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Most men don't really know how long the prostate lasts, or what exactly it does, for that matter. Indeed they are often unaware of its existence until problems begin. Some mistakenly call it their prostrate, which may be a more appropriate word to describe how they feel when they have chronic problems with their prostate. Most do know, however, that the prostate has to do with sex and if it is removed it could ruin their sex life as they know it. This is a compelling fear, and probably the reason why so many men never seek treatment for prostate problems, even those brought on by the ordinary and natural condition of aging. The prostate is a gland of the male reproductive tract and its primary role is to produce seminal fluid. It sits like a doughnut at the base of the bladder with the urethra passing through the hole of the doughnut. The urethra carries urine or ejaculate out through the penis. The rectum lies directly behind the prostate, and it is this back part of the prostate that can be reached by the doctor during a digital rectal examination (DRE). When a man is born, his prostate gland is about the size of a pea, and weighs one gram, which is a fraction of an ounce. There are two spurts of growth in the prostate. One, at puberty, when the prostate gland grows until it matures around age 20 and is the size of a golf ball. It weighs 15 to 20 grams (still less than an ounce). Another growth spurt occurs when a man is in his 40s or 50s. This enlargement is known as benign prostatic hyperplasia (BPH), which is explained in the next chapter. By the time a man is 70 or 80, his prostate can weigh 30 to 60 grams (one to two pounds), or more. Some men have prostates bigger than an apple. The prostate is made of smooth muscle, and spongy glandular and fibrous tissue. The glands are lined with cells that secrete fluid which is deposited in the urethra during ejaculation through a system of branching ducts. The smooth muscle and fibrous tissue are interwoven between the glandular tissue, much the way the glands and milk ducts are interwoven in the female breast. In middle age, or when the prostate begins to enlarge, the smooth muscle and connective tissue is known as the stroma. The most striking feature of the enlargement of the prostate is this stromal outgrowth.
This small but complex gland has many tasks to carry out in its primary function to support and promote male insemination and fertility. It is a factory for production of nutrient?rich seminal fluid to help carry sperm from the testicles out of the body during ejaculation, and help them survive in the female reproductive tract. jobs. It is a gatekeeper, or valve, that allows sperm and urine to flow in the right direction through the urethra. A ring of muscles near the neck of the bladder, the internal sphincter clamp down during ejaculation to prevent semen from backing up into the bladder. If this mechanism is damaged, retrograde ejaculation or back up of semen into the bladder may result. The prostate is also a pump during orgasm, contracting the muscles to force semen into the urethra.
Sperm and Seminal Fluid Using heterosexual intercourse as an example, when semen is ejaculated into the female vagina, it exists as a semi solid gel which forms a plug on the cervix of female reproductive tract. The plug serves as an effecient delivery system for sperm trapped in the seminal coagulant. The gel spontaneously liquifies after 10 to 15 minutes due to the presence of an enzyme known as prostate specific antigen (PSA), a protein which is also produced by the prostate gland. This protein molecule enters the bloodstream in greater amounts when something is wrong. Any process that disrupts the normal ductal structure of the prostate like prostate cancer, BPH, or prostatitis (inflammation) will cause more PSA to leak into the blood. So when serum PSA is elevated it suggests a process in the prostate is disrupting the normal glandular architecture. The seminal fluid also contains minerals such as zinc and sugar such as fructose and glucose, as well as other enzymes and nutrients that sperm need to suvive in the female reproductive tract. It is believed that prostate fluid also serves in some anti bacterial capacity and that elderly men with chronic bacterial inflammation of the prostate (prostatitis), have reduced anti bacterial activity as well as reduced zinc levels. Nevertheless, studies with dietary zinc supplements have failed to confirm the use of dietary zinc as protection against recurrence. When the prostate is removed, no seminal fluid is produced. In other words, there is no emission during sexual climax. However, this does not change the ability for sexual arousal and orgasm. Erection, orgasm, and ejaculation are three separate events, but usually are coordinated to occur together. Ejaculation and orgasm still occur with impotence or erectile dysfunction. Despite its complex role, the prostate is not a vital organ like the heart or lungs. Men can live without it, although given a choice, most would rather not.
For diagnostic purposes, the prostate is divided into three major zones. Knowing the geography of the prostate can help in understanding how symptoms develop when something is wrong with the prostate.
Testosterone is an essential player in prostate cancer. This hormone or androgen, as male hormones are labeled, is produced mostly by the testicles. It can produce prostate cancer in rats who are given large doses. However, while all men produce testosterone, not all men get prostate cancer. (Studies have found that men who have testicles damaged or removed prior to puberty, never get prostate cancer.) The reason the prostate grows so rapidly during puberty, is that it is fed by the androgens which make it possible for the prostate to produce seminal fluid. Androgens also stimulate the development of body hair, deepen the voice, and increase muscle bulk in the upper body. The primary androgen is testosterone, but some androgens are produced by the adrenal glands which lie above each kidney. Briefly, here is how the process works:
The prostate of every man begins to enlarge in middle age and this is the primary cause of symptoms such as the need to urinate more often. The first wave of 76 million baby boomers in the United States turned 50 in 1996. The total male population over 50 will nearly double by the year 2020 and primary care physicians and urologists will see more men with symptoms developing from enlarged prostates. At this age, a prostate weighs from 30 to 100 grams (one to three and a half pounds) and is 10 times larger than it was at age 20 when it weighed only a few ounces. There are approximately 15 million men in the country with symptoms of BPH and the vast majority are not seeking treatment. More than half the men over 60 have some degree of this problem, known as benign prostatic hyperplasia (BPH), and by the time they are 80, most men have the disease. BPH is one of two non-cancerous conditions of the prostate whose symptoms are sometimes confused with prostate cancer. The other is prostatitis, an inflammatory condition. It is ironic that although the prostate is primarily concerned with sexual reproduction, when something goes wrong, it more frequently causes problems with urination. Because the prostate surrounds the urethra, an 8-inch long tube extending from the neck of the bladder through the prostate and penis, any change in the prostate's size can affect the dynamics of urinary flow. This close proximity to the urethra and bladder, make it a crucial link in the efficient flow of urine. For example, as the prostate enlarges, the space around the urethra -- the hole of the doughnut -- gets pinched off or blocked. The enlarged prostate gland squeezes on the urethra, the way a fist would squeeze on a straw. In extreme cases it can close off the passage altogether and impede the flow of urine.
Benign Prostatic Hyperplasia (BPH) Benign prostatic hyperplasia, or BPH, is a very common disease of aging which develops gradually during the second growth cycle of the prostate, when a man is in his 40s and 50s. The inner core of prostate tissue -- the transition zone which surrounds the urethra -- expands from the proliferation of cells. This cell growth is called hyperplasia. The enlargement of the prostate tissue and the reduction of the doughnut hole, cause problems with urination, or ejaculation because of the pressure on the urethra. These same symptoms can be signs of cancer but with cancer, the symptoms usually develop more insidiously. The benign condition of BPH does not increase the risk of cancer. However, both conditions can exist simultaneously, so screening and treatment for BPH is always important. For this reason, it is important to understand as much as possible about the natural processes of the prostate. Because BPH develops on the inside, or the core of the prostate, it cannot generally be detected with a digital rectal exam (DRE). Only about half the men with microscopic BPH develop prostate enlargement that can be felt with a DRE. The 50 percent of men who do develop enlargement to this degree usually need surgery to remove the excess tissue from the inner core and relieve the pressure on the urethra. According to some studies, approximately 25 percent of all men will require treatment for their symptoms of BPH if they live to be 80. A 60-year-old man has a 60 percent chance of developing microscopic BPH and a 25 percent cumulative chance of requiring surgery. With the advent of new pharmacological ways to treat BPH, this cumulative risk has significantly decreased. There is more about this later. The natural history of BPH is highly variable and currently we don't have good data about how patients over time do with or without treatment. And we don't know if diet, smoking, or race, are contributing factors. Size or volume of the BPH tissue is different in so far as Asians have smaller prostates in general, but they develop symptoms with similar frequency, so size is not the important feature by itself. It does appear in some men that the symptoms may not progress. Between 60 and 70 percent of patients studied with BPH, either stabilized or had spontaneous improvement over time. This lack of data explains the lack of uniformity about surgical treatment around the country. There are few absolute indications for intervention and treatment and many men with symptoms do not require surgical treatment to remove the excessive tissue growth. While the cause of BPH is not completely understood, it is clearly related to aging, and the presence of functioning testicles. A number of clinical and experimental observations attest to this as a factor in development of BPH. It has been known since the 1800s that removal of the testes results in shrinkage of prostate tissue and clinical improvement of symptoms of BPH. It is also known that if testicles are removed from boys prior to puberty, the boys never develop BPH or prostate cancer later in life. In the early 1970s, Dr. Julianne Imperato McGinley of Cornell Medical College, noticed an interesting genetic syndrome in a population of male infants in the Dominican Republic known as congenital 5-alpha reductase deficiency. This is the enzyme that converts testosterone to the more potent androgen, dihydrotestosterone (DHT). Boys with this recessive genetic disorder lack the enzyme, and so the prostate does not grow normally. At birth, these children have a small phallus, and in adulthood the prostate remains small. Some tissues of the body respond to testosterone itself whereas others, such as the prostate, require DHT for growth and differentiation. These males are otherwise normal, and have no sexual problems. From this observation it is clear that DHT, and not testosterone, is necessary for BPH development. Without DHT, the BPH cannot develop. Medications that block the conversion of testosterone to DHT are often used to treat BPH as well. Treatment with medications for BPH can also affect the PSA. For example, if a man's PSA level was 3.0 before beginning treatment with Proscar, and after six months of treatment, the level decreased to 1.6, he should double that figure to 3.2 to learn exactly what his PSA level is.
THE DYNAMIC AND STATIC PROSTATE The dynamic and static components vary widely in men. It may be that for some men with a small prostate examined by DRE, their symptoms may be due more to the dynamic component. That is, the muscles of the bladder neck and prostate cannot contract or relax. On the other hand, in men with large prostates, the static component may be more predominant in causing symptoms of BPH because: The symptoms of BPH are highly variable and most men are relatively symptom free. Symptoms are caused by obstruction of urethra and alterations in bladder function. The size of the prostate is not always a predictor of the type or severity of symptoms. Some men with very large prostates have minimal symptoms whereas others with relative small glands, are very symptomatic. Reasons for this paradox are incompletely understood but are believed due to relative contributions of dynamic and static conditions. During voiding, urine flows from the bladder through the urethra. In a BPH prostate, the urethra is narrowed by mechanical obstruction of the enlarged prostate or by the dynamic obstruction of increased smooth muscle tone. The bladder tries to compensate for this increased resistance by generating a stronger and more forceful bladder contraction to force it out. Over time, the muscle is unable to compensate for the resistance and it fatigues. This gives rise to the inability to completely empty the bladder and the possibility of leakage and incontinence. Imagine a stretched rubber band. If it is stretched to a considerably longer length and kept stretched, and then released, it eventually looses its elasticity and fails to come back to its original shape. It becomes floppy and incapable of generating the same tension as it used to. Similarly, the bladder can lose its capacity to empty itself of urine if it is chronically obstructed and overstretched. This happens to a bladder trying to overcome chronic mechanical outlet obstruction due to BPH. The retention of urine in bladder can lead to infection as well as bladder stones, and in more cases, can result in kidney failure, with long standing obstruction.
SYMPTOMS OF BPH Obstructive symptoms are a result of the bladder muscle's inability to overcome the outlet obstruction. These include a poor and slow stream, feeling of incomplete empty, dribbling at the end of urination, interruption of flow, and hesitancy or inability to initiate urinary flow easily. Men with BPH may also develop blood in the urine due to the bursting of dilated blood vessels which are at the bladder neck or surface of BPH tissue during voiding. Some have obstructive and irritative voiding symptoms whereas other "silently" develop chronic renal dysfunction and urinary tract infections. Some have no real symptoms or complaints until these complications develop. Ultimate control of the development of BPH, however, occurs in the brain's control center, in the interaction of the hypothalamus and pituitary glands. The hypothalamus releases a hormone known as leutinizing hormone releasing hormone (LHRH) which stimulates the pituitary gland to release leutinizing hormone (LH). LH travels in the blood and reaches the testicles where testosterone is produced. Testosterone is converted in the prostate epithelial cells to DHT by the enzyme, alpha reductase. DHT in turn combines with receptors in the nucleus of the prostate epithelial cell to produce cell growth and proliferation. The paradox is that hormones diminish slightly as a man ages, yet the hormones are responsible for the increased cell proliferation that causes BPH. Normal growth and function of the prostate is dependent on androgens maintaining a balance between cell growth and cell death.
PSA and BPH Whether irritative or obstructive, symptoms of BPH are subjective, highly variable, unpredictable, and can vary in the same person. The perplexing issue is the complex relationship between prostate size and type and severity of symptoms. There is no correlation between severity and size of prostate. Because so many men do not seek medical help for the problem, they suffer in silence and here is how most of them cope with their symptoms.
Always keep in mind that many of these symptoms are not unique to BPH and can also be caused by urinary tract infection, cancer, and neurological dysfunction. Such conditions must be carefully considered when there are BPH-like symptoms. Indications for treatment of BPH are not absolute and given the vast array of medical and non-surgical alternatives it is important to have a very thorough workup with a urologist before deciding on treatment for BPH.
HOW BPH IS DIAGNOSED A digital rectal exam (DRE) should be performed to assess the prostate as well as a urinalysis and urine culture to exclude possibility of a urinary tract infection. Blood studies, such as the serum PSA level and assessment of kidney function should be done. If blood is found in the urine, either microscopically or is clearly visible, further evaluation is warranted. This should include an imaging study of the upper urinary tract with an intravenous pyelogram (IVP), an X-ray study of the urinary tract. A dye is given intervenously which is taken up by the kidneys and later excreted. When X-ray images are taken, the dye outlines the kidneys, ureters, and bladder. If abnormalities exist in the urinary tract such as a stone or blockage to the kidneys, it can be clearly seen. An ultrasound of the kidney can also be used to determine the problem. Evaluation of the lower urinary tract -- the urethra and bladder -- is done with a fiberoptic scope known as a cystoscope. Possible causes for blood in the urine (hematuria) other than BPH include the presence of stones in the kidney or bladder, prostate cancer, tumors of kidney or ureter, or congenital abnormalities of the urinary tract. Part of the workup for BPH may often include a urinary flow rate determination. In this very simple test a patient with a full bladder is asked to urinate into a funnel connected to a measuring device that records the urine (low rate in ccs per second). Then, with ultrasound it can be determined if any urine is still in the bladder. Men with severe BPH will often have a slow flow and a moderate or high level of residual urine in the bladder.
TREATMENT FOR BPH
Medications Therapy with Proscar is directed at the hormonal cause for BPH development and the goal is to reduce the size or volume of the gland to improve urinary flow and symptoms, and disrupt the progression of BPH by effecting the static or mechanical component of outlet obstruction. In clinical trials, men treated with Proscar for up to 12 months saw an approximately 25 percent reduction in prostate volume compared to men who did not take the medication. Because it blocks some of the hormonal action that effects the prostate, this drug is also being studied for use as a possible prevention of prostate cancer in a large prostate cancer chemoprevention trial sponsored by the National Cancer Institute. There appear to be two locations of 5-alpha reductase activity. One in the prostate and the other in the middle layer of skin where the hair follicles are located. The Food and Drug Administration is about to approve the use of Proscar to stimulate hair growth in balding men.
Side Effects After six months of therapy with Proscar, the prostate not only shrinks, but the medication reduces the PSA level by half. It is vital to understand this because if a man is using the PSA test for annual screening for prostate cancer, the reading will be misleading.
Other Pharmacological Treatment In men without BPH, the ratio of stromal to glandular tissue is 2 to 1. In men with BPH, the ratio is 5 to 1. So, BPH is primarily a stromal disease and studies have found that the stromal tissue of the prostate gland and bladder neck area are richly endowed with alpha I adrenogenic receptors with mediate the ability of the smooth muscle surrounding the prostate to contract and relax. These receptors are sparse in the body of the bladder so it has been observed that drugs that would block the receptor would relax the smooth muscle and reduce the resistance in the bladder neck and improve the flow of urine. The contractility of the bladder would not be effected because of the lack of alpha receptor innervation. This led to the development of a number of alpha one adrenogenic receptor blockers that could be used to medically manage patients with BPH. The idea behind this is by blocking the alpha one receptor, the smooth muscle tone, outlet obstruction would relax and decrease resistance, making it easier to urinate. Like all alpha 1 receptor blockers, these drugs can lower blood pressure and therefore are useful in treating hypertension as well. They are taken once a day and unlike Proscar, have no significant affect on PSA. Side effects noted with these medications include dizziness, light headedness, fatigue and sometimes impotence.
Surgical Treatment In 1992 over 400,000 TURPs were performed in the United States and was the second most costly surgical procedure performed on men after cataract surgery. It accounted for about 40 percent of major surgical procedures performed by urologists at a cost to the healthcare system of four billion dollars a year. With cost containment the focus of health care, there is a great deal of incentive to develop non-surgical alternatives for treating BPH. This has been achieved somewhat by the increased use of pharmocologic alternatives. Transurethral resection of the prostate (TURP) removes some of the prostate tissue. Mostwiden the passageway and allow free flow of urine through the urethra. For obvious reasons, TURP is commonly known as the "Roto-Rooter" procedure. The entire gland is not removed during a TURP. Only the transition zone where BPH tissue develops. The peripheral zone is retained. However, if the prostate is very large, open abdominal surgery may be required to remove the excess tissue. These surgical procedures are all considered a form of prostatectomy, but they differ from a radical prostatectomy which is surgical removal of the entire prostate, a common treatment for localized prostate cancer. TURP involves inserting a fiberoptic telescope through the urethra of the penis. Through this tube, the urologist can see and operate. Connected to this tube is the resectoscope, an electric loop, which removes prostate tissue and cauterizes-seals the blood vessels. Essentially, the instrument is used to make the hole of the doughnut larger and relieve pressure on the urethra. This procedure is used to relieve urinary symptoms such as weak stream or sense of incomplete bladder emptying. Treatment would require being in the hospital from one to three days, It may take from two to four weeks to recover from a TURF procedure and regain the ability to urinate normally. While it is not used in the treatment of prostate cancer, TURP may sometimes be used to relieve the symptoms caused by the cancer, such as pressure on the urethra. It may also be used as a biopsy method to check the tissue at the inner core or peripheral zone of the prostate. Tissue removed during the TURP procedure is routinely sent to a pathologist to check for the presence of prostate cancer. About 80 percent of cancers found this way are cured. Although not always successful, TURP was the most common surgical treatment for BPH before the development of medical therapies. It was recognized that 21 percent of patients treated with TURP were unsatisfied or did not improve, and 20 percent needed to be reoperated after 8 years because of regrowth of of BPH tissue. Clearly, there was a need to identify beneficial alternatives to TURP treatment in men with symptomatic BPH. Prostate cancers found on pathological examination of TURP removed tissue are known as transition zone cancers because the BPH tissue comes from that zone. Of cancers found this way, 80 percent of transition zone cancers are cured after the TURP procedure removes the tissue because the procedure removes all the cancerous tissue. But there is a need to follow up because the peripheral zone is still vulnerable, and this zone is not removed by the turp. Therefore, you still need an annual DRE and PSA to monitor for prostate cancer. The chance that symptoms will improve after TURP is from 75 to 95 percent compared to 60 to 85 percent with the alpha I receptor blockers, 50 to 70 percent with Proscar, and 30 to 50 percent with watchful waiting.
Side Effects of TURP
Treatment with Microwaves The Prostatron is a device that heats the enlarged prostate with microwaves. A catheter is threaded through the urethra into the prostate. A computer sends microwaves through the catheter, heating the prostate to 111 degrees. This kills BPH tissue which sloughs off and relieves pressure on the blocked urethra, accomplishing the same result as the TURP does surgically. Cooling water circulates inside the catheter so the patient will not feel the heat or get burned. Treatment with the Prostatron? takes an hour, requires no anesthetic, and costs half as much as surgery. It has been used in 25 countries since 1991, and was approved by the Food and Drug Administration for use in the United States in 1996.
PROSTATITIS There are many different types of prostatitis depending on whether or not they are due to infectious agent. Acute bacterial prostatitis causes fever or chills as well as severe irritative and obstructive voiding symptoms, a general feeling of malaise, muscle aches and pains. When examined with a DRE, the prostate will feel very warm and pliable. Urine analysis will show bacteria as well as red and white blood cells. In chronic bacterial prostatitis, clinical features are more vaiable. However the syndrome is unique because of the persistence of bacteria in the prostate which have not been fully treated and do not clear. It may feature relapsing recurrent urinary tract infection caused by the same bacteria as exists in prostate despite prior treatment with oral antibiotic. Non bacterial prostatitis is more common, but the cause of infection is unknown.
Symptoms of Prostatitis
Treatment Because most antibiotics taken orally achieve poor levels of concentration within the prostate the bacteria in chronic prostatitis often persist during treatment with antibiotic. Also, symptoms may persist while repeated urine cultures fail to show any bacteria, once the antibiotic is stopped, the bacteria reinfects the prostate and symptoms return.
PROSTATIC INTRAEPITHELIAL NEOPLASIA (PIN) PIN may develop decades before a cancer is detected. It is most often discovered when the PSA is higher than normal and indicates the need for biopsy and further screening. PIN is detected under the microscope in tissue removed with the needle biopsy. If it is low grade, it is not cause for alarm, but a high grade PIN calls for active surveillance, with periodic PSA tests and biopsies to watch for any change. Studies are in progress to determine if drugs can reverse the condition, but these are not yet completed. Like the other conditions of the prostate, PIN is most often related to aging. Whether PIN remains stable, regresses, or progresses, is not yet clearly understood, but there is strong implication that it can progress. PIN has a very distinctive appearance and can only be diagnosed on biopsy. Because PIN has such a high predictive value as a marker of cancer, if it is identified it must be closely watched and followed up. PIN is divided into three grades with grade one low, and grades two and three being high. Patients with high grade PIN should have biopsies periodically to look for cancer, so that it can be detected early enough for curative treatment. In some studies, up to 36 percent of patients who were identified with a high grade of PIN in an initial biopsy, were found to have prostate cancer on later biopsies. Autopsy studies of men with PIN and cancer increases with age. Interestingly, there is a marked decrease in the prevelance and extent of high grade PIN in men after hormonal therapy when compared with untreated patients. These findings suggest that prostate cells are hormone dependent. The decrease in PIN when androgens are blocked is believed to be caused by the acceleration of programmed cell death (apoptosis) and suggests that drugs such as Proscar may someday be used to prevent the development of prostate cancer.
OVERVIEW Cancer is really many different diseases. There are several major types of cancer and hundreds of subtypes. Lung cancer is very different from lymphoma, or skin cancer. However, all cancers have in common the abnormal growth and division of cells. DNA is in the nucleus of each cell and this is where the genes are. The activity of human cells is controlled, or programmed, by DNA, much the way software controls what a computer will do. If the DNA programming runs amok for some reason, the genes lose control. It is as if the computer operator were hitting the command key over and over again without hitting the program key to give it direction. Cancer cells are normal cells which have developed the ability to multiply at an abnormal rate and are out of control. They do not attach to normal cells, but they do form abnormal groups and patterns. Cancer cells proliferate on their own and become autonomous. This is how they become "differentiated," meaning they are forming abnormal groups and patterns of their own. A cancer forming in a gland is called an adenocarcinoma, which accounts for 90 percent of prostate cancer. Most prostate cells are glandular cells which produce secretions As mentioned earlier, the prostate is made up of a system of ducts in the fibrous tissue. A smaller portion of the prostate's cells make up the muscle and pumping activity. If the carcinoma is detected early enough, before it has spread out of the prostate capsule, it can potentially be cured. Cancer is either in situ or invasive. In situ means "in place," contained within the gland. The cancer has not broken through the prostate wall into the surrounding soft tissue and fat. Invasive, or infiltrating, cancer can or already has broken through the ductal wall of the gland, perhaps pentrated through the prostate capsule and into the seminal vesicles, blood vessels, bladder, and spread or metastasized to the lymph system, or bones. If the cancer is invasive, lymph nodes around the prostate will also be examined if surgery is done to find out if the cancer has begun to spread elsewhere. Lymphatic fluid flows through the body just like the blood stream does, and the bean?shaped lymph nodes are like filters, catching what comes through the pipes. As part of the immune system, they filter out and get rid of foreign or abnormal cells. It is here that cancer cells are likely to travel first when they migrate from the prostate. Prostate cancer is generally slow growing and its "doubling time," the time it takes to double in size from one cell to two, or one million to two million, could be years long, rather than weeks or months, as in some other cancers. About half of all prostate cancer takes more than four years to double in size, while breast cancer does this every three months, although recent studies have indicated there may also be some slow?growing breast cancers. Prostate cancer grows so slowly, that in autopsy studies 80 percent of men who died of other causes after age 90, had latent prostate cancer unrecognized during their lifetime. The proportion of histologic prostate cancer that will progress to clinical disease varies and there are interracial differences as well. African Americans have a higher number, Asians less, but this may have more to do with how the diseases progresses, not who gets it. In its early stages, prostate cancer may remain clinically obscure for years as one might expect if the doubling time of the cancer is four years or more. Most prostate cancer typically develops as a lesion in the peripheral zone so it is unlikely to cause urethral obstruction until it is advanced. The transition zone, which does cause obstruction when enlarged, however, is the site of only about 10 to 15 percent of prostate cancer.
SYMPTOMS OF LOCALIZED PROSTATE CANCER Commonly, local tumor growth in the prostate, whether it is benign or malignant, makes itself known by causing problems with urination, such as the need to urinate more often, having a sense of urgency, or a weak stream. If the cancer has metastasized, the symptoms will appear primarily in the bones. Prostate cancer can also be detected during a DRE by the change in the consistency, configuration, and symmetry of the prostate gland. Approximately 10 percent of men with voiding symptoms and no other clinical signs or symptoms of cancer have an occult (hidden) malignancy. Obstructive and irritative symptoms are most common symptoms of local cancer growth. When the cancer is the cause rather than the incidental finding of the local symptoms, the cancer usually has appreciable mass and volume already, and is frequently not confined to the prostate. Blood in the urine, or hematuria, is rarely associated with prostate cancer, but if it does occur, especially in an elderly man, this would suggest the need for further tests to look for cancer. Hematuria is an uncommon nonspecific sign in less than 15 percent of men with prostate cancer. Reasons for having blood in the urine involve local invasion of prostate cancer in the urethra or the base of the bladder. Renal failure may be a late manifestation of local spread, once the cancer has invaded the base of the bladder (the trigone) and obstructed the ureters. Because the symptoms are so nonspecific, and because they resemble symptoms of benign prostate conditions, the only way to find out is through thorough screening with tests that will eliminate all other possibilities.
METASTATIC CANCER Cancer is always identified by the site of the primary. If we know of prostate cancer, and find cancer in the bone, it is not bone cancer. It is important to understand these differences because it will determine treatment.
Symptoms of Metastatic Prostate Cancer The pelvic lymph nodes are another common site of metastatic cancer, often swelling and obstructing the flow of blood and lymph fluid. Such swelling, called lymphedema, occurs in the legs, feet, and scrotum. The presence of such symptoms needs to be studied with bone scan and CAT scan to determine the extent of metastasis. Urinary symptoms are very much like those of BPH. There may be more urgency to urinate, more frequent urination, a burning sensation, or blood in the urine. There could also be blood in the semen, and a decrease in the amount of semen ejaculated. By themselves, these are not symptoms of cancer, but they indicate that the urethra or ejaculatory ducts are blocked by something. When cancer is advanced, it may cause impotence, or a less rigid erection.
Hormone Refractory Prostate Cancer
In general, a man 70 or older with a slow growing cancer, who has the temperament to live with cancer in his body, may be an excellent candidate for watchful waiting. There are exceptions to all rules and each man is unique. A 72 year old may be much stronger and healthier than a 58 year old, so this must be considered. But in general, the difference between the ages of 50 and 80 (assuming a cancer doubling time of four years) is that there are seven doubling times for the cancer cells. Watchful waiting would be much more of a risk for the younger man. A 76 year old retired diplomatic liaison who chose this option more than four years ago, is still doing fine with no symptoms or changes in his lifestyle. When he discovered prostate cancer, and he had a T2A tumor, a Gleason score of 5, a PSA of 8, and no symptoms at all. Bone and CT scans showed no metastasis. His cancer was confined to the prostate, but there was no way of knowing if it would stay there, or how aggressive it might become. He had hypertension and was on some medications, but he decided he did not want hormonal treatment or radiation. He would not have been a candidate for surgery because of his age. This man's attitude was philosophical. He liked his life the way it was. He was enjoyhing himself, and did not want to risk changing that with possible side effects of radiation or hormonal therapy. Now 80, his PSA is 14, but he has no symptoms and is still content. Bone and CT scans once again showed no sign of metastasis. This is the primary gamble of this choice. What if your cancer's aggressiveness has been miscalculated and the disease will spread faster than assumed. Clinical estimates of the extent and aggressiveness of cancer cells are not 100 percent accurate. Your particular cancer could be resistant to hormone therapy aimed at slowing the cancer's growth. Another risk factor is the possibility that you may become ill from other conditions, such as heart disease or stroke, which will mean that should you choose to have surgery if your cancer grows, you may no longer be a good candidate for this treatment. The highest death rates from prostate cancer are in Scandinavia where the wait and watch approach is preferred. Watchful waiting is not the same as doing nothing. You could decide to wait a year and during that time, use hormone therapy to slow the progress of the disease. You can also change your diet as a way of possibly slowing the progress of the cancer, avoiding a high intake of animal fat, and adding more fresh fruits, vegetables, and grains. So this is not a "do nothing" choice. It means you will religiously monitor your disease through regular PSAs and DREs.
CONTROVERSY OF EARLY TREATMENT Despite hundreds of articles and treatment regimens, the appropriate treatment for early stage prostate cancer remains controversial. Surgical and radiation studies are hampered by an inadequate staging system. We don't have enough clinical trials and long term studies. The disease itself adds to the dilemma with its long natural history and slow doubling time. Surgical studies have often reported results based on pathological staging done after surgery. Radiation studies have not had the advantage of removing patients with positive nodes or extracapsular disease from the studies. Patients have different PSA levels. These factors make direct comparison of surgery with either external beam or bracytherapy difficult. Gleeson grade and stage have been historically reported as the most important pretreatment factors for predicting the outcome for early stage cancer. However, directly comparing surgical and radiation outcomes on the basis of stage alone is frought with problems because patients with higher PSA and grade are more frequently treated with radiation therapy, either external or internal. Several recent surgical and radiation studies have indicated that PSA levels before treatment may be more significant thatn either grade or stage as an objective prognostic factor. Grade also appears to be an important factor. How do you measure a successful treatment outcome? Normalization of the PSA? The fact that he is still alive? But couldn't the patient have been incompletely treated and still be alive? In recent years, it has been more difficult to analyze outcomes of prostate cancer treatment. In the past, local control was established by performing periodic DRE to look for evidence of recurrance of prostate cancer. However, it can take a decade or more for cancer to become detectable this way, so we look to more sensitive parameters through biopsy after treatment, or by following the PSA levels. The rise in PSA following treatment is considered "biochemical evidence" of either local failure or progression of the disease.
DEGREES OF DIFFERENCE IN EARLY CANCER In contrast, TIB, means there is a slightly higher volume and grade and progression rates could be as high or higher than a stage with a larger volume. This stage is comparable to T2A. The cancer is more than 5 percent of the volume of the prostate, and the Gleason score may be between 8 and 10. Men with either of these stages have a higher risk that the disease will progress and metastasize. Men with cancers staged at TlA and TIB might probably be safe with watchful waiting, but cancer staged at TIC is borderline. The number of men diagnosed with TIC disease has increased markedly since the introduction of PSA screening. Although there are obvious benefits of detecting more organ confined prostate cancer, there is still major controversy about the large numbers of men with clinically insignificant cancer staged at TIC. It is believed this stage poses no threat, and may safely be followed with watchful waiting. To determine criteria for TIC, Johns Hopkins University examined the pathological results of men who had radical prostatectomies, and who had been staged TIC before treatment. After study of the prostate specimens, the staging remained about the same. Most were between Stage TIA and T2. The tumors were confined to the prostate, their Gleason scores were less than 7, and the tumors were small. Such minimal tumors were found in 16 percent of Stage TIC patients. The cancer was confined to the prostate in half of the men. Almost 20 percent had cancer which had progressed to the wall of the prostate. Therefore, Stage TIC represents a different kind of tumors. So while 20 percent may have cancer that will not progress, some men had evidence of a significant cancer, but potentially curable with surgery. Obviously, we need a reliable means of distinguishing between low volume, indolent tumors, and those that will progress. This is a rationale for using PSA density and velocity, as well as Gleason score, and cancer volume. Studies reporting results of watchful waiting or conservative management are flawed by design, but it is clear that most men with moderately differentiated cancer will not die from the cancer ten years later. This suggests overall survival in men with a life expectancy of 10 years or less, and who have many other health conditions, are unlikely to improve with aggressive treatment of early prostate cancer. However, the risk of progression to metastastic cancer in 10 years is approximately 40 percent in men who are watchfully waiting with moderately differentiated tumors. Although these men avoid the side effects of radiation and radical prostatetcomy, many are likely to suffer from side effects from secondary symtpoms such as urinary problems if the disease progresses. In additional to hormonal therapy which can be palliative for bone pain, some may also need surgery to relieve bladder obstruction. Men who are diagnosed with early localized cancer face difficult choices. Conflicting studies, reports that are often incomplete or biased in the media, add to the confusion. It is important to be fully informed about the pros and cons of sugrery and radiation before considering this treatment.
We do not yet know the cause of prostate cancer, but we do know the strongest risk factor is age, despite the recent discovery of a prostate cancer gene implicating family history as a risk factor for so called hereditary prostate cancer. Cancer of any kind can be defined as an acquired genetic disease produced by exposure to environmental carcinogens that have caused damage to normal cells that accrues over many, many years. During our lifetime, we are all exposed to potential carcinogens in the environment: cigarettes, radiation, gasoline, animal fats, pesticides. Prostate cancer is a multi-stage process and the passage of time is needed for these chance events to accumulate and produce the mutations in our genes that cause the cancer.
In the United States, where one in four deaths is from cancer, men have a 20 percent lifetime risk of developing prostate cancer by the time they are 80. Lifetime risk is the probability that anyone over the course of a lifetime will develop cancer or die from it. However, the relative risk must also be taken into consideration. This is a measure of the relationship between risk factors and a particular cancer. Relative risk increases with exposure to particular environmental element, or there is an inherited predisposition. Smokers, for example, have ten times the relative risk of developing lung cancer compared to nonsmokers. A woman with a first degree relative with breast cancer, has far greater risk of developing that cancer.
Aging
By the age of 40, the number of men getting prostate cancer each year begins to accelerate, doubling every decade until about age 80. For the majority--about 70 percent--of patients diagnosed with prostate cancer, the only risk factor they have is their advancing age.
Family History
Until the discovery of the prostate cancer gene in 1996, there was no conclusive link between family history and incidence of prostate cancer. That is, we were not sure if the family connection was genetic, or environmental; the idea being that people in the same families may experience the same environmental or dietary risk factors.
When this gene--HPC1 for hereditary prostate cancer--is inherited in mutated form, it predisposes a man to prostate cancer. The risk`of developing prostate cancer by age 80 is about 50 percent in all men, but if you have the mutated gene, the risk increases to 88 percent.
While the significance of this discovery is important, it accounts for only a small number--perhaps three percent--of prostate cancers. Men who get prostate cancer early in life are thought to carry this gene, just as women with the BRCA I breast cancer gene, get breast cancer earlier than most women. The discovery of the prostate cancer gene may also shed some light on genetic factors responsible for the high incidence of this cancer in African American men.
When prostate cancer does occur in several members of a family, it is likely to be a more aggressive form of the cancer, and thus, it appears at an earlier age. Men with a history of this cancer on their father's--or their mother's--side of the family, should begin screening for prostate cancer no later than age 40.
There has been some speculation that if your mother has breast cancer, you are at increased for prostate cancer. However, more research needs to be done before we can be certain of this connection.
Race When we look at a racial and ethnic cross section of men at the age of 50, latent prostate cancer in all men is equal; there are no inter-racial variations. About 20 percent of these men will have prostate cancer among all races. The potential inter-racial differences come with the rate of progression of the disease and this may be influenced by genetics and diet. African-American men generally discover prostate cancer later, and this could be why the death rate is double that of white men, but it does not mean the cancer is more aggressive. It could mean as a group, they have less access to good healthcare, or they do not participate in early detection programs. We need to do more research to compare the PSA levels in comparable communities. For example, is the PSA rate effected by the size or density of the prostate? Or by the amount of testosterone produced? So far, much of the research into prostate cancer has compared apples to oranges rather than apples to apples. PSA rates need to be compared among men with the same racial background, age, and prostate size. This is being done in the Chinese community in New York City. In exchange for free screenings, these men become part of a large study on prostate cancer. Each year the men are invited back to repeat the test, so that the PSA results can be monitored over a period of years. One of the areas of investigation is the difference in the PSA levels in Chinese and non-Chinese men. A 4.0 PSA is normal for western man, but should it be the same for Chinese man with a smaller prostate? This could be an added clue to the PSA measurement. Perhaps the PSA level must be measured against the size or density of the prostate. The density of the PSA may be higher in a smaller prostate. Chapter 6 includes comparisons of PSA levels in Arican Americans, Asians, and white men.
Many variables affect the growth of cancer cells, from genetic susceptibility, to diet to exposure to carcinogens. Perhaps something in our environment--in the industrialized western world--causes prostate cells to become cancerous. Interestingly, the dog is the only animal that gets prostate cancer. Is this because the dog lives in our environment? Studies have highlighted certain occupational risks, too. For example, higher death rates from prostate cancer are reported in farmers, mechanics, welders, plumbers, newspaper workers, and men who work with metals or rubber manufacturing. No occupation has been linked conclusively, but some research would indicate that men exposed to cadmium--welders and electroplate workers--may be at increased risk. Cadmium is a trace mineral found in cigarette smoke and alkaline batteries. It is related indirectly because it diffuses the body's zinc, which is necessary for cellular growth. Of all body organs, the prostate has the highest need for zinc. In these studies, too, we cannot be sure if these men are at greater risk because of their jobs, or because they are the types of men who might be eating higher fat diets, or perhaps they smoke more than other men. Much more still needs to be studied. A change of diet is not as dramatically therapeutic against prostate cancer as quitting smoking would be in preventing lung cancer, but you are more likely to have many other health problems if your diet is loaded with animal fats and no fiber from grains and vegetables and fruits.
High Animal Fat Animal fat, especially red meat, has been heavily implicated in prostate cancer. Although we do not know if a high fat diet causes prostate cancer, we do know that there is some evidence in animal studies to suggest that it may affect the course of the disease. Conversely, these studies also suggest that a low fat diet can often be considered a way to slow the progress of prostate cancer. A Harvard study showed a 79 percent increase in risk for men who eat a high-fat diet. One theory is that dietary fat increases the serum sex hormone levels. A study showed that when fat consumption was lowered, these hormone levels in the urine were lower, too. Studies also show that diet is most strongly related to risk, so change can be beneficial. Earlier studies at Harvard have proven to medical investigators that men who eat a lot of fat, at least 5 or more servings a week of red meat, for example, are at the highest risk for prostate cancer. Their risk is almost double that of men who do not eat this much. Researchers theorize that this may be because fat is necessary for the production of testosterone, which in turn feeds the cancer cells. Fat contains an ingredient called alphalinolenic acid. This is found in red meat, whole milk, butter, and processed soybean oil. Studies at Memorial Sloan Kettering Cancer Center found that prostate tumors grew only half as fast in mice with diets of about 21 percent fat as in mice with diets of about 40 percent fat, which is what most American men consume. Tumors did not disappear, but the slower growth rate was impressive. Most prostate cancers develop around the age of 60, so if you change your diet to slow down the growth, you may live many more years without clinical progression of the cancer. Interestingly, tumor growth was two and a half times greater in mice fed the high fat diet. A new dietary study of men who have prostate cancer was begun by Dr. William Fair, chief of urology at Memorial Sloan Kettering Cancer Center and Dr. Warren Heston in collaboration with the American Health Foundation. Half the men are consuming a normal diet with 30 percent of their calories coming from fat. The other half are consuming only 15 percent of their calories from fat. This research is being done to find out why there are such vast differences in the incidence of prostate cancer in America and elsewhere. Autopsies have shown that the incidence of undiagnosed latent prostate cancer is about the same in American men as in Chinese men, but the incidence of full blown clinical cancer is 120 times greater in America than it is in China, where men eat a low-fat, high-fiber diet, compared to western meateating diets. While there is meat in the Chinese diet, there is less of it, because the bulk of a meal is made up of grains and vegetables. In this country, meat often provides more than half the calories for a meal. The American quarter pounder with bacon and cheese, is a good example. When compared with the Chinese, Americans eat 6 times more meat and eggs, 55 times more milk, slightly more fats and oils, and 3 times more fruit than the Chinese. The Chinese, on the other hand, eat 3 times more fish and grain, and 30 times more vegetables. Overall, the American diet contains 43 percent fat, while the Chinese diet contains less than 20 percent. Much research has been done and continues to be done about the effect of what we eat on our risk of cancer. Although no nutrients have been proven to prevent cancer, many scientists believe low fat can slow the growth of already slow-growing prostate cancer. While we cannot say a man who eats lots of animal fat and no fiber, will get prostate cancer, neither can we say for sure that every person who smokes will get lung cancer. However, with such obviously poor dietary habits, the odds are stacked against you. Most lung cancer is found among smokers. Most prostate cancer is found in societies with high animal fat and animal protein diets. Studies tell us that western populations, where red meat is highly consumed, have more cancer--prostate, breast, and colon--than communities where it is not, such as in Asia. Additionally, the highest number of overweight people live in the industrialized nations. Whether or not such poor habits cause prostate cancer is almost beside the point, if your prostate has been removed. But proper diet could make a difference simply because we do know that balanced diet will keep you feeling better and protect you against many ordinary ailments. But if research is correct, and too much animal fat, has an effect on prostate cancer, then by changing your diet you can quite possibly slow down the development of prostate cancer. Very few American men who have had treatment for prostate cancer, ask if they should change their diet to make themselves healthier, yet most Chinese patients do ask.
Vegetables and Fruit But reports are contradictory. Betacarotene, the precursor of Vitamin A, is a good example. For years it was believed that betacarotene inhibited cancer cell proliferation, but in 1996, the conclusion of along-term study revealed that it had no effect on cancer cells, and in fact, may have increased the incidence of cancer in some cases. The scientific community has only just begun to study our diets and there are many things they don't know. There could be elements' in vegetables that give us cancer, too, although the positive benefits far outweigh any potential hazards. Naturally-occurring food substances can be metabolized into mutagens. For example, bracken fern, which cattle eat (and thus, we eat), contains at least two carcinogens. Another potent carcinogen is a natural substance of mushrooms. Eating five pounds of mushrooms a day you might be pushing the risk level, but the digestive system is so complex and variable, that we cannot know for sure if these processes will take place. To put it in the most simple terms, a cancer cell or mutagen can take up residence in the body, hang around and do nothing, and eventually leave of its own accord. Or, it can dig in and start trouble with nearby cells. Pesticides and fertilizers are also under scrutiny by medical researchers. The metabolic fate of toxic chemicals synthesized by plants as a defense against bugs, animals and bacteria, is extremely complex, and varies greatly in every individual. Variety and moderation offers the best protection from the naturally occurring mutagens and carcinogens we cannot avoid. Whether they are pesticides used to grow our fruits and vegetables, hormones fed to market animals, or pollutants ingested by fish. If we tried to avoid everything that might potentially cause a cell mutation, we would starve to death.
Tomatoes Soy - Several studies have concentrated on soy products, including one at the comprehensive cancer center at the University of Alabama, to find out if the consumption of soy foods reduces the risk of prostate cancer. Genisten is an' element found in soybeans and some cruciferous vegetables, which blocks angiogenesis-the growth of new blood vessels. If this could be used in treatment, it might prevent cancer cells from developing new capillaries that supply blood to tumors. Antioxidants - certain foods contain anti-oxidants. These act like our body's own nutrition police, protecting us from free radicals. While we are breathing and burning up energy our cells continuously generate hazardous waste which can set the stage for cancer. This waste is made of molecules known as free radicals. Poor nutrition leaves our anti-oxidant levels low. Vitamins A, C, and E, are all antioxidants. Good food sources are melons and citrus fruits, yellow and green vegetables, tomatoes, green leafy vegetables, potatoes, wheat germ, oatmeal, peanuts, and brown rice. Garlic and broccoli are especially rich in anti-oxidants. In fact, the National Cancer Institute puts garlic high on its list of natural anti-oxidants. Eaten raw, garlic also stimulates immunological functions, lowers blood cholesterol, thins blood, and helps prevent embolisms. Cruciferous vegetables such as broccoli, cabbage, cauliflower, and Brussels sprouts, contain indoles, which are thought to inhibit cancer in animals, but there is still no definitive proof that they will protect humans. Vitamin C, and E, may have preventive components, according to some studies. However, large numbers of people must be studied for long periods of time before we can come to any conclusions about the benefit of vitamins in preventing cancer. A well balanced diet will provide most of the vitamins we need.
The Sunbelt Theory
Benign prostate conditions
Vasectomy
OVERVIEW PSA is a protein molecule, or protease, produced by the epithelial cells of the prostate. The purpose of PSA is to liquefy the gelatinous seminal fluid once it is inside the female reproductive tract. PSA is normally present in the blood of all men in low amounts. When PSA is elevated it means a "process" is disrupting the normal ductal architecture of the prostate causing more PSA to leak into the blood. This can be caused by benign prostate disease such as BPH, infections such as prostatitis, as well as prostate cancer, so the PSA test alone cannot determine the presence of cancer. For example, the PSA rises with BPH, but usually not as fast as it does with prostate cancer. However, the PSA reading could be confused if the prostate is enlarged with BPH, and cancer was also present. The two most definitely can co-exist. To add to the confusion, a man who is taking Proscar to treat BPH, would have a reduced PSA level. It could decrease to half the normal baseline value. PSA levels also increase after ejaculation, so having a blood test for PSA within 24 hours of ejaculation could present a false reading. The same thing can happen after riding a bicycle for any length of time. In BPH patients treated with Proscar, for example, the PSA level will decrease to half its baseline value. This would be an artificial decrease induced by the medication, however, and you would need to double your PSA in order to get an accurate reading. PSA levels can go into the thousands in cases of acute prostatitis or if a recent needle biopsy has been performed on the prostate. A higher reading means something may be wrong and investigation with ultrasound or biopsy should be considered. However, it does not automatically mean prostate cancer is present. Many men who showed PSA levels of 10 and higher, turned out not to have cancer.
HOW PSA IS MEASURED Now, here is another aspect to add to the dilemma. PSA exists in more than one molecular form in the blood. From 60 to 95 percent of PSA in the blood is bound to another substance--alpha I antic hymotrypsin--while the rest is circulating free and unbound. Studies suggest that prostate cancer detection is more accurate if we analyze the ratio of unbound PSA with complex PSA. Detection ability may improve as much as 20 percent. The PSA is measured by nanograms per milliliter (ng/mL) of blood serum. The normal range is 0.1 to 4.0 ng/mL. The assay used for measuring PSA does not go to zero, so the lowest possible measure is 0.1. (For purposes of simplicity, the ng/mL will be omitted in the text, and only the numbers will be used.) While the laboratory baseline reading for a normal PSA is less than 4.0, this level has a different meaning for a 40-yearold man and an 80-year old. For men over 70, for instance, a 6.5 would be considered normal if age is taken into account.
ADJUSTING FOR AGE AND RACE It is no longer appropriate to use one reference range for men of all ages. Investigators show that the use of age-specific ranges make the PSA more sensitive in younger and more specific in older men. These ranges also improved detection of curable cancer in younger men, and the decision not to do invasive biopsies in older men. So, to get a true picture of what a PSA level means, a man's age needs to be con sidered. So does his race. Asians have smaller prostates compared to caucasians of the same age. African Americans, are at higher risk for prostate cancer, and this needs to be considered. Several studies of the distribution of PSA levels have been done, and agespecific guidelines have been established for white, African American, and Japanese men.
By using narrower reference ranges, the sensitivity of PSA as a tumor marker is increased. This should help to make the early detection of more cancers in younger men in their 40s or 5Os. By using wider reference ranges in men 60 and over, the specificity of the test is increased. This means that many men in their 60s or 70s are spared further invasive testing with ultrasound needle biopsy, for example. However, it could also mean that some of the older men would not have their cancer detected. With these age specific reference ranges, we can develop a more accurate diagnostic picture for early curable prostate cancer. If the PSA is less than or equal to the range, and the DRE is not remarkable, the patient should be followed with annual checkups to monitor for change. If the PSA level is greater than the age-specific range and a DRE is unremarkable, then an ultrasound biopsy should be done.
ADJUSTING FOR DENSITY AND VELOCITY There is a variable amount of BPH tissue in men with and without prostate cancer that contributes to the overall PSA. Thus, PSA values appear to overlap greatly in men with prostate cancers of similar stage and between men with glands that harbor cancer cells and BPH. Another complication is that on a volume to volume basis, poorly differentiated cancers produce less PSA than do well differentiated cancers. So PSA is not a perfect marker. It has confounding variables. Two methods of coping with these variables are to look at the PSA density (PSA-D) and velocity (PSA-V). Density is the ratio of PSA compared to the size, or volume of the prostate. Velocity is the rate of increase of PSA. Density can be measured with ultrasound biopsy, and velocity can be measured with periodic blood tests. In general, cancer spikes PSA levels more than BPH does. Since PSA is related to the volume of cancer, it seems reasonable that men with cancer should havve more rapid rise in PSA. We have evidence that these significant differences in rate of change in PSA in men with cancer and those with BPH. The most effective way to distinguish between the two was to use the average velocity to find rate of change per year by measuring PSA three times in 6 months or a year. If the rate of change is greater than .75, it may be an indication that cancer is present. Velocity may be best used to follow men with normal PSA levels, and those who had biopsy but not evidence of cancer. If PSA is over 10, velocity is not a useful indicator.
SCREENING DILEMMAS By screening with PSA, about 20 percent of the cancers found are clinically indolent and this is the root of the controversy about whether it is helpful or harmful for a man to know he has this cancer. Prostate cancer is the only cancer with such a high disparity between the occult--latent--and the clinical. There is an argument that screening is not helpful unless it helps people live longer. When men first come to their doctors with prostate cancer, about one third have potentially curable cancers, while the other two thirds have cancer which has already broken through the wall of the prostate, and metastasized. Among those with potentially curable cancer who choose surgery, about half will have their cancer upstaged after surgery when more information is available from the pathologist who has examined the prostate and surrounding tissue. About a third of this group may develop local or metastacized cancer ten years after radical prostatectomy. So what is the value of aggressive therapy? Now that the PSA has allowed us to detect latent cancer in large populations, there are many controversies about treatment. There is an argument that identifying a large population of men offers nothing if curative therapy is not available. Before it is rational to answer this question, and to do universal early screening, we need more studies. We need answers to questions on whether treatment alters the natural history of the prostate cancer. The appendix in the back of this book lists information about some of the clinical studies in progress. Over detection is the greatest problem of screening. This gives us the big discrepancy between latent and clinical cancer and leaves little doubt we are identifying men who have no likelihood of ever getting clinical prostate cancer. Without a reliable way to predict the aggressiveness of the cancer cells, we would be treating men with no benefit at all. To further support critics of early detection, the disease has a long naturalhistory and a low death rate. The economic burden for screening, patient education, treatment of complications, primary and secondary therapy, follow up care, also needs to be considered. Screening is associated with benefit as well as problems. In order to reduce the death rate by 3 percent, we need to identify the cancer in 6 percent of all men. The use of the PSA annually may identify enough men to achieve this, but the identified cancer must be one of the aggressive ones that will cause death. Most studies suggest that screening programs identify those cancers exhibiting the greatest malignancy potential. Whether universal screening results in less death remains to be seen. But it must be remembered that nearly 60 percent of men whose cancer is detected only by a DRE have already advanced disease, while only about a third of those whose cancer was detected after an increase in their PSA, have advanced disease. This by itself appears to be a good reason for screening. Obviously, the clinical trials will help answer. Whatever is finally decided about the usefullness of the PSA for screening early prostate cancer, one prostate cancer has been diagnosed, the PSA becomes a very important yardstick for monitoring the effects of treatment on the progress of the disease. It is imperative to keep tabs on the PSA level.
OVERVIEW
The psychological problem is usually much worse than the physical problem. During the weeks or months of recovery you may need incontinence pants or pads to protect you from stress leaks and you may feel you are not in control of your own body, that you are like a baby wetting your pants. Perhaps you cannot play golf, or dance, or laugh out loud, for fear of leaking or worse. And how do you enter a locker room, or public men's room without feeling mortified.
The encouraging news is that this incontinence is rarely permanent, and there is a great deal that you can do to speed the process of complete recovery through special exercises, diet modification, and medications. There is no way to predict how long this will last. Every man is different. It can take longer the older you are. Some men regain control in days, while others need months. Nighttime continence always comes back first because when you are lying down, there is no pressure on the bladder or the sphincter and the pelvic floor. In time you may notice that you are sleeping longer through the night and your diaper is dry in the morning.
Before surgery you had two sphincter muscles that control the flow of urine. The internal sphincter, the one at the bladder neck, is the involuntary smooth muscle that is always at work without your conscious control. Because of the prostate's location at the base of the bladder and because the urethra passes through the prostate, the internal sphincter muscle is disrupted when the prostate is removed. The bladder neck itself, with its ring of muscles to control the flow of urine, may be completely removed in most cases. This sphincter is gone for good after prostatectomy. It is replaced by the anastomosis which rejoins your urethra to your bladder.
Without your internal sphincter muscle, your body must rely only on your external sphincter. This is a skeletal muscle located in the pelvic floor muscle, which is like a sling that supports your bladder and other organs. The external sphincter is the one that you are aware of, the one you tighten up when you control the urge to urinate, and the one you release when you want urine to flow. This muscle may be weakened by surgery, but there are ways to retrain and strengthen it. When any part of this system fails, some type of incontinence occurs.
Functioning With a Catheter
The hospital staff will teach you how to manage the catheter, so that the urine can drain without backing up. In fact, most hospitals cannot discharge you until they are confident you can operate the overnight bag and the leg bag.
The catheter drains into an overnight bag. When you get up or go out, you can connect the catheter to a leg bag which will not show beneath your clothing. (Bring baggy trousers for trip home to hide the bag. Put gauze pads in your underwear in case the catheter leaks.) This is strapped to your leg and is unobtrusive. However, this bag does not hold as much urine, so you cannot allow it to get full. The bag will not overflow and leak out, but urine backs up in the bladder with not place to go, it can cause problems, such as infection.
Don't worry if your catheter and leg bag get wet when you shower. This won't hurt anything. Be sure to keep the tip of your penis clean, where the catheter comes out. Your penis may be swollen for a while after surgery, and your scrotum, too. When you are walking around, wear jockey shorts for support, and when you are resting, try to elevate your scrotum and penis by placing a rolled up towel or pillow beneath them. It may be uncomfortable sleeping with a catheter but you will adjust by finding the best position.
Urine will constantly drain during the first few weeks. It is not a stop and start action during this time. When you empty the receptacles, be aware of anything unusual and alert your physician if any of these problems occur.
STRENGTHENING THE EXTERNAL SPHINCTER
How to Do Kegels
While standing, squeeze and hold for ten seconds. Breathe and count out loud. Relax for ten seconds. Stop and start and gradually increase the number of squeezes. Repeat this up to 15 times until you are too tired, or unable to hold the squeeze for ten seconds.
If you do Kegel exercises every day for at least two or three months, you will notice the change. They should be done 30 to 80 times a day for pelvic muscle rehabilitation. The more often you do these exercises, the sooner you will see results. They are especially effective if you do them when you are engaged in an activity that causes urine leakage, such as when you feel a cough or sneeze coming on, when you are about to get up from a chair, or lift something, do them.
You might even keep a record of how often you lose urine, what activities cause leakage, so you can be ready for it, or practice a Kegel to try to prevent it. Such a record will also keep track of your progress, as well. Make a chart for each day, for example, every two hour time frame. For each time period, record any incontinence episode -- small or large -- and the reason for it. For example, you sneezed, or got up from a chair. Record the amount of liquid you drank, and when or if you urinated. Keep track of the number of times you got up during the night to urinate. At the end of each day's record the total number of episodes.
Once the muscles of your pelvic floor are stronger, they are better able to control urine leakage.
Biofeedback
While you are connected to the instrument and sensors, a video monitor displays information on a video monitor about electrical impulses from your body. These sensors read electrical signals you create when you contract or relax your muscles. You see what is happening on the computer screen, and this is how you learn to control the muscles. By watching how you learn to control your reaction, you are encouraging yourself. The positive feedback from the therapist reinforces the exercises.
Diet Modification
Carbonated drinks, citrus fruits and juices, spicy foods, and artificial sweeteners can irritate your bladder and cause more need to urinate. Alcohol is a diuretic and also works like a sedative and can impair the muscles needed to prevent incontinence.
Some medications and drugs can have the same affect. High blood pressure pills, sleeping pills, tranquilizers, antidepressants, sedatives, diuretics, antihistamines, decongestants, or cold remedies. Some pain killers, too. If you are taking a medication that cannot be discontinued, then there may be other ways to create a balance, such as cutting out coffee, tea, and alcohol, or one of your other medications.
USING PROTECTIVE PRODUCTS
TREATING SEVERE INCONTINENCE
Collagen Implants
While these do not work for everyone, and many physicians believe they are not a good solution to the problem, some physicians believe they can be effective for some men. The implanting is done in a hospital on an outpatient basis with local anesthesia.
A cystoscope is used for this procedure. This is a fiberoptic tube with a telescope inserted into the penis, that allows the physician to see inside the urethra. Then, a needle is inserted through the cystoscope so collagen can be injected through the needle in | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||