What is the prostate?
The prostate is a variable sized gland located in the male pelvis, usually the size of a walnut measuring 3-4cm long and 3-5cm wide. On average the gland weighs about 20gm. The prostate surrounds the urethra which carries urine from the bladder to the penis. The seminal vesicles attach to the prostate and produce material that mixes with the prostatic fluid to form semen. The tubes from the testicles carry sperm to the prostate where the sperm are mixed with the prostate and the seminal vesicle fluid. The fluid is then ejaculated during orgasm by a connection to the urethra called the ejaculatory ducts.
Three main prostate disorders
Prostate disease is a term used to describe any medical problem involving the prostate gland. Common prostate problems experienced by men include:
- Prostatitis is inflammation and swelling of the prostate gland, occurs mainly in younger men
- Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland, occurs as men age
- Prostate cancer occurs in men after 40-45 year of age, it is the most common form of cancer in men in Australia
Prostatitis is a difficult to treat inflammation of the prostate gland in younger men. Often bacteria can’t be identified, so the condition is then described as non-bacterial prostatitis, even though antibiotics may be used for treatment. Prostatitis may present with pain on urination, pain on ejaculation and a chronic pelvic/genital discomfort.
BPH is one of the most common diseases affecting the prostate and is the most common benign tumour in men as they get older. This condition is present in 50% of men over 50 years.
Symptoms of BPH: The symptoms involve noticeable changes in urination due to the effects of enlargement of the prostate around the urethra, called lower urinary tract symptoms (LUTS). The urinary symptoms may be voiding (weak stream, dribbling, intermittency and inadequate emptying) or storage (urgency, frequency, nocturia and incontinence).
Assessment of BPH: The prostate can be assessed by a digital rectal examination (DRE) where a gloved and lubricated finger is inserted into the anus. The back of the prostate can thus be felt and an assessment of its size may be possible. This digital examination may also feel a cancerous lump though not all prostate cancers are palpable in this manner.
The PSA blood test (prostate specific antigen) is an important marker of prostate cancer though it is not cancer specific. It is very sensitive to the detection of prostate cancer, however it isn’t very specific in the sense it is not able to tell how aggressive the cancer is. It may also be raised in benign enlargement or prostatitis. Normal values for PSA blood test results are available for different age groups.
Treatment of BPH: Treatments for BPH range from watchful waiting to medication to surgery. Medications derived from plants have shown some benefit, for example, Saw Palmetto. Prescription medications may reduce the prostate size thus improving symptoms, yet often this is only a temporary relief. These medications include alpha blockers, 5 alpha reductase inhibitors and a combination of both. LUTS can be also associated with symptoms of an overactive bladder, and if primary treatments are not effective then oral anti-cholinergic medications can assist. However, sudden occurrence of overactive bladder symptoms can mean an insidious cause such as bladder cancer.
Treatments for BPH causing bladder outlet obstruction can be divided into cavitating (creation of a new channel) or non cavitating (no creation of a new channel).
Cavitating treatments include transurethral resection of the prostate (TURP) or HoLEP (holmium laser enucleation of the prostate). This involves removal of obstructive prostate tissue with an electrical blade or laser. Newer modalities of laser (greenlight) or heat treatment do not seem to create as large a channel as TURP/HoLEP but benefit from less bleeding .
A new treatment for BPH is the UroliftTM which can be performed as a day stay and most men will return to normal activities within a week. The UroliftTM uses implants to essentially stent apart the prostate that is blocking the urethra. Your urologist will discuss the most appropriate treatment for you.
Prostate cancer is the commonest cancer in men. It usually does not present with urinary symptoms unlike BPH. Prostate cancer has an increased incidence in men who have a close relative diagnosed with this condition or in men who have an African American heritage. It may be diagnosed by routine testing with the PSA blood test and DRE (digital rectal exam). Recently the use of high strength 3T MRI (magnetic resonance imaging) can assist with precision of diagnosis.
Prostate cancer needs confirmation by a biopsy and this can be done in a variety of ways. Transrectal ultrasound guided prostate biopsy (TRUS) requires the use of a rectal ultrasound probe to guide biopsy needles into the prostate. This can be done either awake using local anaesthetic or asleep with a general anaesthetic. Transperineal (TP) ultrasound guided prostate biopsy (TP) is similar to TRUS except the needles are placed through the perineum (skin between the scrotum and anus). The latter requires day stay in hospital and a general anaesthetic but has less risk of infective complications. If a patient has had an MRI, a computer can extrapolate areas to an ultrasound image and a biopsy this way is called a MRI/US fusion biopsy. Recently, a robot (Biobot) can be used to in conjunction with MRI and US fusion techniques to target areas of interest transperineally and via only two needle punctures. The most accurate way to target the smallest area of concern in a prostate is via MRI ingantry guided prostate biopsies. This will require both a dedicated MRI radiologist and a Urologist to guide the needle into the prostate. Once confirmed, the aggressiveness of the cancer is measured by the Gleason score.
Treatment of prostate cancer is complex and the decision on the most appropriate treatment involves many factors, the grade and stage of the cancer and importantly, the patient’s own preferences. If the cancer has the potential for cure then the choices are active surveillance, seed brachytherapy, external beam radiotherapy, or radical prostatectomy (open or robotic). If the cancer is incurable then treatment is usually with hormones or chemotherapy. Your urologist will discuss the most appropriate treatment with you for prostate cancer.