In medical school we learned that if you were male and lived long enough, you
would likely get prostate cancer. We also learned that men are more likely
to die with prostate cancer than to die from it. There are some things we can
do to improve the likelihood that prostate problems can be found earlier, hopefully
resulting in improved outcomes.
Location and function of the prostate
The size of a walnut, wrapped like a cuff around the urethra (the tube leading
from the base of the bladder to the penis), this little organ is important for
reproduction. The journey that spermatozoa must travel to fertilize the ripe
ova is perilous, through acidic vaginal secretions, up the cervical passage,
into the uterus and through the openings of the fallopian tubes. These delicate,
mobile cells need a safe medium in which they can easily move without being
damaged. Like the fire retardant foam sprayed on the runway to cushion the aircraft's
contact during a forced crash landing, during ejaculation the prostate secretes
an alkaline, nutritive fluid into the urethra to be mixed with sperm traveling
from testicular tubules, to create semen which is deposited in the female genital
Types of prostate problems
Growth and activities of prostate cells are under the influence of sex hormones,
such as testosterone. Like old men's noses and ears, the prostate gets bigger
with age, a process called benign prostatic hypertrophy. As the gland enlarges
it pushes on nearby structures, including the urethra. This can block bladder
emptying and might require treatment - medical or surgical - to remove the obstruction.
The prostate may become infected, resulting in a painful condition sometimes
difficult to eradicate. Infections cause inflammation and swelling, resulting
in partial or complete urinary obstruction, pain, and fever. Because the fatty
tissues of the prostate are poorly infused with blood, antibiotics such as ciprofloxacin (Cipro®) or trimethoprim - sulfamethoxazole (Septra®) need to be continued for several weeks to eradicate the infection.
Much like the glandular cells of the female breast, prostate cells, influenced by hormones, can become cancerous. At first these cancer cells stay put and replicate slowly, resulting in gradual enlargement of the tumor. Once the cancer mass reaches a certain size it can be detected by rectal exam. After a period of in-situ growth the cancer spreads or metastasizes to other parts of the body, especially to bone.
Prostate cells put out a small amount of protein, called prostatic specific
antigen (PSA), that may be detected using a blood test. Since the amount
of prostate tissue increases with age, PSA levels normally increase with age as well,
so the normal range gradually increases from under 2.5 ng/mL between the ages
of 40 and 49 to as high as 6.5 ng/mL by the age of 79. Elevated levels of PSA
can be caused by prostatic enlargement, infection, manipulation, or prostate
cancer. More recent techniques have been able to separate and identify two kinds
of PSA: free PSA and a complexed PSA that is attached to other molecules. In
prostate cancer the ratio of free PSA to total PSA is much lower than in other
prostate conditions, so this ratio provides important information to plan further
investigations and treatment.
Treatments and side effects
The traditional treatment for benign prostatic hypertrophy has been removal
of a small amount of the glandular tissue via the cystoscope, inserted through
the penis - an operation called transurethral prostatic resection (TUPR).
Possible side effects include temporary obstruction requiring catheterization,
infection and, occasionally, erectile dysfunction. More recently drugs have
been discovered that block the nerve and hormonal stimulation of prostate cells,
allowing them to decrease in size.
Prostate cancer can be treated with surgery to remove the cancer tissue; castration to remove the hormones that stimulate tumor growth; drugs that inhibit production, secretion or the activity of tumor-stimulating hormones; radiation; and chemotherapy. As well as the common side effects of surgery and chemotherapy, temporary urinary tract obstruction, erectile dysfunction, and loss of libido are frequently caused by these treatments. Detected early, improved rates of long-term remission are obtained for patients with prostate cancer.
There is disagreement about whether PSA screening performed on all men over
45 is a good idea. Proponents of routine PSA screening point out that it improves
early diagnosis of a common, curable cancer at an earlier stage than can be
detected by physical exam. Those who oppose routine screening state that it
is costly and will result in unnecessary, invasive biopsies and treatment of
people whose prostate problems would not have resulted in significant disease.
Although the jury is still out on this, the reader might be interested to know
that I, and just about every middle-aged male physician I know, have periodic PSA testing done. Screening protocol recommendations vary,
but most experts agree that rather than the absolute PSA level, it is the relative
change that is important. So, a baseline level at 40 to 45 years old is valuable
because PSA levels can be rechecked every few years and compared to it. This
provides a very sensitive alarm system to pick up cancers early.
The bottom line
Prostate cancer is the second most common cancer experienced by men. Women
get breast cancer and we men get prostate problems. With both conditions there
is controversy about the best methods of screening and treatment. But there
is general agreement for both that earlier detection results in better outcomes.
Watch for changes in urinary stream: difficulty beginning the urine stream
in the morning, slower bladder emptying, pain, or discomfort. Get regular physical
exams, and if you are over 40, expect a rectal exam. Consider asking for a PSA test,
even if you have to pay for it.
In this aging man's opinion, it just seems like pretty cheap insurance.