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The prostate is a small, ball-like gland found between the bladder and the penis. It surrounds the urethra, which is the tube that takes urine from the bladder out of the body. The prostate gland produces the fluid that lubricates and nourishes the sperm in semen. In fact, semen is mostly fluid from the prostate, with sperm making up only a small portion. The muscles in the prostate gland contract during ejaculation, pumping fluid from the prostate into the semen. Approximately 3 million American men have prostate disease. The three most common conditions are benign prostatic hyperplasia (BPH), prostatitis, and prostate cancer. In benign prostatic hyperplasia (BPH), the prostate gland enlarges. BPH is caused by the long-term effect of male sex hormones (eg, testosterone) on the prostate gland. It is one of the most common conditions in aging men. Over half of men over age 65, and 90% of men over age 85 have BPH. As the prostate gland enlarges, it pinches the urethra, causing irritation and/or blockage of urine flow. Symptoms of irritation include the following:
Common symptoms of urine blockage include the following:
These symptoms primarily affect quality of life, but they can also lead to urinary tract infection, bladder stones, “holding” urine, bloody urine, and even chronic kidney disease. BPH is most commonly diagnosed on a rectal examination. Your healthcare provider will insert a finger into the rectum to feel the prostate. The prostate gland is often larger than usual, smooth, and rubbery. However, sometimes the prostate gland can feel normal even when BPH is present. So, your healthcare provider may recommend other tests, such as ultrasound (an examination of the bladder and prostate using sound waves), to obtain a clearer picture of prostate size. Blood and urine tests are routinely performed to check for urinary tract problems (eg, bladder infection), which can cause similar symptoms (see also Infectious Illness and Urinary Incontinence). More sophisticated and specialized tests are occasionally needed. Several treatment options are available for BPH, depending on the individual and on the effect that symptoms have on quality of life. Each of these treatments has its advantages and disadvantages. Lifestyle changes, such as avoiding caffeine, can improve symptoms and may be enough for older men whose symptoms are fairly mild. If lifestyle changes are not enough or symptoms are more severe, medication is needed. Surgery is often recommended for men who are dissatisfied with drug treatment or who have more serious urinary tract problems. Treatment Options for Benign Prostatic Hyperplasia
A class of drugs called alpha-blockers relaxes the smooth muscles around the urethra. This lets urine flow more easily and improves symptoms of irritation (eg, urgency, pain, frequency). There are both short-acting (eg, prazosin, alfuzosin) and longer-acting drugs (eg, terazosin, doxazosin, tamsulosin) in this class. The most common side effects are dizziness, mild fatigue or weakness, and headaches. Another class of drugs that are called 5-alpha-reductase inhibitors is also used to treat BPH. These drugs inhibit testosterone, which causes the prostate gland to shrink over time. The most commonly used drug in this class is finasteride. Side effects are not common but may include breast enlargement, skin rash, abdominal pain, and sexual problems. Improvement in symptoms can take up to 6 months. Some of these drugs also work well in combination to relieve symptoms and slow down the progression of disease. Combination therapy also lowers the risk of urinary problems, including “holding” urine, urinary incontinence, kidney disease, and bladder infections. Research has also shown that the herbal preparation called saw palmetto can improve urinary symptoms and flow in men with BPH, without serious side effects. (See also Complementary and Alternative Medicine.) Surgically removing prostate tissue surrounding the urethra is often recommended when symptoms are serious, including changes in kidney function, complete blockage of urine flow, urinary tract infections that come back over and over, or “holding” urine in the bladder. Surgery offers the best chance for improvement of symptoms, but it also has the highest rate of complications. Different types of surgery can be done, depending on the size of the prostate and other considerations. The various procedures have similar benefits but different postoperative complications. Your healthcare provider can help you decide which one is right for you.
Prostatitis means inflammation of the prostate. Prostatitis is relatively common in older men. It can be caused by bacterial infection, or by non-bacterial causes. The most common bacterial form is a chronic infection caused by the organisms commonly found in urinary tract infections. However, non-bacterial prostatitis appears to be most common, because no infectious organisms can be identified in more than 75% of cases of prostatitis. Older men with prostatitis may have no symptoms at all, or they may have pain in the middle to lower back, urinary urgency, a need to urinate often and/or at night, or discomfort between the scrotum and rectum. A sudden prostate infection may be associated with fever, chills, painful urination, and a tender prostate. Chronic prostate infection often causes urinary tract infections that do not clear up completely and come back when antibiotic treatment is stopped. Prostatitis is diagnosed by history, physical examination, and urinalysis. Your healthcare provider may obtain a urine sample after massaging the prostate with a finger inserted in the rectum. This “post-massage” sample often contains a large number of white blood cells from the prostate. Urine samples are usually cultured to identify any infectious organisms. A CAT scan or MRI may be necessary if an abscess is suspected. Sudden prostate infection is treated with antibiotics. Symptoms typically resolve promptly. Antibiotics are less effective for chronic bacterial infection, which usually requires at least 6–16 weeks of treatment to cure 30%–40% of cases. Continual antibiotic therapy at a low dosage is possible if symptoms come back often. Removing the prostate is a sure cure, but the risk of complications (eg, impotence, scarring, incontinence) is high. Transurethral resection, in which the center of the prostate is “cored” out, is safer but cures only one-third of cases. Non-bacterial prostatitis is treated symptomatically. Treatments to reduce pain and discomfort include anti-inflammatory drugs, alpha-blockers (see Benign Prostatic Hyperplasia), sitz baths, and fluid adjustments (eg, avoid caffeine). In a few cases, infection may be “hidden,” so antibiotic therapy is often tried. Prostate cancer is one of the most common cancers in American men, with over 200,000 cases diagnosed in 2004. Prostate cancer is rare in men younger than 40 years of age, but it becomes more common as age increases. This reflects the overall effect of male sex hormones (eg, testosterone), which stimulate prostate tissue throughout life. The risk of prostate cancer varies according to race. African Americans have the highest risk. In this group, prostate cancer begins at a younger age, has a higher death rate, and tends to be more advanced when diagnosed. Family history is also a risk factor for prostate cancer. Your risk is doubled if your father or brother has prostate cancer, and it is 8 times higher if you have two close relatives with prostate cancer (eg, father and a brother, or two brothers). Prostate cancer can be a deadly disease. However, most affected men have tumors that cause no or few symptoms. This is especially true for men with early, potentially curable disease. In fact, it is quite common for a man to have prostate cancer for many years, before dying from a totally unrelated cause. Symptoms tend to increase as the cancer spreads to nearby tissues or elsewhere in the body:
Screening and diagnostic tests The main screening tests for prostate cancer are digital rectal exam (DRE) and prostate-specific antigen (PSA). In a DRE, your healthcare provider will insert a finger in the rectum to feel the back part of the prostate, where cancer most often begins. A cancerous prostate generally feels hard, nodular, and irregular. However, because parts of the prostate gland cannot be reached on DRE, it is not always accurate. About half of the cancers thought to be limited to the prostate on the basis of DRE are found during surgery to have already spread. On the other hand, only about one-third of positive DRE tests turn out to be cancer on biopsy. The PSA test measures the amount of prostate-specific antigen in the blood. Despite the term “prostate-specific,” PSA can be high in diseases other than cancer of the prostate. For example, PSA levels are also high in benign prostatic hypertrophy and in prostatitis, as well as after ejaculation or prostatic massage. Overall, only about one-third of men who have a positive PSA test actually have prostate cancer. In addition, normal PSA levels are found in approximately one-third of men with cancer limited to the prostate. For these reasons, abnormal DRE or PSA tests generally prompt a biopsy of the prostate gland. Other tests (eg, MRI, CAT scan, or lymph node biopsy) may be needed to evaluate cancer spread. Prostate cancer is most curable in the early stages. However, early detection and treatment of prostate cancer is controversial. At the heart of this “screening” debate is the fact that no direct evidence exists to show that early detection decreases the risk of early death. Most men with prostate cancer die from other causes. Early diagnosis in these men leads to unnecessary worry and treatment, including complications from treatment. This debate has led to a difference of opinion within the medical community. Some expert groups recommend yearly screening to identify and cure cancer at an early stage. This includes the American Urological Association and the American Cancer Society, who recommend that PSA and DRE tests begin at age 50 for most men and at age 40 for men at high risk (eg, African American men or men with affected close relatives). However, other groups of experts recommend against routine PSA screening. These groups include the US Preventive Services Task Force, the American College of Physicians, and the Canadian Task Force on Periodic Health Examination. All experts agree that the controversy surrounding screening should be discussed on an individual basis so that men can decide on an informed course of action. You should talk to your healthcare provider about this issue to come up with a plan of action for yourself. The results of diagnostic tests are used to determine the overall prognosis of prostate cancer. Prostate cancer is “graded” according to microscopic characteristics (eg, signs of aggressive disease) and “staged” according to its spread. This information, combined with the results of the DRE, PSA, lymph node biopsies, and other diagnostic tests, is used to plan a treatment strategy. The choice of treatment strategy depends on the stage and grade of cancer, as well as on overall health, life expectancy, and personal preference. Localized cancer is limited to the prostate, with no evidence of spread to other areas of the body. This form of cancer has the lowest risk of causing problems, but it can often be cured. Most men with localized prostate cancer die years later from unrelated causes, often without ever having developed any prostate symptoms. No research has shown that treatment of localized disease prolongs life. You and your healthcare provider should discuss the pros and cons of the various treatment options to decide which one is right for you. The most conservative approach is “watchful waiting,” which means doing nothing until symptoms develop (if ever). Most men with cancer of the prostate do not develop symptoms, so watchful waiting avoids going through unnecessary treatment. However, if symptoms do develop later on, there is less chance of a cure. Localized cancer can often be cured by surgery to remove the prostate gland or radiation therapy, which can involve either an external beam of radiation or radioactive “seeds” implanted into the prostate. Surgery and radiation have different side effects. Radiation therapy is more likely to cause problems with the intestines or bladder, whereas surgery is more likely to cause impotence and urinary incontinence. The chance of impotence after surgery has decreased over the years because of improved procedures. Newer radiation techniques have also decreased the side effects associated with this approach. In more advanced cancer, cancer cells have spread outside the prostate. Several treatment options are available to try to stop the growth of the tumor. Hormone therapy is often used to deprive the tumor of testosterone, which is necessary for its growth. The level of testosterone can be decreased by castration, drug therapy, or combination therapies. The side effects associated with long-term loss of testosterone include weakness, fatigue, hot flashes, loss of muscle mass, and osteoporosis. Radiation therapy or surgery is sometimes used to decrease the amount/size of the tumor and to relieve urinary blockage or pain. Radiation is usually the treatment of choice for advanced prostate cancer that extends into nearby tissue, without evidence of spread to distant organs. Radiation therapy is especially useful for relieving pain and reducing fractures linked to spread of cancer into the bone. Widespread prostate cancer is not currently curable, but the use of chemotherapy is being investigated. Bone pain is a major complication of advanced prostate cancer, but it usually responds to hormone therapy, radiation treatments, corticosteroids, or pain medications. |
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Published: 10/28/2005