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Genito-urinary system

The prostate gland is a small gland located just below the bladder which surrounds the urethra, the tube carrying urine from the bladder to the penis. The prostate gland is only found in males, not in females, and its main function is to store and secrete a fluid that makes up about a quarter of the volume of semen, the fluid that carries the sperm made by the testicles. Contraction of the muscles of the prostate gland also helps during ejaculation, the release of sperm from the penis during the male orgasm.

There are three main conditions that affect the prostate gland. These are:

BPH - Benign prostatic hypertrophy or benign prostatic hyperplasia, are non-cancerous conditions that lead to an enlargement of the prostate gland and which tend to occur after the age of 45. An estimated 1 out of 3 men over the age of 50 is considered to have some degree of prostatic enlargement that interferes with their urinating.

Prostatitis - Inflammation of the prostate gland, through a bacterial infection or other causes, most commonly occurs between the ages of 25 and 45.

Prostate cancer - a malignant or cancerous condition affecting the prostate that usually only affects men over the age of 55, but it can occur much earlier. Around 30,000 men in the UK are diagnosed with prostate cancer each year. Men of Afro-Caribbean or African-American origin are more commonly affected than white men. Prostate cancer is rare among men of Asian origin.

The prostate gland is under the control of the male sex hormone called testosterone. In BPH, the testosterone either leads to an increase in the number of cells in the prostate (hyperplasia), or causes an increase in the size of the cells of the prostate (hypertrophy). In either case, the prostate gland grows in size and, as it does so, it begins to squeeze the urethra that passes through it, making it difficult to pass urine. In older men, calcium deposits in the prostate gland may also contribute to the problem.

Prostatitis is an inflammation of the prostate gland caused either by an infection by bacteria or some other unknown cause. Acute bacterial prostatitis may be caused by a sexually transmitted infection, such as Chlamydia or gonorrhoea, or may be the result of bacteria entering the urethra from the bowel. The causes of chronic prostatitis, the more common form of prostatitis, are not known, but are thought to be increased by stress and anxiety.

Prostate cancer is one of the most common forms of cancer affecting elderly men. It probably occurs as a result of an uncontrolled growth of the cells of the prostate in response to testosterone. It is not known why this should happen, but there does appear to be a genetic link. If there is a history of prostate cancer in close relatives, then the risk of getting prostate cancer are slightly higher. There was once thought to be a link between vasectomy and prostate cancer. Men who had had a vasectomy were once thought to be at greater risk from developing prostate cancer, but this link has not been established and, if there is an increased risk, it is only slight.

Symptoms of BPH and the early symptoms of prostate cancer are similar and they both affect the man’s ability to urinate. These symptoms may include:

• Getting up to go to the toilet at least twice during the night
• Often needing to rush to the toilet
• Sometimes finding it difficult to go and having to push or strain
• A weak or slow urine stream
• An inability or difficulty in stopping the flow of urine
• Bladder never feeling completely empty

In some men these problems can be very bothersome indeed. Symptoms can affect many areas of life, with many men finding it embarrassing to have to spend longer than normal in the toilet. Some of the most common problems can also affect wives and partners, who often find their sleep is disturbed by their partner’s need to get up to go to the toilet at night. Often needing to rush to the toilet may disrupt work or social life.

Symptoms of prostatitis include pain when passing urine or ejaculating, blood in the urine or a discharge from the penis.

Medicines

Treatment depends upon the type of condition affecting the prostate gland.

BPH
In BPH, the aim is to reduce the impact that symptoms have on daily activities and to assist the flow of urine. In mild forms of the condition, this may be achieved by some simple changes in lifestyle. For example, avoiding drinking large volumes of liquid at night, particularly tea, coffee and cola drinks that contain caffeine, may help reduce the urge to get up to go to the toilet during the night.

If these measures do not work, then there are drugs available that can help. These drugs fall into two main types, known as 5-alpha reductase inhibitors and alpha blockers.

5-alpha reductase inhibitors include dutasteride and finasteride. They act by inhibiting the enzyme that is responsible for converting testosterone into a more potent hormone called dihydrotestosterone or DHT. It is the action of DHT that is responsible for the enlargement of the prostate gland. By inhibiting the enzyme, both dutasteride and finasteride have been shown to reduce the size of the prostate gland and so help remove the obstruction to the urethra and restore the normal flow of urine. There is a herbal remedy derived from the palm tree saw palmetto (Serenoa repens, Serenoa serrulata) that has been used in the treatment of BPH. There is evidence to suggest that saw palmetto has a similar mechanism of action to finasteride in that it prevents the formation of DHT and causes shrinkage of the prostate gland. If you have tried this remedy, it is important that you tell your doctor as it can interfere with the diagnosis and treatment of BPH and prostate cancer.

Alpha blockers include alfuzosin, doxazosin, indoramin, prazosin, tamsulosin and terazosin. These drugs all block the nerve activity controlling the muscles in the prostate gland. The muscles relax, loosening the tension that the prostate exerts on the urethra and so helping the flow of urine.

If drug treatment is inadequate, surgery can be used to remove parts of the prostate that are pressing on the urethra. The most commonly performed operation is transurethral resection of the prostate or TURP, where an instrument is inserted through the urethra to remove the obstructing prostate tissue.

Prostate cancer
Prostate cancer can develop very slowly and so late in life in some men that it will not require any form of treatment. In such circumstances, your doctor will examine you regularly and will perform PSA (prostate specific antigen) tests to keep an eye on how fast the cancer is developing and whether it has spread to other areas of the body.

If treatment for prostate cancer is considered necessary, then there are a number of options. Some or all of the prostate gland may be removed surgically by TURP or prostatectomy. Radiotherapy may also be used to destroy the cancer cells in the prostate gland. Hormonal therapy may be used to reduce the amount of testosterone that is stimulating the growth of the cancer cells in the prostate.

Hormonal therapy falls into two main types known as GnRH analogues and anti-androgens.

GnRH analogues include goserelin, leuprorelin and triptorelin. These drugs are given by injection and they work by inhibiting the secretion of another hormone called luteinising hormone that stimulates the testicles to produce testosterone. A fall in the level of testosterone removes the influence the hormone has on the cancer cells, allowing the cancer to regress.

Anti-androgens include flutamide, bicalutamide and cyproterone. These drugs oppose the action of testosterone and so reduce its influence on the prostate cancer cells.

Prostatitis
In prostatitis, antibiotics against the offending bacteria may be used to treat acute prostatitis, or anti-inflammatories may be used to reduce pain and inflammation in chronic prostatitis.

Let your pharmacist know if you are being treated for prostate problems, especially when purchasing over the counter medicines for other illnesses. Certain drugs such as antihistamines used for the treatment of hayfever and other allergic conditions may make urination difficult and make your condition worse. The drugs used to treat prostate problems may also interact with other medicines and it is important that you pharmacist knows what these medicines are to be able to warn you.

If you recognise any of the symptoms listed above, there is no need to suffer in silence. Simple and effective treatments are often available and your doctor may be able to help. Going to see your doctor really is the best thing you can do.

Some men may put off seeing their doctor because they are embarrassed or feel a little uncomfortable discussing this type of problem. Be reassured that these symptoms are common and doctors are used to helping their patients with these types of problems. Worry, due to concern about cancer or the need for surgery, is another factor. However, for the vast majority these symptoms are not caused by cancer and for most men the problems they have can be treated simply and effectively.

Your doctor will ask you about your symptoms and how often you pass urine. Your doctor may perform a digital rectal examination. This is when a doctor inserts a gloved finger into the rectum to feel the prostate gland through the front wall of the rectum. A cancerous prostate feels lumpy or irregular, while an enlarged prostate feels smooth and even. An inflamed prostate may be tender to the touch and a small amount of pus may be discharged from your penis.

If your doctor decides that you have BPH or prostatitis you will probably be prescribed one of the medicines described above.

If your doctor suspects prostate cancer, you may be referred to a specialist (urologist) for further tests, including PSA tests, to confirm any diagnosis.