there are estimates that at least half of all men, at some point in their lives, will develop symptoms of this condition. It is not contagious and is not considered to be a sexually transmitted disease.
Symptoms of prostatitis may include some or all of the following:
These symptoms can be associated with feelings of stress, anxiety and depression. If you have these symptoms see your doctor, who can assess their likely cause and significance.
What Causes It?
Prostatitis can be caused by bacterial infections, viral infections, sexually transmitted infections, inflammation of the urinary tract and other conditions, including stress. Sometimes the cause of prostatitis is unknown. Bacterial infection of the prostate can occur when bugs enter the prostate. This tends to occur suddenly, with sharp, severe symptoms. Men may find urination difficult and extremely painful. It is important to seek treatment promptly as this condition is easy to diagnose.
Chronic prostatitis, sometimes known as chronic pelvic pain syndrome, is the most common form of the disease. It is thought to be due to low-grade inflammation of the prostate gland, sometimes triggered by stress. It is typically difficult to treat and the symptoms tend to recur.
Treatment of Prostatitis
Treatment depends on the underlying cause. For example, antibiotics are used to treat bacterial causes of prostatitis. Sometimes warm baths and anti-inflammatory medication can be helpful. Reassurance that there is no serious underlying cause, such as prostate cancer, for these symptoms can also be helpful for men.
As men get older, two things may happen to their prostates: their prostate can get bigger and/or they can get prostate cancer.
Enlargement of the Prostate or Benign Prostatic Hyperplasia (BPH)
BPH is a non-cancerous condition of ageing, which in some men may cause no more than minimal symptoms. The prostate gland enlarges and may cause problems associated with urination.
What Causes the Prostate to Enlarge?
In normal men, the prostate starts to increase in size, very slowly, from about age 40. The cause of BPH is unknown and is the subject of ongoing research. It is certainly a condition of the ageing male, but we don’t know why some men get severe symptoms of BPH while others do not.
There may be genetic factors involved. There may also be dietary factors involved, such as eating a lot of saturated fat and eating only small quantities of fresh fruit. Obesity is associated with more severe BPH symptoms. Regular exercise is thought to protect against BPH, as can moderate amounts of alcohol. The same healthy lifestyle choices for optimal health discussed earlier also seem to apply to this condition.
How Common Is BPH?
Benign enlargement of the prostate is very common and is almost a normal part of ageing. Its incidence rises dramatically as you age.
As you can see above, after a certain age it would be unusual not to have symptoms of an enlarged prostate.
Symptoms and Signs of BPH
You may have BPH and no symptoms whatsoever. However, as the prostate enlarges, it eventually begins to squeeze the urethral tube going through its centre. The common symptoms of BPH can include some or all of the following:
These symptoms are known together as ‘prostatism’. They can vary widely from one individual to another and men with similar degrees of prostate enlargement may be affected quite differently. This is an important point as ultimately any treatment decision for BPH should be judged on whether the symptoms are affecting your quality of life sufficiently to justify active treatment.
Diagnosis of BPH in its earlier stages can lower the risk of developing complications. The American Urological Association has devised a useful scoring system for BPH. This can help assess the severity of BPH and the need for treatment. It can be a useful monitoring tool to see if your BPH is getting worse over time. Check out the questionnaire on the next page and see how you fare.
Medical complications from BPH are uncommon. Occasionally it can progress to cause retention of urine but this tends to happen slowly over time. Other recognised complications can include kidney damage, bladder damage, urinary tract infections and bladder stones.
What Can My Doctor Do to Help?
Your doctor can discuss your symptoms with you and help decide on their likely significance. They can help explore your ideas, concerns and expectations. They will look at your medical history and will probably do a prostate exam to evaluate the size and degree of enlargement of the prostate, while at the same time checking for possible infection and cancer. This involves a rectal examination by your doctor using a gloved and lubricated index finger. This allows the prostate to be felt and your doctor can assess its size and also determine whether there are any irregularities on its surface. They may want to do some tests, including analysis of urine and some blood tests to check kidney function. They may also want to do a PSA blood test to rule out prostate cancer.
In more complex cases, your doctor may recommend referral to a urologist for a more detailed assessment and evaluation of your urinary tract. This may include further tests, which may be used to check the prostate and also to examine the rest of the urinary system, including the kidneys and bladder.
Treatment
Options include no active treatment (this is known as watchful waiting), lifestyle measures, herbal remedies including saw palmetto, medication and surgery.
Watchful Waiting
This is a very reasonable option for men who have mild symptoms. Serious complications from BPH are rare. Occasionally it can progress to cause retention of urine but this tends to happen slowly over time.
BPH does not increase the risk of getting prostate cancer. However it can sometimes interfere with the diagnosis of prostate cancer as it can cause the PSA level to increase. The key issue is quality of life. As a man, you need to inform yourself about the pros and cons of active treatment. Educating yourself is the key. Remember, knowledge is power.
Lifestyle Measures
What’s the Alternative Doc?
Saw palmetto is thought to be a natural remedy for prostatism. It is otherwise known as Serenoa repens and is an American dwarf palm plant. The ripe berry of this plant is the source of the herbal extract, which is known to contain a mixture of fatty acids and flavinoids (antioxidants), as well as other substances thought to be good for the prostate. It is not known exactly how saw palmetto works but it appears to be safe. Side effects may include mild nausea or reduced libido but the rate of such problems appears to be much less common than in men taking drugs to treat BPH symptoms. However its long-term safety has not been proven. If saw palmetto does not provide any relief of symptoms after a period of three months then it is reasonable to stop using it.
There has been some suggestion that saw palmetto may affect PSA levels. Therefore, before commencing taking it, it is best to discuss this with your doctor so all the issues relating to your prostate, including the possibility of prostate cancer, can be fully discussed.
Medication
Currently there are two pharmaceutical drug treatment options for BPH. Firstly, alpha blockers can improve BPH symptoms in about 70 per cent of men. These medications relax the smooth muscle of the prostate and bladder neck, which allows urine to flow more easily. These drugs can work quickly to provide relief of symptoms but reverse on stopping the drug. One side effect of alpha blockers is low blood pressure upon standing, which can cause dizziness and light-headedness. Other side effects can include fatigue, headaches and nasal congestion. To minimise these side effects, the dose of medication is usually gradually increased and the first dose is usually given at night. There are several alpha blockers available, all of which can be effective. Examples include terazosin, doxazosin and tamsulosin. The effect of terazosin and doxazosin on blood pressure can be worsened as a result of using medications for erectile dysfunction (ED), such as sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis). These medications should not be used by men who take terazosin or doxazosin. Tamsulosin and alfuzosin do not usually interact with ED medications and can provide a safer alternative option. As with all medication, check with your doctor and pharmacist first.
Secondly, alpha reductase inhibitors (finasteride) work by counteracting the effects of testosterone within cells of the prostate. By doing so, they may help the prostate from increasing further in size and can sometimes actually shrink the size of the prostate. This can decrease BPH symptoms. Finasteride may take several months to work and it must be used indefinitely to prevent recurrence of symptoms. Up to one-third of men have clinically significant improvements. These drugs tend to be more effective in men with larger prostates. The main side effects are impotence, decreased libido and decreased volume of ejaculate in a small percentage of men. These side effects tend to resolve on stopping the drug. Of note, finasteride tends to lower the PSA (prostate specific antigen) level by about 50 per cent. This is important to realise when screening for prostate cancer. Therefore it is recommended that patients starting finasteride should have a PSA level taken before and six to twelve months after starting therapy.
Surgery
In the past the only effective treatment for BPH was an operation known as a transurethral resection of the prostate (TURP), where the prostate gland was cut and removed or reduced in size. Unfortunately, however, the cure can be worse than the disease. Complications, including impotence, difficulties with ejaculation and problems with urinary continence, can occur, which can raise important issues about a man’s quality of life. New forms of minimally invasive prostate surgery are becoming available, including laser surgery. The key issue is to fully understand the risks and benefits of any proposed procedure so that a fully informed decision can be taken. Sometimes the best treatment may be no treatment at all. A decision to undergo surgery should not be taken lightly and reaching one should involve a detailed discussion of the risks and benefits with your urologist.
BPH and Prostate Cancer
BPH can interfere with the diagnosis of prostate cancer as it can cause the PSA level to increase. An increased PSA level does not indicate cancer, but the higher the PSA level the higher the chances of having cancer. Some of the signs of BPH and prostate cancer are the same. However, having BPH does not seem to increase the chances of developing prostate cancer. A man who has BPH may also have undetected prostate cancer at the same time or may develop prostate cancer in the future. Always consult your doctor for more information if you have any concerns in this area.
Prostate Cancer
Prostate cancer is a disease that can affect any man and has no respect for upbringing or address. Irish men have about a one in twelve chance of developing prostate cancer over the course of their lifetime. The vast majority of these cases occur in men over the age of 50. The frequency of prostate cancer is on the rise in Irish men. It has become the most common cancer in men, overtaking lung cancer. With PSA testing on the increase and an ageing population, the incidence of prostate cancer is predicted to rise ahead of breast cancer in women over the next decade.
Prostate cancer differs from most other cancers in the body because small areas of cancer within the prostate are very common and may stay dormant for many years. Most of these cancers grow extremely slowly and so, particularly in elderly men, will never cause any problems. In a small proportion of men, the prostate cancer does grow more quickly and in some cases may spread to other parts of the body, particularly the bones.
What Are the Risk Factors for Developing Prostate Cancer?
We do not yet know exactly what causes prostate cancer, but we do know that certain risk factors are linked to the disease. Some risk factors, such as smoking, can be eliminated by simply quitting (or better again not starting in the first place). Others, like a person’s age or family history, can’t be changed. But having a risk factor, or even several, doesn’t mean that you will get a particular disease. Many people with one or more risk factors never get cancer, while others with this disease may have had no known risk factors.
As well as increasing age, there are a number of recognised risk factors for prostate cancer:
It should be mentioned that vasectomy and BPH are not associated with an increased risk of prostate cancer.
The Prostate Diet
There are currently a number of foodstuffs rich in antioxidants (substances that have cancer-preventing properties) that are thought to help prevent prostate cancer. You will notice that there is a good deal of crossover here with heart disease prevention and general wellness. Nevertheless, I have put some of these together and labelled them as the ‘prostate diet’.
Tomatoes
Tomatoes appear to be out on their own as far as prostate cancer prevention is concerned. Tomatoes, pink grapefruit, watermelon and apricots are rich in a powerful antioxidant known as lycopene that helps prevent damage to DNA and may help lower prostate cancer risk. People who have diets rich in tomatoes appear to have a lower risk of certain types of cancer, especially cancer of the prostate. Other potential benefits of lycopenes include a lower risk of heart disease, lower levels of LDL (bad) cholesterol (see Chapter 6), less macular degeneration (a disease of the eyes that can lead to blindness), and strengthening of the immune system.
Tomatoes are the best food source of lycopene. Tomato-based products such as tomato juice, puree and pastes, canned tomatoes and cooked tomatoes may be even better than raw tomatoes, as lycopene becomes concentrated in cooked or processed tomatoes; pizza and pasta lovers take note. Lycopene from eating fruit and vegetables has no known side effects as long as you are not allergic to these foods. Very large quantities of tomato-based products taken over a long period of time can give the skin an orange colour, however.
Other dietary sources that can reduce the risk of prostate cancer include:
It’s always a good idea to check with your doctor about taking vitamins or supplements before you start to do so. Natural dietary sources of vitamins and minerals are preferable to taking supplements. As well as eating plenty of the listed foods that are good for you, it is important to stay away from the bad stuff. In this case I mean saturated fat, red meat and processed foods.
Signs and Symptoms of Prostate Cancer
One of the problems related to prostate cancer is that, in its early stages, it often does not have symptoms. When symptoms do occur, they may include any of the following:
Of course, these symptoms can be caused by many other conditions, including a urinary tract infection, BPH or even simple wear and tear arthritis in the case of back stiffness. The prostate enlarges as men get older, and most men have some symptoms affecting urination. However, if you have these symptoms, it is important to go to your doctor so they can be properly evaluated. There is little to be gained from sticking your head in the sand, yet there is good evidence that many men do delay seeking medical help, often to their cost.
Diagnosis of Prostate Cancer
Early diagnosis of prostate cancer is important for successful treatment. None of the following tests is an individually conclusive indicator of prostate cancer. Your doctor is likely to use more than one test to determine whether or not you are affected by prostate cancer.
Rectal Examination
Your doctor can actually feel the size of the prostate gland by doing a rectal examination with a gloved finger, which allows him/her to feel your prostate. This can help tell if it is enlarged and/or if there are any suspicious-feeling bumps or irregularities on the prostate. However, an enlarged prostate does not, on its own, indicate prostate cancer.
The PSA Test
This is a blood test that measures the amount of prostate specific antigen (PSA) in the bloodstream. PSA is a substance produced in the prostate gland that helps to liquefy semen. Some PSA can also get into the bloodstream, which is why measuring the level of PSA can be a marker of prostate health. A raised PSA level can be the first indicator of otherwise asymptomatic prostate cancer. However, while a high reading suggests prostate cancer, the PSA test is not specific for cancer and raised levels can occur because of benign enlargement or inflammation of the prostate gland.
The PSA test is the best way to detect prostate cancer in its early stage. Traditionally, PSA levels of zero to four were considered normal. It is now recognised that PSA levels tend to rise with age so age-adjusted PSA levels are suggested. The table below shows the upper limits of acceptable PSA levels in the bloodstream, adjusted by age.
So far so good; shouldn’t we all have this test done? Well, if you have symptoms that indicate possible prostate cancer, such as urinary prostatic symptoms, weight loss, backache or abnormal findings on rectal examination, then the answer is most definitely yes – a PSA test can help in the diagnosis. However, for the man who has no symptoms the answer is not so clearcut. The problem is that not all men with a raised PSA level will have prostate cancer so these men may be subjected to unnecessary follow-up tests, including prostate biopsy, and all the potential anxiety that these can generate, as well as potential side effects from an invasive procedure.
Research suggests that many men with a raised PSA will not have any prostate cancer in their biopsy. On the other hand, some men with prostate cancer will have a normal PSA result.
In addition, prostate cancer has a long dormant phase and this means that cancer cells can exist in the prostate for many years without causing any harm, and sometimes will never cause any harm. Prostate cancer is one of those conditions that older men can die with, but not necessarily from. This is a big potential difference between prostate cancer and many other cancers. However, sometimes prostate cancer can be more aggressive and spread to other parts of the body, especially the bones.
Other conditions that can cause a raised PSA reading include benign enlargement of the prostate (BPH) and inflammation and/or infection of the prostate. Ejaculation can cause a temporary rise in the PSA level, peaking after about an hour and returning to base line after a period of 24 to 48 hours. Therefore, it is recommended not to perform a PSA test if you have an active urinary tract infection or if you have ejaculated in the previous 48 hours.
Research is ongoing as to whether PSA testing should be used to routinely screen every man for prostate cancer. Many medical professionals feel it wrong to introduce national screening in this country because the effectiveness of screening is currently unproven and the side effects of treatment can be significant. At the moment the potential benefits from PSA screening remain unproven and the jury is still out. Two large international trials are currently underway to try to answer this important question. The results of these trials hopefully will provide more clarity around this complex issue. Information is power. By educating yourself about your own bodily functions you are in the best position to appreciate any changes. You have the right to have a PSA test done if you request it. The main thing to understand is that it is not a black and white issue. Discuss any areas of concern with your family doctor. He or she can help you make an informed decision about what is best for your health.
Other Tests
Further tests on the prostate can be carried out by a specialist in the area (a urologist). These can include:
Treatment Options for Prostate Cancer
This is an area that is the subject of ongoing research. There are a number of treatment options that can be taken singly or sometimes in combination. All of these treatments have pluses and minuses. It is important to inform yourself fully about all the options, including the option of ‘watchful waiting’, i.e. simply keeping an eye on your prostate. This can be a very reasonable option as many men with prostate cancer do not have aggressive forms of the condition and their condition grows so slowly that no active treatment is needed.
The decision to have active treatment and which type of treatment to undergo is an important decision that you should take in conjunction with your specialist, as side effects from these treatments can be significant. Surgery, radiotherapy and hormone therapy all have different side effects that need to be considered. These side effects include urinary incontinence, reduced ejaculation, lowered sex drive and long-term impotence, as well as hot flushes, tiredness and sweats.
Options include surgery, radiotherapy, hormone therapy or a combination of these treatments:
Research is ongoing into other potential treatments for prostate cancer. One such option may be a new drug called abiraterone. Early research suggests that this drug can shrink the prostate in men with prostate cancer. Large scale trials will be needed comparing this treatment to established treatment options to see if it really is a step forward.
Key Points
