Prostate disorders

Prostatitis

Inflammation of the prostate gland, sometimes due to infection.

Inflammation of the prostate gland, known as prostatitis, may be acute or chronic. Acute prostatitis is uncommon and tends to produce sudden, severe symptoms that clear up rapidly with treatment. By contrast, chronic prostatitis usually causes mild but persistent symptoms and can be difficult to treat. Both types are most common in sexually active men aged between 30 and 50.

What are the causes?

In many cases of acute or chronic prostatitis, an exact cause of the disorder cannot be determined. However, acute prostatitis tends to be the result of bacterial infection and chronic prostatitis is generally nonbacterial. Inflammation of the prostate gland may also develop in association with sexually transmitted infections.

What are the symptoms?

The symptoms of acute prostatitis develop suddenly and are usually severe. They may include the following:

• Fever and chills
• Pain around the base of the penis
• Lower back pain
• Pain during bowel movements
• Frequent, urgent, and painful passing of urine

Acute prostatitis sometimes causes urinary retention, painful swelling behind the testes, or the formation of an abscess in the prostate gland.

Chronic prostatitis may not produce symptoms. If symptoms do occur, they develop gradually and may include:

• Pain and tenderness at the base of the penis and in the testes, groin, pelvis, or back
• Pain on ejaculation
• Blood in the semen
• Frequent, painful passing of urine

If you suspect that you have either acute or chronic prostatitis, you should consult your doctor immediately.

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The structure and function of the testes, scrotum and penis

1. 1

   Urethra

2. 2

   Bladder

3. 3

   Vas deferens

4. 4

   Ureter

5. 5

   Scrotum

6. 6

   Epididymis

7. 7

   Testis

8. 8

   Penis

How is it diagnosed?

Your doctor will perform a digital rectal examination, in which a finger is inserted into the rectum to feel the prostate. The doctor may also ask you to provide a urine sample and may obtain a sample of prostate gland secretions by massaging the prostate through the rectum and collecting secretions from the urethra.

Both the urine sample and the prostate gland secretions will then be tested for the presence of infectious organisms. Ultrasound scanning may also be carried out to check for an abscess in the prostate gland.

What is the treatment?

If a bacterial infection is found, antibiotics will be prescribed. It may take several months for the infection to clear up completely. In the meantime, your doctor may recommend painkillers and may also give you drugs that soften the stools to make bowel movements more comfortable.

If your symptoms are severe, your doctor may advise bed rest. Prostatitis that is not caused by a bacterial infection may be treated with painkillers to relieve the symptoms and with drugs that act to relax the muscle at the exit of the bladder.

Although most affected men recover fully, both types of prostatitis can recur.

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Enlarged prostate gland

Noncancerous enlargement of the prostate gland, causing difficulty in passing urine.

In most men over the age of 50, the prostate gland has become enlarged to some degree. Such prostate enlargement is known as benign prostatic hyperplasia. The condition is noncancerous and is not associated with prostate cancer. Minor prostate enlargement is considered a natural part of the aging process. The cause of the condition is unknown.

What are the symptoms?

As the prostate gland grows larger, it constricts and distorts the urethra (the tube from the bladder to the outside of the body). At first, this enlargement does not cause any symptoms. However, if the prostate gland continues to enlarge, it may cause difficulty in passing urine, resulting in the following symptoms:

• Frequent need to pass urine, during the day and night
• Delay in starting to pass urine, especially at night or if the bladder is full
• Weak, intermittent flow of urine
• Dribbling at the end of urine flow
• Feeling that the bladder has not completely emptied

These symptoms may be worsened by cold weather; drinking large volumes of fluids (especially alcohol); taking drugs that increase urine production, such as diuretics; or taking drugs that may cause urinary retention, such as antispasmodics.

If the bladder does not empty completely, it may enlarge and make the abdomen swell visibly. Urine may collect in the bladder and stagnate. If the condition is left untreated, the urinary tract may become infected and there is an increased risk of bladder stones.

Rarely, retained urine can produce a build-up of backward pressure from the bladder to the kidneys, leading to kidney damage, and kidney failure may occur. Occasionally, an enlarged prostate gland may suddenly block the outflow of urine completely, causing rapidly increasing pain. This problem requires emergency treatment.

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Prostate enlargement

How is it diagnosed?

Your doctor will perform a digital rectal examination, in which a finger is inserted into the rectum to feel the prostate. The doctor may also arrange for blood tests to assess kidney function and rule out prostate cancer and urine tests to look for evidence of infection. Urine flow may also be assessed.

Ultrasound scanning may be carried out to measure the amount of urine left in your bladder after passing urine and check that your kidneys are not abnormally enlarged.

What is the treatment?

The choice of treatment depends on factors such as age, general health, the degree of the prostate enlargement, and whether the obstruction of urine flow is having harmful effects on the bladder and kidneys. Treatment may affect sexual function, and you should discuss the available treatments with your doctor.

If your symptoms are mild, your doctor may simply advise you not to drink fluids in the evening so that urinary frequency is decreased at night. If the symptoms persist, drugs, surgery, or catheterization may be necessary.

Alpha blockers are commonly used to treat prostate enlargement and can relieve the symptoms in some cases.

If your symptoms are more severe, your doctor may suggest prostate surgery to remove part of the gland through the urethra. Only tissue that is obstructing urine flow is removed. If the prostate is considered to be too large for a partial prostatectomy, the prostate may be removed through an abdominal incision.

This procedure may result in infertility. It may also cause erectile dysfunction. Laser surgery and shrinkage of the prostate using microwaves are alternative treatments that are now becoming available.

If surgery is not advisable due to old age or poor health, a catheter or urethral stent (a tube inside the urethra) may be left in permanently to drain the urine.

What is the prognosis?

The outlook varies greatly. Mild cases may be improved with drug treatment, but surgery is more effective for severe cases. About 1 in 7 men needs a second partial prostatectomy after 8–10 years.

Partial prostatectomy

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Partial prostatectomy

1. 1

   Urethra

2. 2

   Enlarged prostate gland

3. 3

   Bladder

4. 4

   Diathermy wire

5. 5

   Resectoscope

6. 6

   Penis

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Partial prostatectomy treatment

1. 1

   Attachment for irrigation system

2. 2

   Catheter

3. 3

   Widened urethra

4. 4

   Bladder

5. 5

   Balloon to hold catheter in place

1. Partial prostatectomy
2. Partial prostatectomy treatment

Treatment: Partial prostatectomy

There are several operations to treat an enlarged prostate gland. The most common procedure is a transurethral prostatectomy, in which only the core of the gland is removed. The operation is performed under general or spinal anaesthesia and requires a hospital stay. Since the rest of the gland will continue to enlarge, symptoms may recur and further surgery may be necessary later.

About 8 in 10 men are infertile after this type of surgery because sperm pass into the bladder on ejaculation, but orgasm is normal. Transurethral prostatectomy can also result in erectile dysfunction.

Step 1:

A specialized viewing instrument called a resectoscope is passed along the urethra (the tube leading from the bladder to the outside of the body) until it reaches the prostate. A heated wire (diathermy wire) is then introduced through the resectoscope and used to cut away prostate tissue, thus widening the urethra.

Step 2:

After surgery, the diathermy wire and the resectoscope are withdrawn. A catheter is passed into the bladder to drain urine. An irrigation system is attached to the catheter to wash out urine and blood, with the aim of stopping clots from forming. The catheter is left in place for 2–3 days.

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Prostate cancer

A cancerous tumour arising from the glandular tissue of the prostate gland.

Prostate cancer is the most commonly diagnosed male cancer in the UK, affecting about 1 in 10 men at some time in their lives. The disorder is more common in northern Europeans and black men, but it is rare in men from Asian countries.

The number of cases of prostate cancer identified in the UK has been rising since the 1970s, not only in elderly men, in whom it is most common, but also in men in their 40s and 50s. This increased identification in recent years has been largely due to increased public awareness and the availability of a screening test that measures the level of a protein called prostate-specific antigen, secreted by the prostate gland.

Although prostate cancer is the cause of about 10,000 deaths each year in the UK, many tumours grow slowly, especially in elderly men, and may never cause symptoms. Treatment is more likely to be necessary in younger men.

What are the causes?

The exact cause of prostate cancer is not known, although the male sex hormone testosterone, produced by the testes, has been found to influence the growth and spread of the tumour. In about 5 to 10 per cent of cases, the cancer is partly due to an inherited abnormal gene. In these cases, it is more likely to occur before the age of 60.

Although there has been concern that having had a vasectomy increases the risk of prostate cancer, there is no firm evidence to support this view.

What are the symptoms?

Prostate cancer may not produce any symptoms, particularly in elderly men. If symptoms do occur, they are likely to develop when the tumour starts to constrict the urethra. The symptoms may then include:

• Weak urinary stream or inability to pass urine normally.
• Frequent urge to pass urine, especially during the night.
• Rarely, blood in the urine.

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Metastatic cancer

This radionuclide bone scan of the chest shows “hot spots” in the spine and in the shoulder blade due to the spread of a cancer that originated in the prostate gland.

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   Tumour in spine

2. 2

   Tumour in shoulder blade

In some men, the initial symptoms of prostate cancer are due to the metastasis (spreading) of the cancer to other parts of the body, most commonly the bones, lymph nodes, and lungs. In these cases, the symptoms may include back pain, enlarged lymph nodes, shortness of breath, and significant weight loss.

How is it diagnosed?

If you develop the symptoms of prostate cancer or if the disorder runs in your family, you should consult your doctor. The doctor will perform a digital rectal examination, in which a finger is inserted into the rectum to feel the prostate gland. He or she may also arrange for a blood test to measure your prostate-specific antigen levels.

You may be referred to hospital to have a type of ultrasound scanning in which a probe is inserted into the rectum to visualize the prostate gland. This procedure enables the doctor to assess the size of the gland and to look for any abnormalities. During scanning, a prostate gland biopsy may also be carried out. In this procedure, some cells are removed from areas of the gland that appear abnormal and are examined under a microscope.

If prostate cancer is diagnosed, you may need imaging tests, such as MRI and radionuclide scanning, to check whether the prostate cancer has spread to other parts of the body.

What is the treatment?

The choice of treatment depends on age, general health, and whether the cancer has spread to other parts of the body. If the cancer is confined to the prostate and your health is otherwise good, your doctor may recommend that the entire prostate gland be surgically removed, along with some of the surrounding tissues.

Alternatively, radiotherapy may be given. This form of therapy involves either having a radioactive implant or radioactive seeds placed in the prostate gland or undergoing external radiotherapy over several weeks. In elderly men in whom the cancer is confined to a small area of the prostate gland, no immediate treatment may be required, but the course of the disease will be closely monitored.

If the cancer has spread beyond the prostate, a cure may not be possible. However, progress of the disease can be slowed significantly with hormone ablation therapy. In this treatment, drugs that block the release or actions of testosterone are given to suppress the effects of the hormone on the cancer. In some cases, part of both testes may be surgically removed to stop the production of testosterone.

Rarely, treatments that block the actions or production of testosterone result in erectile dysfunction and loss of interest in sex.

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Test: Prostate Gland Biopsy

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Prostate cancer

What is the prognosis?

A diagnosis of cancer of the prostate gland does not necessarily mean that the cancer will cause symptoms or be life-threatening. Sometimes the best policy, especially in elderly men, is to defer treatment and begin regular checkups to monitor the disease. Men with certain types of small tumour do not need treatment and are likely to live for several years with no symptoms before dying from some other cause.

For men who have had surgery for a tumour confined to the prostate gland, the outlook is good, with about 9 out of 10 men surviving for at least 5 years after diagnosis. However, surgery may result in erectile dysfunction and urinary incontinence.

Cancer that has spread beyond the prostate is unlikely to be cured completely, but hormone ablation therapy often controls the symptoms for years.

Treatment: Radical prostatectomy

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Treatment: Radical Prostatectomy

A radical prostatectomy may be done to treat prostate cancer if the cancer has not spread beyond the gland. The procedure is performed under general anaesthesia and usually requires a hospital stay of about 3-5 days. The operation removes the cancer in most men, but afterwards about 1 in 2 men will have erectile dysfunction, and some will have a degree of urinary incontinence.

The tumour is removed, together with the entire prostate gland, the seminal vesicles, and the neck of the bladder.

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   Area to be removed

2. 2

   Neck of bladder

3. 3

   Prostate tumour

4. 4

   Seminal vesicle

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Site of incision

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   Site of incision

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After the procedure

The bladder neck has been reconstructed and rejoined to the urethra (the tube from the bladder to the outside of the body).

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   Urethra

2. 2

   Reconstructed bladder neck

1. Treatment: Radical Prostatectomy
2. Site of incision
3. After the procedure

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