What tests would give answer to prostate problem?

Q . I am 38 yrs old. I exhibit the classic symptoms of prostate problems (eg poor flow, frequent nocturnal visits, urgency) and have just had a blood test for PSA - I am still awaiting the results which will be available in one week's time. The advice on malehealth.co.uk seems to be that this test is inconclusive in determining either prostate cancer or BPH. I am very worried and would like to know what tests exist that can prove conclusively what the problems are. I am even willing to pay for this privately if necessary. Is a biopsy more conclusive for example than a MRI scan, or ultrasound scan.

A. Firstly relax. It is pointless getting upset until you know what you are dealing with and the PSA test result will help clarify that. You are a very young man to have prostate cancer so it is much more likely to be a benign increase in size or indeed a completely different diagnosis such as prostatitis.

Forget about going privately. If you have all the symptoms of an enlarged prostate you should be refered to a specialist for further investigation. This will include ultrasound and possibly an MRI scan. Biopsies can be taken but his is often done during the operation to allow you to pass water more easily. (A transurethral resection of prostate TURP.) I advise you ask for a referral first and if it is not forthcoming or is a very long time in the future then by all means consider private consultation.

Concern about consistency of discharge with prostatitis

Q . I have had a few cases of prostatitis and am taking cipro for another occurence. I have been masturbating during this period, since I seem to get the infection after long periods of no sexual activity and understand that the ejaculations help to remove the infected fluids. The last several times I have noticed that the initial discharge is as I expect in it's consitency, but there are now follow on discharges that are very thick and just hang at the end.

A. Prostatitis is a very difficult condition to treat despite being fairly common. It does tend to recur. Normal function of the prostate in producing the nutrients for the sperm is often disturbed for quite some time. If there is any offensive smell from the semen or pain on ejaculation you should see your GP.

High level of calcification of prostate

Q . I recently suffered symptoms of urinating a lot and needing to go urgently all the time. The symptoms passed, and I was told I was okay after an ultrasound. However, the doctor who did the scan informed me that I had a high level of calcification of my prostate although it was nothing to worry about. What does this mean and why does it happen?

A. What a brilliant question. There are men all over the country who want to know the answer so thank you for asking it. All glands, and the prostate is simply a gland which produces the nutrients for sperm, suffer from calcification at some point in their career. Women have the same problem with their breasts. Anywhere you have lots of blood sloshing through along with a high secretion rate, calcium can build up in the ducts or arteries. The question, as you so rightly ask, is whether this is a problem. It can result from infection or inflammation - prostatitis. This is not important so long as any infection has been dealt with. There is no good evidence that calcification of the prostate increases your risk from cancer.

Doctor won't test for prostatitis

Q . I think I may have prostatitis, but my doctor won't examine me, what can I do?

6 months ago I was diagnosed with non-specific urethritis, and was treated at a Sexual Health Clinic with antibiotics. The symptoms never went away entirely, even though subsequent urine and urethral smear tests at the Sexual Health Clinic were negative for infections. Over the past 6 months the symptoms have deteriorated. They include perineal pain, pain in the pubic area, tingling in the penis, and yellowish, gel-like semen. The pain in the pubic area is particularly bad when sitting down.

My doctor says it's probably prostatitis but will not perform the test for infected expressed prostate fluid (EPF). He's referred me to a urologist but this will take 16 weeks for an appointment. Is there anywhere I can go to find out before then? Will self prostate-drainage help? And why don't Sexual Health Clinics perform an EPF test as standard with symptoms like these?

A. You are caught in the trap of NHS resources. We have the lowest number of urologists per head of population in the EU. What you describe certainly does sound like prostatitis and yes, you do need to be treated and yes, you do need to see a urologist and yes, 16 weeks is an absolute bloody disgrace. GUM clinics do not generally deal with this problem but a desperate plea for help from them may elicit a phone call to the urologists. Similarly telling your GP that you just cannot go on any longer might have the same effect. It is a sad fact that men's health is badly neglected by the NHS. Other than going privately, and I don't see why you should have to, there is not much else I can advise. Believe me, I see this every single day of my working life as a GP and frankly it is not good enough.

Prostatitis - information please

Q . I have prostatitis, which is very uncomfortable. I have had antibiotics for nearly a month now with not too much positive effect. What can I expect now? I have an appointment soon to see a speacialist. Any tips would be appreciated on how to help this or even make everyday life more comfortable.

A. Prostatitis is a nasty problem which only us prostate owners will ever understand. We do not know what causes it, but it can happen to any man. The dull aching pain which can become quite severe is classical for this condition. As the prostate straddles the urethra - the pipe which takes urine and semen to the penis - it can be badly irritated either while passing water or during ejaculation.

Like any inflammation it is hot, tender and easily upset so trying to reduce the irritation factor makes good sense. Drinking cranberry juice a few times each day can help stop any infection of the bladder and reduce inflammation. Pain killers and anti-inflammatory drugs do help, especially aspirin or ibuprofen but it is notoriously difficult to treat quickly and it does not surprise me that you are still taking antibiotics.

Your specialist may want to examine your prostate in greater detail by using ultrasound and possibly take a biopsy (all painless). Look for seats which provide good support and do not cut into the thighs just at the join of the groin. It is a good idea to either suspend bicycle riding or at least get a softer saddle for a while too.

Does Saw Palmetto provide good protection from prostate problems?

Q . I read in a men's health mag a while back that Saw Palmetto is a good source of natural protection for the male prostate from a number of ills. I fall into the 20-35 age group which seems to suffer most. I take this every day. Is it a waste, is it a help?

A. Saw Palmetto is an extract from the plant Serenoa repens. It has been known for some time that Saw Palmetto is useful in the treatment of benign enlargement of the prostate gland.

If you are under 35 (which I infer from your message) it is most unlikely that you have significant enlargement of your prostate gland. Whether you will develop symptoms from BPH in the future is difficult to say. At your age it is not certain what benefits you might derive from taking Saw Palmetto. It is not known whether the extract has any harmful side effects.

You have not stated whether you have any difficulty passing urine. If you do have symptoms I would suggest you make an appointment with your GP for a check up, since it is not likely to be due to BPH (Benign Prostatic hypertrophy) and another cause should be sought.

Soft and mushy prostate

Q . I went to a doctor a month ago and they checked my prostate and he said it was soft, and kind of mushy. I took septra for two weeks and no change. I am still having to go the the bathroom lots, and still can not get a full erection. Help

A. I regret that I don't have enough information to be able to give you a full answer. I would need at least to know how old you are, and what(if any) other symptoms you have.

"Soft and mushy" is not a very scientific phrase and it is difficult to interpret what that might mean. You clearly have continuing lower urinary tract symptoms, as well as erectile dysfunction (which is probably not related to the urinary symptoms) and both of these should be investigated.

I would suggest as a minimum another trip to your GP, and if this does not quickly resolve the symptoms then you should be referred to a urologist.

Urinating problem

Q . I wake to pee several times each night. I produce tiny quantities of urine both day and night. The stream is very slow, so much so that I get bored just standing and waiting for it to stop. Occasionally I will produce a much larger quantity, perhaps 3/4 of a pint. I have had a PSA blood test done which had a reading of 1. So I guess my prostate is OK.

What else could be wrong? What methods are used to diagnose? What choices do I have about those methods?

Many thanks.

A. The advice given to this question will depend largely how on how old you are.

Taking the PSA first - A PSA of 1 (ng/ml) is almost certainly normal. The usual cut off ranges used today are as follows:

• 40-49 Years old < 2.5 ng/ml
• 50-59 <3.5 ng/ml
• 60-69 <4.5 ng/ml
• 70-79 <6.5ng/ml

Thus, whatever your age, a PSA of 1.0 would be considered normal.

It is difficult to be didactic about the remainder of your problems. You have a number of lower urinary tract symptoms (LUTS). Getting out of bed to pass urine at night may, of course, be related to fluid intake late in the evening. Older men pass a greater proportion of their daily urine output at night. It is therefore considered normal to get out to pee once or maybe twice at night. More than this might indicate a problem, but you should review your fluid intake in the evening and see if this could be reduced.

Restricting your alcohol intake will also help - whatever alcohol you drink in the evening will make you have to get up at night to pee.

You should visit your general practitioner in the first instance to talk about your symptoms. Your GP may be able to investigate and start treatment for you, or may refer you to a urologist. Usual investigations include a "flow rate" to see how fast you can pee, and how much you leave behind in your bladder when you think you have finished. This is an easy test to perform and merely involves peeing into a specially adapted lavatory. If your flow rate is satisfactory, and you empty your bladder well, then you may not need treatment provided you can live with your symptoms.

If treatment is required then this will usually be with tablets. Drugs from the so called "alpha-blocker" family can help relax the muscle in the prostate and bladder neck and help you to pass urine more easily. More severe cases may require an operation called a TURP (Trans urethral resection of prostate). This is performed with a telescope passed up the urethra (water pipe) under a general anaesthetic. The urologist can remove prostate tissue to widen the channel through the prostate.

When to have a PSA test?

Q . Should I have a PSA test and what will it mean?

A. Unless you have symptoms of difficulty passing urine, an abnormal-feeling prostate gland, or a strong family history of prostate cancer it is unlikely that your doctor will recommend that you have a PSA test performed. This is partly because of the problems with false-positive and false-negative results.

There has been a case put forward for the screening of asymptomatic (without symptoms) men — i.e. looking for possible cancer in men who have absolutely no symptoms at all.

The arguments for this view can be summarised as follows:

• Advanced cancer which has spread beyond the prostate is not curable, so if there is any hope of curing a prostate cancer it must be detected whilst it remains confined to the prostate
• In a lot of men referred to the specialist and who are found to have prostate cancer it is already too late to offer a complete cure. Screening might detect the cancer at an earlier stage.
• Tumours detected by PSA testing are now thought to be significant tumours, which should be treated.

Against this are the following points:

• There is no conclusive proof that treatment of tumours discovered by screening makes any difference to the survival of the patient treated
• Lots of men discovered to have prostate cancer are elderly and suffer from other serious illnesses. Many of these men will die from other causes not related to the prostate cancer.

If a PSA test is performed and is normal this is not cast-iron proof that you do not have prostate cancer, and your doctor may still wish to perform further tests (a biopsy, see below) if your prostate feels abnormal. Equally if your PSA is raised this does not necessarily mean that you do have prostate cancer, although there is good evidence that the higher the value of PSA test result the more likely it is that cancer is present.

If you choose to have a PSA test done you should be prepared to undergo a prostate biopsy if the PSA value is sufficiently raised to justify this course of action.

What is a PSA test?

Q . My GP's said I should have a PSA test. What is it?

A. Prostate Specific Antigen (PSA) is a chemical produced normally by prostate cells. It is a type of chemical known as an enzyme, and it is believed to have a role in liquefying semen after ejaculation (which may help in sperm motility).

PSA is only produced by prostate cells (it is prostate specific), but is produced by both cancerous and non-cancerous prostate cells (it is not cancer specific). Although PSA is the best example we have of a marker for prostate cancer this non-specificity for cancer means that there are reservations about the interpretation of raised values.

Essentially, one of the following scenarios may commonly occur:

• A man with prostate cancer may not have a raised PSA test (this is known as a false-negative result)
• A man with a raised PSA may not have prostate cancer (this is known as false-positive result)

The recent introduction of age-specific ranges for normal PSA values was an attempt to make the PSA test a better one. Rather than use the absolute limit of more than 4 ng/ml most urologists now use the following values:

Age (Years) Reference Range (ng/ml)

• 40-49 <2.5
• 50-59 <3.5
• 60-69 <4.5
• 70-79 <6.5

As with a digital rectal examination (where the doctor feels the prostate by putting his/her finger inside the back passage), the use of PSA by itself is not particularly accurate.

Diagnosing prostate cancer

Q . How do you find out if you've got prostate cancer?

A. Many of the men seen in the Urology Clinics have been referred because of one of three reasons:

• For investigation of troublesome symptoms with urination
• If, as a result of an examination by the GP, there appears to be an abnormal feel to the patient's prostate
• If, as a result of tests which the GP has arranged, there appears to be an abnormally high result to what is know as the PSA test

In the early stages of prostate cancer there are no particular symptoms which might signal the fact that cancer is present.

Prostate cancer sometimes produces a "nodularity” or "firmness” to the prostate that can make its presence known on a digital rectal examination (DRE) of the prostate (where the doctor feels with his/her finger inside the back passage). The problem is that other inflammations of the prostate that are not cancers can produce similar abnormalities and this can confuse the issue. Furthermore, a number of prostate tumours occur within the front part of the prostate on the other side from the rectum. These tumours cannot be felt by DRE.

If the DRE is abnormal or suspicious, or the PSA is raised, then the urologist will normally recommend that a biopsy of the prostate gland be performed.

Prostate cancer

Q . What is Prostate Cancer?

A. Prostate cancer is a condition of the prostate in which there is abnormal growth of prostate cells. The growth is uncontrolled (compared to growth of normal prostate tissue) and the cancer cells have a tendency to spread (known as "metastasise”) outside the confines of the prostate tissue to involve other parts of the body.

Incontinence

Q . I leak urine — what can be done to help me?

A. The problem of urine incontinence is a common reason for a referral to a urology specialist. The exact number of patients with this problem is not known because many patients find the problem embarrassing and keep their symptoms hidden. Women are affected by this problem more often than men, possibly because of the after-effects of child bearing. Incontinence in men may happen after operations on the prostate.

There are several different types of incontinence although all of them result in urine leakage at inopportune times. The term "stress" incontinence refers to leakage of urine which results in response to any physical activity such as coughing, sneezing, bending down, or exercise. "Urge incontinence" describes the leakage of urine which is preceded by a urgent desire to pass urine. The continual leakage of urine is a third, although uncommon, type of incontinence.

What will the Doctor do? - The first thing the specialist will decide, with your help, is whether any further investigation is necessary or desirable. The degree of leakage some patients experience is so mild that further investigation or treatment is unlikely to make the symptoms better. For those remaining patients with troublesome leakage some investigation is justifiable.

Sometimes the symptoms reported to the specialist may seem to represent either stress incontinence or urge incontinence. As the treatments for each are quite different it is important that the true cause of the problem be defined carefully. This is done by "Urodynamic assessment" of the bladder (this test is also known as a VCMG, or video-cysto-metrogram). This is an outpatient investigation which lasts approximately half an hour. After emptying the bladder the patient is asked to lie on a special couch. A small catheter is inserted into the urethra ("water-pipe") and a similar catheter is placed inside the entrance to the rectum ("back passage"). The bladder is filled with a special liquid, a mixture of saline and contrast medium which shows up on x-ray films. The pressure that develops inside the bladder is monitored and recorded on a computer screen. When the patient says the bladder is full the filling is stopped and the table is tipped slowly so that the patient is standing up. The patient is then asked to cough and strain to see whether any leakage occurs. Finally the patient passes urine until the bladder is empty. This test is will usually sort out which type of incontinence is present.

Prostate cancer and consequences of surgery

Q . What is the cause of prostate cancer and what can a man aged 53 realistically expect after an operation to remove the prostate, i.e. what is the likelihood of impotence and incontinence?

A. Your question needs to be answered in two parts.

The exact cause of prostate cancer is not known. There are certain factors known to be associated with the development of prostate cancer but the results of more studies are required.

Certain cases of prostate cancer run in families. If you have an affected first-degree relative - that is if your father, brother, or son developed prostate cancer, particularly if it happened to them at an early age, then you should consider seeing your general practitioner for further investigations. This would include a rectal examination to feel the prostate, and a blood test for PSA (prostate specific antigen). Familial and hereditary forms of cancer account for over 40% of prostate cancers occurring in men under 55 years of age.

There are known to be racial factors involved in the development of prostate cancer. For instance, there is a higher rate of prostate cancer in American Blacks compared to Caucasian Americans, and there is a wide difference in the rate of prostate cancer between westerners and Asians - the exact reason is not known but thought to be due to environmental or dietary factors.

Fat consumption is thought to lead to a higher risk of developing prostate cancer, and the risk of prostate cancer in obese men is 1.25 times higher than that of men in general.

The operation to remove the prostate entirely, in cases of localised prostate cancer, is called a radical prostatectomy. This operation has been performed for a number of years but the so-called "nerve-sparing” approach by Patrick Walsh from Johns Hopkins Medical School in Baltimore has revolutionised the procedure.

The actual incontinence or impotence rates you can expect will depend upon the experience of the surgeon who performs the operation and this may vary widely. It also depends on the size of the tumour that is being removed. In the USA, because of the widespread testing of men for prostate cancer, the majority of men who present for surgery have very small and localised tumours.

In countries where the amount of testing is less - and this is true of the United Kingdom - the same may not be true. If surgeons are operating on larger tumours, then the nerve bundles which run close to the prostate may be damaged and there may be a higher rate of impotence.

The references which provide more information on the points made can be found in the following academic papers which you could find through your library:

1. Narayan P. Neoplasms of the Prostate Gland in Smith's General Urology edited by Tanagho EA and McAninch JW. Published by Prentice Hall International 1995

2. Ekman P, Adolfsson J, Gronberg H. The Natural History of Prostate Cancer. In Textbook of Prostate Cancer edited by Kaisary AV, Murphy GP, Denis L, Griffiths K. Published by Martin Dunitz 1999

Enlarged prostate

Q . Why would a man with an enlarged prostate have blood in hisurine and also dysuria?

A. Normally the size of a walnut, the prostate which straddles the pipe leading from the bladder to the penis (urethra) and supplies all the backup chemicals for sperm to survive in the vagina steadily gets bigger with age. Hence the joke, "What's the definition of middle age...When your prostate is bigger than your brain".

In truth, we all will suffer from enlarged prostate and a large proportion of us will experience problems, pain or hesitation, with passing water (dysuria). As the prostate enlarges it stretches the blood vessels which serve it. These can leak producing blood in the urine or even semen. Although eminently treatable with drugs or surgery the symptoms can also be a warning of prostate cancer. Any blood in the urine or semen, problems with passing water or unexplained pain in the groin needs the attention of your doctor. A PSA (prostate specific antigen) test, along with a rectal examination will help sort out what is going wrong.