In this page, you will find details about benign prostatic hypertrophy, prostatitis and prostate cancer.
Benign Prostatic Hypertrophy (B.P.H.)
Also known as prostatic adenomatosis, this is a phenomenon that affects all men in varying proportions and seriousness from the age of 30 onwards. Since it can coexist with prostate cancer, the appropriate tests are necessary before operating. This eventuality should also be eliminated prior to starting any medical treatment. Operating or starting a therapy before having ruled out the existence of cancer exposes a patient to very serious risks. How to diagnose prostate cancer in good time will be described in the next chapter.
When “enlarged prostate in the elderly” is referred to, the wrong terminology is almost always used because:
With age, it is not so much the prostate that enlarges but a small group of glands set behind the urinary canal that goes through the prostate. So "inside the prostate" a kind of new gland grows that squeezes the prostate outwards. Usually this “ball” that grows inside the prostate is made of two parts, to the left and right of the urethra; on occasions there is also a third part called the middle lobe that grows between these two, towards the bladder.
After years of development of this benign prostatic hyperplasia or B.P.H. (to distinguish it from malignant prostate adenocarcinoma, that is, cancer) it can even reach the size of a grapefruit, and the “real” prostate is squeezed outside like peel.
Cause
The exact cause of B.P.H. is not known. Some researchers believe that under the stimulus of continuing urination, ejaculation and inflammations, micro traumas occur that release a substance from the prostatic tissues, which can cause the enlargement of the adjacent glands. Changes in the hormone balance in those tissues are also probable causes.
When to Treat Prostate Enlargement?
It is not a larger or smaller size that makes the treatment of B.P.H. necessary. It should be realised that prostates with small adenomas can give rise to a great deal of disorder and large prostates may also be no bother. In many centres a special questionnaire is used to establish the degree of disorder in a patient. Points are assigned to patient responses, and the higher the end total, the greater is the need of therapy.
The urology specialist will work together with the patient’s usual physician to treat the B.P.H.
Can B.P.H. Transform into Cancer?
Only 20% of tumours originate in the B.P.H. area, and it has not been demonstrated that a large B.P.H. degenerates into cancer more readily than a small one. Therefore there is no need to decide to operate on a B.P.H. for the purpose of cancer prevention.
As we have stated, even after an adenoma has been removed, the “real” prostate remains in place! In fact, whoever has undergone a “prostate” operation must undergo programs for prostate cancer prevention, just the same as someone who has not been operated on.
Indeed, a gland that has been “cut” to remove an adenoma may also facilitate the spread of a tumour that has later arisen in the prostate, and thus make it more dangerous.
Treatment
Medical treatments exist, as do surgical operations, and deciding which to use depends on the nature of the symptoms, the size of the adenoma, the age and the general conditions of the patient and also on the urologist’s experience.
It is true that in the last few years pharmaceuticals have been placed on the market that are very effective in reducing disorders associated with the "prostate". For maximum simplicity: these are medicines that need to be taken over a long period and which, using various mechanisms, widen the urinary tract that goes through the prostate, and thus permit a more comfortable flow of urine. Their effectiveness has been amply demonstrated. Thanks to these medications the number of patients that require operations has been greatly reduced during recent times. Not all cases however, can derive the same benefits.
There are three main groups of medications for the non-surgical treatment of B.P.H.
"Artificial" medicines with a hormonal action, which reduce the size of the prostate and thus reduce the constriction of the urethra.
"Artificial" medicines that act on the muscles of the urinary channel and force them open, thus widening it.
“Natural” substances of plant origin whose action is not fully known, but which seem to act by reducing any inflammation and/or through a “local” hormonal effect, which reduces the volume of the prostate. Recently these substances too have been subjected to controlled clinical research, which has proven their effectiveness. Even if these are products a patient can “self-prescribe”, it is always best for them to be taken under medical-urological supervision.
What Medication is Suitable for this Case?
Only a urologist can suggest the most suitable treatment for the case to the patient. The choice is not always easy, and sometimes it can be useful and even vital to combine several medicines. Furthermore, not all patients tolerate these medicines equally well, and good results obtained initially are not always maintained. One can thus understand why surgery maintains a major role.
Can Prostate Health be Taken Care of, by Dietary Action?
In this very website you will soon find a very detailed article on diet in preventing benign enlargement (adenomatosis) or in the form of tumours (adenocarcinomas). In every case, excesses are to be avoided in every area, both in caring for the spirit in every form and sense, and in caring for the body. Spicy and alcoholic foods, fried foods, high in saturated fats should be avoided: care should be taken with sexual excesses and also with long journeys in which not only the diet is irregular, but in which we are often forcibly required to remain in a seated posture which can foster pelvic blocking.
What Surgical Operations are Involved in the case of BPH?
Surgical adenomectomy: this is the traditional operation performed through the patient’s abdomen and it is reserved for large prostates, and for patients who overall condition is at least fair.
Endoscopic transurethral resection of the prostate or T.U.R.P.: this too is a traditional surgical operation, but it is performed without “incision”, using a special instrument inserted into the urinary channel through the penis. It is not a lesser operation than the previous one, and certain cases even demonstrate the contrary; it is reserved for medium/small prostates.
New alternative therapies have been put forward recently. They are all for outpatients and not very troublesome for patients. Not all of them are equally effective and they should be considered experimental. Notwithstanding this, at least for a few of them, the absence of major complications makes them an interesting alternative pathway. Amongst them, we will refer to prostate alcoholisation that consists of injecting a small quantity of alcohol into the prostate using a fine needle. This liquid “burns” the tissues and causes a reduced volume of the glands, and thus an improvement in the symptoms.
The advantages of the technique are: its low invasiveness, the possibility of operating on patients in poor condition with a high risk from operations, without hospitalisation, with brief convalescence, a rapid return to normal urination, and avoiding the risks involved in traditional surgical techniques.
The disadvantages are: in essence we do not yet know what the extended follow-up is for this technique. It is probable that some patients will need a second obstruction clearing procedure with the passage of time. At any rate, this eventuality occurs even with traditional techniques, and so it does not represent an exclusive point against this method, but concerns all surgical practices.
In practice
We need to stress the fact that only a careful examination of each individual case will enable it to be established whether a patient is a candidate for a particular type of therapy where, as for every kind of treatment, not only the disadvantages but also the advantages of the various possible solutions must be taken into consideration.
Consequences on Everyday Life and on the Sex Life
There should be no impotence after prostate surgery. However, it happens that in some cases this happens, and the exact causes of this occurrence are not known.
A certain degree of urinary incontinence is possible after a traditional surgical operation. Usually however, the problem is resolved within a few weeks or months.
Prostatitis
Prostatitis is an inflammation of the prostate, with various origins and seriousness.
Acute prostatitis can involve high fever, perineal pain, frequent, painful, and difficult urination. Alternatively it can be chronic, with symptoms that can be rare or hardly significant and disorders that can be persistent or recurrent and of various kinds: diffuse slight pain in the urethra, difficulty in urinating, a feeling of perineal weight, and irritation of the testicles, etc.
Intermediate situations between acute and chronic conditions also exist.
Prostatitis has multiple causes and they are not always easy to identify. Very often, germs have come up the urinary channel, or have come down from the bladder, and they can reach the prostate and cause an inflammation. Since the tubules of the prostate gland resemble bunches of grapes that have grown in the urethra, one can easily see how these discharges of prostatic secretions could become an entrance pathway for germs into the prostate. Furthermore, since these groups of glands are covered in hard and fibrous muscular tissue, in the case of inflammation, they tend to be strangled and to change because of the “swelling” associated with inflammation. In this way it is possible for secretions and bacteria to pool, and not to find an outlet: in this way acute prostatitis tends to last over time and become chronic.
Diagnosis
It is important to consult an urologist as soon as the first disorders manifest, and especially burning urination, or an increased urinary frequency. Caring for prostatitis in its early stages is easier compared with once it has already become chronic. It can thus be very important to turn to a physician in order to rapidly apply the appropriate diagnostic procedures.
The urologist may discover prostatitis in the patient’s history, from laboratory examinations, from ultrasound scan imagery, from the outcome of a biopsy and from rectal examination.
This diagnosis can sometimes be difficult; in certain cases, however, it can be a pleasant surprise when certain cases of prostatitis simulate prostate cancer.
Therapy
Prostatitis is treated using antibiotic medicines, anti-inflammatories, and a healthy lifestyle and dietary rules.
Experience shows that often, satisfactory results can be obtained even after years of neglect. It happens though, at other times, that only after a few weeks of disorder it is no longer possible to obtain a complete cure.
Sexual Relations with Prostatitis
At the acute stage, it will be difficult to have sexual relations that are satisfactory or trouble free, but at the chronic stages nothing stands in the way of regular activity. During relations account must be taken of the fact that there can often be phenomena of erectile dysfunction and ejaculatory disorders, which are often premature compared with the patient’s normal state. Sometimes ejaculation can be painful or troublesome. These facts should not necessarily preclude relations. Prolonged abstinence should be advised against outright, as should the “genitalisation” of awareness (always thinking of the trouble in the testicles, touching the perineum, worrying about the slightest minute burning, and despairing about not “technically perfect” sexual relations).
Can Prostatitis Come Back?
It is possible: the “grape-like” shape of the prostate gland favours both the condition becoming chronic and the return of inflammation after it has been defeated. At the chronic stage it will be enough to maintain an uncomfortable or forced seated position for too many hours on the run (like in a car on a long journey) to block the pelvic passages, and foster the return of inflammation and weakening the gland.
Prostatic Adenocarcinoma
Prostate cancer: the words alone evoke fear. Let us discover what it is together, how it forms, and how we can combat it.
Cancer is a disease characterised by the uncontrolled growth of abnormal cells in the organs. The human body is made up of billions of cells. The cells reproduce by dividing, and in this way growth, or repairing wounds is possible. Sometimes cells reproduce excessively and create a mass called a tumour. Some tumours are benign (non cancerous) and others are malignant (cancerous).
The growth of benign tumours is limited and rarely endangers life, even if it can interfere with the normal bodily functions. Malignant tumours, on the other hand, invade and destroy normal tissues. Metastasis refers to delayed cancerous formations apart from the original cancer. Metastasis occurs when tumour cells separate from the original tumour and spread with the blood or lymphatic circulation to other parts of the body where they establish themselves and reproduce, giving rise to new tumours.
In some cases malignant tumours grow and spread rapidly, and in other cases slowly. For this reason sometimes the development of a large, but not aggressive tumour (defined as “well differentiated”) is more favourable, compared with a small one with uncontrolled growth (“undifferentiated tumours”). One of the places in which tumours develop most frequently in man is the prostate. The widespread opinion that a malignant tumour or cancer is synonymous with certain and imminent death, is absolutely false. In particular, prostate cancer can be easily diagnosed in an early stage, and thus it can be cured; furthermore, because of its feature of very slow growth it permits long survival, even in the large majority of cases in which it was discovered at a stage in which a complete cure was no longer possible.
How Frequent is Prostate Cancer?
The presence of cancer cells in the prostate is rare before 40 years of age (1 %), but with advancing years it becomes extremely common until it reaches close to 100% for men aged over 70. Fortunately, however, only in part of these cases do these cells develop, giving rise to a clinically manifest tumour.
In Italy, prostate cancer represents the 3rd cause of death amongst tumours, with a percentage that is 60% higher in the North of the country. Currently, every Italian aged 65 or more has a 3 % theoretical probability of dying from this condition. In the USA for example, there were 31,900 fatalities in 2000 caused by this disease. The number of tumours discovered using modern methods of prevention has, however, raised a dilemma that is still current: since not all tumours discovered will give problems for the patient, when is it appropriate to act after diagnosis? Diagnosis itself: when is it desirable and useful?
Periodic check-ups help a physician to diagnose prostate cancer early: that is, when it is not only treatable, but curable. The symptoms of prostate cancer are absent or rare in initial stages, and are often associated with those of a co-existing benign prostatic hyperplasia (B.P.H.). Both conditions are common in men, and often cause difficulties with urination with a weak and frequent urination. B.P.H. is the enlargement of that internal part of the prostate close to the urethra. As we have stated in previous sections, it is not cancer. The only accurate way to distinguish between B.P.H. and cancer is a trans-rectal prostate ultrasound scan, combined with the amount of P.S.A., with a biopsy and an examination by a specialist physician. It is reasonable to undergo examinations after the age of 50, or after the age of 40 if relatives have had prostate cancer.
An important video will soon be made available in which we perform a biopsy on 3 patients suspected of having prostate cancer. After sedation for the biopsy, they await the judgement of the histologist in attendance at the time, so they can undergo a cryosurgical procedure if necessary (Link to the Video).
What Causes Prostate Cancer?
The exact cause of prostate cancer is unknown. It is not yet known why, in certain cases, the few cancer cells present in the majority of senior citizens start to proliferate, and give rise to tumours. In its early stages ,the tumour may give no trouble, and then, with the passage of time, as it grows, the tumour starts to compress adjoining parts, such as the urethra for example. This phenomenon obstructs the free flow of urine from the bladder. At this stage of the condition, men urinate more frequently than normal (this is often the first symptom of the disease); sometimes urination is very difficult and even painful.
Other symptoms are the presence of red or white blood corpuscles in the urine or in the sperm. it is important to recall that prostate cancer, especially in the initial stages, can fail to have symptoms of any kind, so that after 40/50 years of age, regular specialist check-ups are recommended. When prostate cancer spreads to adjoining lymph nodes, to the bones or other organs, many men feel bone or joint pain.
What makes Prostate Cancer Grow?
The growth and the normal functioning of the prostate depend on a male hormone: testosterone. Almost all testosterone is produced by the testicles, and a small part is made by the adrenal glands. Testosterone has the same effect on prostate cancer that gasoline has on fire. For as long as the organism produces testosterone, the tumour will grow and spread.
Diagnosis
Physicians use several methods to diagnose prostate cancer.
Rectal exploration in the most common and most ancient system. In this examination, the physician inserts a gloved and lubricated finger into the rectum, feels the rear surface of the prostate through the intestinal wall, and in this way assess its shape and consistency. This procedure is fast and causes minimum disturbance to the patient. Unfortunately, when the physician feels “something” and it turns out to be a tumour, one time out of two the disease is already advanced and can no longer be cured. This is because not all tumours have a shape and consistency that is such that it makes them feel different and thus recognisable, apart from healthy tissue. Furthermore, they are also very often located in the part of the prostate that cannot be touched by the physician’s finger.
Prostate-specific antigen (P.S.A.) is a protein produced exclusively by healthy and diseased prostate gland tissue. This substance increases in the blood when a larger number of gland cells develop in the prostate; diseased, inflamed, or tumorous gland cells produce much more PSA than normal cells. Recent studies have enabled it to be demonstrated that there is a relationship between the volume of BPH and the level of PSA. By means of trans-rectal ultrasound scanning, the individual reference value for each patent can be derived (PSAP: PSA prediction). When the dose of PSA in the blood exceeds the PSAP, a great deal of care is necessary because the presence of carcinomatous cells is highly probable. The reference levels at several analysis laboratories are very high, and thus they can give rise to false optimism; sometimes even with much lower values than those that are deemed normal, significant prostatic adenocarcinomas can be present.
Trans-rectal ultrasound scanning is an examination that enables the value of the PSAP, suspect areas, bladder functioning, the presence of prostatic stones, and the structure of the prostate to be identified, even in the part far from the rectum where the physician’s finger cannot reach through rectal exploration.
During this examination a thin instrument, able to generate ultrasound waves, is inserted in the rectum. Those waves are reflected by the tissues according to their consistency and generate various echoes. The same ultrasound source is able to receive echoes on the way back, and those echoes are then converted into an image that the physician can see on a TV screen.
IN EACH CASE, when the presence of prostate cancer is suspected, there is only one way to be certain of the diagnosis: a biopsy. The physician may take small samples of the prostate using a thin needle. Those samples are examined under the microscope in order to check if carcinomatous cells exist. The safest and most painless method to take prostate samples in suspected areas is via an ultrasound scan, guided trans-rectally. The physician “sees” an ultrasound scan of the areas at risk, and takes samples (targeted ultrasound scan technique). Furthermore, it is possible to take samples of tissue from around the prostate to find out how far the disease has reached (biopsies in stages).
Who Treats Prostate Cancer?
When prostate disorders are suspected the doctor in charge can call upon a specialist, the urologist. The latter is a physician and surgeon trained to diagnose and treat diseases of the urinary and genital apparatus. The urologist will understand if the symptoms of a patient have been caused by B.P.H. or cancer. In certain cases the patient can also be sent to an oncologist (a specialist in the medical treatment of cancer).
How to Choose the Best Treatment?
This text dies not intend to and cannot give complete answers for each and every single problem. Aspects that are too technical have been excluded on purpose. For example there is no reference to staging laparoscopic lymphadenectomy, of destructive prostate resection etc. Experience leads one to state that each treatment option should be discussed and clarified as much as possible between doctor and patient, without necessarily wishing to exclude the closest relatives. Only in this way can everyone make their contribution to the prescribed treatment in such a way as to derive the greatest benefit.
What will Happen to Me?
It is normal to find out about being affected by prostate cancer with anxiety, concern or distress. The same feelings will impact friends and family.
Talking with someone who has already faced these issues can be a way to receive help and encouragement. Experience teaches that with the passage of time, patients discover that even when a complete cure is not possible, prostate cancer is a factor with which it is possible to be at peace, living a normal life. If you so wish, you can ask your doctor to put you in touch with other patients. The patients who belong to our group are encouraged to compare their own experience with other patients, so as to be able to make appropriate therapeutic decisions in the most informed and conscious manner possible.
What are the Classifications for the Stages of Prostate Cancer?
The best care for each individual case can only be set up if the physician manages to determine the stage of the illness. Treatment can vary according to the general condition of the patient, his age and the stage the disease has reached. It is important for the patient to discuss the various possible options with the doctor, and their advantages and disadvantages.
Currently, in Italy, the TNM system is used. That is an international classification system for tumour development according to 3 parameters. Together with Gleason Grading and the PSA test, it is possible to best classify the seriousness of the disease.
T combined with a number from 0 to 4 indicates the tumour volume. N on the other hand concerns the lymph nodes: this is also combined with a number from 0 to 3, where N0 indicates that the regional lymph nodes (that is those that are adjacent and connected to the volume affected by the tumour) have not been impacted by the tumorous cells and are therefore healthy. Codes from N1 to N3 instead indicate the more or less extensive involvement of the lymph nodes; M0 instead indicates the absence of metastasis, with M1 showing their presence instead.
The Gleason scale on the other hand catalogues the aggressiveness and speed of growth of a tumour, with scores from 2 to 10, where the lower numbers correspond to a tumour that Is highly differentiated from healthy cells. After a biopsy, a pathologist will assign a score from 1 to 5 for the cancer formations that are most represented in the sample, and immediately after that a score from 1 to 5 for the less common ones. Their total will form the value on the scale.
Therapy
The statistics and data relating to this item are now out-dated. We are working to update them with the most recent statistics. As regards cryosurgery please see the dedicated page for some information of a general and historical nature:
Radical prostatectomy;
Partial prostatectomy;
Radiotherapy;
Hormone therapy; and
Brachytherapy.
IN CONCLUSION
Prostate cancer is still an enigmatic disease today: there is still no general consensus on a single ideal treatment. A radical prostatectomy and external radiotherapy are traditionally considered the gold standard. Unfortunately, both these procedures have a high failure and complication rate: in fact, not all patients could have need of such aggressive treatment. For some people, indeed, these options could represent excessive treatment that exposes them to potential complications needlessly. Less invasive approaches such as cryotherapy and brachytherapy are the most valuable for many situations. Even over a short period they show a high success rate. In fact, the majority of patients maintain a living standard that is comparable to the past. The cost of treatment too has dropped remarkably.
It must be absolutely clear that the foremost factor in choosing a suitable treatment must be the early stage of the tumour, precisely. We would like to stress that cryotherapy and brachytherapy are procedures that depend greatly in the operator’s ability. Centres for treating prostate cancer should be able to offer all kinds of treatment. The use of up to date equipment is essential. It is prudent for each patient to investigate the various therapeutic options in depth. Since prostate cancer is a disease with slow growth, the patient has all the time needed to educate himself and to investigate the various therapeutic options.
