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Prostate gland enlargement

Definition

The prostate gland is the male organ that produces semen, the milky-colored fluid that nourishes and transports sperm during ejaculation. It sits beneath your bladder and surrounds your urethra — the tube that drains urine from your bladder. When it becomes enlarged, the prostate can put pressure on your urethra and cause difficulty urinating.

Most men have a period of prostate growth in their mid- to late 40s. At this time, cells in the central portion reproduce more rapidly, resulting in prostate gland enlargement. As tissues in the area enlarge, they often compress the urethra and partially block urine flow. Benign prostatic hyperplasia (BPH) is the medical term for prostate gland enlargement.

Treatment of prostate gland enlargement depends on your signs and symptoms and may include medications, surgery or nonsurgical therapies. Prostate gland enlargement is not related to the development of prostate cancer.

Symptoms

Prostate gland enlargement varies in severity among men and doesn't always pose a problem. Only about half the men with prostate gland enlargement experience signs and symptoms that become noticeable or bothersome enough for them to seek medical treatment. These signs and symptoms may include:

Weak urine stream Difficulty starting urination Stopping and starting while urinating Dribbling at the end of urination Straining while urinating Frequent need to urinate Increased frequency of urination at night (nocturia) Urgent need to urinate Not being able to completely empty the bladder Blood in the urine (hematuria) Urinary tract infection

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Causes

Comparing normal and enlarged prostate glands

At normal size, the prostate gland is about the size and shape of a walnut or golf ball. When enlarged, the prostate may obstruct urine flow from the bladder and out the urethra.

At birth, your prostate gland is about the size of a pea. It grows slightly during childhood and then at puberty undergoes a rapid growth spurt. By age 25, your prostate is fully developed and is about the size of a walnut.

Doctors aren't sure exactly what causes prostate enlargement. It's thought that with age, changes in the ratio of male hormone (testosterone) and female hormone (estrogen) levels in men stimulate the prostate to grow. Another theory is that with aging, the prostate gland becomes more sensitive or responsive to normal levels of male hormone and grows more rapidly.

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Risk factors

The main risk factors for prostate gland enlargement include:

Aging. Prostate gland enlargement rarely causes signs and symptoms in men younger than 40, but about half the men in their 60s have some signs and symptoms.

Heredity. A family history of prostate enlargement can increase the odds of developing problems from prostate enlargement.

National origin. Prostate enlargement is more common in white and black men than in Asian men.

When to seek medical advice

If you're having urinary problems, seek medical advice. Your doctor can help determine whether you have prostate gland enlargement and whether your symptoms warrant further evaluation and treatment. If you're unable to pass urine at all, seek immediate medical attention.

If you don't find urinary symptoms too bothersome and they don't pose a health threat, you may not need treatment. But you should still have your symptoms evaluated by a doctor to make sure they aren't caused by another condition, such as a bladder stone, a bladder infection, side effects of medication, heart failure, diabetes, a neurological problem, inflammation of the prostate (prostatitis) or prostate cancer.

Tests and diagnosis

An evaluation for enlarged prostate will likely include:

Detailed questions about your symptoms. Your doctor will also want to know about other health problems, medications you're taking and whether there's a history of prostate problems in your family. Over-the-counter (OTC) drugs, such as aspirin, decongestants and antacids, are considered medications, so tell your doctor about those too. Your doctor may have you complete a symptom questionnaire.

Digital rectal exam. Wearing a lubricated examination glove, your doctor gently inserts a finger into your rectum. Because the prostate is located next to the rectum, your doctor can determine whether your prostate is enlarged and check for signs of prostate cancer.

Urine test. Analyzing a sample of your urine in the laboratory can help rule out an infection or other conditions that cause BPH-like symptoms, such as temporary inflammation of the prostate (prostatitis), bladder infection and kidney disease.

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Other tests your doctor may use to help confirm a BPH diagnosis include:

Transrectal ultrasound (TRUS). This test estimates the size of your prostate gland and can be helpful in diagnosing or ruling out prostate cancer. After a lubricating gel is applied to your rectum, the ultrasound probe — about the size and shape of a large cigar — is inserted. Sound waves bouncing off your prostate create an image of your prostate gland. Ultrasound takes about five minutes and isn't painful, though you may feel some uncomfortable pressure.

Urodynamic pressure-flow studies. This test measures bladder pressure and function while you urinate. After you receive a local anesthetic, a small catheter is threaded through your urethra into your bladder. Water is slowly injected into your bladder to measure internal bladder pressure and to determine how effectively your bladder contracts. Bladder pressure and urinary flow may be measured while you urinate. The test takes 30 to 60 minutes. Generally this test is reserved for men with complicated or unusual urinary symptoms.

Cystoscopy. This procedure allows your doctor to see inside your urethra and bladder. After you receive a local anesthetic, a thin tube containing a lighted lens (cystoscope) is gently inserted into your urethra. Your doctor can tell if you have urethral compression caused by an enlarged prostate, blockage of the urethra or bladder neck, anatomical abnormalities, or bladder stones. The instrument is inside you for five minutes or less. The procedure can be moderately painful.

Intravenous pyelogram or CT urogram. These studies use X-ray images of your urinary tract to help find obstructions and other abnormalities. These tests are most often used for those who have bladder stones, blood in the urine (hematuria) or frequent urinary tract infections. Dye containing iodine is injected into a vein, and an X-ray or CT scan is taken of your kidneys, bladder and the tubes that connect your kidneys to your bladder (ureters). The dye helps outline the drainage systems of the kidneys. If you're allergic to iodine, you may need special preparation for these tests or an alternative test that doesn't use dye.

Additional tests sometimes used to evaluate BPH include:

Prostate-specific antigen (PSA) blood test. It's normal for your prostate gland to produce PSA, which helps liquefy semen. A small amount of PSA normally circulates in your blood. Higher than normal PSA values are often associated with BPH — but some men have normal PSA values despite having an enlarged prostate. Higher than normal levels in your blood also can be signs of prostate cancer or an inflamed prostate (prostatitis). Most doctors use this test in men with BPH to be sure that a hidden prostate cancer isn't missed.

Urinary flow test. This test measures the strength and amount of your urine flow. You urinate into a receptacle attached to a special machine. The test takes no longer than a normal urination. Charting the results of this test over time helps determine if your condition is getting better or worse. It's normal for peak urine flow to decrease with age, but it can also be a sign of BPH or a weakened bladder muscle.

Postvoid residual volume test. This test measures whether you can empty your bladder completely. The test is done one of two ways: by inserting a thin, soft tube (catheter) into your urethra through your penis and up into your bladder after you urinate,

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or by using ultrasound imaging to measure the size of your bladder after you urinate. Ultrasound is more commonly used and less uncomfortable. Test results can vary, so you may need to have it done more than once to determine an accurate pattern. These tests take only a couple of minutes.

Complications

Prostate gland enlargement becomes a serious health threat only if it interferes with your ability to empty your bladder. A bladder that's continuously full can interfere with your sleep, cause recurrent bladder infection or result in kidney damage. Men who have an enlarged prostate are at increased risk of:

Acute urinary retention (AUR). AUR is a sudden painful inability to urinate. To empty the bladder, a catheter must be inserted into the bladder through the penis. Some men with BPH require surgery to treat AUR.

Urinary tract infections (UTIs). Some men with BPH end up having surgery to remove part of the prostate to prevent frequent UTIs.

Bladder stones. These are mineral deposits that can cause infection, bladder irritation, blood in the urine and obstruction of urine flow.

Bladder damage. This occurs when, over a long period of time, the bladder hasn't emptied completely. The muscular wall of the bladder stretches, weakens and no longer contracts properly. Often, men with BPH-caused bladder damage improve after surgery to remove part of the prostate.

Kidney damage. This is caused by frequent infections and acute urinary retention. BPH can also cause a condition called hydronephrosis, a swelling (dilation) of the urine-collecting structures in one or both kidneys due to pooled urine that can't drain out of the kidney.

Most men with BPH don't develop these complications. However, acute urinary retention and kidney damage in particular can be serious health threats when they do occur.

Treatments for prostate gland enlargement don't reduce or increase the risk of prostate cancer. Even if you're being treated for an enlarged prostate gland, you still need to continue regular prostate exams to screen for cancer. Surgical treatment for prostate gland enlargement can identify cancer in its early stages.

Treatments and drugs

Treatment for an enlarged prostate is determined by your signs and symptoms and their severity. If you have significant problems, such as urinary bleeding, persistent urinary tract infections, bladder and kidney damage, your doctor will probably recommend treatment. If your prostate is enlarged but your symptoms aren't too bothersome, treatment may not be necessary.

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A wide variety of treatments are available to ease the signs and symptoms of an enlarged prostate. They include medications, other nonsurgical therapies and surgical procedures.

Medications

Medications are the most common method for controlling moderate symptoms of prostate enlargement and include:

Alpha blockers. These drugs were originally developed to treat high blood pressure. They relax muscles around your bladder neck and make it easier to urinate. Four alpha blockers have been approved by the Food and Drug Administration (FDA) for treatment of BPH: terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax) and alfuzosin (Uroxatral).

All four alpha blockers are equally effective. These medications work quickly. Within a day or two, you'll probably have increased urinary flow and need to urinate less often. Doctors are uncertain about the long-term benefits and risks of alpha blockers. To reduce your risk of side effects, your doctor may start with a low dose of medication and gradually increase the dosage.

Alpha blockers taken with drugs for impotence, such as sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis), may interact and cause low blood pressure. Discuss with your doctor the possible side effects of these medications before taking them.

Alpha blockers can cause a pupil disorder that interferes with eye surgery. If you take tamsulosin or any other alpha blocker, be sure to tell your eye doctor if you're planning to have eye surgery. Some of the alpha blockers can cause dizziness and lightheadedness if you stand up too fast. In many cases simply changing from one type to another is all that needs to be done.

Enzyme (5 alpha reductase) inhibitors. These drugs shrink your prostate gland. Two that have been approved by the FDA for BPH are finasteride (Proscar) and dutasteride (Avodart).

For some men with large prostates, these drugs may produce a noticeable improvement in symptoms. They're generally not effective for men who have only a moderately enlarged or normal-sized prostate.

Enzyme inhibitors take longer to work than alpha blockers do. You may notice some urine flow improvement after a few months, but it can take up to a year for complete results.

Finasteride and dutasteride lower prostate-specific antigen (PSA) levels in your blood. Your doctor needs to know that you're taking these medications to properly interpret your PSA test results.

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Combination drug therapy. Taking an alpha blocker and an enzyme inhibitor at the same time can sometimes be more effective than taking just one type of BPH drug. Combination therapy can be more effective for relieving symptoms and preventing your symptoms from getting worse. It can also be more effective at lowering your long-term risk of developing acute urinary retention or needing surgery. The most tested combination is doxazosin and finasteride, though it's believed any combination of alpha blocker and enzyme inhibitor is equally effective.

Nonsurgical therapies Also called minimally invasive treatments, several nonsurgical treatment methods are available to reduce the size of the prostate. These therapies focus on enlarging the urethra, making it easier for you to urinate. These include:

Microwave therapy. Also called transurethral microwave therapy (TUMT), this procedure uses heat in the form of microwave energy to safely destroy the inner portion of the enlarged prostate gland.

Your doctor will insert a catheter through the tip of your penis. A tiny internal microwave antenna inside the catheter delivers a dose of microwave energy that heats and destroys enlarged cells. A local anesthetic helps control pain. You may feel some heat in the prostate and bladder area and have a strong desire to urinate. These responses usually disappear after the treatment is finished. You can go home when you're urinating satisfactorily, usually the same day.

The size and shape of an enlarged prostate is critical to the success of microwave therapy. If your prostate is very large or growing in an unusual shape into your bladder, this treatment generally isn't effective. TUMT isn't recommended if you have a pacemaker or any metal implants.

It may take several weeks before you begin to see a noticeable improvement in your symptoms. Those who seem to respond best over time are men whose initial symptoms are mild. The long-term effectiveness of the procedure is uncertain.

It's normal to have frequent, painful urination and small amounts of blood in your urine during recovery. You may ejaculate less semen after the procedure. However, unlike more invasive surgery, TUMT generally doesn't produce impotence, incontinence or retrograde ejaculation - semen flowing backward into the bladder instead of out through the penis during ejaculation.

Transurethral needle ablation (TUNA). Also called radiofrequency therapy, this outpatient procedure uses radio waves to heat and destroy the part of your prostate that's blocking urine flow.

During this procedure, a cystoscope is passed into your urethra and needles are placed into your prostate gland under visual guidance. Radio waves pass through the needles and heat the prostate and destroy the blockage.

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TUNA typically is less effective than is traditional surgery in reducing symptoms and improving urine flow. Its long-term effectiveness also isn't known. Another drawback of the procedure is that it doesn't work as well in men who have very large prostates. Side effects may include urine retention, blood in your urine, painful urination and a small risk of retrograde ejaculation.

Interstitial laser therapy (ILT). Also called interstitial laser coagulation, this procedure destroys overgrown prostate tissue by directing laser energy at the inside of your enlarged prostate gland.

During ILT, a small tube containing a laser fiber is inserted through a cystoscope into the prostate tissue by puncturing through the part of the urethra that's next to your prostate. Several punctures are usually needed to treat the entire prostate. Once the laser fiber is inside the prostate tissue, laser energy is activated to heat and destroy the tissue and shrink the gland.

You may be given spinal or general anesthesia to control pain. Or, you may be given a combination of local anesthetics in the urethra and intravenous sedation.

You may have small amounts of blood in your urine for a few days after treatment. Most men resume routine activities and sexual activity in a week or two.

Laser therapy is used less commonly than TUMT or TUNA. It's similar to other heat therapies, except it uses a laser instead of microwave energy, radio waves or electrical current to produce heat. It generally doesn't cause impotence or prolonged incontinence.

Prostatic stents. A prostatic stent is a tiny metal coil that is inserted into your urethra to widen it and keep it open. Tissue grows over the stent to hold it in place.

Although this procedure produces little or no bleeding and doesn't require a catheter, in most cases doctors don't consider stents a viable long-term treatment. Usually, they are used only for men who are unwilling or unable to take medications or who are reluctant or unable to have surgery.

While stents can provide immediate relief, some men find that stents don't improve their symptoms. A stent may shift positions, cause painful urination or frequent urinary tract infections. Stents often become obstructed by tissue growth and can be extremely difficult to remove. These side effects, along with the cost, have made stents a less popular treatment option. They're not the best choice for most men.

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Surgery

At one time surgery was the most common treatment for BPH. But because of increased use of medications and the development of other less invasive therapies, surgery is on the decline. Today it's used mainly for more-severe signs and symptoms or if you have complicating factors, such as:

Frequent urinary tract infections Recurring episodes of urine retention Bladder stones Blood in your urine Kidney damage from urine retention

Surgery is the most effective of all therapies for relieving symptoms of an enlarged prostate. It's also the most likely to produce side effects — but fortunately, most men experience few problems.

Surgery is probably not the best choice if you have a serious medical problem that would make undergoing anesthesia risky.

Some surgical procedures for the prostate require a hospital stay while others can be done in an outpatient setting. Depending on the procedure chosen and other medical problems you may have, you may need to avoid strenuous activities for up to a month. You'll probably need to take one to four weeks off work.

The types of surgery for an enlarged prostate include:

Transurethral resection of the prostate (TURP). Before the procedure, you're given a general anesthesia or anesthetized from the waist down with a spinal block. A surgeon threads a narrow instrument (resectoscope) into your urethra and uses small cutting tools to scrape away excess prostate tissue.

You can expect to stay in the hospital for one to three days after surgery. During your recovery, you may have a urinary catheter in place for one or more days but most patients can have it removed by the next day. At first you may feel some pain or a sense of urgency when urine passes over the surgical area. This discomfort should gradually improve. You can expect some blood or small blood clots to appear in your urine after TURP.

TURP is the most effective surgical procedure and relieves symptoms quickly. Most men experience a stronger urine flow within a few days.

In few cases, TURP can cause impotence and loss of bladder control. Generally, these conditions are only temporary. Pelvic floor muscle exercises (Kegels) often help restore bladder control. Normal sexual function often returns within a few weeks to months.

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Another more common side effect of surgery is retrograde ejaculation, but you shouldn't have any trouble with achieving climax and the sensation of orgasm. TURP may also produce scarring and narrowing in the urethra or bladder neck. This often can be remedied by stretching of the scar tissue, done on an outpatient basis. Some men who have TURP may need some sort of prostate surgery again if the prostate grows back or the scar tissue from a previous procedure needs to be removed.

Transurethral incision of the prostate (TUIP). This surgery is an option if you have only a moderately enlarged or small prostate gland. It's also an option for men who aren't good candidates for more invasive surgery for health reasons or because they don't want to risk sterility.

Like TURP, TUIP involves special instruments that are inserted through the urethra. But instead of removing prostate tissue, the surgeon makes one or two small cuts in the prostate gland. The cuts help enlarge the opening of the urethra, making it easier to urinate.

The procedure produces less risk of complications than do other kinds of surgery. It doesn't require an overnight hospital stay, but it's less effective and often needs to be repeated. Some men experience only a small improvement in urinary flow.

Laser surgery. Laser surgery uses a high-energy laser to destroy overgrown prostate tissue. The laser doesn't penetrate tissue deeply, so surrounding tissue isn't harmed.

The most common types of laser surgery are photosensitive vaporization of the prostate (PVP) and holmium laser enucleation of the prostate (HoLEP).

Laser surgery is done under general or spinal anesthesia. Depending on what type of surgery you have, you may need to stay overnight in the hospital and you may go home with a urinary catheter. Modern laser therapies use a high-energy, low-penetration laser that destroys prostate tissue on contact. After laser treatment, you can resume sexual activity and return to any type of work within a few weeks.

Laser surgery often provides immediate symptom relief, but you may have painful urination for days to weeks. Compared with TURP, laser surgery causes significantly less blood loss and recovery is quicker. Retrograde ejaculation also is a common side effect of laser surgeries.

Laser surgery to relieve BPH symptoms is relatively new, so its long-term effectiveness is unknown. Over time, your symptoms may worsen again and you may need re-treatment.

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Open prostatectomy. This type of surgery is generally performed only if you have an excessively large prostate, bladder damage or other complicating factors, such as bladder stones or urethral strictures. It's called open because the surgeon makes an incision in your lower abdomen to reach the prostate rather than going up through the urethra. During an open prostatectomy, only the inner portion of your prostate gland is removed, leaving the outer portion intact.

Open prostatectomy is the most effective therapy for men with extreme prostate enlargement. But it poses the greatest risk of side effects. Complications of the procedure are similar to those of TURP, and their effects may be more severe. The procedure usually requires a hospital stay of two to three days.

Lifestyle and home remedies

Making some lifestyle changes can often help control the symptoms of an enlarged prostate and prevent your condition from worsening. Consider these measures:

Limit beverages in the evening. Don't drink anything for an hour or two before bedtime to help you avoid wake-up trips to the bathroom at night.

Limit caffeine or alcohol. These can increase urine production, irritate your bladder and worsen your symptoms.

Limit diuretics. If you take water pills (diuretics), talk to your doctor. Maybe a lower dose, a milder diuretic or a change in the time you take your medication will help. Don't stop taking diuretics without first talking to your doctor.

Limit decongestants or antihistamines. These drugs tighten the band of muscles around your urethra that control urine flow, which makes it harder to urinate.

Go when you feel the urge. Try to urinate when you first feel the urge. Waiting too long to urinate may overstretch the bladder muscle and cause damage.

Schedule bathroom visits. Try to urinate at regular times to "retrain" the bladder. This can be done every four to six hours during the day and can be especially useful if you have severe frequency and urgency.

Stay active. Inactivity causes you to retain urine. Even a small amount of exercise can help reduce urinary problems caused by BPH.

Keep warm. Colder temperatures can cause urine retention and increase your urgency to urinate.

Alternative medicine

Herbal treatments for BPH are available at pharmacies, at grocery stores, over the Internet and in magazines. Common herbal treatments that show some evidence of helping reduce enlarged prostate symptoms include:

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Saw palmetto, made from the ripened berries of the saw palmetto shrub Beta-sitosterol, extracted from rye grass pollen and other plants Pygeum, made from the bark of an African plum tree

Be aware that the FDA does not regulate herbs. This means their safety and effectiveness has not been proved. Dosages, purities and ingredients available on the market vary, so it's not known which dosage is most effective and safe. The American Urological Association doesn't recommend using these remedies, and doctors have differing opinions about their use. Despite these drawbacks, growing evidence indicates that some alternative treatments may help relieve urinary symptoms caused by BPH. Herbal medications are commonly used in Europe to treat BPH.

Herbal products may increase your risk of bleeding and cause adverse drug interactions. Saw palmetto may suppress your baseline PSA level, which can interfere with the effectiveness of the PSA test for prostate cancer. If you take any herbal remedies, be sure to tell your doctor.

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Prostate Cancer

What is the prostate gland?

The prostate gland is an organ that is located at the base or outlet (neck) of the urinary bladder.

(See the diagram.) The gland surrounds the first part of the urethra. The urethra is the passage

through which urine drains from the bladder to exit from the penis. One function of the prostate

gland is to help control urination by pressing directly against the part of the urethra that it

surrounds. Another function of the prostate gland is to produce some of the substances that are

found in normal semen, such as minerals and sugar. Semen is the fluid that transports the sperm.

A man can manage quite well, however, without his prostate gland. (See the section on surgical

treatment for prostate cancer.)

In a young man, the normal prostate gland is the size of a walnut. During normal aging, however,

the gland usually grows larger. This enlargement with aging is called benign prostatic

hypertrophy (BPH), but this condition is not associated with prostate cancer. Both BPH and

prostate cancer, however, can cause similar problems in older men. For example, an enlarged

prostate gland can squeeze or impinge on the outlet of the bladder or the urethra, leading to

difficulty with urination. The resulting symptoms commonly include slowing of the urinary

stream and urinating more frequently, particularly at night.

What is prostate cancer?

Prostate cancer is a malignant (cancerous) tumor (growth) that consists of cells from the prostate

gland. The tumor usually grows slowly and remains confined to the gland for many years.

During this time, the tumor produces little or no symptoms or outward signs (abnormalities on

physical examination). As the cancer advances, however, it can spread beyond the prostate into

the surrounding tissues (local spread). Moreover, the cancer also can metastasize (spread even

farther) throughout other areas of the body, such as the bones, lungs, and liver. Symptoms and

signs, therefore, are more often associated with advanced prostate cancer.

Why is prostate cancer important?

Prostate cancer is the most common malignancy in American men and the second leading cause

of deaths from cancer, after lung cancer. Most experts in this field, therefore, recommend that

beginning at age 40, all men should undergo yearly screening for prostate cancer.

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What causes prostate cancer?

The cause of prostate cancer is unknown, but the cancer is thought not to be related to benign

prostatic hypertrophy (BPH). The risk (predisposing) factors for prostate cancer include

advancing age, genetics (heredity), hormonal influences, and such environmental factors as

toxins, chemicals, and industrial products. The chances of developing prostate cancer increase

with age. Thus, prostate cancer under age 40 is extremely rare, while it is common in men older

than 80 years of age. As a matter of fact, some studies have suggested that among men over 80,

between 50 and 80% of them may have prostate cancer!

Genetics (heredity), as just mentioned, plays a role in the risk of developing a prostate cancer.

For example, black American men have a higher risk of getting prostate cancer than do Japanese

or white American men. Environment, diet, and other unknown factors, however, can modify

such genetic predispositions. For example, prostate cancer is uncommon in Japanese men living

in their native Japan. However, when these men move to the United States, their incidence of

prostate cancer rises significantly. Prostate cancer is also more common among family members

of individuals with prostate cancer. Thus, a person whose father, grandfather, or even uncle has

prostate cancer is at an increased risk for also developing prostate cancer. To date, however, no

specific prostate cancer gene has been identified and verified. (Genes, which are situated on

chromosomes within the nucleus of cells, are the chemical compounds that determine specific

traits in individuals.)

Testosterone, the male hormone, directly stimulates the growth of both normal prostate tissue

and prostate cancer cells. Not surprisingly, therefore, this hormone is thought to be involved in

the development and growth of prostate cancer. The important implication of the role of this

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hormone is that decreasing the level of testosterone should be (and usually is) effective in

inhibiting the growth of prostate cancer.

Environmental factors, such as cigarette smoking and diets that are high in saturated fat, seem to

increase the risk of prostate cancer. Additional substances or toxins in the environment or from

industrial sources might also promote the development of prostate cancer, but these have not yet

been clearly identified.

What are the symptoms of prostate cancer?

In the early stages, prostate cancer often causes no symptoms for many years. As a matter of fact,

these cancers frequently are first detected by an abnormality on a blood test (the PSA, discussed

below) or as a hard nodule (lump) in the prostate gland. Usually, the doctor first feels the nodule

during a routine digital (done with the finger) rectal examination. The prostate gland is located

immediately in front of the rectum. As the cancer enlarges and presses on the urethra, the flow of

urine diminishes and urination becomes more difficult. Patients may also experience burning

with urination or blood in the urine. As the tumor continues to grow, it can completely block the

flow of urine, resulting in a painfully obstructed and enlarged urinary bladder.

In the later stages, prostate cancer can spread locally into the surrounding tissue or the nearby

lymph nodes, called the pelvic nodes. The cancer then can spread even farther (metastasize) to

other areas of the body. The doctor on a rectal examination can sometimes detect local spread

into the surrounding tissues. That is, the physician can feel a hard, fixed (not moveable) tumor

extending from and beyond the gland. Prostate cancer usually metastasizes first to the lower

spine or the pelvic bones (the bones connecting the lower spine to the hips), thereby causing

back or pelvic pain. The cancer can then spread to the liver and lungs. Metastases (areas to which

the cancer has spread) to the liver can cause pain in the abdomen and jaundice (yellow color of

the skin) in rare instances. Metastases to the lungs can cause chest pain and coughing.

What are the screening tests for prostate cancer?

Screening tests are those that are done at regular intervals to detect a disease such as prostate

cancer at an early stage. If the result of a screening test is normal, the disease is presumed not to

be present. If a screening test is abnormal, the disease is then suspected to be present, and further

tests usually are needed to confirm the suspicion (that is, to make the diagnosis definitively).

Prostate cancer usually is suspected initially because of an abnormality of one or both of the two

screening tests that are used to detect prostate cancer. These screening tests are a digital rectal

examination and a blood test called the prostate specific antigen (PSA).

In the digital rectal examination, the doctor feels (palpates) the prostate gland with his gloved

index finger in the rectum to detect abnormalities of the gland. Thus, a lump, irregularity, or

hardness felt on the surface of the gland is a finding that is suspicious for prostate cancer.

Accordingly, doctors usually recommend doing a digital rectal examination annually in men age

40 and over.

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The PSA test is a simple, reproducible, and accurate blood test. It is used to detect a protein (the

prostate specific antigen) that is released from the prostate gland into the blood. Most

importantly, the level of the PSA is usually higher in people with prostate cancer than in people

without the cancer. The PSA, therefore, is valuable as a screening test for prostate cancer.

Accordingly, doctors usually recommend doing a PSA annually in men age 50 and over.

Furthermore, for men who have high risks for prostate cancer as discussed above, most doctors

recommend starting the PSA screening at an even younger age (for example, at age 40).

Results of the PSA test under 4 nanograms per milliliter of blood are generally considered

normal. (See the next two sections on false-positive elevations of the PSA and on refinements in

the PSA test.) Results between 4 and 10 are considered borderline. These borderline values are

interpreted in the context of the patient's age, symptoms, signs, family history, and changes in the

PSA levels over time. Results higher than 10 are considered abnormal, suggesting the possibility

of prostate cancer. The higher the PSA value, the more likely the diagnosis of prostate cancer.

Moreover, the level of PSA tends to increase when the cancer has progressed from organ-

confined prostate cancer to local spread to distant (metastatic) spread. Very high values, such as

30 or 40 and over, are usually caused by prostate cancer.

What are false-positive elevations in the PSA test?

False-positive elevations in the PSA are increases in the PSA that are caused by conditions other

than prostate cancer. For example, benign prostatic hypertrophy (BPH) and infection or

inflammation of the prostate (prostatitis) from whatever cause can elevate the PSA. Note also

that even a rectal examination or an ejaculation within the prior 48 hours can sometimes elevate

the PSA. False-positive elevations are usually in the 4 to10 range, but they can go as high as 25

or 30. At these higher levels, however, caution in the interpretation of the test is warranted

because a prostate cancer may well be present. Non-prostatic diseases or infections, medications,

foods, smoking, and alcohol do not cause false-positive elevations of the PSA.

The ability of the PSA test to detect prostate cancer (called the sensitivity of the test) is high. The

reason for this is that most patients, although not all, with prostate cancer have a borderline or an

abnormally elevated PSA. The ability of the test to exclude other diagnoses (called the

specificity of the test), however, is lower because of the other conditions that can cause false-

positive elevations of the PSA.

What refinements have been made in the PSA test?

Recently, several refinements have been made in the PSA blood test. The purpose of these

refinements is to help doctors to better assess a borderline or an elevated PSA. The goal is to

determine more accurately who has prostate cancer and who has a false-positive elevation of the

PSA from another condition. In other words, the purpose of the improvements is to improve the

sensitivity and the specificity of the test.

One refinement is called the PSA ratio. This ratio is determined by dividing the amount of PSA

that circulates freely in the blood stream by the amount of PSA that is bound to proteins in the

blood stream. Research has shown the PSA that circulates freely in the blood tends to be

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associated with benign prostatic hypertrophy (BPH) whereas the PSA that is bound to protein

tends to be linked with prostate cancer. Thus, a high PSA ratio suggests a false-positive elevation

of the PSA and weighs against the diagnosis of prostate cancer. In contrast, a high PSA with a

low PSA ratio favors the diagnosis of prostate cancer.

Another recent modification of the PSA test is based on the observation that as men age, the

amount of PSA in the blood can normally rise without the presence of a prostate cancer. Thus,

doctors can use what is referred to as an age-specific PSA, especially to evaluate borderline

values. In the age-specific PSA, the normal values are adjusted for the age of the patient.

Accordingly, the age-specific normal ranges are 0 to 2.5 for men in their 40s, 0 to 3.5 in their

50s, 0 to 4.5 in their 60s, and 0 to 6.5 for men 70 and over. Therefore, as an example, a PSA of 4

would be considered borderline for men in their 30s and 40s, but could be normal for men in

their 50s, 60s, and 70s.

Yet another improvement of the PSA test is called the PSA velocity or slope. The velocity is

calculated as the rate at which the PSA changes with repeated testing over time. The more rapid

the rise in the PSA, the more likely is the presence of a prostate cancer. The less rapid the rise in

the PSA, the less likelihood there is that a prostate cancer is present.

How is prostate cancer diagnosed?

Prostate cancer is diagnosed from the results of a biopsy of the prostate gland. If the digital rectal

exam of the prostate or the PSA blood test is abnormal, a prostate cancer is suspected. A biopsy

of the prostate is usually then recommended. The biopsy is done from the rectum (trans-rectally)

and is guided by ultrasound images of the area. A small piece of prostate tissue is withdrawn

through a cutting needle. The TRUS-guided Tru-Cut biopsy is currently the standard method to

diagnose prostate cancer. Classically a 6-core set is taken by sampling the base, apex and mid

gland on each side of the gland. More cores may be sampled to increase the yield, especially in

larger glands. A pathologist then examines the tissue under a microscope for signs of cancer in

the cells of the tissue.

When prostate cancer is diagnosed on the biopsy tissue, the pathologist will then grade each of

two pieces of the tissue from 1 to 5 on the Gleason scale. The scale is based on certain

microscopic characteristics of the cancerous cells and reflects the aggressiveness of the tumor.

The two scores are then added together. Sums of 2 to 4 are considered low, indicating a slowly

growing tumor. Sums of 5 and 6 are intermediate, representing an intermediate degree of

aggressiveness. Sums of 7 to 10 are considered high, signaling a rapidly growing tumor with the

worst prognosis (outcome).

Gleason scores can be helpful in guiding treatment that is based, at least in part, on the

aggressiveness of the tumor. The principal application of the Gleason score, however, is in

predicting the risk for death from a prostate cancer. The tumor grade strongly affects the

prognosis. Higher tumor grades are more frequently associated with lymph node and distant

spread (metastases). Thus, recent studies have shown that men with Gleason scores of 2 to 4 face

a minimal risk (4 to 7%) of death from prostate cancer over the ensuing 15 years, while men with

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scores of 8 to 10 face a high risk (60 to 87%) of death from prostate cancer over the 15 year

period.

How is the staging of prostate cancer done?

The staging of a cancer refers to determining the extent of the disease. Once a prostate cancer is

diagnosed on a biopsy, additional tests are done to assess whether the cancer has spread beyond

the gland. For this assessment, biopsies of the surrounding organs, such as the rectum or urinary

bladder, or of the nearby (pelvic) lymph nodes might be done. In addition, imaging tests are

usually performed. For example, radionuclide bone scans can determine if there is a spread of the

tumor to the bones. Additionally, CAT scans (coaxial tomography) and MRIs (magnetic

resonance imaging) can determine if the cancer has spread to adjacent tissues or organs such as

the bladder or rectum or to other parts of the body such as the liver or lungs. Newer scanning

using a method called PET scan can sometimes help to detect hidden locations of cancer that has

spread to various areas of the body.

In brief, doctors do the staging of prostate cancer based primarily on the results of the prostate

biopsy, possibly other biopsies, and imaging tests. In staging a cancer, doctors assign various

letters and numbers to the cancer, depending on which of the classifications for staging they use.

The numbers and letters in the different classifications define the volume or amount of the tumor

and the spread of the cancer. The stage of the prostate cancer, therefore, helps to predict the

expected course of the disease and determine the choice of treatment.

Two main systems are used to stage prostate cancer. In the American urologic staging system,

stage A describes a minimal cancer that can neither be palpated (felt) on physical examination

nor seen by imaging techniques. Such a tumor is so small that it can be detected only by viewing

it under a microscope. Stage B refers to a larger cancer that may be palpated, but that still is

confined (localized) to the prostate gland. Stage C indicates local spread beyond the prostate into

the surrounding tissues. Stage D1 signifies a spread to the nearby (pelvic) lymph nodes and D2 is

for distant spread (metastasis), for example, to the bones, liver, or lungs.

The other main system for staging prostate cancer is called the tumor, nodes, and metastasis

(TNM) classification. In this system, T1 and T2 are equivalent to stage A and B (respectively) in

the American urologic system. T3 describes cancer that extends just beyond the capsule (coat) of

the prostate, and T4 describes cancer that is fixed to the surrounding tissues. N1 is equivalent to

Stage D1 and M1 is equivalent to D2.

What are the treatment options for prostate cancer?

Deciding on treatment can be daunting, partly because the options for treatment today are far

better than they were ten years ago, but also because not enough reliable data are available on

which to base the decisions. Accordingly, scientifically controlled, long term studies are still

needed to compare the benefits and risks of the various treatments.

To decide on treatment for an individual patient, doctors categorize prostate cancers as organ-

confined (localized to the gland), locally advanced (a large prostate tumor or one that has spread

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only locally), or metastatic (spread distantly or widely). The treatment options for organ-

confined prostate cancer or locally advanced prostate cancer usually include surgery, radiation

therapy, hormonal therapy, cryotherapy, combinations of some of these treatments, and watchful

waiting. A cure for metastatic prostate cancer is, unfortunately, unattainable at the present time.

The treatments for metastatic prostate cancer, which include hormonal therapy and

chemotherapy, therefore, are considered palliative. By definition, the aims of palliative

treatments are, at best, to slow the growth of the tumor and relieve the symptoms of the patient.

What are the differences between hormonal treatment and chemotherapy?

Hormonal therapy is the mainstay of treatment for symptomatic advanced prostate cancer.

Patients without symptoms, but with advanced disease, do not appear to have improved survival

with treatment when compared with untreated patients. Therefore, treatment of patients with

asymptomatic advanced disease is not essential. The treatments available for hormonal therapy

are:

1. Orchiectomy is the surgical removal of the testicles.

2. Luteinizing hormone-releasing hormone agonists, otherwise known as Lupron and Zoladex,

and antiandrogens, specifically a drug called Casodex, each produce symptomatic relief in about

80% of patients. Improvement is often dramatic.

3. Other agents that are helpful include the following: progrestins such as megastrol acetate

given daily orally and other drugs that inhibit androgen production such as aminoglutethimide

or ketoconazole. These agents are effective but are difficult to tolerate. Corticosteroids are

often given simultaneously. As opposed to hormonal therapy, chemotherapy provides relief in

only 20-25% of symptomatic patients with prostate cancer. Various regimens are being used.

Estramustine, cisplatin, 5-FU, vinorelbine, and mitoxantrone are the most popular agents.

However, recently Taxol has become the drug of choice used by oncologists in treating

hormone-resistant prostate cancer.

When to use hormonal therapy and chemotherapy depends on the nature of the prostate cancer

itself. If the prostate cancer is hormone-sensitive, then hormonal therapy is the therapy of choice.

When the cancer becomes hormone resistant (for example, manipulation of the hormone levels

has no effect on the prostate cancer), then the only potential therapy available to the patient is

chemotherapy. Chemotherapy, then, is used generally when advanced prostate cancer is

hormone-resistant. Unfortunately, chemotherapy coming after hormone therapy is nowhere near

as effective as hormonal therapy because the cancer itself has often evolved to become more

aggressive so that the prognosis is significantly worse. When patients' prostate cancer goes from

being hormone-sensitive to hormone-resistant, the prognosis has taken a significant turn for the

worse and the chemotherapy option at that particular time is usually the only treatment option

available.

Other factors considered in choosing treatment include the age, general health, and preference of

the individual and the Gleason score and stage of the cancer. The results of the PSA test

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sometimes also can help to decide on the treatment. For example, a borderline elevation of the

PSA (4-10), if shown to be due to a prostate cancer, suggests that the cancer is confined to the

gland. If other tests also point to an organ-confined tumor, surgery or possibly radiation can be

considered to attempt a cure. In contrast, a very high PSA (for example, over 30 or 40) raises the

possibility of metastases. If the metastases are then confirmed by other tests, the treatment

options would be limited to hormonal therapy or chemotherapy.

PSA tests also should be done periodically after treatment to help assess the results of treatment.

For example, an increasing PSA suggests growth or spread of the cancer, despite the treatment.

In contrast, a decreasing PSA indicates improvement. As a matter of fact, a post-treatment PSA

of zero may indicate complete control or cure of the cancer.

What about surgical treatment for prostate cancer?

The surgical treatment for prostate cancer is commonly referred to as a radical or total

prostatectomy, which is the removal of the entire prostate gland. Since 1990, the radical

prostatectomy has been the most common treatment for prostate cancer in the United States. This

operation is done in about 36% of patients with organ-confined (localized) prostate cancer. The

American Cancer Society estimates a 90% cure rate nationwide when the disease is confined to

the prostate and the entire gland is removed. The potential complications of a radical

prostatectomy include the risks of anesthesia, local bleeding, impotence (loss of sexual function)

in 30%-70% of patients, and incontinence (loss of control of urination) in 3%-10% of patients.

Great strides have been made in lowering the frequency of the complications of radical

prostatectomy. These advances have been accomplished largely through improved anesthesia

and surgical techniques. The improved surgical techniques, in turn, stem from a better

understanding of the key anatomy and physiology of sexual potency and urinary continence.

Specifically, the recent introduction of nerve-sparing techniques for the prostatectomy has helped

to reduce the frequency of impotence and incontinence.

If post-treatment impotence does occur, it can be treated by sildenafil (Viagra) tablets, injections

of such medications as alprostadil (Caverject) into the penis, various devices to pump up or

stiffen the penis, or a penile prosthesis (an artificial penis). Incontinence after treatment often

improves with time, special exercises, and medications to improve the control of urination.

Occasionally, however, incontinence requires implanting an artificial sphincter around the

urethra. The artificial sphincter is made up of muscle or other material and is designed to control

the flow of urine through the urethra.

What about radiation therapy for prostate cancer?

The goal of radiation therapy is to damage the cancer cells and stop their growth or kill them.

This works because the rapidly dividing (reproducing) cancer cells are more vulnerable to

destruction by the radiation than are the neighboring normal cells. Clinical trials have been

conducted using radiation therapy for patients with organ-confined (localized) prostate cancer.

These trials have shown that radiation therapy resulted in a rate of survival (being alive) at 10

years after treatment that is comparable to that for radical prostatectomy. Incontinence and

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impotence can occur as complications of radiation therapy, as with surgery, although perhaps

less often than with surgery. More data are needed, however, on the risks and benefits of

radiation therapy beyond 10 years, especially because late recurrences (reappearances) of the

cancer can sometimes occur after radiation.

Choosing between radiation and surgery to treat organ-confined prostate cancer involves

considerations of the patient's preference, age, and co-existing medical conditions (fitness for

surgery), as well as of the extent of the cancer. Approximately 30% of patients with organ-

confined prostate cancer are treated with radiation. Sometimes, oncologists combine radiation

therapy with surgery or hormonal therapy in efforts to improve the long-term results of treatment

in the early or later stages of prostate cancer.

Radiation therapy can be given either as external beam radiation over perhaps 6 or 7 weeks or as

an implant of radioactive seeds (brachytherapy) directly into the prostate. In external beam

radiation, high energy x-rays are aimed at the tumor and the area immediately surrounding it. In

brachytherapy, radioactive seeds are inserted through needles into the prostate gland under the

guidance of transrectally taken ultrasound pictures. Brachy, from the Greek language, means

short. The term brachytherapy thus refers to placing the treatment (radiation therapy) directly

into or a short distance away from the cancerous target tissue. The theoretical advantage of

brachytherapy over external beam radiation is that delivering the radiation energy directly into

the prostate tissue should minimize damage to the surrounding tissues and organs. The actual

advantages or disadvantages of brachytherapy as compared to external beam radiation, however,

are still being studied.

What about hormonal treatment for prostate cancer?

The male (androgenic) hormone is called testosterone. It stimulates the growth of cancerous

prostatic cells and, therefore, is the primary fuel for the growth of prostate cancer. The idea of all

of the hormonal treatments (medical and surgical), in short, is to decrease the stimulation by

testosterone of the cancerous prostatic cells. Testosterone normally is produced by the testes in

response to stimulation from a hormonal signal called LH-RH. The LH-RH stands for luteinizing

hormone-releasing hormone and is also called gonadotropin-releasing hormone. This hormone

comes from a control station in the brain and travels in the blood stream to the testes. Once there,

the LH-RH stimulates the testes to produce and release testosterone.

Hormonal treatment, also referred to as androgenic deprivation (depriving the prostate of

testosterone), can be accomplished surgically or medically. The surgical hormonal treatment is

removal of the testes in an operation called an orchiectomy or a castration. This surgery thus

removes the body's source of testosterone. The medical hormonal treatment involves taking one

or two types of medication. One type is referred to as the LH-RH agonists. They work by

competing with the body's own LH-RH. These drugs thereby inhibit (block) the release of LH-

RH from the brain. The other type of drug is referred to as anti-androgenic, meaning that these

drugs work against the male hormone. That is, they work by blocking the effect of testosterone

itself on the prostate.

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Today, most men electing hormonal treatment choose medication over surgery, probably because

they view surgical castration as more devastating cosmetically or psychologically. Actually,

however, the effectiveness and side effects of medical hormonal treatment as compared to

surgical hormonal treatment are very much the same. Both types of hormonal treatment usually

effectively eliminate stimulation of the cancer cells by testosterone. Some tumors of the prostate,

however, do not respond to this form of treatment. They are referred to as androgen-independent

prostate cancers. The principal side effects of all of these hormonal treatments (that is, the side

effects of androgenic deprivation) are enlarged breasts (gynecomastia) that often are tender,

flushing (like hot flashes), and impotence.

The LH-RH agonists, leuprolide (Lupron) or goserelin (Zoladex), are given as monthly injections

in the doctor's office. The anti-androgenic drugs, flutamide (Eulexin) or bicalutamide (Casodex),

are oral capsules that are used usually in combination with the LH-RH agonists. The LH-RH

agonists are often effective alone. The anti-androgenic drugs are added, however, if the cancer

progresses despite the use of the LH-RH agonists. The hormonal treatments may have value, as

well, when combined with radiation therapy. Studies are currently being conducted to determine

if hormonal therapy enhances the therapeutic effect of radiation.

Generally, hormonal treatment is reserved for individuals who have advanced prostate cancer

with local spread or metastases. Occasionally, an individual with organ-confined (localized)

prostate cancer will receive hormonal treatment because he has severe associated medical

problems or simply because he refuses to undergo surgery or radiation. Hormonal treatment is

used in less than 10% of men with organ-confined (localized) prostate cancer. Remember that

the intent of hormonal therapy usually is palliative. This means that the goal is to control the

cancer rather than cure it because a cure is not possible.

What is cryotherapy for prostate cancer?

Cryotherapy is one of the newer treatments that is being evaluated for use in the early stage of

prostate cancer. This treatment kills the cancer cells by freezing them. The freezing is

accomplished by inserting a freezing liquid (for example, liquid nitrogen or argon) through

needles directly into the prostate gland. The procedure is accomplished under the guidance of

ultrasound images. Actually, cryotherapy is not a new technique. Rather, it is a modification of a

procedure that was tried previously, but had an unacceptably high rate of complications. Thus,

cryotherapy was used in the 1960s to freeze the lining of the stomach to treat ulcers, but was

discontinued because it also severely damaged the lining of the stomach.

At present, cryotherapy is recommended for patients with locally advanced prostate cancer who,

for whatever reason, are not candidates for the more established treatments. Cryotherapy is

further being studied to determine which other patients might benefit from this treatment. For

example, studies are underway to establish whether cryotherapy is beneficial as an initial

treatment for organ-confined (localized) prostate cancer. The effectiveness of cryotherapy in

eliminating prostate cancer, however, has not yet been proven. We do know that sometimes the

freezing liquid fails to kill all of the cancer cells. Moreover, the potential side effects of this

treatment include damage to the urethra and bladder. This damage can cause obstruction

(blockage) of the urethra, fistulas (abnormal tunnels) that leak urine, or serious infections.

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What is chemotherapy for prostate cancer?

Chemotherapeutic agents, or chemotherapy, are anti-cancer drugs. They are used (for hormone

resistant prostate cancer) as a palliative treatment (palliation to relieve symptoms) in patients

with advanced cancer for whom a cure is unattainable. Recall that the goal of palliation is simply

to slow the tumor's growth and relieve the patient's symptoms. Chemotherapy is not ordinarily

used for organ-confined or locally advanced prostate cancers because a cure in these cases is

possible with other treatments. Currently, chemotherapy is used only for advanced metastatic

prostate cancers that have failed to respond to other treatments.

Several chemotherapeutic agents have been used effectively to palliate metastatic prostate

cancer. One such agent is estramustine (Emcyt). Another agent, mitoxantrone (Novantrone), has

been shown to be effective in combination with prednisone for palliating androgen-independent

prostate cancer. As mentioned previously, metastatic tumors that have not responded specifically

to hormonal therapy are referred to as androgen-independent (hormone-refractory) prostate

cancers.

The more common side effects of chemotherapy include weakness, nausea, hair loss, and

suppression of the bone marrow. The suppression of marrow, in turn, can decrease the red blood

cells (causing anemia), the white blood cells (leading to infections), and the platelets (resulting in

bleeding).

New chemotherapeutic agents for prostate cancer are continually being studied for their

effectiveness and safety in cancer centers throughout the United States and elsewhere. For

example, cancer specialists (oncologists) have been evaluating paclitaxel (Taxol) or docetaxel

(Taxotere) for metastatic prostate cancer. (These two drugs are effective in palliating metastatic

breast cancer.) Another one of the newer chemotherapeutic agents under investigation for

androgen independent prostate cancer is Suramin.

What about herbal or other alternative medicine treatments for prostate

cancer?

Alternative medicine, also called integrative or complementary medicine, includes such non-

traditional treatments as herbs, dietary supplements, and acupuncture. A major problem with

most herbal treatments is that their composition is not standardized. Moreover, the way herbal

treatments work and their long-term side effects usually are not known.

One new treatment for prostate cancer, new at least in the United States, is an herbal medicine

called PC Spes. The name comes from PC, which stands for prostate cancer, and Spes, which is

the Latin word for hope. In some initial trials of PC Spes in men who have failed the traditional

treatments (hormonal therapy and chemotherapy) for advanced prostate cancer, this herbal

medicine appeared to be promising. More rigorous studies are ongoing to evaluate more fully the

risks and benefits of this treatment.

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What is watchful waiting?

Watchful waiting is observing a patient while no treatment is given. Such a patient usually has an

organ-confined tumor and no symptoms. Understand, however, that although watchful waiting

involves no actual treatment, the patient still needs close follow-up and monitoring. The follow-

up involves frequent visits to the doctor, perhaps every three to six months. The visits include

questions about new or worsening symptoms and digital rectal examinations for any change in

the prostate gland. In addition, blood tests are done to watch for a rising PSA and imaging

studies can be conducted to detect the spread of the cancer. If the history, examinations, or any of

the tests signal the possibility of an advancing cancer, the watchful waiting usually is

discontinued and treatment is recommended.

This option of watchful waiting actually has been chosen over a therapeutic intervention, such as

surgery or radiation, in up to 30% of patients who have organ-confined (localized) prostate

cancer. The main reason for taking a course of watchful waiting is that prostate cancers generally

grow more slowly than most other cancers. Thus, many localized prostate cancers found at an

early stage can take years or sometimes even decades to spread locally and metastasize.

Therefore, watchful waiting seems to make sense for organ-confined (localized) prostate cancers

in men who are elderly. It is also a reasonable decision in men who have tiny (seen only with a

microscope) tumors and a low PSA (for example, in the 4-10 range or lower). Additionally,

watchful waiting often is the most appropriate choice in men who are ill with other serious

medical diseases, such as heart or lung disease, poorly controlled high blood pressure, diabetes,

AIDS, or other cancers.

Watchful waiting in prostate cancer, however, remains controversial. Some medical authors have

stated outright that it is not a good choice. They point out that few doctors would just watch

other cancers to see whether they would spread without treatment. Furthermore, the treatment for

an individual could become less effective in the future if and when the cancer does progress.

Finally, one expert summarized some recently published information on watchful waiting. He

indicated that among men with organ-confined (localized) prostate cancer, the development of

distant spread (metastasis) and death from the cancer was 50% higher in those who received no

treatment than in those who underwent surgical removal of the prostate (radical prostatectomy).

Can prostate cancer be prevented?

No specific measures are known to prevent the development of prostate cancer. At present,

therefore, we can hope only to prevent progression of the cancer by making early diagnoses and

then attempting to cure the disease. Early diagnoses can be made by screening men for prostate

cancer. Screening is done, as mentioned previously, by routine yearly digital rectal examinations

beginning at age 40 and the addition of an annual PSA test beginning at age 50. The purpose of

the screening is to detect early, tiny, or even microscopic cancers that are confined to the prostate

gland. Early treatment of these malignancies (cancers) can stop the growth, prevent the spread,

and possibly cure the cancer.

Based on some research in animals and people, certain dietary measures have been suggested to

prevent the progression of prostate cancer. For example, low fat diets, particularly avoiding red

25

meats, have been suggested because they are thought to slow down the growth of prostate tumors

in a manner not yet known. Soybean products, which work by decreasing the amount of

testosterone circulating in the blood, also reportedly can inhibit the growth of prostate tumors.

Finally, other studies show that tomato products (lycopenes), the mineral selenium, and vitamin

E might slow the growth of prostate tumors in ways that are not yet understood.

What will be the future treatments for prostate cancer?

The treatment of organ-confined prostate cancer to date has involved cutting out, radiating, or

freezing the gland in trying to cure the disease. In more advanced cases, the goal has been to

control the cancer for at least some time by using hormonal treatment or chemotherapy. Earlier

diagnosis and improved treatment techniques in recent years have certainly led to better results.

In addition, other treatments are being sought. For example, microwave treatment of the prostate

is being used for benign prostatic hypertrophy (enlargement of the prostate, BPH) in a minimally

invasive (minimal cutting or probing), outpatient (outside the hospital) procedure. Studies may

soon begin to evaluate this technique as a treatment for prostate cancer.

The key to curing prostate cancer, however, ultimately will come from an understanding of the

genetic basis of this disease. Genes, which are chemical compounds located on the

chromosomes, determine the characteristics of individuals. Accordingly, investigators at research

centers have focused on identifying and isolating the gene or genes responsible for prostate

cancer. For example, studies are being conducted in men who have a family history of prostate

cancer to try to uncover the genetic links of the disease. The investigators ultimately will try to

block or modify the offending genes so as to prevent or alter the disease. Finally, perhaps a

vaccine to either prevent or treat prostate cancer will be developed in the future.

Prostate Cancer At A Glance

Prostate cancer is the second leading cause of deaths from cancer among US men.

While the causes of prostate cancer are still unknown, some risk factors for the disease, such as advancing age and a family history of prostate cancer, have been identified.

Prostate cancer is often initially suspected because of an abnormal PSA blood test or a hard nodule (lump) felt on the prostate gland during a routine digital (done with a finger) rectal examination.

The digital rectal examination (starting at age 40) and the PSA blood test (starting at age 50) should be done at yearly intervals to screen men for prostate cancer.

Refinements in the PSA test, including the PSA ratio, age-specific PSA, and PSA velocity or slope have improved the accuracy of the test.

If one of the screening tests is abnormal, the diagnosis of prostate cancer should be suspected and a biopsy of the prostate gland is usually done.

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The diagnosis of prostate cancer is made when cancerous prostatic cells are identified in the biopsy tissue under a microscope.

In some men, prostate cancer is life threatening, while in many others, it can exist for many years without causing health problems.

The choice of treatment for prostate cancer depends on the size, aggressiveness, and extent or spread of the tumor, as well as on the age, general health, and preference of the patient.

The many options for treating prostate cancer include surgery, radiation therapy, hormonal treatment, cryotherapy, chemotherapy, combinations of some of these treatments, and watchful waiting.

Research is underway to identify the genes that cause prostate cancer.

27

The Prostate Gland

The prostate is a walnut-sized gland that forms part of the male reproductive system. The gland

is made of two lobes, or regions, enclosed by an outer layer of tissue. As the diagrams show, the

prostate is located in front of the rectum and just below the bladder, where urine is stored. The

prostate also surrounds the urethra, the canal through which urine passes out of the body.

Scientists do not know all the prostate's functions. One of its main roles, though, is to squeeze

fluid into the urethra as sperm move through during sexual climax. This fluid, which helps make

up semen, energizes the sperm and makes the vaginal canal less acidic.

Benign Prostatic Hyperplasia: A Common Part of Aging

It is common for the prostate gland to become enlarged as a man ages. Doctors call this condition

benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy.

Normal urine flow.

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Urine flow with BPH.

As a man matures, the prostate goes through two main periods of growth. The first occurs early

in puberty, when the prostate doubles in size. At around age 25, the gland begins to grow again.

This second growth phase often results, years later, in BPH.

Though the prostate continues to grow during most of a man's life, the enlargement doesn't

usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more

than half of men in their sixties and as many as 90 percent in their seventies and eighties have

some symptoms of BPH.

As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the

gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes

thicker and irritable. The bladder begins to contract even when it contains small amounts of

urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to

empty itself, so some of the urine remains in the bladder. The narrowing of the urethra and

partial emptying of the bladder cause many of the problems associated with BPH.

Many people feel uncomfortable talking about the prostate, since the gland plays a role in both

sex and urination. Still, prostate enlargement is as common a part of aging as gray hair. As life

expectancy rises, so does the occurrence of BPH. In the United States in 2000, there were 4.5

million visits to physicians for BPH.

Why BPH Occurs

The cause of BPH is not well understood. No definite information on risk factors exists. For

centuries, it has been known that BPH occurs mainly in older men and that it doesn't develop in

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men whose testes were removed before puberty. For this reason, some researchers believe that

factors related to aging and the testes may spur the development of BPH.

Throughout their lives, men produce both testosterone, an important male hormone, and small

amounts of estrogen, a female hormone. As men age, the amount of active testosterone in the

blood decreases, leaving a higher proportion of estrogen. Studies done on animals have

suggested that BPH may occur because the higher amount of estrogen within the gland increases

the activity of substances that promote cell growth.

Another theory focuses on dihydrotestosterone (DHT), a substance derived from testosterone in

the prostate, which may help control its growth. Most animals lose their ability to produce DHT

as they age. However, some research has indicated that even with a drop in the blood's

testosterone level, older men continue to produce and accumulate high levels of DHT in the

prostate. This accumulation of DHT may encourage the growth of cells. Scientists have also

noted that men who do not produce DHT do not develop BPH.

Some researchers suggest that BPH may develop as a result of “instructions” given to cells early

in life. According to this theory, BPH occurs because cells in one section of the gland follow

these instructions and “reawaken” later in life. These “reawakened” cells then deliver signals to

other cells in the gland, instructing them to grow or making them more sensitive to hormones

that influence growth.

Symptoms

Many symptoms of BPH stem from obstruction of the urethra and gradual loss of bladder

function, which results in incomplete emptying of the bladder. The symptoms of BPH vary, but

the most common ones involve changes or problems with urination, such as

a hesitant, interrupted, weak stream urgency and leaking or dribbling more frequent urination, especially at night

The size of the prostate does not always determine how severe the obstruction or the symptoms

will be. Some men with greatly enlarged glands have little obstruction and few symptoms while

others, whose glands are less enlarged, have more blockage and greater problems.

Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to

urinate at all. This condition, called acute urinary retention, may be triggered by taking over-the-

counter cold or allergy medicines. Such medicines contain a decongestant drug, known as a

sympathomimetic. A potential side effect of this drug may prevent the bladder opening from

relaxing and allowing urine to empty. When partial obstruction is present, urinary retention also

can be brought on by alcohol, cold temperatures, or a long period of immobility.

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It is important to tell your doctor about urinary problems such as those described above. In eight

out of 10 cases, these symptoms suggest BPH, but they also can signal other, more serious

conditions that require prompt treatment. These conditions, including prostate cancer, can be

ruled out only by a doctor's examination.

Severe BPH can cause serious problems over time. Urine retention and strain on the bladder can

lead to urinary tract infections, bladder or kidney damage, bladder stones, and incontinence—the

inability to control urination. If the bladder is permanently damaged, treatment for BPH may be

ineffective. When BPH is found in its earlier stages, there is a lower risk of developing such

complications.

Diagnosis

You may first notice symptoms of BPH yourself, or your doctor may find that your prostate is

enlarged during a routine checkup. When BPH is suspected, you may be referred to a urologist, a

doctor who specializes in problems of the urinary tract and the male reproductive system.

Several tests help the doctor identify the problem and decide whether surgery is needed. The

tests vary from patient to patient, but the following are the most common.

Digital Rectal Examination (DRE)

This examination is usually the first test done. The doctor inserts a gloved finger into the rectum

and feels the part of the prostate next to the rectum. This examination gives the doctor a general

idea of the size and condition of the gland.

Prostate-Specific Antigen (PSA) Blood Test

To rule out cancer as a cause of urinary symptoms, your doctor may recommend a PSA blood

test. PSA, a protein produced by prostate cells, is frequently present at elevated levels in the

blood of men who have prostate cancer. The U.S. Food and Drug Administration (FDA) has

approved a PSA test for use in conjunction with a digital rectal examination to help detect

prostate cancer in men who are age 50 or older and for monitoring men with prostate cancer after

treatment. However, much remains unknown about the interpretation of PSA levels, the test's

ability to discriminate cancer from benign prostate conditions, and the best course of action

following a finding of elevated PSA.

Rectal Ultrasound and Prostate Biopsy

If there is a suspicion of prostate cancer, your doctor may recommend a test with rectal

ultrasound. In this procedure, a probe inserted in the rectum directs sound waves at the prostate.

The echo patterns of the sound waves form an image of the prostate gland on a display screen.

To determine whether an abnormal-looking area is indeed a tumor, the doctor can use the probe

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and the ultrasound images to guide a biopsy needle to the suspected tumor. The needle collects a

few pieces of prostate tissue for examination with a microscope.

Urine Flow Study

Your doctor may ask you to urinate into a special device that measures how quickly the urine is

flowing. A reduced flow often suggests BPH.

Cystoscopy

In this examination, the doctor inserts a small tube through the opening of the urethra in the

penis. This procedure is done after a solution numbs the inside of the penis so all sensation is

lost. The tube, called a cystoscope, contains a lens and a light system that help the doctor see the

inside of the urethra and the bladder. This test allows the doctor to determine the size of the

gland and identify the location and degree of the obstruction.

Treatment

Men who have BPH with symptoms usually need some kind of treatment at some time.

However, a number of researchers have questioned the need for early treatment when the gland

is just mildly enlarged. The results of their studies indicate that early treatment may not be

needed because the symptoms of BPH clear up without treatment in as many as one-third of all

mild cases. Instead of immediate treatment, they suggest regular checkups to watch for early

problems. If the condition begins to pose a danger to the patient's health or causes a major

inconvenience to him, treatment is usually recommended.

Since BPH can cause urinary tract infections, a doctor will usually clear up any infection with

antibiotics before treating the BPH itself. Although the need for treatment is not usually urgent,

doctors generally advise going ahead with treatment once the problems become bothersome or

present a health risk.

The following section describes the types of treatment that are most commonly used for BPH.

Drug Treatment

Over the years, researchers have tried to find a way to shrink or at least stop the growth of the

prostate without using surgery. The FDA has approved six drugs to relieve common symptoms

associated with an enlarged prostate.

Finasteride (Proscar), FDA-approved in 1992, and dutasteride (Avodart), FDA-approved in

2001, inhibit production of the hormone DHT, which is involved with prostate enlargement. The

use of either of these drugs can either prevent progression of growth of the prostate or actually

shrink the prostate in some men.

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The FDA also approved the drugs terazosin (Hytrin) in 1993, doxazosin (Cardura) in 1995,

tamsulosin (Flomax) in 1997, and alfuzosin (Uroxatral) in 2003 for the treatment of BPH. All

four drugs act by relaxing the smooth muscle of the prostate and bladder neck to improve urine

flow and to reduce bladder outlet obstruction. The four drugs belong to the class known as alpha

blockers. Terazosin and doxazosin were developed first to treat high blood pressure. Tamsulosin

and alfuzosin were developed specifically to treat BPH.

The Medical Therapy of Prostatic Symptoms (MTOPS) Trial, supported by the National Institute

of Diabetes and Digestive and Kidney Diseases (NIDDK), recently found that using finasteride

and doxazosin together is more effective than using either drug alone to relieve symptoms and

prevent BPH progression. The two-drug regimen reduced the risk of BPH progression by 67

percent, compared with 39 percent for doxazosin alone and 34 percent for finasteride alone.

Minimally Invasive Therapy

Because drug treatment is not effective in all cases, researchers in recent years have developed a

number of procedures that relieve BPH symptoms but are less invasive than conventional

surgery.

Transurethral microwave procedures. In 1996, the FDA approved a device that uses

microwaves to heat and destroy excess prostate tissue. In the procedure called transurethral

microwave thermotherapy (TUMT), the device sends computer-regulated microwaves through a

catheter to heat selected portions of the prostate to at least 111 degrees Fahrenheit. A cooling

system protects the urinary tract during the procedure.

The procedure takes about 1 hour and can be performed on an outpatient basis without general

anesthesia. TUMT has not been reported to lead to erectile dysfunction or incontinence.

Although microwave therapy does not cure BPH, it reduces urinary frequency, urgency,

straining, and intermittent flow. It does not correct the problem of incomplete emptying of the

bladder. Ongoing research will determine any long-term effects of microwave therapy and who

might benefit most from this therapy.

Transurethral needle ablation. Also in 1996, the FDA approved the minimally invasive

transurethral needle ablation (TUNA) system for the treatment of BPH.

The TUNA system delivers low-level radiofrequency energy through twin needles to burn away

a well-defined region of the enlarged prostate. Shields protect the urethra from heat damage. The

TUNA system improves urine flow and relieves symptoms with fewer side effects when

compared with transurethral resection of the prostate (TURP). No incontinence or impotence has

been observed.

Water-induced thermotherapy. This therapy uses heated water to destroy excess tissue in the

prostate. A catheter containing multiple shafts is positioned in the urethra so that a treatment

balloon rests in the middle of the prostate. A computer controls the temperature of the water,

which flows into the balloon and heats the surrounding prostate tissue. The system focuses the

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heat in a precise region of the prostate. Surrounding tissues in the urethra and bladder are

protected. Destroyed tissue either escapes with urine through the urethra or is reabsorbed by the

body.

High-intensity focused ultrasound. The use of ultrasound waves to destroy prostate tissue is

still undergoing clinical trials in the United States. The FDA has not yet approved high-intensity

focused ultrasound.

Surgical Treatment

Most doctors recommend removal of the enlarged part of the prostate as the best long-term

solution for patients with BPH. With surgery for BPH, only the enlarged tissue that is pressing

against the urethra is removed; the rest of the inside tissue and the outside capsule are left intact.

Surgery usually relieves the obstruction and incomplete emptying caused by BPH. The following

section describes the types of surgery that are used.

Transurethral surgery. In this type of surgery, no external incision is needed. After giving

anesthesia, the surgeon reaches the prostate by inserting an instrument through the urethra.

A procedure called transurethral resection of the prostate (TURP) is used for 90 percent of all

prostate surgeries done for BPH. With TURP, an instrument called a resectoscope is inserted

through the penis. The resectoscope, which is about 12 inches long and 1/2 inch in diameter,

contains a light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and

seals blood vessels.

During the 90-minute operation, the surgeon uses the resectoscope's wire loop to remove the

obstructing tissue one piece at a time. The pieces of tissue are carried by the fluid into the

bladder and then flushed out at the end of the operation.

Most doctors suggest using TURP whenever possible. Transurethral procedures are less

traumatic than open forms of surgery and require a shorter recovery period. One possible side

effect of TURP is retrograde, or backward, ejaculation. In this condition, semen flows backward

into the bladder during climax instead of out the urethra.

Another surgical procedure is called transurethral incision of the prostate (TUIP). Instead of

removing tissue, as with TURP, this procedure widens the urethra by making a few small cuts in

the bladder neck, where the urethra joins the bladder, and in the prostate gland itself. Although

some people believe that TUIP gives the same relief as TURP with less risk of side effects such

as retrograde ejaculation, its advantages and long-term side effects have not been clearly

established.

Open surgery. In the few cases when a transurethral procedure cannot be used, open surgery,

which requires an external incision, may be used. Open surgery is often done when the gland is

greatly enlarged, when there are complicating factors, or when the bladder has been damaged

and needs to be repaired. The location of the enlargement within the gland and the patient's

general health help the surgeon decide which of the three open procedures to use.

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With all the open procedures, anesthesia is given and an incision is made. Once the surgeon

reaches the prostate capsule, he or she scoops out the enlarged tissue from inside the gland.

Laser surgery. In March 1996, the FDA approved a surgical procedure that employs side-firing

laser fibers and Nd: YAG lasers to vaporize obstructing prostate tissue. The doctor passes the

laser fiber through the urethra into the prostate using a cystoscope and then delivers several

bursts of energy lasting 30 to 60 seconds. The laser energy destroys prostate tissue and causes

shrinkage. As with TURP, laser surgery requires anesthesia and a hospital stay. One advantage

of laser surgery over TURP is that laser surgery causes little blood loss. Laser surgery also

allows for a quicker recovery time. But laser surgery may not be effective on larger prostates.

The long-term effectiveness of laser surgery is not known.

Newer procedures that use laser technology can be performed on an outpatient basis.

Photoselective vaporization of the prostate (PVP). PVP uses a high-energy laser to destroy

prostate tissue and seal the treated area.

Interstitial laser coagulation. Unlike other laser procedures, interstitial laser coagulation places

the tip of the fiberoptic probe directly into the prostate tissue to destroy it.

Your Recovery After Surgery in the Hospital

The amount of time you will stay in the hospital depends on the type of surgery you had and how

quickly you recover.

Foley catheter

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At the end of surgery, a special catheter is inserted through the opening of the penis to drain

urine from the bladder into a collection bag. Called a Foley catheter, this device has a water-

filled balloon on the end that is put in the bladder, which keeps it in place.

This catheter is usually left in place for several days. Sometimes, the catheter causes recurring

painful bladder spasms the day after surgery. These spasms may be difficult to control, but they

will eventually disappear.

You may also be given antibiotics while you are in the hospital. Many doctors start giving this

medicine before or soon after surgery to prevent infection. However, some recent studies suggest

that antibiotics may not be needed in every case, and your doctor may prefer to wait until an

infection is present to give them.

After surgery, you will probably notice some blood or clots in your urine as the wound starts to

heal. If your bladder is being irrigated (flushed with water), you may notice that your urine

becomes red once the irrigation is stopped. Some bleeding is normal, and it should clear up by

the time you leave the hospital. During your recovery, it is important to drink a lot of water (up

to 8 cups a day) to help flush out the bladder and speed healing.

Do's and Don'ts

Take it easy the first few weeks after you get home. You may not have any pain, but you still

have an incision that is healing—even with transurethral surgery, where the incision can't be

seen. Since many people try to do too much at the beginning and then have a setback, it is a good

idea to talk with your doctor before resuming your normal routine. During this initial period of

recovery at home, avoid any straining or sudden movements that could tear the incision. Here are

some guidelines:

Continue drinking a lot of water to flush the bladder. Avoid straining when having a bowel movement. Eat a balanced diet to prevent constipation. If constipation occurs, ask your doctor if you can

take a laxative. Don't do any heavy lifting. Don't drive or operate machinery.

Getting Back to Normal After Surgery

Even though you should feel much better by the time you leave the hospital, it will probably take

a couple of months for you to heal completely. During the recovery period, the following are

some common problems that can occur.

Problems Urinating

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You may notice that your urinary stream is stronger right after surgery, but it may take awhile

before you can urinate completely normally again. After the catheter is removed, urine will pass

over the surgical wound on the prostate, and you may initially have some discomfort or feel a

sense of urgency when you urinate. This problem will gradually lessen, and after a couple of

months you should be able to urinate less frequently and more easily.

Incontinence

As the bladder returns to normal, you may have some temporary problems controlling urination,

but long-term incontinence rarely occurs. Doctors find that the longer problems existed before

surgery, the longer it takes for the bladder to regain its full function after the operation.

Bleeding

In the first few weeks after transurethral surgery, the scab inside the bladder may loosen, and

blood may suddenly appear in the urine. Although this can be alarming, the bleeding usually

stops with a short period of resting in bed and drinking fluids. However, if your urine is so red

that it is difficult to see through or if it contains clots or if you feel any discomfort, be sure to

contact your doctor.

Sexual Function After Surgery

Many men worry about whether surgery for BPH will affect their ability to enjoy sex. Some

sources state that sexual function is rarely affected, while others claim that it can cause problems

in up to 30 percent of cases. However, most doctors say that even though it takes awhile for

sexual function to return fully, with time, most men are able to enjoy sex again.

Complete recovery of sexual function may take up to 1 year, lagging behind a person's general

recovery. The exact length of time depends on how long after symptoms appeared that BPH

surgery was done and on the type of surgery. Following is a summary of how surgery is likely to

affect the following aspects of sexual function.

Erections

Most doctors agree that if you were able to maintain an erection shortly before surgery, you will

probably be able to have erections afterward. Surgery rarely causes a loss of erectile function.

However, surgery cannot usually restore function that was lost before the operation.

Ejaculation

Although most men are able to continue having erections after surgery, a prostate procedure

frequently makes them sterile (unable to father children) by causing a condition called retrograde

ejaculation or dry climax.

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During sexual activity, sperm from the testes enters the urethra near the opening of the bladder.

Normally, a muscle blocks off the entrance to the bladder, and the semen is expelled through the

penis. However, the coring action of prostate surgery cuts this muscle as it widens the neck of

the bladder. Following surgery, the semen takes the path of least resistance and enters the wider

opening to the bladder rather than being expelled through the penis. Later it is harmlessly flushed

out with urine. In some cases, this condition can be treated with a drug called pseudoephedrine,

found in many cold medicines, or imipramine. These drugs improve muscle tone at the bladder

neck and keep semen from entering the bladder.

Orgasm

Most men find little or no difference in the sensation of orgasm, or sexual climax, before and

after surgery. Although it may take some time to get used to retrograde ejaculation, you should

eventually find sex as pleasurable after surgery as before.

Many people have found that concerns about sexual function can interfere with sex as much as

the operation itself. Understanding the surgical procedure and talking over any worries with the

doctor before surgery often help men regain sexual function earlier. Many men also find it

helpful to talk with a counselor during the adjustment period after surgery.

Is Further Treatment Needed?

In the years after your surgery, it is important to continue having a rectal examination once a

year and to have any symptoms checked by your doctor.

Since surgery for BPH leaves behind a good part of the gland, it is still possible for prostate

problems, including BPH, to develop again. However, surgery usually offers relief from BPH for

at least 15 years. Only 10 percent of the men who have surgery for BPH eventually need a

second operation for enlargement. Usually these are men who had the first surgery at an early

age.

Sometimes, scar tissue resulting from surgery requires treatment in the year after surgery. Rarely,

the opening of the bladder becomes scarred and shrinks, causing obstruction. This problem may

require a surgical procedure similar to transurethral incision (see section on Surgical Treatment).

More often, scar tissue may form in the urethra and cause narrowing. The doctor can solve this

problem during an office visit by stretching the urethra.

Prostatic Stents

A stent is a small device that is inserted through the urethra to the narrowed area and allowed to

expand, like a spring. The stent pushes back the prostatic tissue, widening the urethra. It is

designed to relieve urinary obstruction in men and improve the ability to urinate. The device is

approved for use in men for whom other standard surgical procedures to correct urinary

obstruction have failed.

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BPH and Prostate Cancer: No Apparent Relation

Although some of the signs of BPH and prostate cancer are the same, having BPH does not seem

to increase the chances of getting prostate cancer. Nevertheless, a man who has BPH may have

undetected prostate cancer at the same time or may develop prostate cancer in the future. For this

reason, the National Cancer Institute and the American Cancer Society recommend that all men

over 40 have a rectal examination once a year to screen for prostate cancer.

After BPH surgery, the tissue removed is routinely checked for hidden cancer cells. In about one

out of 10 cases, some cancer tissue is found, but often it is limited to a few cells of a

nonaggressive type of cancer, and no treatment is needed.