Prostate problems

What is the prostate?

It is important to know about the normal development and job of the prostate, where it’s located, and what it’s attached to, as this will help you understand how prostate cancer develops and affects a man’s life over time, due either to disease or as a result of treatments.

The prostate is a small gland (an organ in the body that makes a substance for release inside the body) found only in men. It plays an important role in reproduction by helping to produce the liquid in semen (fluid that contains sperm).

The prostate is found just below the bladder (organ that collects urine) and surrounds the urethra (tube which connects the bladder to the penis for passing water). Running alongside and attached to the sides of the prostate are the nerves that control erectile function.

 The prostate is small at birth but after puberty (the process where a child’s body matures to adulthood) it enlarges, due to the rising levels of testosterone (male sex hormone).

The prostate gland produces an important liquid part of semen. Sperm are produced in the testicles (balls) and then stored in a jelly type substance just behind the prostate in the seminal vesicles (tubes that carry sperm).

When a man has an orgasm (comes) and ejaculates the prostate and seminal vesicles contract, mixing their contents. The fluid in the prostate contains large amounts of a substance known as prostate specific antigen (PSA), which turn the jelly type substance to liquid, letting the sperm move freely in search of an ovum (female egg) to fertilise (join with an egg to create a pregnancy).

The prostate is the only organ that continues to grow all through life. This can cause problems once a man reaches middle age. The earlier men are aware of a problem with their prostate and get help, the more successful the treatment is likely to be. 

Prostate problems

Prostate problems are becoming more common as we are now living longer. Although prostate problems tend to affect older men, some prostate conditions can affect men of any age.

The sooner a prostate problem is discovered and treated the less likely they are to affect your life.

Healthier lifestyles and a better understanding are essential to prevention and early detection of prostate problems.

Symptoms

Problems with urinating (passing urine) are the most common symptoms of prostate disease.

  • A weak sometimes irregular flow of urine.
  • Difficulty starting to urinate.
  • A need to urinate more often.
  • A need to urinate urgently (you feel unable to wait).
  • Waking to go to the toilet several times during the night.
  • Feeling that your bladder is not completely empty after you have finished urinating.
  • Pain or burning when passing urine.
  • Blood in your urine.
  • Pain in the back, hips or pelvis.

If you are having any symptoms you are concerned about it is advisable to see your GP.

A prostate problem is identified using different methods of investigation. Your doctor will ask you some questions about your symptoms and perform some tests or may refer you to a specialist for further tests.

Tests

Digital Rectal Examination

Digital Rectal Exam

A DRE is a physical examination where a doctor or nurse feels the prostate gland with a gloved, lubricated finger through the rectum (back passage).

During the digital rectal examination, your doctor will check whether the prostate

  • Feels enlarged
  • Is tender
  • Feels smooth
  • Feels lumpy

Urine test

Your doctor will take a urine (water) sample to check for signs of infection or blood. This will help rule out a urinary tract infection. You may also be tested for diabetes.

Prostate specific antigen (PSA) test

PSA is a protein that is produced in large quantities by the prostate gland, which turns the jelly like substance into liquid to help sperm move freely.

It is released in very small amounts into the bloodstream. When there’s a problem with the prostate, for example prostate cancer, more and more PSA is released. It eventually reaches an amount where it can be easily detected in the blood.

PSA is present in small quantities in the serum (a part of blood) of men with healthy prostates, but is often high when a man has prostate cancer and other prostate problems.

How is PSA measured?

To do a PSA test a doctor or nurse will take a sample of your blood for testing. During a PSA test, a small amount of blood is taken from the arm, and the level of PSA is measured.

PSA test is measured in nanograms per millilitre. There is no such thing as a “normal” PSA level. PSA levels vary from man to man and increase with age.

PSA is not a perfect test; there are other causes of raised PSA, such as infection, a non cancerous enlarged prostate and even exercise and sex. So if you have a raised PSA level you will need to have more medical tests to find the cause.

Some men with prostate cancer may even have low levels of PSA.

Biopsy and ultrasound scan

If a lump or hardening of your prostate is found during your digital rectal examination, your specialist may take a biopsy (a small sample of cells) to look at under a microscope (a device used to see objects that are too small for the naked eye).

The biopsy is most often done through your rectum (back passage) using a transrectal ultrasound scanner (A small ultrasound microphone that is put into your back passage). But you can also have a biopsy taken through the perineum (the skin behind your testicles) or while you are having a cystoscopy (a test that looks in the bladder with a small camera).

Gleason score

If cancerous cells are found in the biopsy, they can be examined further to see how quickly the cancer is likely to spread.

This measure is known as the Gleason score. The lower the score, the less likely the cancer will spread.

  • A Gleason score of 6 or less means the cancer is unlikely to spread.
  • A Gleason score of 7 means that there is a moderate chance of the cancer spreading.
  • A Gleason score of 8 or above means there is a significant chance that the cancer will spread.

Cystoscopy

A cystoscopy is a test to look at the inside of your bladder using a thin, flexible tube called a cystoscope. A doctor uses the cytoscope to look into the inside of your bladder. You can have a cystoscopy under local anaesthetic (whilst awake) or general anaesthetic (whilst asleep); depending on what the doctor needs to do.

There are three main types of prostate problems

Prostatitis
Prostatitis is an inflammation of the prostate gland. This is caused by a bacterial infection, making the prostate gland get bigger. While most of these infections are acute (brief and severe), some men may have a chronic (recurring every now a then) form of this illness, although the symptoms may be milder.  Symptoms include high temperature, chills, and pain in the lower back and the pelvic area.  About 5 to 10% of men will have this condition throughout their lifetime.  Antibiotics are usually used to treat this condition.

Benign Prostatic Hyperplasia
This is a common term used to describe an enlarged prostate that is not cancerous. The older a man gets the more likely he is to suffer with this condition.
Because BPH causes the prostate gland to enlarge, the swelling can eventually block the urethra (water pipe), making it difficult for sufferers to urinate (pass water).
It can also cause incontinence (inability to hold urine) or dribbling after urinating. Those who have BPH have a frequent urge to urinate, especially at night.

Prostate cancer
Prostate cancer is a disease in which cells of the prostate gland become abnormal and start to grow into tumours.

Cancer is caused when something affects the make-up of our cells. This causes the cells to grow in an uncontrollable manner, creating a lump of tissue, known as a tumour.

What causes prostate cancer?
What makes the cells in the prostate become cancerous is currently unknown.
There are a number of known risk factors (something that increases your chances of getting a disease) for developing prostate cancer.

  • Age.  The risk of prostate cancer increases with age, from about 50 years, and continues to get higher the older you get.
  • Ethnic group.  Prostate cancer is more common among men of African-Caribbean and African descent. The condition is quite rare among men of Asian and South and Central American descent.
  • Family history.  Having a close male relative (brother, father or uncle), who had prostate cancer seems to increase the risk of you developing prostate cancer. Research also shows that having a close female relative (mother or sister) who developed breast cancer may also increase the risk of you developing the condition.
  • Obesity.  Recent research suggests that there may be a link between obesity and prostate cancer.
  • Diet. Research is continuing to look into the links between diet and prostate cancer. There is evidence that a diet high in calcium is linked to an increased risk of developing prostate cancer.
    Also, some research has shown that prostate cancer rates appear to be lower in people who eat foods containing certain nutrients including lycopene, found in tomatoes and other red fruit, and selenium, found in brazil nuts.
  • Exercise. Men who take regular exercise have also been found to be at lower risk of developing prostate cancer. 
















For further advice or information contact:

British Association of Counselling and Psychotherapy (BACP)
www.bacp.co.uk

Sexual Advice Association
www.sexualadviceassociation.co.uk

Disclaimer
All content within Mediplus Patient Info pages is provided for general information only, and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional.  Mediplus is not responsible or liable for any diagnosis made by a user based on the content of the Mediplus website.  Mediplus is not liable for the contents of any external internet sites listed, nor does it endorse any commercial product or service mentioned or advised on any of the sites.  Always consult your own GP if you're in any way concerned about your health.

There are three main stages in prostate cancer:

Early prostate cancer (local)
This is where the cancer is still contained within the prostate as a primary tumour (a tumour that has not spread to the surrounding tissue).

Early Local Prostate Cancer

Locally advanced prostate cancer

This is when the cancer has spread outside of the prostate. The prostate cancer has not spread to lymph nodes (small organs of the immune system) or to the bones.

Local Advanced Prostate Cancer

Metastatic disease
As the cancer becomes more advanced, the cancer cells are able to break off from the primary tumour. These cells go into the blood or lymphatic system and are transported to distant parts of the body. Once deposited at another site such as a bone, the cancer cells start to grow and multiply, forming metastases (secondary cancers).
Knowing the grade and stage of your cancer helps you and the doctors decide on the most appropriate course of treatment.

Treatment options

The treatments options offered to you will depend on various factors.

  • Your prostate cancer grade and stage
  • Age
  • Fitness levels
  • Personal preference
  • Medical history

Every case of prostate cancer is dealt with on an individual basis by a team of healthcare professionals. You should have the opportunity to discuss the various treatment options with your team.  It is important for you to be comfortable with the chosen treatment.
In 2008, the National Institute for Health and Clinical Excellence (NICE) made recommendations about treatments that are offered to men with the three main stages of prostate cancer:

  • localised prostate cancer (cancer that is just in the prostate gland)
  • locally advanced prostate cancer (cancer that has spread beyond the prostate capsule, but is still connected to the prostate gland)
  • Relapsed (cancer that has returned after treatment) and metastatic prostate cancer (cancer that has spread outside the prostate gland, with no remaining link to the original cancer in the prostate gland).

Watchful waiting
Watchful waiting is a way of keeping an eye on prostate cancer that is not causing any symptoms or problems. The aim is to monitor the cancer over the long term because prostate cancer is often slow growing and may not cause you any symptoms or problems in your lifetime.

Active surveillance
Active surveillance is a way of keeping an eye on prostate cancer which aims to avoid or delay unnecessary treatment in men with less aggressive cancer.  Many prostate cancers are discovered at an early stage. Prostate cancer can be slow growing and, for many men, the disease may never progress or cause any symptoms.  Treatments for prostate cancer can cause side effects which can affect your quality of life. By monitoring the cancer, you can avoid or delay these side effects.

Cryotherapy
Cryotherapy treats prostate cancer by using freezing and thawing to kill the cancer cells in the prostate gland.  It is also sometimes known as cryosurgery and cryoablation. Cryotherapy is usually an option for men whose prostate cancer has come back after treatment with radiotherapy or brachytherapy.  It is not usually offered as a first treatment for prostate cancer.  However, it may be an option for men who are unable to have surgery to treat prostate cancer.

Hormone therapy
Hormone therapy helps control prostate cancer by stopping the production of testosterone (male sex hormone) or stopping testosterone reaching the prostate cancer cells. There are different types of hormone therapy available, you may have injections, an operation, tablets or implants.  Hormone therapy can cause side effects such as hot flushes, loss of sex drive and tiredness. It is important that you are aware of the side effects before you start treatment.

Permanent seed brachytherapy
Permanent seed brachytherapy, also known as low dose rate brachytherapy involves having tiny radioactive seeds implanted in your prostate gland.  Radiation from the seeds destroys cancer cells in the prostate. You may have this treatment on its own or together with external beam radiotherapy and/or hormone therapy.  It is just as good at controlling prostate cancer as other treatments.

High dose rate brachytherapy
High dose rate (HDR) brachytherapy, also known as temporary brachytherapy, involves inserting a source of high-dose radiation into the prostate gland for a few minutes at a time to destroy cancer cells. You may have this treatment on its own or you may have it together with external beam radiotherapy and/or hormone therapy.

Bisphosphonates
Bisphosphonates are drugs that can help men with prostate cancer that has spread to the bones and is no longer responding to hormone therapy. They do not actually treat the cancer but they can help to relieve bone pain. They may also help to prevent and slow down the breakdown of bone.

Radiotherapy
Men with advanced prostate cancer may have radiotherapy to help relieve symptoms. This is called palliative radiotherapy.  Palliative radiotherapy does not aim to get rid of your cancer but it can help to slow down its growth. There are two types of palliative

radiotherapy:  external beam radiotherapy (EBRT) and internal radiotherapy (radioisotopes).

External beam radiotherapy uses high energy X-ray beams to treat prostate cancer. The

X-ray beams are directed at the prostate gland from outside the body. They damage the cancer cells and stop them growing.

External beam radiotherapy is sometimes given alongside brachytherapy or high dose rate brachytherapy (internal radiotherapy). Radiotherapy can also be used after surgery if your PSA level starts to rise or if not all the cancer was removed with surgery.

Radical prostatectomy
Radical prostatectomy is an operation to remove the prostate gland and the cancer contained within it. You may be suitable for this treatment if your cancer is thought to be contained within the prostate gland and you are otherwise fit and healthy.

Chemotherapy

Chemotherapy uses cytotoxic (anti cancer) drugs to kill cancer cells.  It is used to help control symptoms but not to cure prostate cancer.  The side effects of chemotherapy are sometimes difficult to cope with so you need to be fairly fit before you start treatment. Most chemotherapy drugs are given as a course of up to ten sessions of treatment.  At each treatment session, a liquid containing the drug will be passed through a cannula (fine plastic tube) into a vein in your arm.  You may have chemotherapy alongside other treatments such as palliative radiotherapy, bisphosphonates, pain-relieving drugs, and steroids.

Treating prostate cancer after hormone therapy
If your prostate cancer is no longer responding to your original hormone therapy you can have further treatments. You may be able to have other types of hormone therapy, chemotherapy or a new treatment as part of a clinical trial.

High intensity focused ultrasound (HIFU)
HIFU uses high frequency ultrasound waves to heat and destroy cancer cells in the prostate. It is a relatively new treatment and we do not know very much about how effective it is at treating prostate cancer in the long-term or how it may affect your everyday life.  Because of this, HIFU is only available in a few centres in the UK, usually as part of a clinical trial.

Clinical trials
A clinical trial is a type of medical research study that aims to find new and improved ways of preventing, diagnosing, treating and controlling illnesses, such as prostate cancer. Clinical trials involve testing new medicines and procedures on people in a controlled and carefully planned way. Clinical trials are the best way to find out whether a new treatment is better than the current standard treatment.

Sex and Prostate Cancer

This advice is a guide only, please speak to your nurse or doctor for guidance.

You may be worried about your love life if you have a prostate problem.  How soon you can resume sexual activity will depend on what type of treatment you have had and how you feel. It may only be a few weeks but for other men it may take longer.  Some men do not feel like sex at all while having their treatment, or for some time after they are diagnosed. Many people feel very down after they have been told they have cancer and don't feel interested in sex. But some men respond to their diagnosis by feeling they should be getting as much out of life as possible. If you feel like this, and your treatment has caused erection problems, this may be very upsetting.
It is important that throughout your treatment and recovery you talk to your partner about how you feel.  There are many ways of having an intimate relationship without having penetrative sex. Physical contact through kissing and cuddling can help couples to feel close to one another.

Radiotherapy
If you have had radiotherapy you might not feel like sex, but if you are willing and able there is no reason why you can’t resume lovemaking.

Brachytherapy
You may also resume sexual activity as soon as you want to following brachytherapy, although most men do not feel ready for a few weeks.

Surgery (prostatectomy)
If you have had surgery such as a radical prostatectomy, you will need to avoid full sexual intercourse for approximately 6-8 weeks whilst everything heals. If you have had keyhole surgery you may feel ready before this.

Some treatments may affect:

  • Your ability to get an erection (erectile dysfunction)
    Erectile dysfunction (ED) is when you have difficulty getting or keeping an erection suitable (good enough) for sexual intercourse. Go to our ED webpage for more information. 
  • Your desire to have sex (libido)
    Prostate cancer and its treatments such as hormone treatments can reduce or cause you to lose your desire for sex.  This is due to the decrease in testosterone (male sex hormone) that is responsible for giving you your “sex drive”. Usually the desire to have sex returns after hormone treatment is stopped.
  • Your ability to ejaculate and have an orgasm (come)
    If you have had a radical prostatectomy you will not be able to ejaculate after the surgery. This is because the prostate gland and seminal vesicles which store and carry semen are taken out during the operation. You may still have an orgasm, but will not release any semen.
  • Your fertility (ability to have a baby)
    Treatment for prostate cancer can affect your ability to produce sperm or ejaculate which leads to infertility.  It may be possible for you to store some sperm before your treatment if you might want to have children in the future.


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