PROSTATE PROBLEMS

Prostate disease is a general term used to describe a number of medical conditions that can affect the prostate gland.

The prostate gland

The prostate gland is a small gland only found in men. It opens into the urethra (the tube that carries urine from the bladder to the penis) and sits just below the bladder and vas deferens (a pair of ducts through which sperm passes before ejaculation).

The prostate gland helps with the production of semen (the fluid that transports sperm). It produces a thick, white fluid that's liquefied by a special protein called prostate-specific antigen (PSA). The fluid is mixed with sperm, produced by the testicles, to create semen.

There are a number of conditions that can affect the prostate gland including:

• Prostate enlargement (benign)
• Inflammation of the prostate gland (prostatitis)
• Prostate cancer

Below is a short summary of these conditions:

Prostate enlargement

Prostate enlargement is a common condition associated with ageing. About a third of all men over 50 years of age will have symptoms of prostate enlargement (see below).

The urethra is a tube that runs from the bladder through the prostate to the end of the penis. Urine flows through the urethra and out of the body when a man urinates. If the prostate becomes enlarged it can place pressure on the urethra, making it more difficult for the bladder to empty.

An enlarged prostate can cause symptoms that can affect the normal pattern of urination. for example, it can:

• Make it difficult for you to start urinating.
• Weaken the flow of urine or cause 'stopping and starting'.
• Cause you to strain to pass urine.
• Cause you to urinate more frequently.
• Wake you up frequently during the night to pass urine.

Investigations may include:

• A frequency volume chart.
• Urine dipstick - to rule out infection.
• Blood tests - looking at kidney function and maybe a PSA after discussion.
• Flow rate and bladder scan - Passing urine into a machine that measures the flow rate and checks that the bladder is emptying.
• Kidney and bladder ultrasound - if indicated.
• A flexible cystoscopy - if indicated. This can rule out other causes of the symptoms such as a narrowing in the urethra.
• Urodynamics - this involves measuring the pressures generated in the bladder to check that it is working properly. This is usually performed when the cause of the symptoms is not clear or if previous surgery has failed to improve the situation.

Treatments:

• Alter your pattern of drinking - For example less fluid at night ane less fizzy drinks, tea and coffee.
• Try medications: Alpha blockers to relax the prostate and 5 alpha reductase inhibitors to reduce the size.
• Surgery - for example, TURP or laser prostate surgery.

All of the above will be discussed in more detail with you when you come for your appointment. If you are suffering with urinary symptoms please attend the appointment with a full bladder so that a flow rate can be performed.

Prostatitis

Prostatitis is a poorly understood condition where the prostate gland becomes inflamed and causes pain and often urinary symptoms. Inflammation can occur as a result of infection but in most cases no evidence of infection can be found.

Symptoms of prostatitis include:

• Pelvic pain
• Testicular pain
• Pain when urinating (this is less common and more likely with a urinary tract infection).
• Pain when ejaculating semen.
• Pain in the perineum (the area between the anus and back of the scrotum) which is often worse when sitting, particularly on hard chairs and bicycle saddles.

Prostatitis is thought to affect up to 3 in 20 men (15%) at some point in their lives. Although it can affect men of any age, it is more common in men between 30-50 years of age. The symptoms tend to come and go and can be triggered by stress, certain types of food and trauma.

Prostatitis can be treated using a combination of painkillers and a type of medication known as an alpha-blocker, which can help relieve the symptoms.

It is really a diagnosis of exclusion.

Prostate cancer

In the UK, prostate cancer is the most common type of cancer in men with over 40,000 new cases diagnosed every year.

Your chances of developing prostate cancer increase with age. Most cases occur in men who are 60 years of age or older.

The causes of prostate cancer are unknown but risk factors include age, ethnic origin and family history.

Prostate cancer is usually asymptomatic and detected following a screening blood test called PSA. Patients often request this test or attend their GP surgery because of urinary symptoms and the cancer is detected. It is very unusual for prostate cancer to cause urinary symptoms, these are usually related to benign enlargement. Very rarely it can present with advanced disease when it has already spread beyond the prostate with back pain and weight loss.

The outlook for prostate cancer is generally good because, unlike many other types of cancer, it usually progresses very slowly. Most men die with prostate cancer, rather than as a result of it.

Investigations include:

• PSA blood test - this is not always accurate. It can result in unnecessary investigations though it remains the most common way of detecting the disease.
• MRI scan - this uses special sequences to image the prostate and define the risk of having high risk disease that could cause problems.
• Prostate biopsies - this involves removing small samples of tissue from the prostate to see if cancer is present. They can be performed through the rectum or perineum. Decisions regarding prostate biopsies and the technique used will depend on the discussion that we have in clinic.

Prostate cancer treatments depend on how aggressive the disease is and if it has spread outside the prostate. Treatments include:

• Monitoring - Not all prostate cancer has to be treated. As only 5% of patients with the disease die from it this may be a sensible approach. It will depend on the patient's age, fitness, volume and type of disease.
• Surgery - This involves removing the entire prostate using a Robot. Complications can include problems with erections, incontinence and failure to remove all of the disease.
• Radiotherapy - Using radiation to kill the cancerous cells. Radiation is either external or placed directly into the prostate with a technique called brachytherapy. Side effects include bowel and bladder symptoms as the radiation can also affect these organs.
• HIFU and Cryotherapy - Carried out in very specialist centres.
• Hormone therapy - Using medication usually in the form of 3 monthly injections to block the effects of testosterone (the hormone that stimulates prostate cancer). Side effects can include: hot flushes, erectile problems and loss of calcium in the bones. It tends to be used for cancer that has spread to bone though maybe used after radiotherapy for a short time if the disease is high risk.

Prostate cancer diagnosis and treatment remains an extremely complex issue. There is no point in detecting disease that would never have caused problems but it is clearly important to identify those patients whose cancer is aggressive. All of the issues will be discussed with you in clinic and a decision made that takes into account all of the above.