Your prostate is a walnut-shaped gland that lies immediately beneath your bladder surrounding the urethra, the tube inside the penis that carries urine out of your body. It secretes a fluid that becomes part of semen. The gland can easily become inflamed during an infection, causing soreness, swelling, frequent urination, and a burning sensation while urinating. The prostate gland also can become enlarged, a condition called benign prostatic hyperplasia, which is a common problem in older men. An enlarged prostate gland can cause a number of bothersome problems when urinating, including hesitancy or straining to urinate; a weak stream of urine; dribbling; retention of urine; or the inability to control urination, also called incontinence. Other common symptoms include frequent urination, feeling an urgent need to urinate, and excessive urination at night.
If you have any of the symptoms of prostate enlargement, you should not feel embarrassed about talking them over with your doctor. You don't need to change your lifestyle to avoid situations, such as going to the movies, when it might be difficult to go for long periods without urinating. Effective surgical and drug treatments exist to help alleviate your symptoms.
The most feared prostate problem is prostate cancer, which now affects one in five men during his lifetime and is a leading cause of cancer death in American men. With early diagnosis and treatment, however, prostate cancer is curable.
Because the prostate lies in front of the rectum, the doctor can feel the prostate by inserting a gloved, lubricated finger into the rectum. This is called a digital rectal examination. It allows the doctor to determine whether the prostate is enlarged or has lumps or other areas of abnormal texture that he or she can feel.
Prostatitis is inflammation of the prostate gland. There are three basic forms of prostatitis: bacterial prostatitis, nonbacterial prostatitis, and prostatodynia.
Bacterial prostatitis, also called infectious prostatitis, is divided into two types: acute and chronic. Acute bacterial prostatitis is a rare but serious disease caused by bacteria in the prostate gland. The bacteria may originate from an infection in another part of the body, such as infections in the sinuses or the ears, or from an infection in another part of the urinary tract. Chronic bacterial pro-statitis is a recurring prostate infection that usually results when acute bacterial prostatitis has not been treated successfully. It tends to occur in older men who have an enlarged prostate gland. Nonbacterial prostatitis, the most common form
Disorders of the Reproductive System
• discharge of fluid from the penis
• pain or itching deep within the penis or at the head of the penis
• discomfort during urination
• fever, pain in the groin area, lower-back pain, and difficult urination that is often accompanied by a burning or an itching sensation
• a frequent urge to urinate without passing much urine
A diagnosis of prostatitis is usually based on the symptoms, a urinalysis, and a physical examination. When the doctor performs a digital rectal examination, the prostate may feel swollen and tender to the touch. If there are symptoms of acute bacterial infection, the digital rectal examination may not be done because manipulation of the prostate may release bacteria into the bloodstream.
To diagnose chronic bacterial prostatitis, a urine culture is done. In this test, the doctor takes one routine urine sample and one midstream urine sample (the person urinates for several seconds before collecting the sample of urine). A digital rectal examination is performed, and the prostate gland is massaged to release prostatic fluid. Another urine sample, which contains the released prostatic fluid, is taken. The samples are then compared to see if the infection is in the prostate or in the urethra.
In a few cases, a cystoscopic examination may be performed to confirm a diagnosis. A cystoscope is a flexible, lighted viewing tube that is inserted into the urethra. Proper diagnosis is essential for treating prostatitis because the various forms of the disease require different treatments.
Bacterial prostatitis is treated with antibiotics, along with bed rest and painkillers, if symptoms are severe. Hospitalization may be required if the urethra becomes blocked, the fever leads to dehydration, or if bacteria spread to other parts of the body. It is difficult to rid the prostate gland of infection. Infections often seem to disappear shortly after treatment begins, but bacteria often hide within the soft tissues of the prostate. Therefore, antibiotic therapy may be required for up to a month.
For chronic infections, it is common to take antibiotics for several months. Surgical therapy is performed only as a last resort for chronic bacterial prostatitis—usually when the condition causes urinary retention (inability to urinate) or kidney problems.
Antibiotics are not effective for treating nonbacterial prostatitis. Prostatodynia is often treated with over-the-counter medications such as aspirin or ibuprofen.
of the disease, is similar to chronic bacterial prostatitis, except that no bacteria are present. Prostatodynia is pain in the prostate caused by inflammation, which is not accompanied by infection or swelling.
The symptoms of bacterial and nonbacterial prostatitis are similar. They include the following:
Muscle relaxants are sometimes prescribed because prostatodynia is considered stress-related. The following steps may lessen the symptoms of nonbacterial prostatitis:
• Avoid coffee, alcohol, and spicy foods if they seem to aggravate the prostate gland.
• Cut back on excessive driving, cycling, heavy lifting, and vigorous exercise that may put stress on your prostate area.
• Soak in a warm bath. The warm water increases blood flow, which decreases inflammation.
Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland. As the prostate becomes larger, it can compress the urethra and obstruct the flow and release of urine. It is difficult to start urinating, and the stream of urine is weak. With such blockage, the bladder muscles enlarge and the bladder nerves become irritable, causing contractions of the bladder that result in a frequent urge to urinate. Eventually the muscles can no longer push urine past the blockage and urine backs up, leading to bladder problems, frequent urinary tract infections, and possible urinary retention (the inability to empty the bladder). Urinary retention requires immediate treatment. BPH usually does not affect sexual function.
By age 50, more than half of all American men show some signs of prostate enlargement, and by age 70, more than 40 percent have enlargement that can be felt on physical examination. No one is sure what causes BPH, but researchers know that it requires the presence of testosterone. BPH does not occur in men who have had their testicles surgically removed or in men who are unable to metabolize testosterone.
Recent studies point to a high-fat and high-cholesterol diet as a risk factor for BPH. Obesity also may be a risk factor. Men with a waist size of more than 43 inches are twice as likely to develop BPH as are men with a waist size of 35 inches or smaller. However, there is no conclusive evidence of a link between obesity and BPH.
Symptoms of BPH are generally described as irritative or obstructive. Irritative symptoms, which are related to bladder muscle failure, include the frequent need to urinate, numerous trips to the bathroom at night, and urgency (the frequent or constant urge to urinate). These are generally the first signs of a prostate problem, even though they might not be noticeable until years after the prostate has begun to enlarge.
Bladder outlet obstruction is a term used to describe a cluster of obstructive symptoms associated with BPH and related to problems with urine flow. They include decreased force and diameter of the urinary stream, the inability to urinate, trouble starting the flow of urine, a weak flow, double voiding (after urinating, a man is able to urinate again in 5 to 10 minutes), dribbling after urination, and overflow urinary incontinence. Other symptoms associated with BPH may include frequent urinary infections marked by a burning feeling during urination and strong-smelling urine. There may also be some blood in the urine, which occurs when blood vessels are stretched and broken by enlarging prostate tissue.
Men who have these symptoms should see their doctor. Other diseases, including cancer, can cause these symptoms. Although BPH is not cancerous, advanced stages can lead to complications related to kidney damage or kidney failure.
To diagnose BPH, a doctor takes a medical history and performs a physical examination, including a urinalysis, to rule out infection. The doctor examines the bladder by pressing down on the abdomen. He or she will perform a digital rectal examination by inserting a gloved, lubricated finger into the rectum to feel the prostate and determine whether it is enlarged.
Since the part of the prostate that usually obstructs urine flow is the tissue immediately surrounding the urethra, which cannot be felt during a rectal examination, a digital rectal examination is somewhat limited in diagnosing obstruction due to BPH. Therefore, the doctor may perform a test known as a urodynamic evaluation to measure urine flow. The amount of urine left in the bladder after urination also will be measured.
Blood tests may be done to rule out kidney dysfunction or to screen for prostate cancer. Ultrasound tests may be used to create an image of the prostate. Cystoscopy (examination with a viewing tube) also may be done to allow visual examination of the urinary tract. While none of these tests alone can diagnose BPH with certainty, as a group they can support a diagnosis.
BPH cannot be cured, but its symptoms can be relieved by various medications and surgical techniques. Initially, before symptoms become overly bothersome, a physician may suggest a "watchful waiting" approach that does not include any treatment. This involves asking the patient to keep track of symptoms to see if they lessen or stabilize on their own, or whether there are certain external factors that bring on the symptoms, such as intake of caffeine or alcohol, exercise, or stress.
As the problems associated with bladder outlet obstruction due to BPH become less tolerable or intolerable, more aggressive treatments may be used. There are two types of medication used to treat an enlarged prostate: alpha-blockers (which are medications to reduce high blood pressure) and drugs that shrink the prostate. Because symptoms return if medication is stopped, medication must be taken indefinitely.
Alpha-blockers work in about 75 percent of men who try them. These medications, such as terazosin, work by relaxing the muscular component of the
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172 prostate, which often allows urine to flow more freely. The problem with alpha-
The blockers is their side effects, which initially include low blood pressure and dizziness on standing. These symptoms typically lessen or disappear with continued use of the drugs. A newer alpha-blocker used to treat BPH, called tamsu-losin, may be less likely to cause these side effects.
Finasteride is a drug that relieves symptoms by reducing the size of the prostate. Finasteride takes about 3 to 6 months before it starts to work, but it has been shown to reduce the size of the prostate by 30 percent. Up to 60 percent of men who use finasteride reported some relief of their symptoms. However, the relief comes with some serious possible side effects. In some cases, finasteride has been associated with a decreased sex drive and erection problems. There is also evidence that finasteride reduces the level of PSA (prostate-specific antigen; see page 174) in the bloodstream by approximately half. For this reason, doctors take this into account when measuring PSA levels for detecting prostate cancer in men who are taking finasteride.
A variety of surgical procedures are used to treat BPH by removing or reducing prostate tissue. A prostatectomy is the removal of part of the prostate gland. A prostatectomy can be either open or closed. In an open prostatectomy, the gland or excess tissue that is causing the obstruction is removed through an abdominal incision. In a closed prostatectomy, surgery is done through a cys-toscope (viewing tube) that is inserted up the urethra. Although closed prostatectomies have largely replaced open prostatectomies, open procedures are still performed if the prostate gland is very large or if other procedures are performed at the same time.
Transurethral resection of the prostate (TURP) is a closed procedure. TURP involves passing a special cystoscope called a resectoscope into the urethra and inserting a tiny wire loop or cutting edge up through the scope to remove excess prostate tissue from around the urethra. TURP is one of the most commonly performed surgical procedures, with 300,000 to 400,000 done each year. One major benefit of this procedure is reduction of urinary problems associated with BPH. Approximately 90 percent of men who undergo this procedure show improvement in their urinary symptoms. However, approximately 1 percent of men who have this procedure experience subsequent problems with urinary incontinence. The procedure may need to be repeated if the tissue that was removed grows back.
Another closed procedure is known as transurethral incision of the prostate (TUIP). This procedure differs from TURP in that the surgeon makes tiny cuts in the prostate to lessen its grip on the urethra. TUIP reduces the chances of experiencing certain problems after surgery, such as retrograde ejaculation, which is ejaculation backward into the bladder during sexual intercourse. In some cases, repeated procedures may be necessary.
Other treatments for benign prostatic hyperplasia are currently being devel oped. Among them are microwave thermotherapy, intraurethral stents, laser therapy, and transurethral needle ablation (TUNA). Microwave thermotherapy uses heat generated by microwaves to eliminate excess prostate tissue. Intraurethral stents are small, tubelike structures that are inserted into the urethra to enlarge it and provide relief from urinary symptoms. Laser therapy uses laser energy to vaporize excess prostate tissue. TUNA uses microwave technology to cut away obstructing tissue. The long-term effectiveness of these techniques has not yet been determined. No matter which treatment you are considering, be sure to discuss the risks and the benefits with your doctor so that you can make an informed decision.
A man with an enlarged prostate may find that certain foods and medications may increase the intensity of BPH symptoms. Try the following lifestyle changes and keep track of your symptoms:
• Stick to a low-fat, low-cholesterol diet. Men who follow such a diet have a lower risk of BPH.
• Eat more vegetables. Men who do so have a lower rate of BPH than those who do not.
• Limit your fluid intake, particularly at bedtime. It may help reduce the number of times you have to get up to urinate in the middle of the night.
• Avoid caffeine and alcohol. They may irritate the prostate and increase the need for nighttime urination.
• Monitor your medications. Certain drugs—including oral bronchodilators, diuretics, tranquilizers, and antidepressants, as well as over-the-counter remedies such as antihistamines and decongestants—aggravate urinary problems. Check with your pharmacist.
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Prostate cancer is very common, although its exact cause is unknown. Each year more than 150,000 new cases of prostate cancer are diagnosed in the United States, and more than 30,000 deaths are caused by this disease. It is third after lung cancer and colon cancer as a cause of cancer death in men.
Your risk of getting prostate cancer escalates after age 50, and having a father or a brother with the disease triples your risk. You are also at increased risk if you are African American. Prostate cancer can grow slowly—so slowly that years can pass before the disease becomes evident. Most cancer of the prostate never becomes life-threatening because men tend to develop it later in life and often die of another cause. However, some cancers of the prostate may be more aggressive and shorten the person's life. In some men the cancer grows so gradually that it never produces any symptoms. In others, prostate cancer causes a weak or interrupted flow of urine, inability to urinate, difficulty in starting or stopping the flow of urine, frequent urination (especially at night), blood in the urine, pain or burning during urination, or persistent pain in the lower back, pelvis, or upper thighs.
Prostate cancer usually is discovered in one of three ways: as the result of a prostate-specific antigen (PSA) blood test (see box below); during a digital rectal examination; or during an operation called a transurethral resection of the prostate, done to treat an enlarged prostate. To promote early detection, every white male over age 50 with no family history of prostate cancer should have a digital rectal examination performed by his doctor. Every African American male over age 45 and every white male over 45 with a family history of prostate cancer also should have a digital rectal examination. See your doctor immediately if you experience any of the symptoms of prostate cancer. When discussing prostate problems with the doctor, men of any age should mention if they are sexually active.
A blood test called the prostate-specific antigen (PSA) test has been developed to diagnose prostate disease, including cancer, enlargement, and inflammation. The PSA test measures the blood level of a protein called prostate-specific antigen that is produced only by the prostate gland and is normally not found in the blood. High levels of this protein in a man's blood suggest the possibility of prostate cancer but also may indicate less serious prostate problems, such as an enlarged prostate or inflammation. Because of this, the test results need to be confirmed by removing a tiny portion of the prostate gland and examining it under a microscope, a procedure known as a biopsy.
A considerable amount of controversy exists about whether the PSA test should become an annual part of the health checkup for men over age 40. The test is useful for detecting tumors that cannot be found during a digital rectal examination. On the other hand, the test results can be uncertain, resulting in unnecessary follow-up procedures that may include a biopsy or even surgery. Still, the PSA test is the best technique doctors currently have to discover tumors in the prostate gland while they remain small and are potentially curable.
If you are over 50 years of age (45 if you are African American), discuss with your doctor the pros and cons of having an annual PSA test and the possibility of follow-up procedures if elevated levels are found. Only by talking with your doctor about the test can you come to the decision that is best for you.
Various treatments for prostate cancer are available, including surgery, radiation therapy, hormone therapy, chemotherapy, and combinations of these. When determining a treatment plan for you, you and your doctor will evaluate the benefits and possible side effects or risks of the available therapies, taking into account your age, your feelings and preferences, any other health conditions you
Reproductive System may have, and the stage of your cancer. If you are an older man and your cancer is at an early stage, your doctor may recommend nothing more than "watchful waiting." Watchful waiting means that you would have regular digital rectal examinations to monitor your prostate, PSA blood tests every 3 to 6 months, and, perhaps, a yearly biopsy of your prostate.
The most common surgical procedure for prostate cancer is a radical prostatectomy. Radical prostatectomies are performed when the cancer does not appear to have spread beyond the prostate. In a radical prostatectomy, the whole prostate gland and the seminal vesicles are removed, along with surrounding tissue and, often, pelvic lymph nodes. In some cases, a procedure called transurethral resection of the prostate (TURP) is used to relieve symptoms before other treatments are used. TURP is most often used to treat noncancerous enlargement of the prostate (see page 170). Cryosurgery (also known as cryotherapy) is occasionally used to treat prostate cancer that has not spread beyond the prostate. In cryosurgery, a surgeon destroys cancerous cells by freezing them with a metal probe. Cryosurgery is generally not used as a first-line therapy.
One of two types of radiation therapy may be used to treat prostate cancer: external radiation therapy and internal radiation therapy (also called brachyther-apy). In external radiation therapy, the physician uses a machine to aim highpower rays (gamma rays or X rays) or particles (electrons, protons, or neutrons) from outside the body directly at the tumor and, in some cases, the surrounding lymph nodes. In brachytherapy, tiny (about the size of a grain of rice), low-level radioactive pellets are inserted (permanently or temporarily) into the prostate gland. The doctor uses an imaging method such as ultrasound or CT scanning to guide the placement of the pellets. The permanent pellets, which give off radiation for a period of weeks or months, are left in place. In some cases, pellets containing high doses of radiation are inserted for less than a day and removed. Brachytherapy and external radiation therapy are frequently used together.
Hormone therapy is usually used for men whose prostate cancer has spread to other parts of the body or whose cancer has returned after treatment. The goal of hormone therapy, which is not a cure, is to lower the levels of androgens (male hormones such as testosterone, which can stimulate the growth of cancer cells in the prostate), thereby shrinking the cancer or slowing its growth. The two most effective ways to lower androgen levels are to surgically remove the source of androgens, the testicles (in a procedure called orchiectomy), or to give injections of medications that block the production of testosterone. The injections are usually given monthly, every 3 months, or every 4 months at the doctor's office or at a cancer center. Hormone therapy probably works best if it is started as soon as possible after the cancer has reached an advanced stage.
Because the adrenal glands produce a small amount of androgens, drugs called antiandrogens are sometimes used in addition to orchiectomy and testosterone-lowering drugs to inhibit the body's ability to produce the hormones.
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176 These medications are usually taken as pills one to three times a day. This
The treatment does not appear to be as effective as the other treatments for prostate cancer.
Chemotherapy is used for men whose prostate cancer has spread beyond the prostate gland and for whom hormone treatment has not been successful. Chemotherapy uses high doses of drugs, given intravenously or by mouth, to kill cancer cells. The treatment may help slow tumor growth and reduce pain. Because chemotherapy does not kill all the cancer cells, it is not recommended for treating early stages of the disease.
The side effects of the various cancer treatments include:
• problems with urination such as frequent urination, incontinence (leakage or dribbling of urine), blockage of urine flow, blood in the urine, or a burning sensation while urinating
• problems with bowel function such as diarrhea, blood in the stool, or irritation
• swelling of the penis, scrotum, or prostate
• bruising of, pain in, or damage to the treatment area or nearby tissues
• nausea, vomiting, or loss of appetite
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