Disorders of the Prostate

1. Disorders of the Prostate

2. Overview • According to the American Cancer Society, the prostate gland, which is about the size of a walnut, is the 2nd most common site of cancer in men, and it is estimated that more than 200,000 men will develop prostate cancer this year. • Even more heartbreaking, the American Cancer Society projects approximately 40,000 men will die this year from prostate cancer.

3. Overview • Today, an estimated 12 million American men have some problem with their prostate. • By age 60, 50% of all men suffer from prostate problems. • By the time a man reaches 85, he has a 90% to 95% chance of having to cope with an enlarged prostate, referred to as benign prostatic hypertrophy (BPH).

4. What is the prostate gland? • It’s a small gland that is part of the male reproductive system. • The prostate muscles surrounding the gland squeeze it to secrete fluid into the urethra that helps transport and nourish the sperm. • Problems arise not because of the gland itself, but because of its location.  Just below the bladder, next to the rectum, the urethra runs through the middle of the prostate and penis and out of the body.

5. Problems of the Prostate Gland • Sometimes the prostate swells or enlarges, which squeezes the urethra like a pinched straw. (benign prostatic hypertrophy). • This squeezing action cuts off the flow of urine, causing backup that can damage the kidneys.  • Other times, bacteria can flow up the urethra, under the prostate, and cause painful inflammation (prostatitis).

6. What are the most common prostate problems? The three most common prostate problems are: • Prostatitis • Benign prostate hypertrophy (BHP) • Prostate cancer

7. What can men do to prevent prostate problems? • Most experts agree that there is very little men can do to prevent the "big 3" prostate problems. • However, be aware of the problems when they first develop and try to treat them before they get out of hand.

8. Treatment of Prostatitis The mainstay of treatment is antibiotics.  Other treatments in conjunction with antibiotics are: • Anti-inflammatory medications • Muscle relaxants • Stress management • Warm baths • Alcohol dietary changes (for example the avoidance of caffeine, alcohol, and spicy foods)

9. Why Does BPH Occur? • Although there is no precise reason for prostatic enlargement, experts think that the stimulation produced by male sex hormones plays a key role. • As a man grows toward middle age his prostate grows.  It continues to grow in size as long as the man is alive.  The prostate is a very little gland in young boys.  It grows to the size of a nickel in diameter as boys turn into adults. 

10. Why Does BPH Occur? • Normally it remains stable for the next 25 to 30 years, and then begins to enlarge, sometimes to the size of an orange.  This enlargement is believed to be due to hormonal changes. • The specific cause is still being debated.  Whatever the reason for BPH, it is an inevitable result of aging -- there are currently no measures to take to prevent it. 

11. Symptoms of BPH • The problem with BPH is that the enlarged prostate can press on a man's urethra, causing difficulty in urinating. • Some men wake up two or three times during the night just to urinate, but are unable to empty their bladders. • Some may strain so hard that they give themselves a hernia (rupture). • A very serious problem occurs when a man is totally unable to void urine (retention) and it builds up in the bladder.

12. Treatment Options for BPH • The most common means for treating BPH is with a transurethral resection of the prostate (TURP).  In this procedure, a urologic surgeon inserts a catheter into the urethra and then uses a tiny looped wire to shave excess prostate tissue from the blocked portion of the urethra in the center of the gland.

13. Treatment Options for BPH Recently a number of non-surgical options have been introduced, namely: • The shrinking agent PROSCAR (finesteride), a drug that shrinks the prostate by interfering with the conversion of the male hormone testosterone into a hormone that causes prostate enlargement.  Early studies report that it can shrink the prostate in most men by about 25% to 30%.  However, it is too new to know how long the results will last.

14. Treatment Options for BPH • Blocking agents, such as Hytrin and Cardura, can relax the smooth muscle areas lining the urethra, which can go into spasms when the prostate enlarges.  Those drugs benefit some BPH patients with mild to moderate symptoms so long as there is no sign of cancer.

15. Treatment Options for BPH • Hyperthermia, laser, and prostatic stents are investigational and may prove to be useful in the future. • Balloon dilation of the prostate has not provided the lasting results that were anticipated, and therefore is being used infrequently and in select cases only.

16. Prostate Cancer

17. There are No Warning Signs or Symptoms of Early Prostate Cancer!

18. Once a malignant tumor causes the prostate gland to swell significantly, or spreads beyond the prostate, the following symptoms may be present: • A frequent need to urinate, especially at night. • Difficulty starting or stopping the urinary stream. • A weak or interrupted urinary stream. • A painful or burning sensation during urination or ejaculation. • Blood in urine or semen. These are not symptoms of the cancer itself. Instead, they are the symptoms of the blockage from the cancer growth within the prostate and surrounding tissues.

19. Symptoms of advanced prostate cancer include: • Dull, incessant deep pain or stiffness in the pelvis, lower back, ribs or upper thighs; arthritic pain in the bones of those areas. • Loss of weight and appetite, fatigue, nausea, or vomiting.

20. Screening for Prostate Cancer • Men aged 50 years and older should undergo a yearly digital rectal examination and blood testing for prostatic specific antigen (PSA). • Men in the high-risk group, such as those with a family history of prostate cancer or of African American ethnicity, should begin screening as early as age 40 years.

21. Predicting and Monitoring Advanced Prostate Cancer Prostate cancer is a complex disease. Doctors cannot always predict how fast or slow it will grow. Nor do they agree on when to treat it, or which treatments to use. Predicting and monitoring the disease with accuracy help doctors and patients make decisions that result in the best survival rates and quality of life.

22. Evaluation of Several Factors to Determine Aggressiveness • These "markers" identify whether the cancer is low risk, intermediate risk, or high risk. • Low-risk prostate cancer is slow growing and not likely to spread quickly. • High-risk prostate cancer is aggressive, meaning it is likely to spread quickly outside the prostate.

23. Commonly Used Markers for Prostate Cancer Include: • Prostate-specific antigen (PSA) levels • PSA velocity • Gleason score

24. Prostate-specific antigen (PSA) levels PSA is a substance produced by the prostate gland. It is normal to secrete small amounts of PSA into the bloodstream. But larger amounts of PSA in the bloodstream usually signal that the prostate gland is enlarged, infected, or diseased. According to the National Cancer Institute, a PSA level of between 0 and 2.5 is low; 2.6 to 10 signals a slightly to moderately elevated level; 10 to 19.9 is moderately elevated; and 20 or more is significantly elevated

25. PSA Velocity PSA velocity: Several studies indicate that when PSA levels increase sharply in the months before surgery, the cancer is likely to be aggressive.

26. Gleason Score The Gleason score "grades" tumors on the basis of how abnormal they look when the tissue is examined under a microscope. The more abnormal they look, the more likely they are to grow fast and to spread to other parts of the body. A grade of less than 4 generally means that cancer cells look similar to normal cells. Grades 5 to 7 fall under the intermediate range. Grades 8 to 10 indicate aggressive growth.

27. The stages of prostate cancer refer to the cancer size and how far it has spread: Localized Prostate Cancer: At this stage, the tumor is confined to the prostate. It cannot be felt, nor can it be seen via imaging techniques. This as stage I prostate cancer. Disease that is more advanced, but still remains within the prostate, is considered stage II prostate cancer.

28. The stages of prostate cancer refer to the cancer size and how far it has spread: Regional Prostate Cancer: The tumor has grown through the prostate capsule, either into the seminal vesicles (a pair of glands next to the prostate) or into nearby muscles and organs. This stage III prostate cancer.

29. The stages of prostate cancer refer to the cancer size and how far it has spread: Metastatic Prostate Cancer: The tumor has spread to the pelvic lymph nodes or more distant parts of the body. Metastatic cancer frequently spreads to the bones. This is stage IV prostate cancer.

30. Other Factors to Determine the Patient’s Best Treatment Options Doctors also look at the general health of a patient, his age, and any (other illnesses) as well. It's also important that doctors learn patients' wishes and concerns. Learning what's important to patients should be part of the treatment decision process.

31. Treatment for Prostate Cancer Treatment for prostate cancer may include everything from "watchful waiting" to removal of the entire prostate gland.

32. Treatment options for early-stage/low-risk prostate cancer are: • Surgery • Cryotherapy – minimally invasive • Radiation therapy– minimally invasive, either external beam radiation or radioactive tumor seeding (brachytherapy) • Active surveillance, also known as expectant management or watchful waiting, a form of close patient management

33. Cryotherapy • CryotherapyWith cryotherapy, thin needles are inserted into the prostate. Extremely cold gases flow through the needles forming ice balls at the tips of the needles, literally freezes the prostate, eradicating the cancer. Cryotherapy reduces the pain, risks, and long recovery times associated with surgery. Most patients are mobile the same day, and many are discharged the same day and return to normal activity within a few days.

34. Cryotherapy

35. Brachytherapy With brachytherapy, small radioactive seeds are implanted into the prostate where they irradiate prostate tissue. Side effects and discomfort are minimal, and the entire procedure usually takes less than an hour. For most patients this is an outpatient procedure and they go home the same day, returning to normal activities a few days later.

36. Other Treatments • Hormone therapy is usually reserved for older men and for treatment of men with more advanced disease. • Chemotherapy plays only a limited role in prostate cancer treatment. It's reserved primarily for the treatment of men with advanced or recurrent prostate cancer that does not respond to hormone therapy.

37. Choice of surgery, radiation, or expectant management may depend on several factors: • Age and life expectancy • Other serious health problems, such as heart disease • Personal preference, informed by the doctor's opinion, about whether to begin treatment or to wait • Concerns about the side effects common with prostate cancer therapies Side effects may include things that affect lifestyle. For example, erectile dysfunction and incontinence.