My Penis Stuff

Surgery Overview

An artificial sphincter is a device made of silicone rubber that is used to treat urinary incontinence.

An artificial sphincter has an inflatable cuff that fits around the urethra close to the point where it joins the bladder. A balloon regulates the pressure of the cuff, and a bulb controls inflation and deflation of the cuff. The balloon is surgically placed within the pelvic area, and the control pump is placed in the scrotum.

The cuff is inflated to keep urine from leaking. When urination is desired, the cuff is deflated, allowing urine to drain out.

What To Expect After Surgery

Because these procedures involve abdominal surgery, hospitalization is required.

You will most likely be able to leave the hospital the day after having the surgery.

Why It Is Done

Installation of an artificial sphincter may be done for:

• Urinary incontinence caused by the removal of the prostate.
• Severe continual leakage of urine from the urethra.
• Severe urinary incontinence for which other methods of treatment have failed.

How Well It Works

Artificial sphincter placement is the most reliable treatment for men who have incontinence after prostate removal for cancer.

In cases of severe stress incontinence and persistent leakage, implantation of an artificial sphincter has been successful in relieving incontinence in up to 90% of men.

Risks

Complications with this type of surgery include needing another surgery, or revision, in 27% of cases, in which 5% reported erosion of the part of the urethra surrounded by the artificial sphincter and 3% developed infections.

What To Think About

Because complications may occur, this is a treatment method that generally is reserved for people for whom all other treatment options have failed. Some people may prefer to manage their symptoms with absorbent pads and changes in habits rather than have this surgery.

Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor’s recommendation.

Key points in making your decision

Radiation therapy and surgery are both used successfully to treat localized prostate cancer. The decision between surgery and radiation often is based on balancing the benefits with the possible side effects of each treatment option, including its effects on sexual activity, bladder control, and other aspects of your quality of life.

• If one of your biggest concerns is that prostate cancer might come back after treatment, you may want to have a radical prostatectomy. Your doctor will be able to evaluate your cancer more accurately by looking at it during surgery and taking tissue samples that can be tested. This information will help your doctor decide how likely it is that your cancer will return.
• If the possibility of having bladder problems and erection problems is a major concern, you may want to consider radiation therapy because these problems are less common with radiation than with surgery.

Treatment choices are different for prostate cancer that is more advanced (has grown or spread outside the prostate gland). For more information, see the topic Prostate Cancer, Advanced or Metastatic.

Medical Information

What is localized prostate cancer?

Prostate cancer is the abnormal growth of cells in the tissues of the prostate gland. Localized prostate cancer is cancer than has not spread beyond the prostate gland.

Prostate cancer is the most common cancer in men. Most men who get it are older than 65. If your father, brother, or son has had prostate cancer, you have a higher-than-average risk for developing the disease.

Unlike many other cancers, prostate cancer is usually slow-growing. Most men will die with prostate cancer but not of prostate cancer.

African-American men have higher rates of both prostate cancer and deaths caused by prostate cancer.

Early prostate cancer usually does not cause symptoms. When prostate cancer is diagnosed early, before it has spread outside the prostate gland, it may be cured with radiation or surgery to remove the prostate. As prostate cancer grows or spreads, symptoms may develop, including urinary problems (such as blood in the urine) and bone pain.

Prostate cancer that has grown through the prostate is called advanced prostate cancer, and treatment choices are different for that stage of cancer. For more information, see the topic Prostate Cancer, Advanced or Metastatic.

What are the treatment choices for localized prostate cancer?

Localized prostate cancer may be treated with radiation therapy, surgery, or drugs. You may also choose to watch and wait.

• Watchful waiting, also called surveillance or observation, means you are being monitored closely by your doctor, but you are not receiving active treatment such as surgery or radiation therapy as long as symptoms do not occur or get worse.
• Radical prostatectomy is an operation to remove the entire prostate as well as any nearby tissue that may contain cancer. It may be done as open surgery, by making a large incision, or as laparoscopic surgery, by making several very small incisions in the belly and using a tiny camera and special instruments to remove the prostate. Sometimes lymph nodes in the area also are removed so they can be checked for signs of cancer.
• Radiation therapy uses X-rays and other types of radiation to kill the cancer cells. This may be done with:
  • External-beam radiation, in which a machine aims high-energy rays at the cancer.
  • Brachytherapy, in which tiny pellets of radioactive material are injected directly into or near the cancer.
  • A combination of external radiation and brachytherapy.

If you are young and in good health or if your prostate cancer is fast-growing (higher-grade), your doctor probably will recommend surgery and/or radiation therapy to remove or destroy the cancer. Even though prostate cancer is usually slow-growing, it may eventually spread and cause symptoms and may threaten your life.

Age is not a reason to not have surgery or other treatment. But if you are around 70 or older, it is important to consider other medical conditions you may have, such as heart disease, as you make your treatment decisions.

When is prostatectomy used to treat prostate cancer?

Radical prostatectomy is most often recommended when a man is in good general health and has a life expectancy of at least another 10 years. In addition, there should be an expectation that the cancer can be entirely removed. If testing suggests that the cancer may have spread outside the prostate, or if you have other health problems that may add to the risks of major surgery, prostatectomy usually is not recommended.

Radical prostatectomy generally is effective in treating cancer that has not spread beyond the prostate gland. In follow-up PSA tests done in the years after prostatectomy, most men show no evidence of cancer.

Laparoscopic radical prostatectomy sometimes is used instead of open prostatectomy, which requires a larger cut in the belly.

A few surgeons do robotic-assisted laparoscopic radical prostatectomy. The surgeon controls the arms that hold the surgery tools and laparoscope. There are reports that it helps the surgeon see very well and work with less error.

When is radiation therapy used to treat prostate cancer?

Radiation therapy is most effective in treating cancers that have not spread outside the prostate. It may be used alone or combined with hormonal treatment. Rarely, it is used with surgery. Radiation therapy works as well as surgery for the treatment of early-stage localized prostate cancer.

What are the risks of prostatectomy?

A radical prostatectomy is a surgical procedure and carries all the risks of any major surgery, including heart attack, pulmonary embolism, bleeding, infection, and reactions to anesthesia or medications.

In addition, prostatectomy may cause bladder problems and erection problems. Increasingly, this surgery is done in a way that helps preserve the nerves that control erections. Most men who have nerve-sparing prostatectomies will regain the ability to have an erection within 4 to 6 months after surgery. It takes some men up to 2 years to regain full function.

More than 30% of men who have a radical prostatectomy develop bladder problems, ranging from a need to wear pads to occasional dribbling during stressful activities. Between 2% and 5% still have severe problems 6 months after having a prostatectomy. After 1 year, 92% no longer have problems.

Other possible complications include scar tissue that may narrow the outlet to your bladder and injury to the rectum or the ureters.

Evidence shows that the side effects of prostate surgery are lessened when the prostatectomy is done by a surgeon who is very experienced in this particular operation.⁷

What are the risks of radiation therapy?

About half of men who have external radiation develop erection problems within 5 years of treatment. Erection problems following radiation therapy increase over time.

Most other side effects generally go away when treatment is finished. In some cases, however, they may become chronic. Other side effects include:⁴

• An irritated rectum and an urgent need to pass a stool. This is called proctitis.
• An inflamed bladder and urination problems. This is called cystitis.
• An inflamed intestine and diarrhea. This is called enteritis.
• Being unable to have an erection. This is called impotence.
• Being unable to control urination. This is called incontinence.
• Painful urination. This is called dysuria.

Follow-up treatment

Any type of treatment for prostate cancer will need to be followed by regular checkups. Your follow-up care probably will include physical exams, prostate-specific antigen (PSA) tests to monitor PSA levels and measure the speed of any changes, digital rectal exams, and biopsies as needed to examine suspicious tissue.

Your Information

This discussion focuses your choice between:

• Having radiation therapy.
• Having a radical prostatectomy.

The decision about whether to have surgery or radiation treatment takes into account your personal feelings and the medical facts.

Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor’s recommendation.

Key points in making your decision

Birth control methods allow a woman or a couple to choose whether or when to have a child. Consider the following when making your decision:

• Permanence. If you are certain that you don’t want children (or more children), you might consider a permanent method of birth control, such as female tubal ligation or implants or male vasectomy.
• Effectiveness. Consider how important it is to you to avoid pregnancy, and then look at how well each method works. Hormonal implants and injections (Depo-Provera) and the hormonal and copper IUDs are the most effective. Birth control pills (both estrogen-progestin and progestin-only), patches, and rings are highly (but slightly less) effective. Barrier methods such as condoms, diaphragms, and spermicides are only moderately effective. See a reliability table for details on each method.
• Convenience. Some methods require more effort than others. Do a reality check by asking yourself how likely you are to use the method consistently. Answer whether you are willing to interrupt lovemaking, to abstain from sex during certain times of the month, or to remember to take a pill every day.
• Sexually transmitted disease protection. The most highly effective hormonal and IUD methods do not protect you from sexually transmitted diseases (STDs). Condoms are the only dependable protection you have from STDs. But condoms alone are not a highly effective birth control method. To avoid both STD infection and pregnancy, be sure to combine a condom with a more effective birth control method.
• Health risks. If you have health risks, some birth control methods may not be right for you. For example, combined (estrogen and progestin) birth control methods are not recommended for women older than 35 who smoke. Other conditions that may limit your choices of birth control include having migraines, heart disease, high blood pressure, blood clots, or diabetes.
• Return to fertility. If you plan to have children within the next year or two, you may want to avoid the Depo-Provera (progestin-only) shot, which can stop your monthly periods and delay your return to fertility.¹ Taking estrogen-progestin for a long time can also make your periods stop. You might not start periods again for several months after you stop taking hormones. But it isn’t permanent. You will start ovulating and having your periods, and your fertility should get back to normal.
• Other benefits. Some birth control methods have beneficial side effects. Combination hormonal methods (estrogen and progestin) can improve acne. Both combination and progestin-only methods reduce menstrual cramping and flow. In fact, with the Lybrel combination pill, the Depo-Provera shot, or the Mirena IUD, your period may stop altogether.

Medical Information

What are the different methods of birth control?

Sterilization is a surgical procedure done for men or women who decide that they do not want to have any or more children. Sterilization is one of the most effective forms of birth control. Sterilization is intended to be permanent, and while you can try to reverse it with another surgery, reversal is not always successful. Methods include:

• Tubal ligation or implants. The fallopian tubes, which carry the eggs from the ovaries to the uterus, are tied, cut, or blocked. A new type of procedure, using a device (called Essure) to block the fallopian tubes, is done without an incision and on an outpatient basis.
• Vasectomy. In this minor procedure, the vas deferens, the tube that carries sperm from the testicles to the seminal fluid (semen), from each testicle is cut and blocked so that sperm are no longer present in the semen.

Hormonal methods are very effective means of birth control. Hormonal methods use two basic formulas:

• Combination hormonal methods contain both estrogen and progestin (synthetic progesterone). Combination methods include pills, skin patches, and rings.
• Progestin-only hormonal methods include pills (also called the “mini-pill”) and injections (Depo-Provera). Progestin-only methods are an option for women who cannot take estrogen.

Compare the:

• Advantages and disadvantages of combination hormonal methods with progestin-only pills, patches, and rings.
• Advantages and disadvantages of the progestin-only (Depo-Provera) shot.

An intrauterine device (IUD) is a small device that is placed in your uterus to prevent pregnancy. IUDs usually contain copper (Copper T 380-A) or a hormone (the Mirena IUD, which releases a progestin called levonorgestrel). IUDs can provide birth control for 5 to 10 years.

Barrier methods include the diaphragm, cervical cap, Lea’s Shield, male condom, female condom, spermicidal foam, sponges, and film. Barrier methods prevent sperm from entering the uterus and reaching the egg. Typically, barrier methods are not highly effective, but they generally have fewer side effects than hormonal methods or IUDs. Spermicides and condoms should be used together or along with another method to increase their effectiveness. Barrier methods can interrupt lovemaking because they must be used every time you have sex. (A diaphragm, cap, or shield can be put in a few hours beforehand, if you can plan ahead.)

Fertility awareness, or natural family planning, requires that a couple chart the time during a woman’s menstrual cycle that she is most likely to become pregnant and avoid intercourse or use a barrier method during that time. Fertility awareness is not a highly effective method of preventing pregnancy.

If you are at risk of getting or spreading a sexually transmitted disease (such as genital herpes, chlamydia, and AIDS), use a condom. To most effectively prevent pregnancy, combine a condom with a highly effective birth control method.

How effective are birth control methods?

Hormonal implants, injections (Depo-Provera), and the hormonal and copper IUDs are very highly successful methods of birth control. These methods are 97% to 99.9% effective. That means fewer than 1 to 3 women out of 100 women who are using these methods will become pregnant during the first year of use.

Birth control pills (both combination and progestin-only) have a high success rate of 92%. But if taken properly (every day or at the same time every day), birth control pills can be highly successful. The hormonal skin patch and vaginal ring are thought to be about as effective as birth control pills, but how well they actually work has not been well studied.

Barrier methods, such as the diaphragm or condom, are moderately successful at preventing pregnancy. The diaphragm and cervical cap are 84% effective for women who have not had children or who have had a cesarean section. Women who have delivered children vaginally have lower rates of success with diaphragms and cervical caps. They are more effective when used consistently and fitted correctly, although not all women are able to achieve this.

Doctors often recommend that you use spermicides and condoms together or along with another method to increase their effectiveness. The male condom is 85% effective. The female condom is 79% effective. Spermicide is 71% effective. In real numbers, this means that of women who use male condoms alone for birth control each time they have sex, 15 out of 100 will become pregnant in the first year of use. Consider carefully whether this risk is acceptable to you.

Using fertility awareness takes organization, good record keeping, close observation of your body changes, and cooperation from your partner. Even when practiced carefully and consistently, fertility awareness is not a reliable method of birth control. Of women who use fertility awareness for birth control, 20 to 25 out of 100 will become pregnant in the first year of use.

Consider how comfortable you feel about using a particular method of birth control. If you are not comfortable or will not consistently use a birth control method for any reason, that method may not be effective. A reality check for birth control methods can help you determine which method is right for you.

Patch warnings

• The patch delivers more estrogen than the low-dose birth control pills do. Some research has found that women using the patch are more likely to get dangerous blood clots in the legs and lungs. The risk may be higher if you smoke or have certain health problems. The U.S. Food and Drug Administration (FDA) suggests that you talk to your doctor about your risks before using the patch.
• Direct sunlight or high heat can increase, then lower, the amount of hormone released from a patch. This can give you a big dose at the time and leave less hormone for the patch to release later in the week. This increases your risk of pregnancy. Avoid direct sunlight on the hormone patch. Also avoid using a tanning bed, heating pad, electric blanket, hot tub, or sauna while you are using a hormone patch.

What are health risks that may affect my choices?

Some health conditions may limit your choice of birth control methods. Discuss appropriate methods of birth control with your health professional if you:

• Have a chronic illness, such as diabetes or heart disease.
• Have a history of cardiovascular problems, such as high blood pressure (hypertension), stroke, high cholesterol, or blood clots.
• Have a history of nervous system problems, such as seizures or headaches.
• Have a history of migraines.
• Smoke cigarettes.
• Have a history of cancer.
• Use prescription medications. Certain antibiotics, antiretrovirals, and anticonvulsants, as well as St. John’s wort, make certain hormonal birth control less effective.²
• Have low bone density (osteoporosis) in your personal or family history.
• Are overweight. The pill and the patch may not work as well if you are overweight (body mass index greater than 30).

Bone thinning. Using Depo-Provera for 2 or more years can cause bone loss, which may not be fully reversible after stopping the medication and can lead to osteoporosis in later life. This concern may be greatest during the teen years, when young women should be building bone mass. Depo-Provera use is not recommended to be used for longer than 2 years unless you are protecting your bones with daily calcium and regular weight-bearing exercise, such as walking or running. Talk to your doctor about your risks if you have been using Depo-Provera for longer than 2 years.

Sexually transmitted disease. If a sexually transmitted disease is present at the time an IUD is inserted, a woman is at increased risk for pelvic inflammatory disease (PID) in the 20 days after insertion. Pelvic inflammatory disease can lead to infertility.⁷ This is why a test for STDs is important before inserting an IUD.

Will some temporary birth control methods prevent me from having children when I want them?

Consider how soon, if ever, you would like to become pregnant. Except for sterilization methods, which permanently prevent pregnancy, all currently available birth control methods allow you to become pregnant again, although some may cause a delay.

Depo-Provera. For some women, it may take 3 to 18 months to get pregnant after the last Depo-Provera (a progestin-only hormonal method) shot.

The estrogen-progestin pill. If you take monthly cycles of birth control hormones for a long time, your periods might stop. You might not start periods again for several months after you stop taking hormones. But it isn’t permanent. You will start ovulating and having your periods, and your fertility should get back to normal. Since it is common to ovulate before your first period comes back, it is possible to get pregnant sooner than you expect. So if you aren’t in a rush to get pregnant, use some form of birth control after you stop birth control hormones.

What can I do if I have unprotected sex?

Emergency contraception is a backup method for unprotected intercourse. This would be when you have not used a birth control method or have reason to believe that your method has not protected you as it should. For example, you could use emergency contraception if the condom breaks during sex.

Your Information

One method may work better than others for a woman or for a couple. You may use more than one method at a time, especially if you need sexually transmitted disease protection and highly effective birth control. And birth control needs change over time. Consider the information below as you make your decision.

You or someone you know may have been diagnosed as having a type of prostatitis, a common and painful disease of the prostate gland and its surrounding structures. The following has been designed to answer your questions about prostatitis.

What is the prostate?

The prostate is a part of the male reproductive system, is about the same size and shape of a walnut and weighs about an ounce. It is located below the bladder and in front of the rectum and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce ejaculatory fluid.

What are the different types of prostatitis and their causes?

Acute bacterial prostatitis is the least common type of prostatitis and is always caused by bacterial infection. It is usually easy to diagnose because of the typical symptoms and signs. It is a severe urinary tract infection associated often with fevers and chills, and a visit to a doctor or hospital is required. Acute bacterial prostatitis can affect any age group but commonly occurs in older and middle-aged men. Another type that is caused by bacterial infection is chronic bacterial prostatitis which is characterized by recurrent urinary tract infections in men. When symptoms do appear, they are generally less severe than acute bacterial prostatitis and rarely have fever, but often recur. This condition can also affect any age group but is most common in young and middle-aged men.

Nonbacterial prostatitis and prostatodynia, now properly referred to as chronic pelvic pain syndrome, are the most common types of prostatitis. The exact cause of these non-bacterial prostatitis conditions is not known, but may be due to persistent infection, inflammation and/or pelvic muscle spasm. Inflammation in the prostate can also occur without symptoms.

What causes prostatitis?

The bacteria that cause acute and chronic bacterial prostatitis get into the prostate from the urethra by backward flow of infected urine into the prostate ducts. Bacterial prostatitis is not contagious and is not considered to be a sexually transmitted disease. A sexual partner cannot catch this infection.

Certain conditions or medical procedures increase the risk of contracting bacterial prostatitis. There is a higher risk if the man has recently had a catheter or other instrument inserted into his urethra, an abnormality of his urinary tract or a recent bladder infection.

Chronic prostatitis/chronic pelvic pain syndrome may be caused by atypical organisms such as chlamydia, mycoplasma (which may be transmitted by sexual contact) ureaplasma or may also be due to a chemical or immunologic reaction to an initial injury, The nerves and muscles in the pelvis may cause pain in the area, either as a response to the prostate infection or inflammation or as an isolated problem itself.

What are the symptoms of prostatitis?

The symptoms of the various prostatitis syndromes depends upon the category.

In acute bacterial prostatitis, the symptoms are severe and sudden and may cause the patient to seek emergency medical care. Chills, fever, severe burning during urination and the inability to completely empty the bladder are common.

In chronic bacterial prostatitis, the symptoms are similar but do not produce fever. They include: burning during urination; urinary frequency, especially at night; perineal, testicular, bladder and low back pain; and painful ejaculation. The condition can be episodic, with flare-ups and remissions, associated with infection, treatment and subsequent recurrence.

The symptoms of chronic prostatitis/chronic pelvic pain syndrome include difficult and sometimes painful urination, discomfort or pain in the perineum, bladder, testicles and penis as well as difficult and painful ejaculation. In some cases, these symptoms can be indistinguishable from those described above for chronic bacterial prostatitis.

How is prostatitis diagnosed?

The correct diagnosis is very important because the treatment is different for the different types of prostatitis syndromes. In addition, it is extremely important to make sure that the symptoms are not caused by other conditions such as urethritis, cystitis, an enlarged prostate or cancer. To help make an accurate diagnosis, several types of examinations are useful.

To examine the prostate gland, the physician will perform a digital rectal examination (DRE). This is a simple examination in which the doctor will pass a lubricated, gloved finger into the rectum. Because the prostate is located just in front of the rectum, it can be easily pressed. The physician will be able to determine whether the prostate is enlarged or tender. Lumps or firm areas can suggest the presence of prostate cancer. The physician will also assess the degree of pain or discomfort the patient experiences as he presses the muscles and ligaments of the pelvic floor and perineum. If a man has prostatitis, this examination may produce momentary pain or discomfort but it causes neither damage nor significant prolonged pain.

If the physician requires a closer look at the prostate gland or decides that a biopsy is necessary, he may order a transrectal ultrasound, which allows him to visualize the prostate gland. If you are at risk for cancer, your physician will consider ordering a PSA test. During a prostate infection however, the PSA can be falsely elevated.

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

The urologist will repeat some of the examinations already performed by the first physician. The urologist will also assess the degree of pain or discomfort the patient experiences as he presses the prostate. The urologist may analyze various urine specimens as well as a specimen of prostatic fluid obtained by massaging the prostate gland during the DRE. The various urine specimens and prostatic fluid will be analyzed for signs of inflammation and infection. These samples may help the urologist determine whether your problem is inflammation or infection and whether the problem is in the urethra, bladder or prostate.

Other tests the urologist may consider employing include cystoscopy in which a small telescope is passed through the urethra into the bladder permitting examination of the urethra, prostate and bladder. The urologist may also order urine flow studies, which help measure the strength of your urine flow and any obstruction caused by the prostate, urethra or pelvic muscles.

How should prostatitis be treated?

Your treatment depends on the type of prostatitis you have.

If acute bacterial prostatitis is diagnosed, the patient will need to take antibiotics for a minimum of 14 days. Sometimes, this means being admitted to the hospital and being given intravenous antibiotics. A catheter is sometimes required if the patient has difficulty urinating. Almost all acute infections can be cured with this treatment. Frequently, the antibiotics will be continued for as long as four weeks.

If chronic bacterial prostatitis is diagnosed, the patient will require antibiotics for a longer period of time, usually four to 12 weeks. About 75 percent of all cases of chronic bacterial prostatitis clear up with this treatment. Sometimes the symptoms recur and antibiotic therapy is again required. For cases that do not respond to this treatment, long-term, low dose antibiotic therapy may be recommended to relieve the symptoms. Other medications (such as those used for nonbacterial prostatitis) or other treatments (e.g., prostate massage therapy) may also be used in difficult cases. In some rare cases, surgery on either the urethra or prostate may be recommended. There must be a specific anatomic problem, such as scar tissue in the urethra, for any surgery aimed at improving prostatitis to be effective.

The patient may not need antibiotics, if they are diagnosed with chronic pelvic pain syndrome. Frequently, physicians have difficulty trying to decide whether a patient has bacterial or nonbacterial prostatitis. This is because of the difficulties in obtaining a specimen and, sometimes, previous antibiotic therapy obscures the diagnosis. An organism that responds to antibiotics, but is difficult to diagnose may also cause chronic pelvic pain syndrome. For these reasons, antibiotics may be prescribed, at least initially, even when a definitive diagnosis of bacterial prostatitis has not been made with the appropriate tests. Your response to the antibiotic therapy will decide whether or not it should be continued. Many patients without a true infection may feel better during antibiotic therapy because many antibiotics have direct anti-inflammatory effects. Depending on your symptoms you may receive one of a variety of other treatments. These may consist of alpha-blockers, anti-inflammatory drugs, muscle relaxants, plant extracts (quercetin and/or bee pollen) and repetitive prostatic massage (to drain the prostate ducts).

Various heat therapies, biofeedback and relaxation exercises may alleviate some of the symptoms. You may be advised to discontinue some foods (e.g. spicy) and drinks (e.g. caffeinated, acidic) and avoid circumstances (e.g. bicycle riding) that exacerbate the problem. Once a correct diagnosis has been made, one of the best therapies may be that of reassurance that the patient does not have a life threatening condition.

Treatment for aysmptomatic prostatatic inflammation is usually not required.

Why do physicians have trouble diagnosing prostatitis?

The diagnosis of the various types of prostatitis can be very difficult and sometimes quite frustrating for the patient and his physician. The symptoms are variable and there is much overlap in symptoms between the various types of prostatitis. Once the patient has been treated with antibiotics, it can be difficult to differentiate a bacterial prostatitis from chronic pelvic pain syndrome.

How will prostatitis affect a patient?

Prostatitis is an extremely frustrating disease for both the patient and his physician. It can seriously affect a patient’s quality of life. The correct diagnosis of the prostatitis problem is difficult and it cannot always be cured. However, prostatitis is a treatable disease and one can usually get relief from major symptoms by following the recommended treatment.

Why are some patients not cured after they have been diagnosed with prostatitis?

Most cases of acute bacterial prostatitis respond completely to therapy. Unfortunately, the treatment for the chronic prostatitis syndrome is far from perfect. Patients with chronic bacterial prostatitis can have persistence of their infectious problem despite antibiotic use. This is because of the difficulty antibiotics have in penetrating the prostate gland to completely kill all the bacteria deep within the prostatic ducts. Repetitive or frequent prostate massages or use of alpha blockers may be helpful in these cases. The patients who have had chronic bacterial prostatitis and have been cured are susceptible to recurrences. Many patients with chronic prostatitis/chronic pelvic pain syndrome fail therapy. The physician may employ a multi-modal approach to therapy (more than one treatment at a time). Patients may find that they have to learn to live, and cope with their symptoms while the inflammation hopefully “burns itself out.”

What are some of the most important facts about prostatitis?

• Correct diagnosis is the key to the management of prostatitis.
• Prostatitis cannot always be cured but can be managed.
• Treatment should be followed even if symptoms have improved.
• Patients with prostatitis are not at higher risk for developing prostate cancer.
• There is no reason to discontinue normal sexual relations unless they are uncomfortable, usually during an acute phase.
• One can live a reasonably normal life with prostatitis.

When is surgical treatment suggested as a form of treatment?

When medical therapy fails, surgery is required to remove the obstructing tissue. Surgery is almost always recommended for men who are unable to urinate, have kidney damage, frequent urinary tract infections, significant urethral bleeding or stones in the bladder.

What are the different surgical treatments available?

Removal of the prostate can be accomplished in several different ways. The location of the enlargement within the prostate and the patient’s general health will help the urologist determine which of the three following procedures to use.

Transurethral resection of the prostate (TURP): Transurethral resection is the most common surgery for BPH. In the United States, approximately 200,000 people have TURPs performed each year. After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the tip of the penis into the urethra. The resectoscope contains a light, valves for controlling irrigating fluid and an electrical loop that cuts tissue and seals blood vessels. With this instrument, obstructive prostate tissue is removed one piece at a time. The removed tissue pieces are carried by the irrigating fluid into the bladder and then flushed out and sent to a pathologist for examination under a microscope. At the end of the procedure, a catheter is placed in the bladder through the penis. The bladder is continuously irrigated with fluid through the catheter in order to monitor bleeding and prevent blood from clotting and obstructing the catheter. Since there are no surgical incisions with this procedure, patients normally stay in the hospital only one to two days. Depending on surgeon preference, the catheter may be removed while the patient is still in the hospital or the patient may be sent home with the catheter in place, attached to a leg bag for convenience and removed several days later as an outpatient procedure.

Transurethral incision of the prostate (TUIP): Transurethral incision is used for men with smaller prostate glands who suffer from significant obstructive symptoms. Instead of cutting and removing tissue to relieve the obstructed bladder, this procedure widens the urethra by making several small cuts in the bladder neck where the urethra joins the bladder and in the prostate itself. This reduces the pressure of the prostate on the urethra and makes urination easier. Patients normally stay in the hospital one to three days. A catheter is left in the bladder for one to three days after surgery.

Open prostatectomy: When a transurethral procedure cannot be done, open surgery may be required. Open prostatectomy for BPH is also performed for a prostate that is too large to remove through the penis. Other reasons for choosing an open prostatectomy include patients with large bladder diverticula, with large bladder stones and who cannot physically tolerate having their legs placed in stirrups for TURP/TUIP surgery.

An incision is made in the abdominal wall from below the belly button to the pubic bone. The prostate gland can then be removed in its entirety through either an incision in the fibrous capsule surrounding the prostate (retropubic prostatectomy) or through an incision made in the bladder (suprapubic prostatectomy). Postoperative pain is mild to moderate. Patients usually stay in the hospital for several days and go home with a urinary catheter. In some cases a second catheter draining the bladder through the lower abdominal wall is used.

What can be expected after treatment?

Postoperatively, patients typically experience significant improvement in their symptoms (table 1). As with any operative procedure, complications do exist. Some occur in the early postoperative period (table 2) while others may occur many years later (table 3).

Table 1: Overall improvement in patient symptoms

Table 2: Immediate post-operative complications

Table 3: Late post-operative complications

Will surgery for BPH affect my ability to enjoy sex?

Most urologists say that even though it takes a while for sexual function to return fully, most men are able to enjoy sex again. Most experts agree that if you were able to maintain an erection shortly before surgery, you will probably be able to do so after surgery. Most men find little or no difference in the sensation of orgasm although they may find themselves suffering from retrograde ejaculation.

Is BPH a rare condition?

No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

Does BPH lead to prostate cancer?

No, BPH is not cancer and cannot lead to cancer, although both conditions can exist together. There are usually no symptoms during the early stages of prostate cancer, so yearly physical examinations and PSA testing are highly recommended.

Throughout a man’s life, his prostate may grow and start to cause problems as he ages. For many years, a prostatectomy was the only treatment for this very common problem. Although effective, such major surgery requires patients to spend significant time in the hospital and at home in recovery. It also is associated with more side effects. Fortunately, today’s technological advances now provide urologists with an array of minimally invasive techniques to treat BPH. What are some of these new treatments available? The following should help answer that question as well as others.

What is the prostate?

The prostate, a part of the male reproductive system, is about the same size and shape as a walnut and weighs about an ounce. It is located below the bladder and in front of the rectum and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce ejaculatory fluid.

What is BPH?

Benign prostatic hyperplasia (BPH), previously referred to as prostatism, is a common urological condition caused by the non-cancerous enlargement of the prostate gland in aging men.

What are some of the risk factors for BPH?

Risk factors for developing BPH include increasing age and a family history of BPH.

What are some of the symptoms associated with BPH?

Since the prostate surrounds the urethra just below the bladder, its enlargement can result in symptoms that irritate or obstruct the bladder. A common symptom is the need to frequently empty the bladder, especially at night. Other symptoms include difficulty in starting the urine flow or dribbling after urination ends. Also, size and strength of the urine stream may decrease.

How is BPH diagnosed?

In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. The AUA diagnostic system includes a series of questions that target the frequency of the urinary systems identified above, and as a result, helps identify the severity of the BPH—ranging from mild to severe.

There are a number of diagnostic test procedures that can be used to confirm BPH. The tests vary from patient to patient, but the following are the most common: digital rectal examination (DRE), PSA test, transrectal ultrasound, urine flow study, bladder scan for residual urine, and cystoscopy.

What are some of the treatments available for BPH?

Watchful waiting: Is recommended as an important option for men who have mild symptoms and do not find them particularly bothersome. It is the least invasive treatment and avoids the risks, inconvenience and costs of medical and surgical treatments. In some men, symptoms improve over time as long as there are no high-risk symptoms like urinary retention, recurrent urinary tract infection, recurrent blood in the urine, bladder stones, kidney failure or bladder diverticula.

Medical therapy: Today’s most common method for controlling moderate symptoms of BPH. Several medications are available to control moderate symptoms of BPH.

Alpha blockers: These drugs, originally used to treat high blood pressure, work by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and reduce bladder outlet obstruction. Although alpha blockers may relieve the symptoms of BPH, they do not reduce the size of the prostate. They are taken orally, once or twice a day and work almost immediately. Commonly prescribed alpha blockers include: Uroxatral (alfuzosin), Hytrin (terazosin), Cardura (doxazosin) and Flomax (tamsulosin). Side effects can include headaches, dizziness, light-headiness, fatigue and ejaculatory dysfunction.

5-Alpha-Reductase Inhibitors: There are two medications available in this class, dutasteride and finasteride, that work completely different than alpha blockers. In some men, Proscar (finasteride) and Avodart (dutasteride) can relieve BPH symptoms, increase urinary flow rate and actually shrink the prostate. Like all medical therapy, these drugs must be used indefinitely to prevent recurrence of symptoms. This class of medications is best suited for men with relatively large prostate glands. It may take as long as six months to a year, however, to achieve maximum benefits from this drug. Side effects can include impotence, decreased libido and reduced semen release during ejaculation.

What are some of the minimally invasive treatments available for BPH?

Prostatic stent (stenting): Anesthesia is not required for this procedure. The technology involves placing a spring-like contraption inside the prostatic part of the urethra to hold it open. There are many different kinds of stents but their overall use is limited. This is usually best suited for patients who have many medical problems or who are high-risk for surgery. Serious complications include urinary incontinence, dislodgement of stent position, stone formation on the stent with blockage and difficulty removing the stent. Minor complications include urinary frequency and urgency, dribbling of urine, discomfort and light bleeding. Patients with certain conditions are often advised against stent placement including those with strictures (narrowing) in the urethra, urinary infection, bladder stones, weak bladder and cancer, and patients who will be undergoing other procedures performed through the urethra soon after stent placement (e.g., treatment of kidney stones). Generally, prostatic stents are used for the same patients who would otherwise use an indwelling catheter or transurethral microwave thermotherapy (TUMT).

High-intensity focused ultrasound (HIFU): Anesthesia is usually required for this procedure. A special ultrasound probe is placed into the rectum near the prostate. Ultrasound waves heat the prostate up to very high temperatures, which causes destruction to the prostate tissue. The heated prostate tissue is destroyed and initially swells but then shrinks. The need for catheterization due to retention of urine and blood in the urine has been a problem postoperatively.

Holmium laser enucleation of prostate (HoLEP): After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the penis into the urethra. A visual lens and laser are passed through the hollow center of the instrument. The prostate tissue is vaporized using the holium:YAG laser. There is very little bleeding and recovery time is cut significantly. Typically, the patient has a catheter removed the next day and stays overnight in the hospital one day.

Interstitial laser coagulation: Anesthesia is usually required for this procedure, but patients can usually go home the same day. The technology involves placing a “cystoscope” (metal tube through which the visual lens and laser can be passed). A laser is used to pierce through into the prostate and the laser energy burns the tissue. Studies to date have shown limited long term benefits.

Transurethral electroevaporation of the prostate (TUVP): After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the penis into the urethra. An electrode moves across the surface of the prostate and transmits current that vaporizes prostate tissue. The vaporizing effect penetrates below the surface area being treated so underlying blood vessels are coagulated and sealed. Bleeding and fluid absorption are minimal and patients can usually return home without a catheter after an overnight hospital stay.

Transurethral microwave thermotherapy of the prostate (TUMT): This is an office-based procedure performed with topical and oral pain medication and does not require anesthesia. Computer-regulated microwaves are sent through a catheter to heat portions of the prostate. A cooling system is required in some types for better tolerance. Traditionally, the best use of this procedure has been for patients who have too many medical problems for more invasive surgery or for patients who truly wish to avoid any type of anesthesia. Benefits are that there is no need for anesthesia and there is no blood loss or fluid absorption (these would be significant benefits in a person with a weak heart). Patients usually go home the same day. Many urologists have the technology available in their practice and results are pretty reliable regardless of who performs the procedure. The use of TUMT has been expanding to a broader patient population and there are several types of TUMT machines available.

Transurethral radio frequency needle ablation of the prostate (TUNA): The procedure involves anesthesia and medications to make the patient sleepy. The technology involves heating of tissue using radio frequency energy transmitted by needles inserted directly into the prostate. High frequency radiowaves heat the prostate up to very high temperatures. The heated prostate tissue is destroyed and initially swells but then shrinks. Most men require a catheter for a period of time after this procedure. Advantages in the use of TUNA include the limited anesthesia requirement, the ability to perform the procedure in an office setting and avoidance of serious complications sometimes associated with other procedures.

Photoselective vaporization of the prostate (PVP): This is fast becoming a very popular procedure performed either in a well equipped office or as an out-patient at the hospital. It uses a high-powered laser that vaporizes the obstructing prostate tissue with minimal bleeding or side effects. This procedure can serve to get men off of medical therapy. It is effectively replacing more invasive surgical treatment.

Catheterization: Placement of a catheter into the bladder will temporarily drain urine. Catheters can be placed intermittently every six to eight hours—clean intermittent catheterization—or left in place for one to three months at a time (indwelling). Catheters can be placed either through the urethra or by making a small puncture into the bladder above the pubic bone (called a suprapubic tube). Infection is the biggest risk of having a catheter in place for long periods, as bacteria can stick to the surface of the catheter, making it difficult for the body’s immune system or antibiotics to clear the organisms. Another risk is that after a few years there is a higher risk of bladder cancer due probably to the long-term irritation caused by the catheter sitting in the bladder. Catheterization, performed by the individual or a caregiver every six to eight hours, minimizes the risk of infection and cancer compared with an indwelling catheter. Catheters are most useful as a treatment of choice for temporary drainage while waiting for medication to start working, surgery to be scheduled, or clearance of infection. They also might be the most appropriate choice for a patient with multiple medical problems and a short life expectancy, where the risk and discomfort of surgery outweigh the risk of infection or cancer. Catheterization is the treatment of choice over medications or surgery for patients who have neurogenic bladder in addition to prostatic obstruction.

Is BPH a rare condition?

No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

Does BPH lead to prostate cancer?

No, BPH is not cancer and cannot lead to cancer, although both conditions can exist together. There are usually no symptoms during the early stages of prostate cancer; so yearly physical examinations and PSA testing are highly recommended.

Which type of drugs are the best?

To date, there are not enough research data to predict who will respond to medical therapy or which drug will be better for an individual patient.

How do I know if oral medications are the best treatment for me?

If you are diagnosed with BPH, you should discuss all treatment options with your urologist. Together, you can decide whether medication or surgical treatment is best for you.

If I am 65 and healthy with mild urinary symptoms, which is the best treatment for me?

As long as your symptoms are mild, your quality of life is not very affected and you do not have any compelling reason to have invasive surgical therapy right away, you can start with watchful waiting or the medical therapies. If those options are ineffective or your symptoms worsen over time, then minimally invasive therapy or surgical treatment may be the answer.

I am 77 with severe heart disease. My cardiologist tells me we cannot fix my heart. Meanwhile, although I am taking tamsulosin I am still having very bothersome urinary symptoms all night long. Which procedure is the best for me?

Most people can have a PVP without adverse events, but it is much riskier for someone with your medical history. After discussing your options with your urologist, one of the minimally invasive procedures that does not require anesthesia might be a better choice for you, for example, TUMT. Also, a combination of medical therapies may help.

Throughout a man’s life, the prostate may grow and start to cause problems as a man gets older. For many years, surgery was the only relief for this very common problem. Today, medications are the most common method for controlling urinating symptoms of BPH. What are the causes of these symptoms and what are some of the new treatments? The following should help answer that question as well as others.

What is the prostate?

The prostate, part of the male reproductive system, is about the same size and shape as a walnut and weighs about an ounce. It is located below the bladder and in front of the rectum and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce ejaculatory fluid.

What is BPH?

Benign prostatic hyperplasia (BPH) is a common urological condition caused by the non-cancerous enlargement of the prostate gland in aging men. Urinating symptoms can occur as the prostate enlarges.

What are some of the risk factors for BPH?

Risk factors for developing BPH include increasing age and a family history of this condition.

What are some of the symptoms associated with BPH?

Since the prostate surrounds the urethra just below the bladder, its enlargement can result in symptoms that irritate or obstruct the bladder. A common symptom is the need to frequently empty the bladder, especially at night. Other symptoms include difficulty in starting the urine flow or dribbling after urination ends. Also, size and strength of the urine stream may decrease.

How are the urinating symtoms secondary to BPH diagnosed?

In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. This diagnostic system includes a series of questions that target the frequency of the urinary systems identified above, and as a result, helps identify the severity of the BPH — ranging from mild to severe.

There are a number of diagnostic test procedures that can be used to confirm BPH. The tests vary from patient to patient, but the following are the most common: digital rectal examination (DRE), PSA test, transrectal ultrasound (this measures the size of the prostate), urine flow study (this measures the speed and strength of the urinary stream), measurement of how much urine is left after urinating (post-void residual urine) and cystoscopy (a fiber-optic instrument inserted into the urethra to examine both the prostate and the urinary bladder).

What are some of the medical treatments available for BPH?

Alpha blockers: These drugs, originally used to treat high blood pressure, work by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and reduce bladder outlet obstruction. Although alpha blockers may relieve the symptoms of BPH, they usually do not reduce the size of the prostate. They are usually taken orally, once or twice a day and they work almost immediately. Commonly prescribed alpha blockers include: Uroxatral (alfuzosin), Hytrin (terazosin), Cardura (doxazosin) and Flomax (tamsulosin). Side effects can include headaches, dizziness, light-headiness, fatigue and ejaculatory dysfunction.

5-alpha-reductase inhibitors: Finasteride and dutasteride are oral medications that work completely different then alpha blockers. In select men, Proscar (finasteride) and Avodart (dutasteride) can relieve BPH symptoms, increase urinary flow rate and actually shrink the prostate though it must be used indefinitely to prevent recurrence of symptoms. Studies suggest that these medications may be best suited for men with relatively large prostate glands. It may take as long as six months to a year, however, to achieve maximum benefits from this drug. Side effects can include impotence, decreased libido and reduced semen release during ejaculation.

Is BPH a rare condition?

No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

Does BPH lead to prostate cancer?

No, BPH is not cancer and cannot lead to cancer, although both conditions can exist together. There are usually no symptoms during the early stages of prostate cancer, so yearly physical examinations and PSA tests are highly recommended.

Which type of drugs are the best?

To date, there is not enough research data to predict who will respond to medical therapy or which drug will be better for an individual patient.

How do I know if oral medications are the best treatment for me?

If you are diagnosed with BPH, you should discuss all treatment options with your urologist. Together, you can decide whether medication or surgical treatment is best for you.

Throughout a man’s life, his prostate may become larger and start to cause problems as he ages. But what are some of those problems? How do I know if I have BPH? When should I see a doctor? What kinds of tests will my doctor perform? The following should help answer these questions as well as others.

What is the prostate?

The prostate is part of the male reproductive system, is about the same size and shape as a walnut and weighs about an ounce. It is located below the bladder and in front of the rectum, and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce ejaculatory fluid.

What is BPH?

Benign prostatic hyperplasia (BPH), also known as lower urinary tract symptoms (LUTS), is a common urological condition caused by the non-cancerous enlargement of the prostate gland in aging men. As the prostate enlarges, it can squeeze down on the urethra. This can cause men to have trouble urinating leading to the symptoms of BPH.

What are some of the risk factors for BPH?

Risk factors for developing BPH include increasing age and a family history of BPH.

What are some of the symptoms associated with BPH?

Since the prostate surrounds the urethra just below the bladder, its enlargement can result in symptoms that irritate or obstruct the bladder. A common symptom is the need to frequently empty the bladder, sometimes as often as every one to two hours, especially at night. Other symptoms include the sensation that the bladder is not empty, even after a man is done urinating, or that a man cannot postpone urination once the urge to urinate arises. BPH can cause a weak urinary stream, dribbling of urine, or the need to stop and start urinating several times when the bladder is emptied. BPH can cause trouble in starting to urinate, often requiring a man to push or strain in order to urinate. In extreme cases, a man might not be able to urinate at all, which is an emergency that requires prompt attention.

How is BPH diagnosed?

In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. This diagnostic system includes a series of questions that ask how often the urinary symptoms identified above occur. This helps measure how severe the BPH is — ranging from mild to severe.

When a doctor evaluates someone for possible BPH, the evaluation will typically consist of a thorough medical history, a physical examination (including a digital rectal exam or DRE), and use of the AUA BPH Symptom Score Index. In addition, the doctor will generally do a urine test called a urinalysis. There are a series of other studies that may or may not be offered to a patient being evaluated for BPH depending on the clinical situation. These include:

1. prostate specific antigen (PSA), a blood test to screen for prostate cancer
2. urinary cytology, a urine test to screen for bladder cancer
3. a measurement of post-void residual volume (PVR), the amount of urine left in the bladder after urinating
4. uroflowmetry, or urine flow study, a measure of how fast urine flows when a man urinates
5. cystoscopy, a direct look in the urethra and/or bladder using a small flexible scope
6. urodynamic pressure-flow study that tests the pressures inside the bladder during urination
7. ultrasound of the kidney or the prostate

When should I see a doctor about BPH?A man should see a doctor if he has any of the symptoms mentioned previously that are bothersome. In addition, he should see a doctor immediately if he has blood in the urine, pain with urination, burning with urination or is unable to urinate.

Is BPH a rare condition?

No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

Does BPH lead to prostate cancer?

No, BPH is not cancer and cannot lead to cancer, although both conditions can exist together. There are usually no symptoms during the early stages of prostate cancer, and so yearly physical examinations and PSA tests are highly recommended to eliminate cancer diagnosis.

Are there risks in not seeking treatment for BPH?

In the majority of men BPH is a progressive disease. It can lead to bladder damage, infection, blood in the urine, and even kidney damage. It is therefore important for men with this condition to continue to be followed.

Which type of drugs are the best?

To date, there is not enough research data to predict who will respond to medical therapy or which drug will be better for an individual patient. There are a variety of drugs available and, in some men, a combination of drugs may work best.

How do I know if oral medications are the best treatment for me?

If you are diagnosed with BPH, you should discuss all treatment options with your urologist. Together, you can decide whether medication, minimally invasive therapy or surgical treatment is best for you.

Prostate cancer is one of the most common forms of cancer in men. Over 230,000 American men are diagnosed with prostate cancer each year. In recent decades, there has been a steady increase in the incidence of prostate cancer but doctors are making progress in treatment and survival rates are improving. What are its symptoms? How do you know if surgery is the best treatment for you? The following information should help you better understand this condition.

What happens under normal conditions?

The prostate gland is about the size of a walnut. It is located between the bladder and the penis, and surrounds the urethra (the tube that carries urine from the bladder out through the penis). The prostate gland is part of the male reproductive system. The prostate is responsible for the production of semen, the milky white substance which nourishes the sperm. The semen is stored in small pouches, called seminal vesicles, which are attached to the prostate gland.

What is prostate cancer?

Prostate cancer is a disease that affects the cells of the prostate. It occurs when the normal process of cell growth within the prostate becomes abnormal. This causes uncontrolled cell growth resulting in a mass of tissue called a tumor. Like many cancers, the cause of prostate cancer is unknown. But doctors do know that it is more common as men age, in African-American men and men with a family history of the disease. Its growth is also enhanced by the male sex hormone testosterone. Prostate cancer is very common, with every man having a one in six chance of getting prostate cancer within their lifetime. Thanks to widespread knowledge about prostate cancer which has resulted in increased efforts at early detection (prostate cancer screening), about 80 percent of the men who are found to have prostate cancer have a disease which seems to be confined to the prostate and is therefore responsive to treatments, including surgery.

What are the symptoms of prostate cancer?

In its early stages, prostate cancer may not cause any symptoms. But as the cancer grows, the following symptoms may appear: frequent urination (especially at night), problems with urination (inability, weakened flow, pain, burning, etc.), painful ejaculation, blood in urine or semen and/or frequent pain or stiffness in the back, hips or upper thighs.

How is prostate cancer diagnosed?

Ideally, prostate cancer should be detected when it is so small that there are no symptoms. Early detection can be achieved by a digital rectal examination (DRE) and a PSA test. If either the DRE and/or the PSA is abnormal, a prostate biopsy is recommended. This biopsy uses an ultrasonic probe that is inserted into the rectum and a biopsy needle that is directed into various areas of the prostate gland. Believe it or not, this procedure is relatively painless and does not require hospitalization.

Once prostate cancer has been diagnosed by a prostate biopsy, the physician seeks to stage the disease; that is, to determine the extent of the cancer (i.e., the “T” stage) and whether it has spread to the lymph nodes and/or the bones. The clinical T stage is determined by the DRE and can be divided into the following categories:

T1a: Cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement. Cancer is present in less than 5% of the tissue removed

T1b: Cancer is found after TURP but is present in more than 5% of the tissue removed

T1c: Cancer is found by needle biopsy that was done because of an elevated PSA

T2: Doctor can feel the tumor when a digital rectal exam (DRE) is performed but the tumor still appears to be confined to the prostate

T2a: Cancer is found in one half or less of only one side (left or right) of the prostate

T2b: Cancer is found in more than half of only one side (left or right) of the prostate

T2c: Cancer is found in both sides of the prostate

T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles

T3a: Cancer extends outside the prostate but not to the seminal vesicles

T3b: Cancer has spread to the seminal vesicles

T4: Cancer has spread to tissues next to the prostate (other than the seminal vesicles), such as the sphincter, rectum and/or wall of the pelvis

To determine if the cancer has spread to the lymph nodes or bones, the physician may order a CT scan of the pelvis, an MRI of the pelvis, and/or a bone scan.

In addition to clinical staging, the physician seeks to determine the so-called “aggressiveness” of the cancer. This is done in two ways. The first way is by determining the grade of the cancer; that is, how “angry” it looks under the microscope. Briefly, the most popular prostate cancer grading system is the Gleason system. Each area of cancer in the biopsy is assigned a Gleason grade between 1 and 5. The two most common Gleason grades within a biopsy are added together to give the Gleason score which is designated between two and 10. Gleason scores of two to four designate well differentiated cancers that tend to be slow growing. Gleason scores of five or six are moderately differentiated while Gleason scores of seven to 10 are poorly differentiated. The second sign of aggressiveness is the PSA level before biopsy. In general PSA levels less than 10 are ideal, levels between 10 and 20 are somewhat worrisome for more extensive disease while levels greater than 20 are worrisome though cure is still sometimes possible.

What is a radical prostatectomy?

A radical prostatectomy is the removal of the entire prostate, the seminal vesicles, and the tissue immediately surrounding them. Because prostate cancer may be scattered throughout the prostate gland in an unpredictable way, the entire prostate must be removed so that cancer cells are not left behind. The pelvic lymph nodes, small oval or round bodies located along vessels that filter lymphatic fluid, are usually the first site of any spread of the cancer beyond the prostate gland. Normally, these lymph nodes are also removed during the operation. Fortunately, you have many other lymph nodes, so your body will not miss these few.

When is surgery the best treatment for prostate cancer?

In general, prostate cancer surgery is best performed in patients with clinical stage T1 or T2 prostate cancer (confined to the prostate gland) and in selected men with clinical stage T3 disease. While there are no absolute cut-offs, men with a PSA level less than 20 and a Gleason score of less than eight have a higher likelihood of cure. In certain circumstances, patients with more serious parameters are offered surgery. Finally, prostate cancer surgery is usually restricted to men who have a 10-year or more life expectancy. Life expectancy is assessed by both patient age and health.

What are some risk factors associated with prostate cancer surgery?

Radical prostatectomy has the potential for both early and late complications. Early complications occur either at the time of surgery or shortly thereafter. Bleeding can occur in any major operation including radical prostatectomy. Some surgeons will recommend that the patient donate their own blood before surgery or to receive a hormone (epogen, EPO) that boost the patient’s blood count to reduce the risk of the patient requiring blood from an anonymous donor. Injury to nearby structures like the rectum and ureters (tubes that drain urine from the kidney to the bladder) is uncommon. Infection in the incision site and/or urinary tract is also rare. Lastly, deep venous thrombosis (blood clot) and pulmonary embolism (blood clot that goes to the lung) occur in approximately 2% of patients after radical retropubic prostatectomy.

Long-term complications after surgery are primarily urinary incontinence (urine leakage) and erectile dysfunction (impotence). Short-term incontinence after radical prostatectomy is common. Many men will require a protective pad for several weeks to months after surgery. Fortunately, most men will recover urinary control. Long-term (after 1 year) incontinence is rare with occurrence in less than 5 percent of all surgical cases. However, when it does occur, there are procedures that can solve the problem.

Erection of the penis occurs because of the stimulation through the cavernous nerves, which send signals to dilate the blood vessels in the penis, allowing it to fill with blood and become rigid. The two nerve bundles responsible for erection run along either side of the prostate, only a few millimeters away from the area where prostate cancer most commonly arises. Although preserving these nerves at the time of surgery is always possible, it is not always wise. The less tissue removed around the prostate, the greater the chance that cancer cells will remain. Since the primary goal of the operation is to remove all of the cancer, one or both of these nerves may have to be completely or partially resected. Unless both nerves are resected, the chance of recovering erectile function exists, but recovery may be slow. The average time until recovery of erections sufficient for intercourse is four to nine months, but in some men it takes longer. Erections usually improve with time, for as long as two to three years after the operation, because nerve fibers recover slowly. Of course, the operation will not make your erections better than they were before surgery, even if both nerves are spared. Even with full recovery, most men find the erections are a bit less firm and durable than before surgery. Younger men recover sooner than older men and those with stronger erections before the operation have a better chance of recovery than if the erections were weak.

Impotence, if experienced post-surgery, can also be treated by a variety of medications and/or technical devices like penile prostheses.

What are the different types of prostate cancer surgery?

Retropubic prostatectomy: During this procedure, the surgeon makes an incision through the lower abdomen that is about 3 to 4 inches in length. The surgeon can remove the prostate, surrounding tissue and pelvic lymph nodes (if necessary).

Perineal prostatectomy: During this procedure, the surgeon removes the prostate through an incision in the skin between the scrotum and the anus. In general, the perineal surgery is a little easier on the patient, but it may be somewhat inefficient if the cancer is serious and the lymph nodes need to be examined before the prostate is removed.

Laparoscopic prostatectomy is a type of ‘minimally-invasive’ surgery that uses several small incisions rather than one larger incision to remove the prostate. Through the small incisions surgical instruments, including a camera, are inserted. The camera allows the surgeon to view inside the abdomen and perform the surgery. Because the surgery uses smaller incisions, the patient may experience less pain and scarring and a faster recovery than with the retropubic approach. This procedure is technically demanding and requires a surgeon with special training to perform the operation successfully.

Robotic-assisted laparoscopic prostatectomy is similar to laparoscopic prostatectomy but rather than the surgeon directly holding the instruments, a robot serves as an interface between the surgeon and the instruments. Advantages for the patient are similar to laparoscopic surgery.

What can be expected after surgical treatment?

At the time of surgery, the urinary tract is sutured back together over a catheter, a thin flexible tube to drain urine. This gives the anastomosis, or union between the bladder and the urethra, time to heal completely. The catheter will remain in place for one to two weeks after the surgery. The catheter is removed on a return visit to the surgeon’s clinic, and exercises (called Kegel exercises) are begun by the patient to strengthen the urinary control valve. Urinary control (continence) can be immediate but usually takes several weeks to months to recover.

One or two suction drains are left beside the bladder, deep in the pelvic cavity, to drain any fluid that accumulates. The drains will exit from a small incision in your lower abdomen (or pelvic area). They help to decrease the risk of infection and pressure from fluid in the operated area. The drains are usually removed before you are discharged from the hospital.

While in the hospital, the patient begins his physical recovery. After the operation you will be in the Post-Anesthesia Care Unit (PACU) for a recovery period of several hours. You can have ice chips and water as soon as you are fully awake. Family members may also visit you in the PACU. You will be taken to your hospital room after the recovery period.

Fluids will be given to you through an intravenous (IV) line in a vein. The IV line will remain in place until you can tolerate fluids and food by mouth and you begin to eat a regular diet. You can progress to a clear liquid diet that evening or the next morning after the surgery. When your intestinal activity begins to recover, about 24 - 36 hours after the operation, you can eat solid food. Most people do not pass flatus (intestinal gas) for one to two days and do not have a bowel movement for four to five days. The goal during the first few days after your operation will be to prevent the breathing and circulation problems that can develop after any surgery. You must walk at least three to four times a day to help your breathing and circulation.

After the surgery, the surgeon reviews the final assessment of the removed prostate and (if applicable) the lymph nodes. Based on this “final pathology,” a follow-up plan is developed. If the pathology is especially serious (e.g., spread to the seminal vesicles or lymph nodes) additional therapy may be recommended. This may include radiation therapy and/or hormone treatment. If the pathology is not especially serious, the follow-up plan entails regular visits to a physician and a regular PSA test. The PSA level should be non-detectable.

Erectile function may recover soon after the operation or may take up to one year to return. Usually, if erections are not sufficient for intercourse at one month, additional therapies are used until the erections become sufficient. One does not lose the ability to have an orgasm. However the orgasm is “dry”—very little (if any) ejaculation comes out—so the ability to procreate is generally lost.

When can I resume normal activity after the surgery?

The time varies, but usually it is between three to six weeks.

Will I know if I am cured after surgery?

Not completely and it certainly varies depending on the severity of the cancer removed. In general, one must have PSA test values of less than 0.1 ng/ml for ten years before cure is certain.

I worry about potency but I am most afraid of incontinence. What are the odds?

That depends mostly on the surgeon and his/her experience. But age and your current level of continence and potency are also key factors. Usually, incontinence is temporary and does not last long although it can persist for as much as six to twelve months. With more experienced surgeons, the risk of permanent incontinence is rare after prostate cancer surgery.

Radiation therapy is used in a variety of settings to treat prostate cancer. Many prostate cancer patients are benefiting from radiation therapy techniques that decrease side effects and may lead to higher cure rates. What technique is appropriate for you? What are the risks? The following information should help answer these questions and prepare you to discuss radiation therapy with your urologist and/or oncologist.

What is radiation therapy?

Radiation therapy, also sometimes referred to as radiotherapy, is a general term used to describe several types of treatment, including the use of high-powered X-rays, placement of radioactive materials into the body or injection of a radioactive substance into the bloodstream. These various types of radiation treatments are used in a wide range of settings. These circumstances include primary treatment of localized prostate cancer, secondary treatment for cancer recurring within the region of the prostate and for relief of pain and other symptoms related to prostate cancer that has spread to other parts of the body.

What are the different types of radiation therapy?

External beam radiation therapy (EBRT): This is the most commonly used type of radiation therapy. The emergence of EBRT as a treatment for prostate cancer occurred in the 1950s with the development of high-powered X-ray machines called linear accelerators. Linear accelerators produce very powerful X-rays that penetrate deep into the body. These X-rays destroy tumor cells by damaging their DNA. Just as with a diagnostic X-ray, there is a brief exposure to the radiation, typically lasting several minutes. Once the treatment is over, there is no radiation in the patient’s body. The treatment is completely non-invasive, so there is no discomfort to the patient during the delivery of the radiation. EBRT is typically given once per day, five days per week. Primary treatment for localized prostate cancer usually requires about eight weeks of treatment.

Brachytherapy: Is also referred to as  “seed therapy” or a “prostate implant.” Brachytherapy involves the insertion of a radioactive material, commonly referred to as a source, into the body. Attempts to treat prostate cancer by placing radioactive materials into the prostate date back to the early 20th century. However, the lack of a reliable way to ensure that the radioactive materials were placed in their desired locations limited the use of brachytherapy to treat prostate cancer. In the 1980s, a technique was developed using ultrasound to guide the placement of tiny radioactive “seeds” into the prostate. This technique was first made available in the United States in the late 1980s.

There are two approaches to brachytherapy for prostate cancer: low-dose rate (LDR) and high-dose rate (HDR). Prostate brachytherapy is most commonly performed using the LDR technique. With LDR brachytherapy, the seeds are permanently placed into the prostate. The radiation is given off gradually over a period of months. HDR brachytherapy involves the temporary placement of a highly radioactive source into the prostate. The radiation treatment is given off over a period of minutes and typically repeated two or three times over the course of several days. Both LDR and HDR brachytherapy may be combined with EBRT.

An ultrasound study may be performed prior to the day of the procedure to ensure there are no bones interfering with the placement of needles into the prostate. The ultrasound probe is placed into the rectum to obtain pictures of the prostate and surrounding structures. This study is commonly referred to as a transrectal ultrasound (TRUS). The information obtained from the TRUS can also be used to generate a road map for seed implantation. Ultrasound imaging is typically used to define the prostate although newer approaches using CT scan or MRI may be used.

The LDR seed implant procedure is performed under anesthesia. Radioactive seeds (which are smaller than a grain of rice) are loaded in individual needles that are passed into the prostate gland through the skin between the scrotum and anus. As the needles penetrate the prostate they are seen on a monitor and can be accurately guided to their predetermined position. Once the position of the needle in the prostate matches the intended position the needle is withdrawn leaving the seeds behind in the prostate. The radioactivity of the seeds slowly decays during the months after the operation, and there are few long-term risks associated with this treatment.

Alternatively, HDR brachytherapy may be utilized to place a highly radioactive source temporarily into the prostate. Hollow plastic tubes called catheters are pre-positioned in the prostate using a technique similar to LDR brachytherapy. The patient is then awakened and typically two or three treatments are given over the next several days after which the catheters are removed. A remote control device is used to move the radioactive material, which rests for a calculated period of time at various positions within each catheter. A computerized treatment-planning program is used to determine the required time the radioactive material must stay at each position and the sequential positioning of the radioactive material at each location needed to achieve coverage of the prostate with the prescribed radiation dose.

Radionuclide therapy: Radioactive substances may also be used for treatment of prostate cancer that has spread to the bones. These radioactive drugs, known as radiopharmaceuticals or radionuclides, are injected intravenously (IV). These radionuclides are absorbed by the bones. The radiation given off is weak and does not penetrate very far into surrounding tissues and organs. A single injection is given in the doctor’s office after which the patient may return home. Additional injections may be given after a period of a few months once the effects of the prior injection have diminished.

What are some of the side effects of radiation therapy?

External beam radiation therapy (EBRT): The principal side effects of EBRT are related to the treated area. Common side effects of EBRT for prostate cancer include increased urinary frequency; mild burning with urination; weakened urinary stream; bowel irritability including mild diarrhea, gas, bowel urgency and tenderness; mild irritation of the skin around the rectum; lower blood counts; and fatigue. Diet modification and medication may be used to manage symptoms. Within one or two months following completion of treatment, most men notice that symptoms disappear. If changes in bladder or bowel function persist, they are typically mild. About 20 percent of men, however, do experience more significant long-term bowel irritability. Relatively rare complications include significant rectal bleeding, bladder irritability and urethral stricture. The loss of sexual function is also a relatively common side effect of radiation. However, the risk of erectile dysfunction (ED) following radiation varies widely, depending on use of other treatments such as hormonal therapies and the presence of other medical conditions that may affect sexual function.

Brachytherapy: Like EBRT, urinary irritation effects are very common. Obstructive symptoms including difficulty with urination are somewhat more common, however, as the prostate usually swells due to the insertion of needles into the prostate for the procedure. Approximately 5 to 15 percent of men will experience complete urinary obstruction within several weeks of the procedure requiring use of a catheter. Usually this problem disappears within weeks as the swelling subsides. Since the radioactive seeds are placed directly into the prostate, short-term bowel side effects are also relatively uncommon. However, as the front part of the rectum lies close to the prostate, over time bowel side effects similar to those of EBRT may occur. As with other radiation treatments, erectile dysfunction may occur.

Radionuclide therapy: The principal side effect of radionuclide therapy is a decrease in blood counts following treatment. Serious side effects including infection and bleeding are fortunately rare. However, an increase in pain may occur in the first several days or weeks after radionuclide therapy but can be managed with increased use of pain medications until the therapy begins to have its desired effect.

Which treatment is appropriate for each stage of prostate cancer?

In order to guide patients in choosing an appropriate treatment, doctors depend in part on an understanding of prognostic factors that suggest how extensive or aggressive the cancer may actually be. Such factors include digital rectal examination (DRE), PSA test, Gleason score and biopsy. Given the impact on prognosis that each of these factors may have, a combination of these factors is often more useful in understanding the potential for treatment success or failure than the use of any one factor alone. Within the realm of clinically localized cancer, a combination of these factors may be used to categorize patients as “low risk,” “intermediate risk” and “high risk” in terms of treatment failure. It is important to note that while prognostic factors are helpful in guiding treatment choices, there is no “cookbook” for selection of treatment, and other factors including age, overall health, urinary and bowel function and each patient’s own concerns about treatment need to be taken into account. Therefore, a thorough discussion with an individual’s urologist and oncologist is an important part of the decision-making process.

Prostate cancer that has not spread outside the immediate area around the prostate is often referred to as clinically localized cancer. An important distinction within the realm of clinically localized cancer is between prostate cancers confined to the prostate, referred to as organ-confined disease, and prostate cancer that has spread directly outside the prostate or into the seminal vesicles. The term “clinical” is applied to the setting where the determination that cancer has not spread to other sites, including lymph nodes or distant tissues and organs, is based on the findings of physical exam and diagnostic imaging tests that may include CT scan, MRI and/or bone scan. Proof of cancer stage is only obtained by invasive procedures such as surgical removal of the prostate or biopsy.

Treatment of low-risk clinically localized prostate cancer: The “low-risk” category generally includes patients with T1 or T2a cancer (normal examination or small abnormality limited to one side of the prostate), PSA less than 10 ng./ml. and/or Gleason grade less than or equal to six. These men are the most likely to have cancer confined to the prostate. Treatment options may include radical prostatectomy, external beam radiation therapy (EBRT), prostate brachytherapy or in certain circumstances observation. Given that almost all men with early detection of prostate cancer are without symptoms, the impact that treatment may have on quality of life is an important consideration.

Treatment of intermediate-risk clinically localized prostate cancer: The “intermediate-risk” category generally includes patients with bulky T2a disease, PSA greater than 10 ng./ml. but less than or equal to 20 ng./ml. and/or Gleason grade seven. In addition, recent studies have suggested that the extent of tumor on biopsy, often referred to as “percent positive biopsies” may help sort out which men in this category have outcomes more similar to the low or high-risk group. Men with just a little cancer found on biopsy might have outcomes more in line with low-risk patients while men with extensive cancer may be at greater risk for treatment failure. Overall, many men in this category may still have cancer confined to the prostate or along the edge of the prostate. The risk of spread outside the prostate is greater, however, than that for men with all low-risk features.

Given the many nuances in the presentation of intermediate-risk disease a number of treatment options may be appropriate. These options may include radical prostatectomy, EBRT, prostate brachytherapy or a combination of EBRT and brachytherapy. Androgen suppression therapy, commonly referred to as hormonal therapy, may also have a role in treatment of intermediate-risk prostate cancer when combined with radiation. While in men with high-risk prostate cancer the role of hormonal therapy with radiation is now established, the role in treatment of intermediate-risk prostate cancer remains to be fully defined. The results of two large clinical studies now completed are awaited in the next several years and hopefully will provide answers. In the meantime, a large study of previously treated patients at the Dana-Farber Cancer Institute did suggest a benefit to the addition of six months of hormonal therapy to EBRT in this patient group and therefore at least warrants consideration when radiation therapy is used.

Treatment of high-risk clinically localized prostate cancer: The “high-risk” category includes men with any of the following features: T2c, T3 or T4 disease (abnormal examination on both sides of the prostate or cancer that has spread outside of the prostate as determined by digital rectal examination), PSA greater than 20 ng./ml. and/or Gleason grade between eight and 10. Men in this category have a substantial risk of spread of cancer outside of the prostate. Nevertheless, some men in this category do have cancer confined to the prostate and therefore local treatment including prostatectomy may be appropriate. In men deemed to be at greater risk for disease spread, the most standardized radiotherapeutic approach to treatment is the combination of EBRT and hormonal therapy. Other treatments, including combination of EBRT and brachytherapy with or without hormonal therapy, may be considered but the long-term results of newer approaches remain to be fully defined. Two national studies started in the 1980s in the United States and a third large study in Europe all showed benefit to the use of hormonal therapy when combined with EBRT in men with various high-risk features. The European study was the first to show an overall survival benefit to the addition of hormonal therapy to radiation. Early results of another study indicate a benefit to longer duration hormonal therapy in men with high-risk prostate cancer. The use of chemotherapy in this group of men remains to be defined and is now the focus of a few national studies. Given the variety of presentations within the high-risk group, the right treatment for any given individual needs to be carefully considered in consultation with a urologist and/or oncologist.

Should radiation therapy be used as treatment following surgical removal of the prostate (prostatectomy)?

External beam radiation therapy (EBRT) may be used following prostatectomy when there is concern that cancer may remain in the region of the prostate. The use of radiation in this setting to destroy residual cancer has been sporadic for many years but only in the past five to 10 years has this approach started to gain widespread acceptance. The possibility of success with radiation following prostatectomy depends on the likelihood that any remaining cancer is confined to the region of the prostate where radiation is aimed. Therefore, the success rate varies widely depending on the presentation at the time treatment is contemplated. Diagnostic studies may be helpful but unfortunately no test can exclude the possibility of microscopic spread of the cancer. The physician must therefore assess a number of factors including the pretreatment prognostic factors, pathological findings at the time of prostatectomy and the post-surgical PSA history in determining which patients are most likely to have localized cancer versus cancer that has spread (metastasized).

How successful is radiation therapy in the treatment of metastatic cancer?

Radiation is often an effective treatment for preventing or managing symptoms of prostate cancer that has spread. External beam radiation therapy is typically very helpful in decreasing or relieving pain related to prostate cancer that has spread to the bones. A short course of therapy usually no longer then two weeks is sufficient in most cases. In other cases, radiation may be used to prevent debilitating symptoms related to the uncontrolled spread of cancer near critical organs or tissues.

How do I know if radiation therapy is the right treatment for me?

Talk to your urologist and/or oncologist. Every tumor is different, and it is important that your doctor evaluate all aspects of your tumor (such as localization, size, position) in order to prescribe the best treatment.

Will radiation therapy affect my sexual function?

Possibly. The risk of erectile dysfunction following radiation varies widely, and is dependent on the use of other treatments – such as hormonal therapy – and other medical conditions (such as diabetes and heart disease) that may affect sexual function.

Since the doctors aren’t removing my tumor, how will I know if it’s gone?

Followup testing is very important in order to be sure that the tumor has been killed. You may require regular ultrasound, a PSA test or a digital rectal examination to be sure that the cancer has not recurred. Sometimes, you may require additional treatment if the initial radiation does not work.