In order to raise awareness about prostate diseases, the European Association of Urology promotes a yearly Prostate Awareness Day throughout Europe, which this year fell last Friday, primarily directed at men over the age of 50 with the main objective of making them aware of possible ailments, including cancer, that may affect this part of their anatomy. It is a curious fact of life that most men are oblivious, or at best unsure, about what constitutes the "prostate gland", its anatomy and physiology and, indeed, may not be aware of its very existence.
What is the prostate gland?
Only males have a prostate gland. It is the size of a chestnut and is located just below the urinary bladder. The prostate gland surrounds the area where the bladder connects with the urethra (the tube which passes through the penis and through which urine and semen pass out of the body). The male sperm is produced by the testicles. The prostate gland contributes over 90 per cent of the fluid that helps to carry the sperm. This spermatic fluid is ejaculated during orgasm and is essential for fertilisation of females. The prostate depends on the testes functioning normally for its normal growth and development.
What can go wrong with your prostate gland?
There are three important diseases which regularly affect the prostate:
Benign (not cancerous) enlargement of the prostate (BPH for short).
Cancer of the prostate.
Inflammation (prostatitis).
As men get older their prostate gland tends to enlarge, a condition that is medically referred to as benign prostatic hyperplasia (BPH). About 50 per cent of men above the age of 60, and 80 per cent of men above the age of 80 will have benign enlargement of their prostate. Although this is not cancerous it can still cause a lot of inconvenience and negatively affect the quality of life of the individual.
As the prostate enlarges, it presses on the part of the urethra that passes through it, thus obstructing the flow of urine and causing urinary symptoms, the most common of which are: a weak urine stream, sometimes interrupted with terminal dribbling and increased frequency of urination often disrupting sleep. Sometimes the patient has to pass water with urgency and may even wet himself. In a more advanced state, the patient may go into retention of urine and is unable to pass water.
The doctor can determine the presence, or otherwise, of enlargement of the prostate by taking a good history and by doing a good clinical examination which will include a rectal examination. A urine flow test, using a urinary flow meter, may be helpful to decide the extent of obstruction by the enlarged prostate. Blood and urine tests will be done to check kidney function.
One important blood test, known as prostate specific antigen (PSA for short), is regularly done to exclude more serious pathology (like cancer).
If nothing is done about the enlarged prostate, further problems may set in. The urinary bladder will become thickened. Infection may set in. Urinary stones may develop. In advanced cases, back pressure of urine may damage the kidneys.
The aim of treatment of benign enlargement of the prostate is to reduce the size of the prostate or/and its obstruction of the urethra.
The urine flow can be improved by certain drugs which shrink the prostate or relax the obstructed bladder neck. These drugs may take some time to work and may save the patient an operation.
If medical treatment is unsuccessful or contra indicated, the prostate will have to be removed surgically. Open surgery is nowadays rarely carried out, the treatment of choice being transurethral resection of the prostate (or Turp) which involves passing an instrument up the urethra and cutting out the bulk of the prostate. Hospital stay is usually about 3-4 days and the overall results are very good.
Prostatitis is inflammation of the prostate gland. This may come on as a sudden (acute) episode or it may give rise to chronic or recurrent symptoms mainly pain and discomfort in the crotch area, in the back passage (rectum) or low backache. Sometimes the patient complains of painful erections and discomfort during ejaculation. The treatment rests on analgesics and antibiotics, which may have to be administered for a long period of time.
Less common than benign enlargement, but much more serious, is the development of cancer of the prostate.
Prostate cancer is the most commonly-diagnosed malignancy affecting the western male population and the second leading cause of cancer death. Prostate cancer generally occurs in men beyond middle age (over 50 years) although it can occur at a younger age. In the USA alone 200,000 new cases of prostate cancer are diagnosed each year and about 32,000 men die from the disease. In Malta, about 125 new cases of prostate cancer are registered yearly.
The exact cause of prostate cancer is unknown but in some cases it may run in families. If one or more members of a family is/are affected it is advisable for other males to consult their doctor for an early check up. Black people are at a higher risk.
Prostate cancer may arise from an imbalance of certain body chemicals, called growth factors, that control the growth of cells in the prostate gland. There may also be damage to the genetic material (DNA) in the prostate cells, causing uncontrolled growth of cells. The prostate is also influenced by the level of testosterone (the male hormone) which is produced by the testes. There is some evidence that tomato extract exerts a protective effect.
The symptoms of cancer of the prostate in the early stages are essentially similar to those already described for benign growths. However, in the early stages the patient may not notice any inconvenience. In time prostate cancer cells may spread outside the prostate gland and be carried to other areas via the blood stream or lymphatics. The sites most commonly involved are the lymph nodes, bones and lungs. At his later stage the outlook is much more serious and guarded.
Prostate cancer may be detected on rectal examination of the patient by the physician when a nodule or an irregular area may be felt. However, the most common way to detect prostate cancer early is by a blood test which detects prostate specific antigen (PSA). This can detect early cancer even before it can be felt by the specialist's examining finger. The higher the PSA the more extensive and widespread the cancer. However, the relevance of PSA may sometimes be inconclusive and subject to individual interpretation.
When suspicion of cancer exists this has to be confirmed by a biopsy (that is, taking a small piece of the prostate with a fine needle) through the anal canal and sending it for microscopic examination. Other imaging tests (X-Ray of the bones, ultrasound scan, bone scan, CT scan or MRI scan) may become necessary to determine whether the cancer has spread.
There are various ways of treating prostate cancer including surgery, radio therapy, treatment with hormones or chemotherapy. The best chance of a cure is when the disease is diagnosed early, that is when it is still localised to the prostate. If the disease has spread outside the gland one may be able to control it but not cure it.
It is in every man's interest (particularly if above the age of 50 years) to undergo regular (at least once yearly) screening tests for his prostate. This essentially involves a digital rectal examination and the PSA blood test. These can be combined with other routine tests such as cholesterol and blood sugar estimation.
Prof. Cutajar is a consultant urologist and an honorary member of the European Organisation for Research & Treatment of Genito-Urinary Cancer (EORTC).