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Prostate problems

 


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Class
Genito-urinary system
Description
The prostate gland is a small gland located just below the bladder which surrounds the urethra, the tube that carries urine from the bladder to the penis. The prostate gland is only found in males, not in females. Consequently, prostate problems only occur in men.

The main function of the prostate gland 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, also called benign prostatic hyperplasia or enlarged prostate, is a non-cancerous condition that leads to increase in size of the prostate gland which can make it difficult for men to urinate. An estimated 1 out of 3 men over the age of 50 is considered to have some degree of prostate enlargement that interferes with their urinating. (See also separate article on BPH)

Prostatitis - is an infection or an inflammation of the prostate gland. It most commonly occurs between the ages of 25 and 45.

Prostate cancer - is 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.
Causes
Each of the main conditions affecting the prostate gland has its own cause.

BPH - 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.
An increase in tone of the muscles in the prostate gland and at the neck of the bladder increases the gland's grip around the urethra, also obstructing the flow of urine.
In older men, calcium deposits in the prostate gland may contribute to the problem.

Prostatitis - is an infection or an inflammation of the prostate gland, and the condition is described as being acute or chronic. Acute prostatitis is an infection that is usually caused by bacteria such as E. coli entering the urethra from the bowel. In men under the age of 35, a sexually transmitted infection, such as Chlamydia or gonorrhoea, is the main cause of acute prostatitis.
The causes of chronic prostatitis, the more common form of prostatitis, are not known, but it is thought that an initial injury to the prostate triggers an inflammatory reaction that results in an injury to the nerves in the pelvic area. This eventually leads to an increase in the tone of the muscles in the area and causes pain, so the term chronic pelvic pain syndrome (CPPS) may be used.

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.
Men who 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
Symptoms vary according to the type of prostate problem.

BPH and prostate cancer - 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:
  • Difficulty when starting to urinate
  • Urinating for longer or more frequently than usual
  • Needing to urinate again within a short period of time
  • Needing to get up to go to the toilet several times during the night
  • Often needing to rush to the toilet
  • Sometimes finding it difficult to urinate 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


Symptoms can affect many areas of life. Socially, many men find it embarrassing to have to spend longer than normal in the toilet, or if urine leaks and leaves damp patches on the front of their trousers after going to the toilet. Often needing to rush to the toilet may disrupt work or social life. 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.

BPH is a progressive disease and if left untreated may lead to acute urinary retention, a complete inability to urinate.
Prostatitis - Symptoms of acute prostatitis may include high temperature, pain in the pelvic area, pain when passing urine or ejaculating, blood in the urine or a discharge from the penis, urinating frequently and recurring urinary tract infections. Symptoms of chronic prostatitis include genito-urinary pain that may occur with or without symptoms associated with urinating.
Treatment
Treatment depends upon the type of condition affecting the prostate gland.

BPH - In BPH, the aim is to help the flow of urine and reduce the impact that symptoms have on daily activities. In mild forms of the condition, this may be achieved by some simple changes in lifestyle. For example, avoiding drinking tea, coffee and cola drinks late at night 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 5-alpha reductase inhibitors in that it prevents the formation of DHT and causes shrinkage of the prostate gland.
Alpha-blockers include alfuzosin, doxazosin, indoramin, prazosin, tamsulosin and terazosin. These drugs all block the nerve activity controlling the muscles in the prostate gland and at the neck of the bladder. Treatment with alpha-blockers causes the muscles to relax, loosening the tension that the prostate exerts on the urethra and so helping the flow of urine.
As 5-alpha reductase inhibitors and alpha-blockers act in different ways, combinations of both types of drug may also be used to relieve symptoms.
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, the doctor will conduct regular examinations 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 decrease.
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 - Acute prostatitis is treated with antibiotics such as ciprofloxacin, levofloxacin or ofloxacin that are active against the bacteria that are most likely to be the cause of the infection. Alternatively, if a sexually transmitted infection is suspected, antibiotics such as doxycyline or erthyromycin will probably used. Provided the appropriate antibiotic is started promptly, most people make a full and fast recovery.
In chronic prostatitis, anti-inflammatory agents and analgesics may be used to reduce pain. If urinary symptoms are also present, then alpha-blockers (terazosin, prazosin, tamsulosin) may be used to reduce bladder outlet obstruction and so help improve urinating. Combining alpha-blockers with antibiotics may help reduce the risk of recurring prostatitis.
When to see your pharmacist
If you recognise any of the symptoms listed above, there is no need to suffer in silence as your pharmacist may be able to help. Your pharmacist will ask about your symptoms, how long you've had symptoms and whether you are taking any medicines or health supplements to treat the symptoms or any other illnesses. If your pharmacist decides that you have BPH and that you are not taking any other medicines nor have any other medical conditions that could interfere with your treatment, the pharmacist is able to make an initial 2 week supply of tamsulosin, one of the alpha-blockers named above. (See also separate article on BPH)

If you have already been diagnosed with BPH, prostatitis or prostate cancer and are being treated, let your pharmacist know, 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, and decongestants used in cough and cold remedies, may make urinating difficult and make your condition worse. The drugs used to treat prostate problems may also interact with other medicines and it is important that your pharmacist knows what these medicines are to be able to advise you appropriately.

If you have tried saw palmetto as a herbal remedy, it is important that you tell your pharmacist and doctor as this herbal remedy can interfere with the diagnosis and treatment of prostate problems.

If leakage of urine is causing a problem, your pharmacist will also be able to provide advice about the range of absorbent products that are available and which can be used if accidental leakage of urine occurs.
When to see your doctor
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. Seeing a doctor as soon as any differences when urinating are noticed is the best thing to do.

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.
Living with prostate problems
If you have any of the symptoms described above do not be embarrassed about going to see your pharmacist or doctor. It will allow your condition to be diagnosed, help put your mind at rest and, if necessary, allow treatment to begin without delay.

    Coping with urinary problems -
Whichever prostate problem it is, in many cases some simple lifestyle changes can reduce the inconvenience of the urinary problems and help you enjoy everyday life, without the need for treatment.
  • Avoid drinking large volumes of liquid at night, particularly alcohol, tea, coffee and cola drinks. This may help reduce the urge to get up to go to the toilet during the night.
  • Do not rush when you are urinating, take your time to make sure that your bladder is as empty as possible.
  • Avoid situations where it is awkward to use the toilet or where you feel that you will draw attention to yourself if you do go. For example, try to book an aisle seat on trains or planes, or when going to the theatre or cinema.
  • Plan your journeys and make regular stops to go the toilet.
  • If you are taking diuretics for the treatment of heart failure or high blood pressure, ask your doctor if the dosage can be reduced.

  • Avoid cough and cold medicines or hayfever medicines that contain antihistamines or decongestants as these drugs may affect your bladder and make it more difficult to urinate.

  • Try to keep warm when working or walking outside as cold temperatures can increase the urge to urinate.

  • Learn to relax as tension and stress can increase the urge to urinate.

  • If accidents happen and leakage of urine wets your trousers, try using absorbent products such as pads, pouches or drip collectors that are readily available from pharmacies.



Coping with pain - If you suffer from pain, try not to let it get you down. Talk to your doctor or pharmacist if you need pain killers or if you find that your pain killers are no longer helping to control pain. TENS (transcutaneous electrical nerve stimulation), is a small electrical device, readily available from pharmacies that provides a non-drug approach that can be used alone or together with analgesics. Learn to relax and try to enjoy life as anxiety and depression have been found to make pain worse and have been blamed as a cause of chronic pelvic pain syndrome.
Some lifestyle changes may also help:
  • Learn to cope with stress and try to relax
  • Avoid situations that can put pressure on your pelvic area, such as sitting for long periods or cycling
  • Take warm, relaxing baths
  • Try to maintain regular sexual activity as ejaculating helps drainage of the prostate and reduces its size
  • Avoid substances that irritate your bladder, such as alcohol, caffeinated drinks, citrus juices, and hot or spicy foods.
  • Increase fluid intake to several glasses of water a day to urinate often and help flush bacteria from the bladder


Coping with infection - Several weeks of antibiotic treatment may be necessary for acute prostatitis. Even if your symptoms get better during treatment, it is important that you continue to take the full course of antibiotics that have been prescribed. If the full course is not taken, there is a risk that the bacteria causing the infection will develop resistance. This will make it more difficult to treat the infection should it return and it increases the risk of getting chronic prostatitis.

If there is a tendency for your infection to recur, it is important that you maintain long term antibiotic therapy.

Coping with prostate cancer - Your doctor will discuss with you whether or not treatment is necessary for your form of cancer. If treatment is not considered necessary, you will be kept under active surveillance, during which time you will be asked to attend for regular tests. Although you may be apprehensive about these tests, it is important that you keep your regular appointments as these help your doctor determine if your cancer is growing and whether it is likely to cause any symptoms or make symptoms worse.

If treatment is considered necessary, your doctor will explain the different types of treatment available, their benefits and their side effects. Some people find it helpful to take their partner, relative or friend along with them to provide support, to ask questions and to help decide whether they want treatment.

If you do decide to have treatment, you will have regular checks after your treatment has finished to make sure that the cancer has not returned. If you develop any new symptoms, do not wait until the next appointment, but let your doctor know as soon as possible.


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