PROSTATE DISEASE
PROSTATE DISEASE
Disease of the prostate gland is one of the most common afflictions of men as they transition from young adulthood into middle age, and eventual elderly status. There are three major prostate related illnesses. Because the symptoms of prostate disease frequently overlap, and many men have more than one of the major illnesses at the time that they develop symptoms, I will attempt to discuss all three conditions in this overview article, with a view to summarizing the important features of each of these diseases, and hopefully highlight important clinical, diagnostic and therapeutic differences.
Benign Prostatic Hyperplasia (BPH) is the most common of the three major prostate diseases. Almost half of a population of 45 year old men who do not have any symptoms of the disease can expect to develop symptoms over the subsequent thirty years. Common symptoms include needing to urinate more frequently than usual, and sometimes feeling that once the urge to urinate hits you, you will accidentally urinate on yourself unless you can get to a toilet immediately (this phenomenon is called “urgency”). Both frequency and urgency are however not unique to BPH, and are frequently seen in urinary tract infections involving the bladder, as well as in acute and chronic inflammation of the prostate, called prostatitis. Other symptoms include having to wake up several times during the night to urinate (nocturia), a weak urinary stream, the sensation of not being able to completely empty your bladder, and the inability to keep from urinating on yourself (this is known as incontinence). This incontinence my occur when you feel the urge to urinate, in which case it is called “urge incontinence”, or it may follow urination, and feel like you are leaking urine despite having just urinated (this is called post-void dribbling).
Prostate cancer is potentially the most life threatening of the three major prostate diseases. It is a relatively common disease, accounting for about a third of all cancers in men, and it is second only to lung cancer in the number of deaths it causes. One out of every six men can expect to get prostate cancer during their lifetime, and more than three percent of those people who develop the disease can expect to die from it. Your risk for developing prostate cancer is greater as you get older, and if you are of black or African heritage. If you have a first degree relative with the disease you are twice as likely to develop it as the general population. A history of prostatitis also increases your risk of developing the illness. While most men who are diagnosed with prostate cancer do not have any symptoms, and are diagnosed by routine Prostate Specific Antigen (PSA) screening tests, prostate cancer patients can have similar symptoms to those discussed above for BPH, either because the enlargement of the prostate caused by the cancer produces the symptoms, or more frequently because they have concurrent BPH. Patients with disease that has spread outside the prostate at the time of diagnosis often have bone pain, and occasionally present with neurological deficits if the disease has involved the spine, with compression of the spinal cord.
Prostatitis is the third major illness that affects the prostate gland. Inflammation of the prostate maybe acute or chronic, and it may or may not involve a bacterial infection. Acute bacterial prostatitis resembles a urinary tract infection involving the bladder. Symptoms include painful urination, urinating frequently, and may sometimes include fever, chills and muscle aches. There is often blood and white blood cells in a urine specimen, and urine cultures may grow bacteria, particularly gram negative organisms such as Escherichia Coli. These infections can become chronic and recurrent, and usually involve the same kinds of bacteria over and over again. However, the most problematic of the prostatitis syndromes is an illness called Chronic Prostatitis/ Chronic Pelvic Pain Syndrome (CP/CPPS), and the exact cause of this illness is not known. It is quite common, can cause considerable distress, and may be associated with depression and anxiety. The symptoms include pain that may be located almost anywhere in the pelvic region, including the tip of the penis, the testicles, perineum, and the supra-pubic area. Pain may occur during or after ejaculation. There may also be symptoms related to voiding of urine, including frequent urination, pain with urination, and a feeling of incomplete emptying of the bladder after urination.
Evaluation of prostate disease should begin with obtaining a thorough history from the patient. As previously indicated, there is a considerable overlap in symptoms between the three common syndromes, and it is frequently the case that the patient has both BPH and prostate cancer. A physical examination necessarily involves a careful inspection and palpation of the sex organs, including the penis, scrotum, testicles, and the groin lymph nodes. The hallmark of the examination is a digital rectal examination, which involves the insertion of a finger into your rectum by your doctor. Most patients dislike a rectal examination, but it is such a vital aspect of the assessment that it cannot be avoided. A rectal examination assesses the size and consistency of the prostate gland, including the presence of diffuse enlargement. It checks for any areas of nodularity, asymmetry, or abnormal hardness that suggest the presence of prostate cancer. The presence of pain on palpation of the prostate, and the intactness of anal sphincter tone are also assessed.
Diagnostic testing for the evaluation of prostate disease includes tests that are common to the evaluation of all prostate disease, as well as disease specific testing that is determined by the suspected prostate condition under evaluation. An analysis of a urine specimen is a basic test that should be done regardless of the suspected prostate condition under evaluation. Symptoms such as frequent urination and pain on urination may be caused by bladder infections, as well as by bladder cancer, and a urine sample may show evidence of white blood cells and bacteria in the case of an infection, or blood in the urine due either to infection or bladder cancer. Urine bacterial cultures are appropriate if prostatitis is suspected. A complete blood count, and a renal panel (which includes electrolytes and a serum creatinine) are also appropriate to screen for systemic illnesses, and possible kidney damage caused by the prostate condition. Specific testing for suspected BPH or prostate cancer may include a trans-rectal ultrasound to get a detailed look at the prostate, including areas that are hard to assess by physical examination alone. If the digital rectal examination suggests areas of the prostate that are hard and nodular, and if a trans-rectal ultrasound confirms the presence of areas suspicious for cancer, your doctor may refer you to an urologist for a possible trans-rectal biopsy of the prostate gland. In this case multiple biopsies are taken from several areas of the organ, with a particular focus on suspicious areas. While there is some controversy over whether to test for the Prostate Specific Antigen (PSA) in all patients with symptoms of BPH, most doctors will check a PSA if there is any evidence of nodularity or hardness of the prostate on digital rectal examination, or if there is a family history of prostate cancer. The decision to test for PSA is also strengthened by the knowledge that the patient has a life expectancy of ten years or more, and will therefore benefit from treatment for prostate cancer if it is uncovered by PSA testing. The presence of bone pain, or a very high PSA suggests the development of metastatic prostate cancer, and is an indication for imaging studies such as a CT scan of the abdomen and pelvis, or a bone scan.
Bacterial prostatitis is treated with antibiotics after appropriate cultures, and sensitivity testing. Chronic prostatitis/ chronic pelvic pain syndrome (CP/ CPPS) is a much more difficult and frustrating illness to treat. Urine cultures are typically negative for bacterial growth, and the results of antibiotic therapy are uniformly disappointing. The only class of drugs that have study evidence of effectiveness for CP/ CPPS are a class of medications called alpha receptor blockers, but the benefit is modest at best. There are two broad classes of medications that are effective for treating BPH. The first group are called alpha antagonists, and include at least four different drugs in this category. Alpha antagonists relax the prostate muscle around the bladder outflow tract, thereby relieving the obstruction to the outflow of urine. They have the advantage of a relatively rapid onset of action, being able to improve symptoms within 48 hours of starting treatment. More than two thirds of men experience improvement in symptoms after they start taking a drug in this class. These drugs are considered the first line of treatment for BPH. Side effects include problems with ejaculation, as well as dizziness, postural drops in blood pressure, and headaches, particularly in elderly patients. Five alpha-reductase inhibitors are an alternative class of drugs for BPH that work by shrinking the prostate gland by blocking the secretion of testosterone which fuels the hyperplasia of the gland. Unfortunately these drugs act very slowly, and it may take as long as six months for symptoms to improve. Other disadvantages of this class of drugs include side-effects such as erectile dysfunction, ejaculatory difficulties, low sex drive, and breast enlargement. These drugs are particularly useful for the treatment of markedly enlarged prostate glands with intractable symptoms of obstruction. Because these drugs can reduce serum PSA levels by as much as 50 %, it is important to bear that in mind in patients whose PSA levels are being periodically monitored as a means of surveillance for the recurrence or progression of prostate cancer. Surgical removal of the prostate for BPH is reserved for patients with severely enlarged prostate glands with intractable urinary obstruction, particularly if they have responded poorly to treatment with medications.
In order to fully understand the treatment approach to prostate cancer it is essential to understand the classification system for the disease. The risk of death from the disease is determined by a combination of the stage of the disease, the Gleason score, and the serum PSA level. The stage of the disease, which varies from T1 to T4 reflects the degree of advancement of the cancer, and the corresponding likelihood of cure versus death from the cancer. The Gleason score reflects the histological appearance of the cancer cells under a microscope. It is correlated with the degree of aggressiveness of the cancer in terms of metastasis, and therefore of survival with treatment. The higher the Gleason score the worse the prognosis. A high PSA level is correlated with spread outside the prostate gland, and is of prognostic significance in terms of potential cure versus incurability. Patients with stage 1 disease (the tumor is confined to the prostate gland), a low Gleason score, and a normal PSA level may be appropriate candidates for a curative prostatectomy, provided that they have a life expectancy of ten years or more. Advances such as robotics assisted surgery have improved the frequency of complications such as erectile dysfunction and urinary incontinence after surgery, but an awareness of these risks is imperative prior to making the decision to have surgery. Radiation therapy can either be applied externally, or through the implantation of radioactive seeds directly into the prostate gland. Techniques for radiation therapy have improved greatly in recent times, such that radiation therapy and surgery have similar disease free survival rates. Radiation requires eight or more weeks of therapy, and is associated with late occurring complications such as inflammation of the bladder (cystitis) and anal area (proctitis), as well erectile dysfunction. Another treatment option which can be combined with radiation therapy, or offered alone as palliative therapy after unsuccessful cure with more aggressive therapies, is hormonal therapy. This can either be accomplished by surgically removing the testicles, or more commonly by treating the patients with orally administered or injected testosterone blocking medications. This chemical castration is often psychologically more acceptable to patients than having their testicles removed, and has the added advantage of being potentially reversible if the medication is discontinued. Side-effects include erectile dysfunction, hot flashes, breast enlargement and a number of other organ dysfunctions. Such patients also require calcium and vitamin D dietary supplementation, and treatment for osteopenia. Treatment with chemotherapy is reserved for patients in whom the cancer has become resistant to hormone therapy following a period of initial sensitivity, and may prolong life for a variable period of time ranging from three to eighteen months. Bone metastasis associated with debilitating bone pain in advanced, incurable disease can be treated with radio-pharmaceuticals on a palliative, symptom relieving basis.
In conclusion, disease of the prostate gland is a common source of morbidity and mortality for men in the middle aged, and elderly age groups. Understanding the differences in the clinical presentation, assessment and treatment of the three major diseases afflicting the prostate gland allows patients to make rational choices about the care that they receive.
Okoronkwo Ogan
