May 2015- The Prostate and me
As you know, I have chosen to make my life something of an open book as a journalist and blogger and I also believe that there are too many aspects of men's health that (unlike that of the fair sex) we are too private about as a gender. As a direct result, some of these male-only conditions are not commonly understood and hence have less attention and priority in research funding.
Do skip this detail if this comes into the 'Too Much Information' category but, in the sections below, I relate my knowledge and experience of why prostate problems occur, how we can monitor them and what treatments can be invoked. I am able to do this by relating my own situation as a so-called experienced patient who regularly debates these issues with specialist consultants and researchers.
Why am I an expert patient on this (apart from being a generally-annoying know-all and curious guy)? It is because after ‘retirement’ at 37 some thirty years ago I embarked on regular annual health screenings which record keeping and enquiry gave me one of the longest data sets of any patient on record.
Male Prostate Problems – How do they occur?
Like many (or even most) men of a certain age, we are troubled by higher PSA (Prostatic Specific Antigen) hormone level ‘markers’ in our blood stream and experience enlargement of the prostate. This is also a genetic characteristic of Afro Caribbean men and (we like to think) those of us who are Alpha males as well J.
This type of PSA elevation is annoying but quite harmless when it is ‘merely’ associated with ‘urgency’ and ‘frequency’ of passing water with consequent rising in the night and numerous visits to the loo at other times. This benign enlargement of (what is once in youth) a small Prostate straddling the canal becoming successively bigger and restricts urine flow as the years go by, even though there may be no malign or cancerous cause. This is known as ‘Benign Prostatic Hypertensia (BPH) which is not an acute health hazard but some point becomes socially difficult and can endanger the prostate, kidney and bladder health if ignored for too long. This is what I am currently diagnosed with and I therefore only have a 4% risk of prostate cancer to start with, which is not bad.
Why does it happen and how can we monitor it?
The simple answer is that nobody really knows. These little organs (which start the size of a walnut and leathery on the outside and squidgy within) have the main function of adding seminal fluid to the semen upon ejaculation. Like other ‘supposedly disposable’ organs (appendix, spleen, etc.) it has complicated inter-relations with other physiology and until further research takes place, we have a lots to learn about this. Once known as ‘priests disease’, BHP was historically linked with abstinence and lack of opportunities to void this fluid but, as can be noted from the above categories (and after no shortage of field work on the part of me and others to investigate this J) this can be largely discounted.
The PSA marker (found out in blood tests) is also raised by heavy exertion, cycling and sexual activity (one reason to avoid combining these together by riding tandems on picnics with younger members of the opposite sex prior to tests apart from other safety aspects J). This, together with levels rising with age for no known reason makes the whole PSA level testing rather unreliable and a great source of income for some countries (such as the UK and USA) where private medicine can go beyond the beneficial levels of necessary screening and become a profitable activity in its own right.
The trouble is that higher PSAs are also associated with other more significant prostate conditions such as the more benign long term cancers. These are rarely fatal and almost all men die ‘with’ rather than die ‘of’ these and they are invariably detected and dismissed in almost all older men autopsies by pathologists. Also, most importantly, some which can become aggressive and turn into life threatening cancer. For this reason, high PSA levels and associated urinary symptoms cannot be ignored by those men who value their health. Mine has breached the 9-10 level after all these years of active monitoring.
The prostate can be felt for lumps and bumps etc firstly GP’s and Nurse Practitioners via the rectum with smoothness a good indication of prostate health. Next modern NMR or MRE scans (Magnetic Resonance Examination can used to be called Nuclear Magnetic Resonance but changed due to ‘political correctness’ ) is a very ‘sound’ step . Better than Xrays for soft tissue, these scanners can be set up to give a 3-D layered and sliced view of what is going on in the prostate and are non-invasive as a real life ‘potato chipping’ would hardly be desirable!
The next stage, after noting the PSA increase, is to embark upon getting biopsies to get ‘core’ samples of tissue from this little friend by bombarding it with a sophisticated ‘spud gun’. The first and easiest method of access is via the back passage known as Rectal Prostatic Biopsies. This is surgically simple, requires only local anaesthetic and is the first method for further investigation but has significant risks.
It is only to be expected that the rectal canal has some of the most virulent bacteria in the body and so patients are routinely given the strongest antibiotics in advance of, and after, this process and any onset of any high temperature or cold-like symptoms afterwards has to be met with 999 calls or rushing to A&E, hospitalisation and intravenous antibiotics at the upper end of known effectiveness. Add to this, the certain occurrence of blood in the urine for days and in semen for weeks even when the prostate recovers from this onslaught easily and that is not very pleasant. Also there is concern about the risk of contamination of the blood stream and propagating any possibly cancerous cells (though this is denied) and makes this a rather scary procedure. Urologists only recommend this once or twice in a patient’s life ( and I have had two in the past). Also, like a physical anal examination, only one side of the Prostate is accessible from this direction.
The final examinational procedure is a complex matric of biopsies accessed via the perineum (scrotum) under full general anaesthetic called a Perineal Biopsy. Costing over £3,500 to private health plans or the NHS it is in the realm of experienced and skilled urologists. Successful results from these can reduce from 4% to 2% the chances of cancer for otherwise healthy patients with large prostates and are regarded by experts in the field as the necessary preliminary to further surgical intervention. It still has the certain occurrence of blood in the urine for days and in semen for weeks even when the prostate recovers from this onslaught easily but the risk of contamination the blood stream is drastically reduced and the whole of the prostate (and its leathery case) can be properly and fully examined. This is what I had yesterday
The next problem with getting these samples by biopsy is the microscopic examination and interpretation of the cells. We all know from cervical smears and breast samples (a better researched field) that this is very much open to individual interpretation and mutant cells can exist for all sorts of reasons, genetic, dietary and all else. Urology departments try to overcome this by having the consultants, registrars and nurse practitioners sit down together every week or two in regular meetings, throwing images up on to a screen, studying them like tea leaves in a saucer and agreeing by consensus a level on what is known as a Glyson scale . I have never featured on this scale at all, despite some cell irregularities.
Then such cancers can be divided into type 1 (present in just one lobe of small section of the prostate, which can be watched) Type 2 (still confined within the prostate but more wide spread and require action) and Type 3, (which has breached the tougher walls of the prostate and is all set to aggressively affect other nearby organs/bloodstream/bone structure etc).
So what can be done to fix things?
Now one answer to all this is to totally remove the Prostate altogether (known as Radical Prostectomy) rather like many of us had our appendix removed as kids but that is always dangerous when the full function of an organ is not understood and the nerve endings and fine capillaries which clothe this little friend also determine erectile function and even incontinence (not the favourite outcome).
Surgery methods are improving with micro-surgery more effective these days and there are many. American men going around without prostates removed prematurely through fear, commercialism or lack of understanding that have regretted this move. Another ‘solution’ has been Brachytherapy (insertion of radio-active seeds into prostate growths) which have all the same risks and not a great outcome. Also partial Prostectomy where the effected portion is removed but this is far from a final protection.
Recent technology for benign enlargement involves the ‘burning out’ of the core of the prostate to ease urine flow and avoid bladder retention which some patients have claimed make ‘new men’ out of them. They can proudly but annoyingly forsaking the cubicles in Gents loos and spraying all over the urinals from a distance like we did as ten-year-olds! This relieves those symptoms but does not eliminate possibly cancerous developments and so the latest technology is to hollow the prostate out completely but leave it, and its nerves and blood supply, in place. Called HOLEP it involves the use of the sophisticated ‘de Vinci’ robot and microsurgery, costs c£10k and needs an experienced surgeon to handle it. (My own surgeon has performed this 500 + times and trains all others in East Anglia) and so that is the way I am going to go next some time this year… I first had these possibilities investigated by private payment and am now pursuing the outcomes on the NHS with the same surgeon with the same NHS patient priorities but I chose Mr Kaastner and his Cambridge Urological Partnership after studying the matter and noting the survey of Urologists who were all asked which colleague would they choose and trust most!
If this article raises any questions or concerns please feel free to raise them with me privately or comment on this article if you feel able to do so.