Questions

Questions on Prostatitis and Prostate Treatment Center:

Do I need to be hospitalized for treatment?

You don’t need to be hospitalized. The treatment is quite relaxing and takes about ten minutes or so. After treatment you could leave. However, patients need to stay in a motel or hotel nearby to receive treatment every day.

Do I need to stop taking antibiotics before treatment?

You should be off all antibiotics for at least three weeks because antibiotics make it very difficult to isolate the organisms that are causing your problems. However, you can continue to take herbal preparations and non-antibiotics prescriptions.  

Does my female partner need to be treated?

If your prostatitis is caused by STDs, such as infected by Mycoplasma, Ureaplasma, Chlamydia, virus etc, it is highly recommended. Women partners of patients with prostatitis can provide important diagnostic clues. Sometimes, it is easier to identify the causative organism in a woman than in a man.

Also, unless the woman is treated at the same time, it is likely that the man will suffer a recurrence. However, female patients have the option of getting treated at home with the medicine brought back by their male partners.

Do I need to make an appointment?

You need to make an appointment for treatment. You may consult us with your case through email at prostatitischina@yahoo.com.  If necessary, we could initiate telephone consultation by appointment.

Is the injection very painful? How many injections per day?

No. Each injection lasts about 5 minutes and the pain is minimal and quite tolerable. After the injection you need to lay down for a while and the pain will go away gradually. Usually you take one or two shots per day on different genital organs.

Who are suitable for this prostatitis treatment?

Most patients who came to our center have been previously diagnosed with chronic prostatitis, received multiple tests and antibiotics for this condition with only minimal success. They usually are willing to devote time and come physically to the center for treatment.

What is the cost of this prostatitis treatment?

It depends on the complexity of each case, duration of infection, type of pathogens found, degree of blocking, etc, therefore in each specific case the calculation of cost will be carried out strictly individually.

How long does daily treatment take? Besides the injection, are there any other treatments?

Daily treatment takes 2-3 hours. Yes, there are treatment on urethra, ultrasonic massage, throat and nose treatment and some Chinese medicine. Each patient is assigned these supplementary treatments individually.

Before my trip to China, what preparation is needed?

Bring all copies of your previous medical records regarding your situation, including laboratory tests and ultrasound scan. You should have yourself tested for HIV and Syphilis in your country. Allow plenty of time for your appointment. 

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Questions on Prostatitis, Prostate Infection, Prostate Symptoms:


I have to cath myself to pee because of enlarged prostrate what if i have nothing done but keep cathing myself?

Continuous use of catheter in cases of Benign Prostatic Hyperpasia might cause urinary tract infection. The insufficient empting of the bladder causes part of the urine to stay in the bladder all the time, thus causing excellent environment for bacterial infection. Since the infection might be repetitive, there is a possibility that the bacteria would become resistant to the used antibiotics. This might additionally complicate the treatment and affect other organs in severe cases.



Question: Can calcium deposits on the prostate gland be cancerous?

Answer: Calcium deposits can occur anywhere in the body. They most often occur where there has been prior injury, infection, or inflammation. Calcium deposits can also be seen with some types of cancer. When calcium deposits are seen within the breast on a mammogram or within the lungs on a chest X-ray, the pattern of calcium guides the radiologist's interpretation of the finding. Certain patterns suggest a benign process while other patterns are worrisome for a cancer. Calcium deposits in the prostate (called prostatic calcifications) are usually discovered when men have a rectal ultrasound performed. Sometimes they can be seen on a plain X-ray of the pelvis. Prostatic calcifications, no matter what the pattern, do not increase the risk of prostate cancer. But their presence does not exclude the possibility of cancer. An elevated PSA, a prostate nodule felt by the doctor on rectal exam, or other abnormalities on prostate ultrasound will determine the need for further evaluation and possible biopsy. By the way, dietary calcium does not influence the formation of prostatic calcifications.


Question: What options are available for men to treat urinary incontinence?

Answer: Loss of bladder control (incontinence) generally affects men less frequently than women. However, the condition becomes increasingly common as men age, such that equal numbers of men and women have bladder problems once they live beyond age 80. Treating incontinence starts with figuring out why the problem is happening. The reasons that men lose bladder control include the following: Non-cancerous growth of the prostate gland (benign prostate hypertrophy, or BPH; Urinary tract infections; Damage to the bladder or prostate from surgery or radiation treatment; Medications; Nerve damage, which may be caused by diabetes, surgery, spinal cord injuries or multiple sclerosis; Severe or chronic constipation; Other medical problems including diabetes, heart failure, and arthritis (which may make it hard to reach the toilet in time). Men who are having difficulty with bladder control should see their doctor for an evaluation. Don't let embarrassment stand in the way -- incontinence is a common problem, and your doctor may be able to offer some simple, effective treatments. For example, adding a medication can help the incontinence caused by benign prostate enlargement, while stopping a medication might help incontinence that's caused by a drug side effect. Men whose problem cannot be fixed or treated can still find helpful ways to cope with the problem, including use of incontinence pads or special catheters.


What Is the Prostate And What Does It Do?

The prostate is a gland of the male reproductive system. It is located in front of the rectum and just below the bladder, the organ that stores urine. The prostate is quite small--it weighs only about an ounce--and is nearly the same size and shape as a walnut. As shown below, the prostate wraps around a tube called the urethra, which carries urine from the bladder out through the tip of the penis.

The prostate is made up largely of muscular and glandular tissues. Its main function is to produce fluid for semen, which transports sperm. During the male orgasm (climax), muscular contractions squeeze the prostate's fluid into the urethra. Sperm, which are produced in the testicles, are also propelled into the urethra during orgasm. The sperm-containing semen leaves the penis during ejaculation.

Types of Prostatitis

There are three types of prostatitis:

* acute infectious prostatitis

* chronic infectious prostatitis

* noninfectious prostatitis

Acute infectious prostatitis is caused by bacteria and is treated with antimicrobial medication. Acute infectious prostatitis comes on suddenly, and its symptoms--including chills and fever--are severe. Therefore, a visit to your doctor's office or the emergency room is essential, and hospitalization is frequently required.

Chronic infectious prostatitis is also caused by bacteria and requires antimicrobial medication. Unlike an acute prostate infection, the only symptoms of chronic infectious prostatitis may be recurring infectious cystitis (bladder infection).

Noninfectious prostatitis is not caused by bacteria--its cause is not known. Antimicrobial medications are not effective for this type of prostatitis. Treatments described later in this booklet may be helpful in some cases.


How Does Prostatitis Develop?

Despite their names, acute and chronic infectious prostatitis are not contagious and are not considered to be sexually transmitted diseases. Your sexual partner cannot catch this infection from you.

How then did you get it? The way in which the prostate becomes infected is not clearly understood. The bacteria that cause prostatitis may get into the prostate from the urethra by backward flow of infected urine into the prostate ducts or from rectal bacteria.

Certain conditions or medical procedures increase the risk of contracting prostatitis. You are at higher risk for getting prostatitis if you:

* recently have had a medical instrument, such as a urinary catheter (a soft, lubricated tube used to drain urine from the bladder), inserted during a medical procedure

* engage in rectal intercourse

* have an abnormal urinary tract

* have had a recent bladder infection

* have an enlarged prostate

What Are the Symptoms Of Prostatitis?

The symptoms of prostatitis depend on the type of disease you have. You may experience no symptoms or symptoms so sudden and severe that they cause you to seek emergency medical care. Symptoms, when present, can include any of the following: fever, chills, urinary frequency, frequent urination at night, difficulty urinating, burning or painful urination, perineal (referring to the perineum, the area between the scrotum and the anus) and low-back pain, joint or muscle pain, tender or swollen prostate, blood in the urine, or painful ejaculation.

Key Facts on Prostatitis And Its Diagnosis

* Prostatitis is an inflammation of the prostate.

* The symptoms of prostatitis often mimic those of other urinary tract or prostate disorders.

* The digital rectal examination is the first step in diagnosis of any prostate problem; it should also be performed yearly on every man over 40 to detect early, curable prostate cancer.

* Another test that must be performed when prostatitis is suspected is prostate stripping--massaging the gland to get a fluid sample for microscopic evaluation.

Are the Symptoms Of Prostatitis Unique?

The symptoms of prostatitis resemble those of other infections or prostate diseases. Thus, even if the symptoms disappear, you should have your prostate checked. For example, benign prostatic hyperplasia (BPH), a noncancerous enlargement of the prostate that is common in men over age 40, may produce urinary tract symptoms similar to those experienced with prostatitis.

Similarly, urethritis, an inflammation of the urethra (often caused by an infection), may also give rise to many of the symptoms associated with prostatitis.

Still another condition that mimics the symptoms of prostatitis--when prostatitis is not present--is prostatodynia (painful prostate). Patients with prostatodynia have pain in the pelvis or in the perineum. Such pain may result from a prostate problem, but the pain can have a variety of different causes including muscle spasms or other musculoskeletal conditions.

Yet another term your doctor may mention in discussing your prostate problem is prostatosis, a more vague word, which simply means "a condition of the prostate."

Because of the connections between the urethra, the bladder, and the prostate, conditions affecting one or the other often have similar or overlapping symptoms.

How Is Prostatitis Diagnosed?

To help make an accurate diagnosis, several types of examinations are useful.

The prostate is an internal organ, so the physician cannot look at it directly. Because the prostate lies in front of the rectum, however, the doctor can feel it by inserting a gloved, lubricated finger into the rectum.

This simple procedure, called a digital rectal examination, is illustrated below. This examination allows the physician to estimate whether the prostate is enlarged or has lumps or other areas of abnormal texture. While this examination may produce momentary discomfort, it causes neither damage nor significant pain.

Because this examination is essential in detecting early prostate cancer, which is often without symptoms, the American Urological Association recommends a yearly prostate examination for every man over age 40 and an immediate examination for any man who develops persistent urinary symptoms.

If your physician suspects that you have prostatitis or another prostate problem, he or she may refer you to a urologist (a doctor who specializes in diseases of the urinary tract and the male reproductive system) to confirm the diagnosis.

The test that must be performed when prostatitis is suspected is prostate stripping (massaging), during which prostatic fluid is collected. While performing the digital rectal examination, your doctor may vigorously massage, or "strip," the prostate to force prostatic fluid out of the gland and into the urethra. Although prostate stripping is not particularly painful, you may feel some discomfort depending on the sensitivity of your prostate.

The prostatic fluid is then analyzed under a microscope for signs of inflammation and infection. The three-glass urine collection method is used to measure the presence of white blood cells and bacteria in the urine and prostatic fluid. You will be asked to collect two urine samples separately: the first ounce of the urine you void (urine from your urethra) and then another sample of flowing, midstream urine (urine from your bladder).

You will then almost empty your bladder by urinating into the toilet. At this point, your doctor will massage your prostate and collect on a slide any secretions that appear. You will then collect in a third container the first ounce of urine that remains in your bladder.

Examination of these samples will help your physician determine whether your problem is an inflammation or an infection and whether the problem is in your urethra, bladder, or prostate. If an infection is present, your doctor will also be able to identify the type of bacteria involved so that the most effective antimicrobial medication can be prescribed.

How Do I Know Which Type of Prostatitis I Have?

Acute infectious prostatitis is the easiest of the three conditions to diagnose because it comes on suddenly and the symptoms require quick medical attention. Not only will you have urinary problems, but you may also have a fever and pain and, frequently, blood in your urine.

Chronic infectious prostatitis is associated with repeated urinary tract infections, while noninfectious prostatitis is not. In fact, if you do not have a urinary tract infection or a history of one, you probably do not have chronic infectious prostatitis. Other symptoms, if any, may include urinary problems such as the need to urinate frequently, a sense of urgency, burning or painful urination, and possibly perineal and low-back pain.

Noninfectious prostatitis is more common than infectious prostatitis. It may cause no symptoms, or its symptoms may mimic those of chronic infectious prostatitis. If you have noninfectious prostatitis, however, it is unlikely that you will have urinary tract infections.

Why Is Correct Diagnosis So Important?

Because the treatment is different for the three types of prostatitis, the correct diagnosis is very important. Noninfectious prostatitis will not clear up with antimicrobial treatment, and infectious prostatitis will not go away without such treatment.

In addition, it is important to make sure that your symptoms are not caused by urethritis or some other condition that may lead to permanent bladder or kidney damage.

Treatment of Prostatitis

* Correct diagnosis is crucial because each type of prostatitis is treated differently.

* Infectious prostatitis is caused by bacteria and treated with antimicrobial medications.

* Antimicrobial medications are not effective treatments for noninfectious prostatitis.

* Prostatitis is not contagious; if you have it, you will not endanger your sexual partner.

* The treatment regimen your doctor recommends should be followed even if you have no symptoms. With infectious prostatitis, for example, the symptoms may disappear before the infection has completely cleared.

How Is Prostatitis Treated?

Your treatment depends on the type of prostatitis you have.

If you have acute infectious prostatitis, you will usually need to take antimicrobial medication for 7 to 14 days. Almost all acute infections can be cured with this treatment. Analgesic drugs to relieve pain or discomfort and, at times, hospitalization may also be required.

If you have chronic infectious prostatitis, you will require antimicrobial medication for a longer period of time--usually 4 to 12 weeks. About 60 percent of all cases of chronic infectious prostatitis clear up with this treatment. For cases that don't respond to this treatment, long-term, low-dose antimicrobial therapy may be recommended to relieve the symptoms. In some cases, surgical removal of the infected portions of the prostate may be advised.

If you have noninfectious prostatitis, you do not need antimicrobial medication. Depending on your symptoms, you may receive one of a variety of treatments. If your condition responds to muscle relaxation, you may be given an alpha blocker, a drug that can relax the muscle tissue in the prostate and reduce the difficulty in urination.

You may find that tub baths or changes in your diet may help to alleviate your symptoms. While there is no scientific evidence proving that these "home remedies" are effective, they are not harmful and some people experience relief from symptoms while using them.

Will Prostatitis Affect Me Or My Lifestyle?

Prostatitis is a treatable disease. Even if the problem cannot be cured, you can usually get relief from your symptoms by following the recommended treatment.

Prostatitis is not a contagious disease. You can live your life normally and continue sexual relations without passing it on.

You should keep in mind the following ideas:

* Correct diagnosis is key to management of prostatitis.

* Treatment should be followed even if you have no symptoms.

Having prostatitis does not increase your risk of getting any other prostate disease. But remember, even if your prostatitis is cured, there are other prostate conditions, such as prostate cancer, that require prostate checkups at least once a year after age 40.

GLOSSARY

accute: having a sudden onset and (usually) a short, severe course

antimicrobial: a drug that kills bacteria or prevents them from multiplying; antibiotics are naturally occurring antimicrobials

benign: not malignant; noncancerous; benign growths do not generally spread to other organs or come back when they are removed

benign prostatic hyperplasia (BPH): non-cancerous enlargement of the prostate that may cause difficulty in urination

catheter: a soft, lubricated tube inserted through the urethra to drain the bladder

chronic: persisting over a long period of time

cystitis: inflammation of the bladder (may be due to infection)

digital rectal examination: insertion of a gloved, lubricated finger into the rectum to feel the prostate

ejaculation: release of semen from the penis during sexual climax

infection: condition resulting from the presence of bacteria or other microorganisms

inflammation: swelling and pain resulting from irritation or infection

perineum: the area between the scrotum and anus

prostatitis: inflammation of the prostate

prostatodynia: pain in the prostate

prostatosis: a vague term for a "condition of the prostate"

semen: fluid containing sperm and secretions from glands of the male reproductive tract

stripping (prostate): massaging the prostate gland to obtain its secretions

urethra: the tube that carries urine from the bladder and semen from the prostate and other sex glands out through the tip of the penis

urethritis: inflammation of the urethra (may be due to infection)

urologist: a doctor who specializes in diseases of the urinary tract and the male reproductive system

What causes an enlarged Prostate? Are genetics a factor?

Benign enlargement of the prostate (Benign Prostatic Hyperplasia or "BPH") is the most common tumor in men, and usually begins in younger men with microscopic nodules growing within the prostate gland. The prostate begins to enlarge through a process of cell multiplication when men are in their 40's, and increases with aging. According to one study, as many as 80% of men have at least some symptoms of BPH. The causes of this condition are not fully known. Most believe the interplay between testosterone and estrogen (all men make some) plays a role. The problem is more prominent in US and Europe compared to other parts of the world. Genetics may play a role, as some studies suggest that the problem is more common in Caucasians than Asians, for example. Also, a family history of BPH may increase a man's chance of developing the condition.

After prostate surgery, does the prostate continue to grow? Is it removed completely?

The answer depends on the type of surgery. In most treatments for BPH, only a portion of the gland is removed, or in some cases, the gland is heated internally (thermal therapy) without actually removing any tissue. In these instances, it is likely that over time, prostate tissue will re-grow, and there may be a need for further treatment in some men. When the entire prostate gland is removed (as in a "radical prostatectomy" for curative treatment of prostate cancer) there is no tissue left behind, and the chance for re-growth is much less.

Does the lack of a prostate cause erectile dysfunction?

You can have sex without a prostate! It is an organ of mystery to most men. It has an important role in sexual function in that it makes semen, which is a transport medium for sperm. The muscles within the prostate are important for expelling the semen during ejaculation. The testicles make testosterone, and that hormone is responsible for sex drive or libido. Even when the prostate gland is removed, hormonal production is not affected. There may be decreased or absent ejaculate as a consequence. The nerves that control erection travel next to the prostate, and sometimes they may be interfered with as a result of surgery. This is much more common as a side effect of treatment for prostate cancer than for BPH. Special care can be taken to preserve the nerves in many men with prostate cancer requiring surgical removal.

My doctor says I have an "inflamed" prostate. What does that mean and what caused it? Is there a treatment other than surgery?

Inflammation of the prostate is called "prostatitis". It can be caused by bacteria that infect the gland (bacterial prostatitis) and may require treatment with antibiotics. Most cases of prostatitis are not due to an infection (nonbacterial prostatitis), and won't respond to antibiotics. The causes of this condition are unknown, but usually conservative treatments such as diet, exercises, prostate massage, physical therapy, and certain medications such as alpha-blockers or muscle relaxants are indicated. Surgery is a rare form of treatment for prostatitis.

Is incontinence always a result of prostate surgery? 

Well... the most common cause of incontinence in men is prostate surgery. However, most men who have prostate surgery are not incontinent afterward. About 1% of men who are treated surgically for BPH have incontinence. A much higher percentage of men who have surgery for prostate cancer have may have some degree of involuntary leakage afterward. Some studies report the condition in as much as 50% of men undergoing radical prostate removal. The rate of severe incontinence is less than 10% in most reported series.

Are bald men more likely to have high PSA (prostate specific antigen) levels? What does PSA measure?

The PSA measures the level of prostate-specific antigen in the patient's blood. Only prostate cells make this protein, which is important for the liquefaction of semen. It may be elevated in men with benign or cancerous enlargement of the prostate, or prostatitis. It is recommended as a screening test in order to detect early (and hopefully more curable) stages of prostate cancer, and as a marker in order to follow the progress of men known to have prostate cancer. I am not aware of any connection between baldness and PSA levels which should matter to patients.

Is it a signal of possible prostate/dihydrotestosterone (DHT) problems if my husband's hair is balding/thinning?

Male pattern baldness is a common condition, but I am not aware of an important link (other than maleness!) between these two conditions. Finasteride (marketed as Proscar and Propecia) is a medication used to treat both BPH and baldness, so men with both problems could potentially receive a double benefit. Some guys get all the luck!

Why does sitting for some time seem to increase the frequency and urgency of urination?

The muscles of the pelvic floor may be affected by sitting, and change of position (from sitting to standing) can trigger a bladder reflex in some patients. Learning the role of the pelvic floor muscles and exercising them by practicing controlled relaxation and contraction can reduce symptoms of urinary frequency and urgency. Since these are hidden muscles, it may be necessary to use techniques such as biofeedback to learn how to control them properly.

Can you please explain the notion of an "overflowing bladder"? Do only men have the problem of overflow?

An overflowing bladder is usually the result of a blockage or obstruction of the bladder outlet, which may be due to conditions such as BPH or a scar (stricture) of the urethra. These situations occur much more commonly in, but are not exclusive to men. The condition can also be caused by neurological changes such as lower spinal cord damage or peripheral nerve injury due to conditions such as diabetes. This cause is not specific to men. When the bladder doesn't empty, and can become so full that small amounts of urine escape with further filling, or due to certain movements or changes in abdominal pressure. This is called overflow incontinence. Demonstrating a large leftover or residual volume in the bladder after voiding can usually identify it. The treatment is to resolve the blockage when that is the cause. In other cases, intermittent self-catheterization may be needed to enable the bladder to empty completely.

What effect do medicines used for erectile dysfunction have on incontinence?

I am not aware of any.

Do depotestosterone injections have any effect on incontinence?

Men may take these injections to treat low testosterone states. I am not aware of any effect on incontinence from this type of treatment.

I have BPH. Does the size of my prostate gland matter? I thought BPH indicated an enlarged prostate, but my doctor says my gland is small?

Well... in the case of prostates, size does matter, but not in the way that you may think. A large gland may not cause any obstruction, and a small gland may cause a lot. Just like real estate, location matters most! When a small gland is obstructing, medications such as alpha-blockers may be most appropriate, and minimally invasive surgeries can be very effective. When large glands cause the problem, medications such as finasteride may be used to prevent the prostate from growing further, potentially reducing the risk of developing sudden retention requiring surgery. If surgery is required for a large gland, it may need to be more invasive than the options for small glands.

What is bladder outlet obstruction in men? What causes it? How is it treated?

The bladder outlet is located at the mouth of the bladder. In most men, the prostate is situated at the bladder outlet, though it may have been removed in some who have had treatment for prostate cancer. Enlargement of the prostate due to BPH or cancer may cause bladder outlet obstruction. So can conditions such as scarring or contractures following surgery. Treatment may center around reducing the muscle tone or size of the prostate with medications, heating the prostate, or actual surgical removal of all or a portion of the prostate gland depending on the cause of the blockage. A scar of the bladder outlet following surgery is a potential complication, and it may need to be treated with a surgical incision or dilations.

What can you tell me about urethral dilations?

Dilations are performed to stretch a narrowed or scarred segment of the urethra, which is the tube that drains the bladder from the bladder neck to the tip of the penis. The scarring can be the result of a previous procedure such as a catheter placement or telescopic instrumentation (cystoscopy) on the urethra. It can also be caused by trauma (such as a straddle injury) or infection. Once a scar forms in the urethra, it may cause a narrowing or "stricture" which can obstruct the flow of urine. Dilation may be required to open up the narrowed segment. Since it is due to a scar, the area of narrowing may recur, and need future dilations. In some cases, a surgical repair is needed to fix the problem definitively.

Please tell me more about the artificial urinary sphincter. Who is a candidate?

The artificial urinary sphincter (AUS) is a hydraulic device consisting of a cuff, a pump, and a reservoir. The device can be surgically implanted for the treatment urinary incontinence due to damage to the urinary sphincter, such as may occur following prostate surgery. Once in place, the device is completely internal, and not visible to the naked eye. The cuff is placed through an incision around the outside of the urethra, and is connected internally to a small pump which is located in the scrotum. Another tube connects the pump to a reservoir, which is usually placed in the lower abdomen. The AUS controls leakage by having the cuff squeeze around the urethra, thus limiting or preventing loss of urine due to increases in abdominal pressure (stress urinary incontinence), as might occur with a cough or bearing down, or just by walking upright. The patient must squeeze the pump in the scrotum to deflate the cuff in order to allow urination to occur. The cuff remains open for 2-3 minutes, and then closes automatically to maintain continence. The AUS has been used for over 25 years, and is considered to be the "gold standard" for the surgical management of stress urinary incontinence in men. For the right patient, an AUS can be a life changing therapy. Men who are candidates usually have more bothersome degrees of leakage requiring multiple pads throughout the day to keep dry. A urodynamic test is usually done to make sure the type of incontinence is suitable for management with the AUS. They must not have scarring of the urethra or bladder neck, or the scars must remain open and stable after treatment. A cystoscopy is usually done to document this. A certain mental capacity and degree of manual dexterity is needed in order to operate the AUS successfully. The surgical implant of the device is usually done under general or spinal anesthesia, and may be accomplished on an outpatient basis or require an overnight hospital stay. The device is not usually activated at the time of implant, allowing swelling of the urethra to resolve before tissue compression by the cuff is allowed.

My doctor told me I have stress incontinence. I thought this type of incontinence only occurs in women. Please explain.

Stress incontinence means leakage of urine when pressure is increased in the abdomen (stress maneuver), as may occur with a cough, sneeze, lift, or bend. "Urge incontinence" is another type of leakage that is caused by a sudden increase in bladder pressure in the absence of straining. Patients can have more than one form of incontinence at the same time. The treatments for stress and urge incontinence are usually different, so it is important to understand which it is in order to provide the right solution. A history and physical exam can be helpful in distinguishing the type of leakage, but a test of bladder function such as a urodynamic study may be needed to know with certainty. Both stress and urge incontinence are more common in women, but many men suffer from these problems, too. Women tend to develop stress incontinence after childbearing, with aging, menopause, or after hysterectomy. Men typically develop stress incontinence as a complication of prostate surgery.

I am experiencing incontinence after my prostatectomy. Will pelvic floor muscle exercises help me regain continence?

The pelvic floor muscles are accessory muscles of urinary control, and exercising them may increase the rate of recovery of urinary control after prostate surgery. Some doctors advocate beginning the exercises before surgery for this reason. Work with a therapist using biofeedback may be helpful in order to learn to do them properly. In general, patients with mild degrees of leakage are more likely to resolve the problem with exercises as compared to those with a severe degree of leakage. Maximal improvement is usually seen after doing the exercises regularly for 3 to 6 months, though continued exercises may be needed to maintain control. The exercises may be combined with medications for further benefit.

Please tell me more about injectables to help with my continence.

Injectables or bulking agents are materials that can be injected through a telescope into the tissues near the bladder neck in order to build up passive resistance to leakage at the bladder outlet. The material most often used for this in men is collagen, which is processed cowhide. A skin test must be done a month before to make sure there is no allergic reaction to the foreign protein. Though once thought to be a promising, minimally invasive alternative for stress incontinence in men, this form of treatment has largely fallen out of favor with urologists. It usually requires many separate injection procedures over 6 months to a year, and then the benefits tend to be incomplete and temporary. The collagen may not be able to bulk the tissue adequately, which is scarred from prior surgery. It also tends to leak out or break down over time due to its protein makeup. Some patients may be more suitable candidates for this than others, and some urologists may have better results with this technique. In general, I tend to discourage my male patients from this form treatment.

My wife had the sling procedure to help with her incontinence. I have heard there is a sling procedure for men. Is it similar to my wife's procedure, and should I expect a successful treatment like hers?

It's true that minimally invasive sling procedures have revolutionized the management of stress incontinence in women. While the name is similar, the techniques, materials, and outcomes are different for females. There is such a thing as a "Male Sling" which involves the surgical placement of a 4 by 7cm band of material (usually silicone mesh) up against the underside of the urethra. It is inserted through and incision in the perineum (between the scrotum and anus) and held in place by 2-3 sets of bone screws, which are drilled into the pubic bone and attached to the mesh material with sutures. The mesh is pulled tight against the urethra, providing a compressive force that resists stress incontinence, yet allows the voluntary passage of urine. Unlike the AUS, the male sling is not a dynamic device, and does not require manipulation by the patient in order to void. It is immediately effective, and does not need to be activated 4 to 6 weeks after surgery, as does the AUS. Patients with severe degrees of incontinence may be better candidates for the AUS. Unlike the AUS, which has been around for decades, the male sling is relatively new, and urologists do not have the same track record with it to compare. Still, it is an emerging and increasingly attractive form of treatment for many men with stress incontinence.

PATIENT QUESTION:

Hello,

I am a 27 year old male without a history of major health problems. Approximately 6 weeks ago I began to experience some bladder dysfunction. The symptoms that I have experienced are urinary frequency (every 10-15 minutes), urgency, dull pain in the pelvic area, a slight burning sensation during urination, difficulty starting urination, and a weak urinary stream.  



My GP initially believed that I was suffering from a bladder infection and prescribed a one week regiment of antibiotics (Voltarol ? 50mg). When my symptoms persisted, I was referred to a Urologist.



The Urologist immediately suspected that I was suffering from Prostatitis. A Stamey Localization Test and full STD screen were conducted immediately. The STD screen came up negative. The Stamey Localization test, however, showed numerous white and red blood cells and a large number of Gram Positive Cocci from the post-massage specimen. The doctor told me that he had not seen such a high concentration of puss cells in a post-massage specimen in some time. The fluids were cultured and they came up negative.



The doctor proceeded to prescribe a six week course of Ciprofloxacin of 500 mg twice daily and one weekly prostate massage. Unfortunately, I am frustrated to report that 3 weeks after beginning the course of antibiotics I have yet to feel any relief of the symptoms. My doctor insists that I must be patient and that I should begin to feel some relief at the 4-week mark, however, I am becoming somewhat impatient. It is a debilitating ailment that has caused me a great deal of stress and strain. I do derive fleeting relief from the massage sessions, but the symptoms return within 3-4 hours.



My doctor has told me that the success rate for this treatment is 70%. Should I be concerned that I have yet to feel any relief from the symptoms? How long does it usually take for the symptoms to subside? If this treatment does not work, should I be worried? What other treatments will be attempted if this one fails? I would appreciate any advice and insight you may have. Thanks!

ANSWER:
There are some cases of prostatitis that requires 4-12 weeks of antibiotics.  Also, make sure that the bacteria that is growing out of the prostatic massage is sensitive to the antibiotic that is given to you.



If antibiotics do not help, there is the possibility that an abscess may be present.  This does not respond to antibiotics and may require draining.  A transrectal ultrasound can be considered to image the prostate.  This option may be discussed with your personal physician.



Followup with your personal physician is essential.

Why does prostatitis tend to affect younger men?

No one knows why some men get prostatitis and others do not.  The prostate is certainly more prone to inflammation than almost any other part of the body, and one theory is that urine may track backwards into the prostate during urination, causing an inflammatory response.  We still don't know why younger men seem to be more prone to the disease, or why is becomes chronic in some men but not in others.

My doctor has referred to different categories of prostatitis.  What are they and which one have I got?

An American body, the National Institutes of Health, has recently produced the following classification of prostatitis:

• Category I: acute bacterial prostatitis
• Category II: chronic bacterial prostatitis
• Category III: chronic prostatitis/chronic pelvic pain syndrome
• Category IIIA: inflammatory
• Category IIIB: non-inflammatory
• Category IV: asymptomatic inflammatory prostatitis.

As to which category you belong, the important considerations are whether the problem is acute (comes on quickly) or chronic and relapsing (where you have the symptoms for a long time or have regular bouts), and whether it is caused by a specific infection.  In order to answer this second question, a sample of prostatic secretions obtained by massaging the prostate may be sent to the laboratory for analysis (the lower tract localization test or LTLT).  Occasionally, in patients with acute prostatitis, an abscess can develop within the gland.  Usually this responds to antibiotics but occasionally the pus may need to be drained surgically, usually through the urethra (the tube through which urine passes from the body).

How uncomfortable are the tests for prostatitis?

Testing for prostatitis often involves a prostatic massage.  This is unquestionably uncomfortable, but not actually painful.  Urine is subsequently sent for analysis to rule out infection as the cause of your symptoms.  You'll also probably have transrectal ultrasound, which has a similar level of discomfort.  Occasionally, a test known as 'urodynamics' is needed, which involves passing a small catheter into the bladder via the penis and the insertion into the rectum of a small tube to monitor pressure.  The bladder is then filled with a fluid that will show up on X-ray, and you'll he asked to pass urine.  While you're doing this, the pressure in the bladder is recorded and the process can be visualized on an X-ray screen.  In this way, your doctor can check whether there is anything obstructing the urine flow.  A PSA and other blood tests are also requested, to rule out other problems such as prostate cancer or diabetes.

What treatment is right for me and are there any side-effects?

If there is a bacterial cause of your prostatitis, you'll be given a prolonged course of antibiotics.  Even when there are no signs of bacteria, some men still respond to antibiotics.  You'll also probably be prescribed an anti-inflammatory drug to try to reduce the inflammation.

Ciprofloxacin is an antibiotic commonly prescribed for prostatitis and if you are taking this, avoid sunbathing, as it can increase the sensitivity of your skin.  Anti-inflammatory drugs can cause indigestion or even peptic ulcers and bleeding in the stomach.  Report any stomach pains to your doctor and stop taking the tablets.

If the symptoms resolve with treatment, what are the chances of them returning?

Unfortunately, quite high, as prostatitis has a pronounced tendency to recur.  If you do suffer further attacks, see your doctor straight away as prompt treatment can help to stop the infection or inflammation from taking hold.

Can I help myself to avoid the chances of a repeat attack?

The usual health advice is appropriate here – lots of exercise and a healthy diet.  A healthy immune system should help you fight off infections.  Some doctors advise their patients with a history of prostatitis to take vitamins D and E, selenium and zinc supplements, but there is little hard evidence to support their usefulness in avoiding prostatitis.

Is prostatitis sexually transmitted?

In some cases it is, theoretically at least.  In practice, however, prostatitis seldom results from sexual activity, so there is little logic in treating your partner (though very occasionally this may be recommended depending on the bacterial cause).  Ano-rectal sex could certainly cause prostatitis, as can catheterisation.

Does having chronic prostatitis make me more likely to have other prostate problems?

In theory, long-term inflammation could promote the development of cancer, but there is no evidence to suggest that this actually happens.  Similarly, there is nothing to suggest that BPH is more common among prostatitis sufferers.


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Questions on BPH


How common is BPH?

Benign prostatic hyperplasia (BPH) is the commonest condition to affect men beyond middle age.  Around 43% of men over the age of 65 have troublesome symptoms and by the age of 80 almost 80% of men are afflicted.

What causes BPH?

It's caused by a benign (ie non-cancerous) overgrowth of tissue in the middle part of the prostate, but we don't know what actually starts this process off or allows it to progress.  We do know that the male hormone testosterone is involved, as men who have been castrated at an early age (and so don't produce testosterone) never develop BPH.  We also know that testosterone triggers the release of substances in the body called growth factors which can stimulate tissue growth.  But why this happens in some men but not others is still not clear.  The condition does seem to run in some families.

Which are the most troublesome symptoms?

Many men find that having to get up and go to the toilet at night is the most troublesome aspect of this condition, as it makes them tired during the day.  Having to urinate frequently during the day, sometimes with a sense of urgency, can also be trying for patients, and can make travelling or attending events, such as the theatre or cinema, rather difficult.  Incomplete emptying of the bladder can be progressive and eventually result in complete retention of urine.  If this occurs a catheter (tube into the bladder) will be necessary as the bladder rapidly becomes over distended and painful.

Can I ignore them?

If you've read this far, you'll know that the symptoms of BPH can be similar to those of prostate cancer.  For this reason alone you should see your GP.  Even if you do have BPH, an enlarged prostate can cause back pressure effects in the bladder and kidneys.  Pouches called 'diverticula' can form in the bladder and can predispose you to urinary infections (cystitis).  Bladder stones can also form, and can be painful, while continued obstruction of the urethra can cause kidney damage, which may be permanent.  Bleeding may also occur.  The moral of the story is see your doctor sooner rather than later!

What should I do if I am suddenly unable to pass urine?

Acute urinary retention (the sudden, painful inability to urinate) is a common complication of BPH.  It is usually, but not always, preceded by symptoms of prostatic obstruction.  If you find that you cannot pass urine at all, contact your doctor or go to your nearest Accident & Emergency Department.  Try to drink less fluid because your bladder will already be uncomfortably full.  Tell the doctor and nurses how much discomfort you are in so that you do not wait longer than necessary to have a catheter passed via the penis to drain your over distended bladder.  After this, you will usually be admitted to hospital.  Often the doctor will remove the catheter after an alpha-blocker has been given orally to see if you can pass urine normally.  If retention recurs, another catheter will be put in and then you will either be scheduled to have a TURP within the next few days, or sent home with a catheter in place, to await readmission for an operation to restore normal voiding.

So what should I look out for?

Regularly having to get up more than once a night to urinate can be a sign that your bladder is not emptying properly.  You may notice that your urine stream isn't what it used to be in terms of volume or 'force', and/or you may develop a urinary infection (which will make you want to urinate often, give you a burning sensation when you urinate, and possibly also a temperature).  Finally, if you pass blood in your urine, see your doctor urgently.

Why would I be referred to a specialist?

BPH can often be managed by your GP, but some men will be referred to a specialist urologist.  You'll usually be referred if:

• Your symptoms appeared suddenly or are severe
• You have had repeated urinary infections
• You have passed blood in your urine
• Your PSA level is over 4 ng/ml
• Your GP thinks you may have a bladder stone
• The results from your blood tests suggest you might have kidney damage.

What will the specialist do?

He'll ask about your symptoms and examine you.  To see how efficiently you are emptying your bladder, you will probably have a flow test and ultrasound.  Your PSA level may be rechecked, and if it's found to be higher than normal (that is, above 4 ng/ml), you may have a transrectal ultrasound-guided biopsy to check that the swelling is not cancerous.
These tests are not unduly uncomfortable.  Nobody enjoys a digital rectal examination, but it's over in a few seconds.  The flow test and bladder ultrasound are totally painless.  Only a proportion of patients need a biopsy, and the procedure is now much less uncomfortable with the use of local anaesthetic - it is certainly worth asking for this.  More biopsy information from the Prostate Cancer FAQs

Which drug is best for BPH?

Alpha 1-blockers such as Flowmaxtra (tamsulosin) XL, Xatral (alfuzosin) and Cardura (doxazosin) all act quickly to relieve symptoms regardless of the size of your prostate.  5 alpha-reductase inhibitors such as Proscar (finasteride) or Avodart (dutasteride) work more slowly, but as they seem to shrink the prostate, they seem to help avoid complications and reduce the need for surgery.  Alpha-blockers therefore are a 'quick fix' but do not cure the underlying problem.  5 alpha-reductase inhibitors work better in patients with larger glands, but take 6 months or so to become effective.  Sometimes a combination of an alpha blocker and a 5 alpha-reductase inhibitor is appropriate, especially in patients with a large prostate and severe symptoms.

What are the side effects of medical therapy for BPH?

The alpha blockers can all cause dizziness, headaches and nasal stuffiness.  The older drugs also caused low blood pressure and fainting but this is now uncommon.  The 5 alpha-reductase inhibitors cause loss of libido and reduced erections in 3- 5% of patients, as well as a reduction in the volume of ejaculate.  1% of patients develop minor breast enlargement on these medications.  All these side-effects disappear if treatment is stopped.

Are microwave and laser treatments safe? And do they work?

A great deal of work has gone into developing alternatives to traditional surgery.  Both microwave and laser treatment appear to be safe and they probably have less effect on ejaculation than TURP.  In terms of how well they work, results with these techniques are improving as the technology develops, but heat-based treatments such as these still do not produce the rapid and reliable results achieved with TURP.  Patients also complain of a burning sensation during the passage of urine and this may persist for many weeks after the procedure.

What can go wrong if I opt for a TURP?

The equipment with which a TURP is accomplished is improving all the time.  Although this procedure is largely safe and effective, complications can occasionally occur (as with any operation).  The main problem is bleeding, either at the time of the surgery or afterwards.  It can usually be dealt with by washing out the area with relatively large volumes of liquid (irrigation and bladder washouts), but sometimes the patient needs a second anaesthetic and a telescopic examination (cystoscopy) to find and repair by diathermy the source of the bleeding.  In the longer term, incontinence after a TURP is quite rare, but does affect a tiny proportion of men, as does scarring (stricture) of the urethra, which may need further surgery to remedy.

How will having a TURP affect my sex life?

It shouldn't affect your sex drive, erection or sensation at orgasm, but it will mean that you have a dry orgasm with no ejaculate. This doesn't usually bother patients as long as they know about it before they have the surgery.  If it was OK before the operation, most men report that their sex life after a TURP is quite satisfactory.  In addition, you should need to get up less often during the night to urinate, and should have an improved urinary stream.

What are the chances that I'll need a second operation?

Because the prostate continues to grow after a TURP, a proportion of men will need a second operation eventually.  One man in ten undergoing TURP will need a second operation sometime during the following 5 years.

What questions should I put to my urologist before I agree to surgery?

Ask him who will actually carry out the operation, how many times that person has performed the same type of surgery, and what his results are.  You are looking for an experienced surgeon (one who has carried out the operation at least 100 times previously) who has a high rate of success and a low rate of complications.  Also ask how long you'll have to wait for your operation, and check the cancellation rate (through bed shortages).  If you find it difficult to ask the surgeon these questions directly, you can always telephone his secretary and ask her.

What should I discuss at my follow-up visit?

The most important thing to check is the results from the pathology laboratory, where they will have examined, under a microscope, the pieces of prostate tissue removed during the TURP.  Most men (nine out of ten) undergoing TURP will simply have signs of BPH.  But one man in ten also has small quantities of prostate cancer in the tissue fragments.  If this is the case, further investigations will be needed such as a PSA check and, possibly, further biopsies from the remaining prostate tissue; depending on these results, further treatment may be necessary.

After prostate surgery your flow rate should be much stronger, but frequency and urgency of urination take longer to improve.  Tell your doctor about your symptoms and ask him how long it will be before everything is back to normal.


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Questions on Prostate Cancer


How reliable is the PSA test?

It is not a perfect test, but it is the best we have at present and is considered extremely useful by most urologists, especially if it is expertly evaluated, and taken together with a digital rectal examination (DRE).  All men have small amounts of prostate specific antigen (PSA) in the bloodstream and this level can increase with age or if there is any infection or inflammation in the prostate. This can cause falsely high  PSA readings,  which can be alarming.  A raised PSA can be an important sign of prostate cancer and in this setting it can save lives.  The Department of Health has recently sanctioned PSA tests in informed men aged 50–70 and your GP will be able to discuss this with you.

What is the PCA3 test?

The PCA3 test is a new molecular test that measures the extent to which the PCA3 gene is expressed in cells derived from the prostate.  It does not require a biopsy, but instead a prostatic massage is performed and the first 10–20cc of urine is collected and the specimen sent to a specialised laboratory to be analysed.  A value above 35 suggests that there is an increased risk of cancer being present if a biopsy is performed.  The higher the PCA3 value the greater the probability of a positive biopsy.  Unlike PSA, PCA3 values do not increase as the prostate enlarges.  There is now some evidence that PCA3 is more positive in larger more aggressive cancers, and less so in smaller clinically insignificant tumours, so there is great interest in this test.

What is a prostate biopsy, why is it necessary and how is it performed?

A prostate biopsy is a procedure to remove some very small samples of prostate tissue from the prostate gland.
Consultants ordinarily recommend a biopsy to see what degree of cancer may be present if the PSA level is raised above the norm (greater than 4 ng/ml).
A very fine hollow needle is pressed into the prostate so that the tissue becomes a 'core' in the interior of the needle which is then withdrawn.  The process is usually performed under ultrasound control which provides the urologist with an image of the prostate so that he can guide the needle to the best position.  A probe, covered by a condom, and the size of two fingers is introduced into the rectum and the ultrasound image is used to direct the biopsy needle towards the required part of the gland.  Under local anaesthetic and antibiotic cover, 12 or so cores are taken and then sent to a pathology laboratory for analysis.  Each one is assessed for the presence or absence of cancer.

I am told this can be very painful and unpleasant. Is this true?

Biopsies are not exactly thrilling or agreeable to experience; they can vary from just uncomfortable to very uncomfortable or, at worst, rather painful.  They can also cause rectal bleeding and blood in the ejaculate, but this has been likened to having a nosebleed, and it will stop after a few days.  Nowadays, doctors taking biopsies from the prostate, via the rectum, will usually use a local anaesthetic.  You will also be treated with antibiotics to help prevent any associated infections.  If you do develop a temperature or shaking attacks after a biopsy please let your doctor know immediately.  These are usually due to an E coli infection secondary to the biopsy and will need to be treated, often with intravenous antibiotics.

What is the Gleason score?

The biopsy results give very important information about the extent of the cancer within the prostate and also the level of aggressiveness.  The pathologist will give any cancer cells a grade called the Gleason Grade.  Prostate cancers range from slow growing tumours which are unlikely to spread and cause any problems to fast growing tumours which can spread quickly.  The Gleason Grade is a scoring system between 6 and 10. The higher the score, the more aggressive the cancer is thought to be.  These results in combination with the stage of the cancer and the original PSA will be important in deciding the best treatment option.

Can I have my biopsy done under a general anaesthetic??

Yes, biopsies can be done under light anaesthesia in which case they are painless.  Recently, a template biopsy technique is being used which allows biopsies to be taken more precisely through the perineal skin, rather than the rectum.  This reduces the risk of infection and allows more samples to be taken, thereby increasing the accuracy of the technique.

Consultants sometimes want you to have a bone scan, CT scan or MRI scan before they will deliberate on the best course of treatment.  Why is this?

These tests will show if the cancer has spread outside the prostate and again are very important in deciding the best treatment options.  It is common to have a CT or MRI scan which will give information about whether the cancer has spread outside the prostate to the immediate surrounding areas or to the local lymph nodes.  A bone scan may also be arranged to see if any cancer cells have escaped and spread to the bones.  These scans along with the information from feeling the prostate at DRE will enable the doctors to stage the cancer.  There are basically three different stages with different treatment options:

Localised or early prostate cancer is when the tumour is contained within the prostate gland and has not spread to any other parts of the body.  These early tumours can usually be treated with surgery, radiotherapy or sometimes active surveillance (see above).  The stage of the tumour will be considered in combination with the Gleason Grade (above) determined from the biopsies and the PSA results.  Some men have normal scans but a high Gleason Grade or PSA and this can be an indicator that there could be a risk of tiny microscopic prostate cells that have spread to other places in the body that are too small to be seen on a scan.  In this situation it is common to offer both local treatment, (usually with radiotherapy) and also hormone therapy which has been shown to help prevent or delay the cancer developing in other places in the body.

Locally Advance prostate cancer is when the cancer is seen or felt to have spread just outside the capsule of the prostate into the immediate surrounding tissues or local lymph nodes within the pelvis.  Men with locally advanced prostate cancer have a higher risk that microscopic cancer cells may have already spread (as above).  In this situation treatment is usually with radiotherapy to include the surrounding structures (as well as the prostate) in combination with hormone therapy as this can delay or prevent the cancer coming back in other places and is given by tablets or injections.  Some men with locally advanced prostate cancer are treated with hormone therapy alone.  The choice depends on factors that you will discuss with your doctor.

Advanced or Metastatic prostate cancer is diagnosed when the scans show that the cancer has spread to distant sites usually the bones.  This is usually treated with hormone injections initially but there are many other therapies that can be added later if necessary to keep the cancer under control.

So staging scans, as well as biopsies, and the original PSA value, are vitally important for making treatment decisions.

If cancer is diagnosed, should I have radiotherapy, brachytherapy, surgery, or active surveillance?

There is no right and wrong answer in the treatment of early prostate cancer and treatment approaches can vary with many different factors.  The options can be between active surveillance, radical radiotherapy with either external beam treatment or brachytherapy or radical prostatectomy.  The treatment choices that you are offered will depend on some factors related to the tumour itself.  These include the stage of the prostate cancer (how much cancer can be seen and felt in the prostate), the grade (the level of aggressiveness of the biopsies) and the level of presenting PSA.  Some men have other medical conditions that may make certain treatments more difficult or more likely to cause certain side effects and this will also need to be considered.  When there is a choice between several treatment options, it is important that you are able to discuss these therapies with all the relevant doctors and nurses and make a decision as to which treatment best suits your individual needs and circumstances.  The choice can sometimes be influenced by where you live and the how the different side effects of treatment may affect you individually.

What is Active Surveillance ?

Following the increase in testing for prostate cancer by the PSA (prostate specific antigen) test and subsequent prostatic biopsy, the number of patients diagnosed with prostate cancer continues to rise.  The problem then is to distinguish the potentially life-threatening “tiger” cancers from the less dangerous “pussy cat” cancers that pose little or no threat to life, provided that they are carefully monitored.  Active surveillance may be an option for some men with early localised prostate cancer.  Suitable patients are those who would be fit for radical treatment (surgery or radiotherapy) and have low risk localised disease (usually Gleason ≤ 6 and PSA ≤ 10 ng/ml).  Men are monitored with regular PSA checks, MRI scans and repeat prostate biopsies.  If the disease becomes more active (rising PSA or more aggressive disease on scan or biopsy) they can then have radical treatment with surgery or radiotherapy.  Although it can sometimes be difficult for patients and their partners and families to come to terms with living with cancer rather than opting for initial active treatment with surgery or radiotherapy, there is mounting evidence that for a subset of men diagnosed with early prostate cancer this can be an option.  Provided that follow up is meticulous and that speedy treatment is employed if there is clear evidence of prostate cancer progression, there is little reason to suspect that overall outcomes are jeopardised.  And many men following this protocol will in fact avoid the need for radiation or surgery altogether, thereby maintaining their full quality of life, with little jeopardy to their sexual and urinary function.  It is however only one option and some men may elect to have immediate radical therapy for their early disease after considering all the options.

Why are certain patients ineligible for brachytherapy?

Low dose rate (LDR) permanent seed brachytherapy can also be an effective alternative in some men with early prostate cancer.  It involves ‘radioactive seeds’ being implanted in the prostate under anaesthetic.  The seeds are left in the prostate permanently where they slowly lose their radioactivity and treat the prostate cancer over several months.  This type of brachytherapy is most suitable for men with early localised prostate cancers that are growing slowly (Gleason grade 6).  It is not usually suitable for men with high grade or more extensive tumours.  There needs to be a careful assessment of prostate size before treatment as men with large prostates can have an increased risk of urinary side effects with this treatment and this can be another reason why some men are not suitable for seed brachytherapy.  If TURP has been performed previously, the radioactive seeds cannot be sited correctly in the gland.  Pre-treatment with prostate-shrinking drugs such as LHRH analogues can sometimes make brachytherapy suitable for men with large glands.

What are the commonest side-effects of radiotherapy?

Most men experience some side-effects during radiotherapy but the severity varies from person to person.  Side effects can occur during treatment (acute) and are usually temporary or later after the treatment has finished and these can be permanent.  You should however be able to continue normal activities during the radiotherapy.  Acute or Short Term side effects are temporary and usually occur in the last three or four weeks of treatment and start to get better a few weeks after the treatment is over.  You will be given advice about diet and skin care before the treatment starts.  Your doctor will prescribe creams and medicines if you need help with any of these problems.  The common temporary side effects are tiredness, frequency and stinging when passing urine, diarrhoea and soreness in the rectum.  There can be occasionally be some bleeding or mucous (slime) form the rectum.  There may be some darkening and soreness of the skin in the area being treated especially between the legs and around the anus.  Other side-effects can occur many months after the radiotherapy has finished and these can be permanent.  These include loss of erections, long term change in bowel habit with diarrhoea or urgency to have the bowels open and occasionally some bleeding from the rectum.

If I go for surgery, is the aftermath of the operation painful?

Not really, because any pain is expertly controlled.  This can be achieved, for example, through the use of epidural anaesthetics and of drugs given to you post operatively.  The side effects of the surgery and what to expect afterwards will be discussed with you before the operation.  These days more and more operations aimed at removing the whole prostate (radical prostatectomy) are done through keyhole incisions, with or without robotic assistance.  Keyhole surgery causes a lot less post-operative discomfort than traditional open surgery because the wounds are much smaller.

Is there much loss of blood?

No, not normally.  Only a small proportion (less than 5%) of patients undergoing radical prostatectomy nowadays require a blood transfusion, possibly about two pints — not a particularly significant quantity.

The new approaches of removing the prostate with either keyhole (laparoscopic) surgery or robotic assisted keyhole surgery have been shown to reduce blood loss even further so that blood transfusion after these types of operation are now very uncommon.

Do I need to have some of my own blood taken beforehand?

No, unless it will buy you peace of mind, but if there are no exceptional circumstances there is no need.  Use of your own (autologous) blood is more common in the USA, where there is possibly a higher risk of infection from regular blood transfusion.  It is not advised in the UK.

I have heard that you see traces of blood in the urine after the operation.  Is this true and why is it?

It is true, but normally it is only a trace, and just while the catheter is draining urine immediately after the operation, or perhaps for a while longer while the re-routed ‘plumbing’ inside is healing.  It normally clears after a week or two at most.  Drinking extra fluids is helpful, as is taking laxatives, whole wheat cereal, prune juice and fruit to keep the bowels regular.

Is there any risk that I will die during or shortly after the operation?

There is always such a risk with any operation (around 1 in 1000), but we do not often hear of it happening.  Do not be afraid to ask your surgeon what his own mortality rate is.  Ask him or her when the last major complication occurred and what was the outcome.

What about unsightly scars as a result of the operation?

This need be the least of your concerns.  To gain access to the prostate, many surgeons perform an 8—10 cm lateral or vertical incision above the pubic bone, with a small drain hole beside it.  Clips are more commonly used than stitches these days, and the healing process is quick.  Indeed after a few months the scar is almost, but not quite, invisible.  New recent developments include Laparoscopic (keyhole) and Robotic (robot assisted keyhole) radical prostatectomy.
These techniques involve making 4 to 6 very small cuts and the surgeon removes the prostate using tiny instruments under magnification through a telescope.
The surgeon views the operation on a video screen.  This has the advantage of reducing blood loss and shortening the recovery time after the operation.
The very latest development is the use of a robot to assist keyhole surgery.  This involves the surgeon conducting the surgery via a robot.  The surgeon sits at a console and his/her movements are replicated by the robot with extreme precision beyond the capabilities of the human hand.  This again allows reduced blood loss and better preservation of the tiny nerve bundles that are important for achieving erections.  This new technique looks set to increase in the future as cancer excision rates are high with less incontinence and better preservation of sexual function.

How long will I be in hospital?

Between 4 and 7 days, often including a 12—24 hour period in a progressive care ward where you will be monitored for bleeding, signs of respiratory infection, or any heart rate instability.  About a fortnight after the operation, your catheter will be removed and you will be watched closely for 24 hours to make sure the new ‘plumbing’ is in order (for example, your fluid intake will be checked against your urine output). The newer keyhole operations have the advantage of a shorter recovery time and a reduced stay in hospital often only 2 or 3 days. Also the catheter only needs to stay in 1 week as the join between the bladder and the urethra (the tube through which urine passes out of the body) can be performed more accurately.

When will I know if the surgeon has successfully excised the cancer?

He or she will usually tell you what he thinks within 24 hours, but he has to wait for a few days for the laboratory report on the removed prostate to be sure what has been achieved.  If the report is such that some cells are thought to have escaped from the prostate into the surrounding tissue, a so-called ‘positive margin’ then the surgeon may recommend some ‘mop-up’ radiation, which is usually very successful.  The radiation therapy does not have that much to do compared with clearing the whole prostate of cancer (as is necessary if surgery is not performed).  Side-effects are not usually too troublesome, although some rectal irritation and minor bleeding may occur.

Will the PSA have dropped out of sight after the operation?

Yes, it should have dropped to about 0.6 ng/ml or thereabouts immediately after the operation, and then gradually reduce further to an ideal of below 0.1 ng/ml where, in successful cases, it should remain for the rest of your life.  But remember to have it checked every 3 months for at least a year, and at the same laboratory too, otherwise you may get a variation in results that could alarm you.  In other words, one laboratory may have machines that only read as low as 0.5 whereas another might read down to 0.1, or even 0.01.  In essence the result, as far as you are concerned, is the same.  If the PSA begins to increase months or years after the surgery you may need some mop up radiotherapy at that stage and your surgeon and oncologist will advise you about this.

How many years do I have to have these tests?

You will need to have PSA tests for many years but these will be less and less as time goes on.  It is important to note that after surgery we aim for the PSA to be less than 0.1ng/ml to 0.2ng/ml but after radiotherapy the PSA levels will be higher due to the fact that the normal prostate tissue can secrete small amounts of PSA.  The current definition of good response to radiotherapy is a PSA that remains below 2 to 3 ng/ml.  Also if hormone treatments are given in combination with the radiotherapy, the PSA will increase a little after the hormones are stopped as the normal prostate tissue recovers from the therapy.

Are there any special things I need to remember when I am in hospital?

Yes.  Don’t encourage too many visitors; don’t worry about breaking wind (nurses love wind because it shows things are beginning to sort themselves out in the bowel, which will have been a bit disturbed during the operation): don’t eat too heavy a diet because you don’t want to get constipated through lack of exercise and too many heavy meals: drink as much as you can — at least 8 pints of water or soft drinks, like cranberry juice, every day for a couple of weeks if you can stand that (it helps to flush the system through after your internal plumbing has been re-routed); and, most importantly, just look forward to the new future that the surgeon will have given you.

Is it true that my penis will be shorter after the operation?

Well, yes, some men have noticed a detectable change in length, but not circumference, when the penis is at rest once everything has settled down.  But it’s somewhat relative.  It rather depends upon how well endowed (as the expression goes) you were to begin with.  If there is a noticeable difference, it is very slight.  It is because the newly organized and re-routed urethra has been necessarily shortened and therefore had the effect of ‘pulling back’ the penis into the body just a little.  After a few months, the urethra will stretch to accommodate most of the change.  On erection, the difference is usually of little or no consequence.

I have heard that after the operation my scrotum and possibly my penis will be very badly swollen and look severely bruised.  What will they have done to them and why is this?

This is seldom mentioned before the operation because it is of no long-term significance, but yes, there can be some rather alarming–looking swelling — more often associated with the scrotum, which can occasionally swell to the size of a small orange — but it subsides quite quickly, doesn't hurt, and is neither damaging nor even particularly inconvenient or uncomfortable.  The penis can appear a bit bruised also, and this has to do with inevitable disturbance (during the operation) of the blood vessels and nerve endings serving the scrotum.  But it really is a very short-term problem and is soon history.  Scrotal and penile swelling is less common after laparoscopic or robotic surgery than traditional open operations.

Do I need any special nursing care when I first go home?

Not normally, though you may need some help getting up from deep armchairs, or getting into and out of bed during the first few days at home.  And it is advisable to wear loose clothes like tracksuit bottoms because your lower tummy will be a bit swollen, and getting zips done up can be a problem for a while.  Also you need a spare urine collection leg bag, which the hospital can give you, or you can buy them easily from chemists.  You need to keep yourself scrupulously clean to reduce the risks of any infection while the catheter is still in place.  Some patients like to have sleeping tablets to help them get off to sleep when they are at home with a catheter in place.

Is it painful to have the catheter removed?

Not normally, because catheters are much slimmer these days.  Usually it only takes a moment and it's gone, but they can occasionally get a little stuck because of a tight fit.  But a modern catheter getting severely stuck is unusual, and you would have to be unlucky to experience it.

Will I feel tired and washed out after the operation?

Yes, you may, as this is a normal protective mechanism to allow healing.  Some men feel a tremendous loss of energy, and have days when they think they will never regain their original verve, but gradually the energy level returns and the post-operative tiredness and lassitude are soon forgotten.  In others the effect is minimal. Fatigue is less after keyhole (including robotic) surgery than traditional open surgery and patients are back to normal activities quicker, but heavy lifting should be avoided.

How long should I be off work?

Between 6 and 8 weeks is recommended, although reading, telephone calls, and stress-free activity are all fine.  Every single patient with whom we have spoken who has returned to work a bit early has really regretted it, and his recovery has taken longer.  Remember, nobody is indispensable, and it will probably do your colleagues the world of good to shoulder some of your responsibilities while you are away!  Even if you are retired, take it easy, and handle one day at a time.  You can't really drive comfortably for a few weeks, anyway, so get somebody to drive you!

Can I exercise after the operation?

Yes, but listen to your body: it will tell you how much is sensible and when to rest.  But avoid heavy lifting, such as weight training.

Will I lose my continence control?

Not unless you are very unlucky.  Most patients now recover control almost as soon as the catheter is taken away, but it is true that for some it can take a few hours, a few days, a few weeks, and even a few months, and you might need to wear some padding for a while if leakage is a bit of a problem.  As explained earlier, many surgeons ask you to stay in hospital overnight after the removal of the catheter, measuring fluid intake and outflow to see that the plumbing is working as it should and that there are no internal leaks.  To some extent, regaining continence control depends upon individual muscle tone (and you will be taught exercises to strengthen the pelvic muscles), the skill of the surgeon who will have done all he can to spare the nerves that affect continence, and a certain amount of incalculable individual luck.  The good news is that things almost always dry up sooner rather than later, and you should have a urine stream like when you were a teenager.  If the urinary stream does deteriorate, alert your urologist.  You may be developing a bladder neck contracture, which requires gentle stretching under light anaesthetic.

Is sexual dysfunction a problem?

Yes, for nearly everyone, whatever they claim.  However, some ability and sensation, albeit with a dry orgasm (because the seminal vesicles have been removed as part of the operation) can return after a few months, or sooner for a few lucky ones.  Normal penetrative sex is a problem because however careful the surgeon was to avoid damaging the nerves during the operation, achieving a sustainable firm erection is more difficult for most patients, although some men say they can manage reasonably satisfactorily.  Having a successful radical prostatectomy is unquestionably a trade-off because if the alternative is to die of prostate cancer, then it has to be remembered that so far as we know there is not a great deal of sex in the graveyard.  (Although a local vicar, who incidentally has undergone a radical prostatectomy, told us that there is rather too much in his!)  Sexual dysfunction is also quite common after radiotherapy.

Are there things I can do to help me get back my erections?

Yes, there is a lot that can be done to help restore erections.  These days an active programme of rehabilitation is advised.  Tablets such as Viagra, Cialis and Levitra can all help as can the use of a vacuum device to achieve an artificial erection.  Injections of prostaglandin E1 in the form of Caverject almost always are effective.  Penile suppositories of prostaglandin (known as MUSE) are available, but are quite expensive.  They do work, though, and are favoured by some patients.  In a few cases there are silicone implants (for those who wish to afford them privately, or individuals who can persuade the NHS to help), and these either work rather like a bendy toy, in the sense that you bend it up when you want that, and down when you don't, or are available in an inflatable form, which quite closely simulate a normal erection.
Other drugs such as Uprima (apomorphine) can be helpful.  Successors to Viagra, known as Cialis (tadalafil) and vardenafil, may act more quickly and stay effective for longer.

How will my partner be affected?

Nobody can ‘catch’ prostate cancer from you, but your partner will certainly be affected if impotence is the result.  Frank discussion is vital before and after the operation, particularly if you go for a radical prostatectomy, and the partner must understand the implications along with you.  The ‘prostate cancer journey’ can be a lonely one so take your partner with you and allow them to help and support you along the way.

Should I tell my family and friends I have, or have had, a cancer?

It’s up to you of course, but why should there be a need for secrecy and shame, and why not become an advocate for regular check-ups and possibly save a life in the process?  This is particularly true if you have sons or brothers who have yet to reach their 40s and 50s when a check-up would be wise, unless by then medical science has beaten this disease completely.  Prostate cancer does run in some families so it is important that you share information with them candidly.

Will the cancer come back?

Well, yes, this has been known, with any of the treatments.  The doctors will determine the risks of your individual case and do everything to try and prevent any recurrence of the cancer as early as possible.  This can sometimes mean that you will need a course mop up radiotherapy after surgery.  This can be given as a planned procedure after the operation if the surgeon and pathologist feel there is some cancer left behind in the bed of the prostate.  Sometimes a small rise in PSA months or years after the surgery can be an early warning sign that the cancer could be active again and radiotherapy can also be given successfully at this stage.  If there is a risk that there could be tiny microscopic tumour cells in other parts of the body, your doctor may advise a period of preventative hormone therapy with either tablets or injections as this has been shown to prevent or significantly delay any cancer recurrence.  If the cancer does come back there are many other effective treatments including different hormone drugs that can be used in sequence.  Chemotherapy with taxotere has recently been shown to be effective in prostate cancer if and when some of the cancer cells stop responding to hormone therapy.  There are also many new and very promising new drugs that are being developed and are currently being tried out in clinical studies.

Was there anything I could have done to prevent the cancer in the first place?

Not really, because nobody knows for certain why anyone is affected by it.  There are plenty of theories.  Some say it is all to do with diet (ranging from eating too much saturated fat, especially red meat); others believe it is a genetic disease (and there is much research going on in that direction); yet others say it is connected with a multifarious and largely unidentifiable mix of factors, including having had a vasectomy.  Nobody has a monopoly of wisdom on the subject.  The latest research has found that men who carry a damaged version of a mutant gene are four to five times more likely to suffer from prostate cancer than those who do not have this faulty gene.  It’s a case of ‘watch this space’.

And what about the future in terms of treatments?

There is much research going on which may one day find a solution for prostate cancer, through a vaccine, gene or stem cell therapy to achieve a more certain cure without losing the gland, but we are presently years away from this happy circumstance.  And, inevitably, more money is needed to support research into the causes and possible cures of this very common disease.

What is the prostate gland and what does it do?

The prostate gland is situated between the bladder and the rectum, partly surrounding the urethra which carries urine from the bladder out of the body, and forms part of the male reproductive system, making and storing fluid which forms part of a man's semen. The prostate gland is about the size of a walnut in an adult.

What is prostate cancer?

Prostate cancer is a form of cancer which normally appears late in life and tends to be slow growing as a result of which many men, despite having prostate cancer, in fact die of other unrelated conditions. This said, prostate cancer is the second commonest form of cancer in the United States today and in 2006 some 235,000 men were diagnosed with the disease and approximately 27,000 men died from it.

Who is likely to contract prostate cancer?

Men in general are at risk of contracting prostate cancer although as it is an age related disease it tends to appear only from about middle-age onwards with the risk of contracting the disease increasing with age. Prostate cancer is more likely to appear in black men and where there is a family history of the disease.

What are the symptoms of prostate cancer?

In the early stages of the disease there are normally few if any symptoms and it is possible to suffer from prostate cancer for many years without even knowing it. When symptoms do start to appear they are likely to include such things as difficulty in urinating, the need for frequent urination (especially at the night), a poor flow or urine which tends to stop and start, painful urination, blood in the urine or semen, pain when ejaculating and pain in the lower back, hips or upper part of the thighs.

Are there other conditions which can mask the presence of prostate cancer?

Many older men suffer from an enlarged prostate which places pressure on both the bladder and the urethra and interferes with the flow of urine and with sexual function, producing many of the same symptoms that are seen in prostate cancer. This condition is not however cancer but is a benign condition known as benign prostatic hyperplasia, or BPH.

It is also quite common for the prostate gland to become infected and inflamed, again producing similar symptoms, and this also benign condition is known as prostatitis.

Is it possible to be screened for prostate cancer?

Yes, although current screening is not foolproof. The two most commonly used screening test will indicate the possibility of a developing problem, which may or may not be cancer, and point to the need for further more specific testing.

The tests currently in use are the digital rectal exam (DRE), in which a doctor carries out an investigation of the prostate gland by feeling it with a gloved finger inserted through the rectum to detect the presence of hard or lumpy areas, and a blood test used to detect the presence of a substance which is known as prostate specific antigen (PSA) and which is made by the prostate gland.

How reliable are present screening methods?

Neither of the current screening tests is foolproof and both can easily miss prostate cancers. However, the two tests used together can produce quite reasonable results and are certainly preferable to not screening for the condition at all. Research is currently underway to find a more accurate method of screening.

How is a diagnosis of prostate cancer made?

There is really only one way to confirm the presence of prostate cancer and this is by carrying out a prostate biopsy. This involves removing a number of small samples of tissue from various different parts of the prostate gland and examining these under a microscope in the laboratory.

How is prostate cancer treated?

If prostate cancer is localized (that is to say confined only to the prostate gland) there are at present three main forms of treatment available.

One option is to do nothing and to simply watch and wait. If this seems an odd course of action it should be borne in mind that many prostate cancers appear at a very advanced age and, as long as the cancer remains within the prostate gland and is slow growing, the best option for an elderly patient might well be to do nothing at all.

Where active treatment is carried out this will often be to either treat the prostate gland with radiation to kill the cancer cells or to simply remove the prostate gland surgically.

In cases where cancer has spread outside of the prostate gland there are a wide range of treatment options available depending on the degree of spread. This is however a complex area and beyond the scope of this short article.

What is the best treatment for localized prostate cancer?

This is a bit like asking 'how long is a piece of string' as there are a large number of factors which need to be taken into consideration, not the least of which are the patient's own circumstances and wishes.

In the majority of cases however prostate cancer is slow growing and there is usually no need to rush into a treatment plan. This gives patients time to discuss their condition with their doctor, including taking a second or even third opinion if they wish, and also to discuss matters with their partner and family before making any decision.