The Prostate


It is a small gland that is part of the male reproductive system. It's supposed to be about the shape and size of a walnut. It rests below your bladder and in front of your rectum. It surrounds part of the urethra, the tube in your penis that carries pee from your bladder.

The prostate helps make some of the fluid in semen, which carries sperm from your testicles when you ejaculate


Prostate cancer can develop when cells in the prostate start to grow in an uncontrolled way. Prostate cancer often grows slowly to start with and may never cause any problems. But some men have prostate cancer that is more likely to spread. This needs treatment to stop it spreading outside the prostate.

In the UK, about 1 in 8 men will get prostate cancer at some point in their lives.

Men aged 50 or over, men with a family history of prostate cancer and black men are more at risk of getting prostate cancer.

Prostate cancer that’s contained inside the prostate (called localised prostate cancer or early prostate cancer) doesn’t usually cause any symptoms. But some men might have some urinary problems. These can be mild and happen over many years and may be a sign of a benign prostate problem, rather than prostate cancer.

There is no single test to diagnose prostate cancer, but it is normally diagnosed with a blood test called PSA, a rectal examination of your prostate (DRE), and a biopsy of the prostate

The PSA test is a blood test used primarily to screen for prostate cancer. The test measures the amount of prostate-specific antigen (PSA) in your blood. PSA is a protein produced by both cancerous and noncancerous tissue in the prostate

PSA is only produced in the prostate, but its levels can be elevated with urine infections, benign enlargement of the prostate, prostatitis (inflammation in the prostate), as well as prostate cancer. A raised level can therefore lead to unnecessary anxiety.

A raised PSA often leads to a prostate biopsy that is performed usually under local anaesthetic.

How is prostate cancer treated?

For many men with prostate cancer, treatment is not immediately necessary.

If the cancer is at an early stage and not causing symptoms, a policy of "watchful waiting" or "active surveillance" may be adopted. This involves carefully monitoring your condition.

Some cases of prostate cancer can be cured if treated in the early stages. Treatments include surgically removing the prostate, radiotherapy and hormone therapy.

Some cases are only diagnosed at a later stage when the cancer has spread. If the cancer spreads to other parts of the body, typically the bones, it cannot be cured and treatment is focused on prolonging life and relieving symptoms.

All treatment options carry the risk of significant side effects, including erectile dysfunction and urinary incontinence. For this reason, many men choose to delay treatment until there is a risk the cancer might spread.

Newer treatments, such as high-intensity focused ultrasound (HIFU) or cryotherapy, aim to reduce these side effects. Some hospitals may offer them as an alternative to surgery, radiotherapy or hormone therapy.

BPH

The prostate gland surrounds the urethra, the tube through which urine passes out of the body. An enlarged prostate means the gland has grown bigger. Prostate enlargement happens to almost all men as they get older. An enlarged prostate is often called benign prostatic hyperplasia (BPH)

As the prostate grows it squeezes the urethra that carries urine through it, leading to a reduction in urinary stream. If severe this can lead to urinary retention (the inability to pass urine). As a consequence the bladder muscle has to work increasingly hard to eject urine, and it can become irritable as a result leading to urinary frequency and urgency (overactive bladder symptoms).

It can be dangerous because urine trapped in the bladder can cause urinary tract infections (UTIs) and damage your kidneys. BPH is not the same as prostate cancer. It's a benign condition that doesn't increase the risk of cancer

When the prostate is enlarged the following symptoms can occur:

  • Poor flow
  • Difficulty starting or stopping urinating
  • Having to push or strain to start urinating
  • The sensation of not having emptied completely
  • Frequency
  • Urgency
  • Incontinence
  • Getting up at night to pass urine

Conservative treatment:

In those cases where symptoms are mild, there are certain useful things that you can do to help:

  • Avoid caffeinated drinks
  • Double void, to try and empty you bladder completely
  • Reduce you fluid intake in the evening
  • Pass urine before going to bed

Medical (drug) treatment

There are several drugs that can be used to manage, not cure, this condition.

Alpha-blockers (tamsulosin, alfusozin, doxazosin) work by relaxing the muscle of the prostate, increasing urine flow, and should be the first line treatment. Patients usually notice an improvement with 48- 72 hours. Side effects are few, and disappear on stopping the medication, and can include:

  • Low blood pressure (dizziness on standing)
  • Weakness
  • Retrograde ejaculation
  • Headache
  • Nasal congestion

5 alpha-reductase inhibitors (finasteride, dutasteride) work by shrinking the prostate, and thus improving flow. They take up to 6 months to work and maybe prescribed in conjunction with an alpha- blocker. May prevent the complications of BPH in men with big prostates (retention, need for surgery).

Complications include:

  • Erectile dysfunction
  • Loss of libido

Anticholinergic medication (solifenacin, tolterodine ) is usually prescribed for patients with an overactive bladder. In men with symptoms from an enlarged prostate, they maybe used in conjunction with an alpha-blocker to reduce urinary frequency and urgency.

There are several herbal remedies on the market (saw palmetto), but the evidence for any benefit with these is weak.

Treatment for BPH

There are several surgical approaches to the treatment of BPH. The gold standard remains the TURP (transurethral resection of prostate), but other surgical approaches include open prostatectomy, bladder neck incision (BNI) and minimally invasive approaches such as Greenlight laser prostatectomy. More recently a procedure called UroLift® has become available.

Transurethral resection of prostate (TURP)

Transurethral resection of the prostate (TURP) is the endoscopic removal of obstructive benign prostate enlargement (BPH). A resectoscope is passed through the urethra to scrape away the enlarged prostate gland piece by piece to re-establish a channel. The operation takes up to 1 hour and is done under general or spinal anaesthesia. A Foley catheter is inserted into the bladder after the surgery for continuous irrigation to prevent blood clots from forming in the bladder. The catheter can be removed only when the urine is less bloody. As TURP can be a very bloody operation, any blood- thinning medication, such as aspirin or Plavix must be stopped 1 week beforehand. Hospital stay is usually 2 to days depending on the bleeding

Bladder neck incision

Bladder neck incision is a cut made in the neck of the bladder and extended into the prostate. It is also called a transurethral incision of prostate. It is carried out to improve the flow of urine and to relieve your urinary symptoms

Open prostatectomy

When the prostate is too large to perform a TURP, it can be removed via an open incision in the lower abdomen. This is a much more radical operation than a TURP and involves a longer hospital stay and recovery period.

Greenlight laser therapy

This is a minimally invasive procedure in which the prostate is vaporised using a surgical laser, thereby clearing any obstruction it is causing to the urethra (water pipe). You will be given either a general or a spinal anaesthetic for the procedure. The operation takes about an hour and you can go home either on the same day or the next day.

UroLift®

This is a truly minimally invasive procedure that is performed as a day case, sometimes just using local anaesthetic. There is no cutting, heating or removal of prostate tissue. It involves the placement of between 2 to 4 specially designed staples into the prostate using a telescope. It is not suitable for all prostates (large gland, large middle lobe, urinary retention), and it is necessary to perform an ultrasound and a local anaesthetic cystoscopy as part of the work up.

The advantage of surgery is that it provides much greater symptom improvement than medication, cuts down the risks of complications from BPH, and can lead to cessation of medication. The downsides are that it involves an operation, with small complication risks.

Prostatitis is the inflammation (swelling) of the prostate gland. It can be very painful and distressing, but will often get better eventually. The prostate is a small gland found in men that lies between the penis and bladder. It produces fluid that's mixed with sperm to create semen.

Unlike other prostate conditions, such as prostate enlargement or prostate cancer, which usually affect older men, prostatitis can develop in men of all ages. However, it commonly affects men aged between 30 and 50.

There are two main types of prostatitis:

  • chronic prostatitis – where the symptoms come and go over a period of several months; it's the most common type; it's not usually caused by an infection
  • acute prostatitis – where the symptoms are severe and develop suddenly; it's rare but it can be serious and requires immediate treatment; it's always caused by an infection

Symptoms of acute prostatitis include:

  • pain, which may be severe, in or around your penis, testicles, anus, lower abdomen or lower back
  • urinary symptoms, such as pain when peeing, needing to pee frequently (particularly at night), problems starting or "stop-start" peeing, an urgent need to pee and, sometimes, blood in your urine
  • not being able to pee, which leads to a build-up of urine in the bladder known as acute urinary retention (AUR)
  • generally feeling unwell, with aches, pains and possibly a fever
  • a small amount of thick fluid (discharge) may come out of your penis from the urethra (the tube that carries urine out of the bladder)

Chronic prostatitis

You may have chronic prostatitis if you've had the following symptoms for at least three months:

  • pain in and around your penis, testicles, anus, lower abdomen, or lower back
  • pain when peeing, a frequent or urgent need to pee, particularly at night, or "stop-start" peeing
  • an enlarged or tender prostate on rectal examination, although in some cases it may be normal
  • sexual problems, such as erectile dysfunction, pain when ejaculating, or pelvic pain after sex

These symptoms can have a significant impact on your quality of life. However, in most cases, they'll gradually improve over time and with treatment.

Treating prostatitis

Treatment for prostatitis will depend on whether you have acute or chronic prostatitis.

Acute prostatitis

Acute prostatitis (where symptoms are sudden and severe) is usually treated with painkillers and a two to four week course of antibiotics. Hospital treatment may be needed if you're very ill or unable to pass urine (acute urinary retention).

Chronic prostatitis

Treatment for chronic prostatitis (where symptoms come and go over several months) usually aims to control the symptoms. The following treatments may be used to help control your symptoms:

  • painkillers, such as paracetamol or ibuprofen, may help relieve pain
  • a medication called an alpha-blocker, such as tamsulosin, may also be prescribed if you have problems with urination; these can help relax the muscles in the prostate gland and the base of the bladder
  • occasionally, a four- to six-week course of antibiotics, such as ciprofloxacin, may be prescribed even if no infection is found; this is to see if your condition improves
  • if your symptoms are severe, stronger painkillers, such as amitriptyline and gabapentin, may be considered The aim is to reduce symptoms to a level where they interfere less with day-to- day activities, rather than getting rid of the pain completely.

It is important to see an urologist in these situations