The first thing we should clarify about this subject is not to confuse the word PROSTATE – a body organ (no “R”), with the word PROSTRATE a word meaning “to lie down on the ground, face down”.
The prostate gland is a part of the male reproductive system. It is located behind the bladder and in front of the rectum. The gland’s normal function is to add fluid to the ejaculate to help carry and nourish the sperm. The prostate gland surrounds the neck of the bladder and the urethra. It is part muscular (functions to contract) and part glandular (functions to secrete) with ducts that open into the urethra. The prostate secretes a thin, slightly alkaline fluid. It is normally about the size of a walnut (until about the age of 50) and weighs about 20 grams.
There are 3 main problems that can affect the male prostate gland. They are: infection (prostatitis), enlargement (BPH) and prostate cancer.
Infection of the prostate gland, also known as prostatitis, may be caused by various organisms – including bacteria such as gonorrhoea or chlamydia (in young men) and viruses in older men. Prostatitis can cause pain with urination and fever as well as a number of other symptoms including:
Prostatitis can be difficult to treat and may require several months of an antibiotic such as Ciprofloxacin.
In late middle age, many men will develop some degree of benign prostatic hyperplasia (BPH). In simple terms, BPH means the prostate tissue grows but it is a benign condition (not cancer). BPH is annoying because the enlarging gland presses on the urethra and impedes urination. Symptoms include difficulty initiating the flow of urine, a weak urine stream and incomplete emptying of the bladder necessitating getting up several times during the night to void. Retained urine can become infected adding a urinary tract infection to the picture. It can also cause pain with ejaculation and blood in the seminal fluid or urine.
Initially, patients tend to have mild symptoms of BPH. As is the case with prostatitis, your physician will determine the diagnosis by examining you and ordering some tests. The exam usually includes an abdominal exam and a genital exam with DRE (digital rectal exam). Urine and blood tests (PSA – prostate specific antigen) may be ordered and possibly an ultrasound of your kidneys and bladder. Less often, a CT may be ordered.
You physician may well advise you to implement some lifestyle changes to cope with the prostatitis. These adjustments may include:
If symptoms continue to worsen after adopting these changes, the next step is usually medication. Your doctor may recommend a class of drug called alpha-blockers (Cardura, Hytrin), which act to relax the smooth muscle tissue in the prostate. This improves urine flow by opening the urethra. Alternatively, sometimes a 5-alpha-reductase inhibitor, (i.e. Proscar), is used to shrink the prostate gland by up to 30%. Both types of medication have side effects, notably: dizziness, headache, fatigue and nasal congestion (for the alpha blockers). Proscar lowers the PSA test (see below) by 50% (which can affect cancer detection) and may cause loss of libido or even impotence (erectile dysfunction). There are several surgical techniques available to treat BPH including resection of the prostate (cutting away), microwave therapy and transurethral needle ablation (TUNA which is zapping the gland with radio waves). The very latest technique is called REZUM Water Vapour Therapy, which uses steam to alter the prostate gland.
Prostate carcinoma will affect 1 in 8 men and is the most common cancer in males, after skin cancer. By age 50, 1 in 3 men have a focal prostate cancer. Only 3% of those actually have any clinical symptoms.
The cause of prostatic cancer is unknown although we do know that exposure to testosterone makes it grow. Dietary, occupational and environmental risk factors have been implicated as causes of the disease. There is no evidence that sexual activity or vasectomies are risk factors.
Prostatic cancer is generally a slowly progressing disease that may not cause any symptoms at all for a lot of men. For others, early signs of the disease include pain, urgency, and a change in frequency of urination or dribbling. Late in the disease symptoms are obstruction of the urethra (inability to void), obstruction of the ureters, hematuria (blood in the urine), and urinary infection. Prostatic cancer commonly metastases (spreads) to the pelvis, ribs and vertebrae hence there may be pain in the lower back, upper thighs and pelvis. Your doctor should perform a digital rectal exam (DRE) annually from age 50 onward (age 40 if there is a family history). The DRE can distinguish a benign enlargement of the prostate (caused by BPH or infection) from a carcinoma which feels stony hard and asymmetrical. If your physician has any suspicions, he will send you for a PSA test, a urine test to check for infection, an ultrasound and a trans rectal biopsy of the prostate gland.
PSA is a protein that is released into the bloodstream from the prostate and can be measured with a simple test. PSA is elevated in a number of processes including: BPH, infection (prostatitis) and carcinoma. Ejaculation can also elevate PSA. PSA will be elevated in up to 92% of prostate cancers and in 50% of BPH.
PSA has different normal values as a man ages. The PSA should not rise more than 0.75 in a year. The following table shows the normal values for PSA:
AGE Value
40’s <2.5
50’s <3.5
60’s <4.5
70’s <5.5
The ultrasound and MRI guided biopsy of the prostate gland will measure the organ and take pieces of tissue for pathology. The usual practice is to put a patient on antibiotics prior to the procedure. The biopsies are obtained by accessing the prostate through the rectum. The exam can be uncomfortable.
Because it is usually such a slow-growing cancer, most men will die from other causes before their prostate cancer becomes a significant problem. A man over 70 may simply be observed. For those who are younger, there are several treatment options. Surgery to remove the prostate is commonly performed. Unfortunately, there is a high degree of impotence following this procedure which makes it a very unattractive option for a lot of men. Female hormones may be administered to slow the growth of the cancer. Anti-testosterone medications are also used (since testosterone seems to stimulate growth of this cancer). Radiation, chemotherapy and cryosurgery are other treatment options. If you are diagnosed with prostatic cancer, an urologist will discuss the various treatment options and appropriate monitoring and follow up. For a complete review of treatment options for prostate cancer please see the Canadian Cancer Society’s information page.
The take home message for men is this: Don’t accept changes in urination as a normal sign of aging. Hasten to your family doctor at the first sign of any trouble. He or she will give you a physical exam (including a DRE) and send you for the appropriate tests (urinalysis, PSA screen, prostatic ultrasound & biopsy) as required.
The prostate gland is susceptible to a number of different diseases during a man’s life. All of them are treatable. Most of them are curable.
For further reading on the prostate gland, check out these excellent resources:
© 2020 Ask the Lady Doctor – Dr. Shannon Lee Dutchyn, MD, CCFP, FCFP
