Prostates: What every man needs to know

When it comes to men’s ‘plumbing’ issues, the culprit in many cases is the prostate, the gland which produces the fluid that mixes with sperm to create semen. In a piece of inarguably poor design, the walnut-sized prostate, which is positioned below the bladder, is wrapped around the urethra, the tube that carries urine out of the body through the penis.

That arrangement works just fine when men are in their prime. But as men grow older, the prostate gradually enlarges, placing increasing pressure on the urethra and interfering with the flow of urine.

That, says consultant urological surgeon Giles hellawell, is when alarm bells start ringing for most men.

‘Of course, prostate cancer is the first thing that goes through their minds,’ he says — difficulty urinating, or needing to urinate more often are common symptoms of prostate cancer. ‘But the first thing I say to patients referred to me is that about half of men over the age of 50 have some degree of prostatic enlargement — a benign condition — and quite a high proportion of those will have some reduction in flow.’

In fact, most men who go to see their GP have been spooked by symptoms caused by a harmlessly enlarged prostate. They might have poor flow of urine — what once was a river in flood becomes a mere stream. Or, if they have tolerated poor flow for a number of years, as many men do, they may have started to experience secondary effects on the bladder.

These effects can include ‘ urinary frequency’ — having to go to the loo a lot — or ‘ urgency’, a sudden, overwhelming urge to go. But for many, says Mr hellawell, the trigger to go and visit the GP is having regularly to get up once or twice during the night to pass water.

A GP confronted with a man worried about urinary problems will usually conduct a physical examination of the prostate to see if it is, indeed, enlarged. If it is, the next step will be a blood test to check for levels of a protein called Prostate Specific Antigen, or PSA. This is produced by cancerous cells in the prostate, but also by normal ones, and PSA levels rise naturally as men grow older.

AS A result, a raised PSA level is just an indication that further tests might be necessary, says Mr hellawell. The PSA throws up ‘false positives’ and many men with an elevated reading do not have prostate cancer.

Conversely, though less often, some men with a low PSA reading do prove to have the condition. So ‘increasingly we don’t rely just on that’, he says.

‘In my nhS practice we always do an MRI scan of the prostate once the patient has come in with elevated PSA before deciding whether to do a biopsy.’

Prostate cancer ‘affects more than 300,000 men in the UK and kills one man every 45 minutes’, says Ali Rooke, senior specialist nurse at Prostate Cancer UK. ‘however, it’s a disease which can be successfully treated, if caught early enough.

In many cases, prostate cancer doesn’t have any symptoms at all, especially in its early stages. ‘Therefore, being aware of your risk is crucial and is a man’s best line of defence,’ she says. Men over 50, black men, or men with a father or brother who has had the disease all face a higher than average risk.

‘If you fall into one of these high-risk groups, or have noticed any changes in your waterworks, it’s important to have a conversation with your GP about your risk.’

Anyone with concerns about prostate cancer can contact Prostate Cancer UK’s specialist nurses on 0800 074 83 83.

If cancer has been ruled out, a benign enlarged prostate can be treated. This can mean lifestyle changes — cutting down on caffeine, which irritates the bladder, and alcohol, generally drinking less in the evening — and learning to ‘double void’: peeing, waiting a few seconds, and peeing again. Some men with enlarged prostate develop overflow incontinence — where they leak urine (See previous pages) . In cases of ‘chronic urine retention’, in which peeing is really difficult, a man may have to regularly insert a catheter through the penis to drain the bladder. When cancer is found, or in some cases of a severely enlarged but benign prostate, a prostatectomy, in which part or all of the prostate is removed, will be carried out. This can lead to other problems.

The problem is that the prostate ‘is not a greatly located organ: it’s very close to the bladder and the voluntary sphincter, which allows you to relax and have a wee. If one is going to surgically remove it you have to be careful,’ says Mr hellawell.

even then, following a standard prostatectomy the risk of incontinence is about 5 per cent or higher. Sometimes this is only temporary. ‘We usually wait 12 to 18 months after the operation to see what the eventual baseline incontinence levels will be, and luckily in the majority of patients it does improve,’ explains Mr hellawell. During this time men may have to wear pads.

If there is no improvement, more surgery can be carried out. This includes the insertion of an internal urethral sling, a synthetic mesh positioned to give the urethra some support.

Still a relatively new innovation, used in men and women, there are no long-term results for this operation, which usually involves two nights in hospital. But in the short-term there is a success rate of about 80 per cent — with success defined as being able to stop using pads or seeing urinary leakage reduced by half.

For severe cases of incontinence an artificial urinary sphincter can be fitted to replace the weakened ring of muscle that contracts to prevent urine leaving the bladder. The artificial device, which is filled with fluid to compress the urethra, is operated by a small hand pump concealed in the scrotum.

Patients aged 70 or older are more likely to be given radiotherapy to reduce the size of an enlarged prostate rather than undergo radical surgery. There is little evidence to show one procedure is better than the other, but with older patients there is more caution about giving anaesthetics and undergoing a lengthy operation.

WHEN YOU FIND A LUMP . . .

UnDeRSTAnDABly, many men become worried when they find a lump in their scrotum — but only four in 100 is likely to be cancerous. Frequently what they have found is a harmless testicular cyst, says Giles hellawell.

By the age of 50, between 15 and 20 per cent of men can expect to have a testicular cyst of some kind, a lump they can feel at the top of one of their testicles.

Cysts are situated in the epididymis, a duct that carries sperm from the testes, and which is often tender in its own right. ‘ Typically, somebody has a slightly tender epididymis, which can happen from a bit of inflammation, and they examine it and find a lump,’ says Mr hellawell. ‘But it’s not actually in the testes, it’s in the bit above.’

A cyst is best left alone, says Mr hellawell. It rarely causes pain or discomfort and removing it is not without possible consequences: ‘The testes area is not a great place to operate on because the risk of infection is so high.’

To reassure a man his lump is harmless, ‘we would almost automatically get an ultrasound scan, certainly up to the age of 40 and probably beyond.’ This can also pick up hernias and hydrocele testis, a build-up of fluid around the testes. ‘Men should get to know how they usually look and feel, which can help you spot if something changes,’ says Fiona Osgun, Cancer Research UK’s senior health information officer.

Any lump, swelling, change in firmness or texture of the testicles, or a feeling of heaviness or pain in the testicles or scrotum should be checked out by a doctor.