Prostate Cancer Canada Network

In The News

Well-Done Meat Consumption May Increase Prostate Cancer Risk
Research into the dietary habits of about a thousand men from the Cleveland area has found that a high consumption of meats, especially of red meat prepared by grilling, is positively associated with an increased risk of developing aggressive prostate cancer. This particular study, which was led by Dr. John Witte of the University of California, San Francisco (UCSF), has a number of limitations, but it does add support to other investigations connecting meat consumption with cancer risk.

Toronto researchers speculate regarding a link between prostate cancer and oral contraceptive use
Very preliminary and speculative research, designed to spark further inquires, suggests that there may be a connection between oral contraceptive use and rising rates of prostate cancer. One theory is that the widespread use of birth-control pills in various populations may result in a higher level of estrogen in the environment, which might, in turn, increase prostate cancer risk.

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Noncancerous conditions: Benign Prostatic Hyperplasia

In young men, the prostate gland is quite small, about the size of a walnut or a chestnut. As men age, however, the prostate grows. Sometimes, prostate growth is so minimal that men have no symptoms at all. In extreme cases, the prostate can become ten to twenty times larger, reaching the size of an apple. The enlargement of the prostate, which usually does not occur until after age 40, is called benign prostatic hyperplasia or BPH:

Benign means that the overgrowth of the prostate is not cancer. And BPH does not become cancer or indicate that a man will develop cancer. No matter how large the prostate becomes with BPH, the abnormal overgrowth remains in the prostate and does not invade other areas.

Prostatic just means relating to the prostate gland.

Hyperplasia means an overgrowth of cells.

So ... BPH is a benign (non-cancerous or non-malignant) overgrowth of cells in the prostate gland.

CAUSES
Not much detail is known about the exact causes of BPH. Researchers think that prostate enlargement is related to subtle shifts in hormone levels, which occur naturally as men age. As men grow older, they produce smaller amounts of male hormones (androgens), and they experience a slight increase in the production of female hormones (estrogens). This change in hormone balance probably encourages BPH.

Although scientists are still unsure of the exact causes of BPH, they know that aging is the key factor. Men under age 40 are rarely affected by BPH, but autopsy studies have shown some degree of BPH in approximately 90 per cent of men in their 80s. The good news is that most of these men will experience no or few symptoms. About one quarter of the men who have BPH, do experience symptoms that are serious enough for them to seek medical help.

SYMPTOMS
Not all men with enlarged prostates experience symptoms. Sometimes, however, men with BPH can have trouble with urination. BPH usually develops in the transition zone of the prostate, and this zone surrounds the urethra, which moves urine from the bladder through the prostate and penis and out of the body.

Bladder

When the prostate's transition zone enlarges, it progressively narrows the urethra. (Think of gently squeezing a watering hose with your hand.) When the urethra narrows, the bladder has to work harder to expel urine, so it builds more muscles. Eventually, these muscles may limit the bladder's ability to expand, so the bladder cannot store as much urine. What can these things mean for you?

more frequent urination (during both the day and night)
difficulty stopping and starting the urine flow
a weak urine stream (like a tap with poor water pressure)
an intermittent urine stream (once you've got it going, it stops and starts)
feeling unable to empty the bladder completely
overflow incontinence (the bladder is so full that urine leeks out)
urge incontinence (when you need to urinate, you feel you that you must do so immediately)
incontinence (no control over urination)
painful urination
blood in the urine

Although seeing blood in your urine may be shocking (and should be reported to your doctor), this BPH symptom is usually not more serious than the others. Most frequently, a blood vessel that has been stretched by the growing prostate is bleeding.

DIAGNOSIS
If you go to your doctor with symptoms of BPH, you should expect some of these tests or follow-up procedures.

Medical history: you will probably be asked about your symptoms (what they are and how long they have been going on) and your previous and current medical status (e.g., previous surgeries or treatments, current medications, and general health). Effects and Severity of Symptoms: Often, the doctor will ask you to use a scoring system to describe how much pain you are having and how much your symptoms affect your quality of life (and in which ways). One system is the International Prostate Symptom Score (IPSS).

Physical Exam and Digital Rectal Examination: The doctor will probably examine you to determine your general health and the state of your motor and sensory functions. You should expect a digital rectal examination: the doctor will insert a gloved and lubricated finger into your rectum to feel for prostate enlargement and abnormalities. For more information on the digital rectal examination or DRE, click here.

Transabdominal Ultrasound: Ultrasound pictures, taken by a scanning device placed on the skin covering your abdomen, can show the doctor whether you are retaining urine in your bladder.

Urine Flow Check: The doctor may have you urinate into a funnel-like apparatus that measures the amount of urine you can void, the strength of the urine flow, and the time it takes for you to finish urinating.

Voiding Diary: You may be asked to complete a diary for a number of days, recording in it when you urinate and various other facts relating to urination.

Urinalysis: The urine will most likely be examined for blood, protein, and sugar.

Blood Tests: Your doctor will probably order blood work to check your kidney and to determine the level of prostate-specific antigen (PSA) in your blood. These tests will help rule out problems other than BPH, although men with BPH do often have high or rising PSA levels. Men whose blood tests show a high or rising level of prostate-specific antigen (PSA) in the blood may be advised to have more tests because a higher than normal PSA level is an indicator of the possibility of prostate cancer. The doctor will want to determine whether BPH or prostate cancer is causing the amount of prostate-specific antigen in the blood to increase. Click here for more information on the PSA test.

TREATMENTS
The treatment option that you and your doctor select will depend on the severity of your symptoms and on how much these symptoms are affecting the quality of your life. They range from monitoring the condition while making changes in your daily routines to surgery.

Monitoring: You may be advised to watch for changing symptoms while you make simple adjustments to your daily routine, such as, for example, restricting the amount you drink before bed and emptying your bladder as completely as possible before exercise or before extended periods away from washrooms.

Medication: Usually, the first treatment option recommended other than monitoring involves the use of medicines. Medication is a less aggressive treatment than, say, surgery, and, if side effects occur with a particular drug, it can be stopped. The main medications used are alpha blockers (doxazosin, terazosin, tamsulosin, alfuzosin), 5-alpha-reductase inhibitors (finasteride, dutasteride), and herbal remedies (saw palmetto).

Alpha Blockers: Some of these medicines, such as doxazosin (Cardura) or terazosin (Hytrin), were originally developed to treat high blood pressure. They work by relaxing your body's smooth muscles (sometimes called involuntary muscles). These muscles contract involuntarily (without your control) to help guide fluid in the body, fluid such as blood, urine, sperm, and bile. The alpha blockers help sufferers of BPH by lowering muscle tension in the prostate, bladder, and urethra, which lets urine flow more freely. Newer alpha blockers, such as tamsulosin (Flomax) or alfuzosin (Uroxatral), relax only the smooth muscles of the prostate and bladder, so they may have fewer side effects, although they have not been in use long enough for scientists to determine this.

Usually, these drugs are tolerated well and work within a few days. Approximately two-thirds of men who use them get mild to moderate relief of their symptoms.

Side effects: About 15 per cent of those who use alpha blockers experience mild dizziness, the most common side effect. Other side effects include fatigue, headache, and nasal stuffiness. Another harmless side effect is possible: retrograde ejaculation. This means that some sperm goes up into the bladder when a man ejaculates rather than out the penis.

5-Alpha-Reductase Inhibitors: Drugs such as finasteride (Proscar) and dutasteride (Avodart) interfere with the production of the enzyme 5-alpha-reductase. This enzyme helps convert testosterone into a more powerful form, so, by blocking production of this enzyme, these drugs modify the effects of testosterone on the prostate. Gradually, the prostate shrinks. These drugs take longer to work than alpha blockers, but they may have other benefits. Most men on these drugs report a noticeable improvement, and researchers are currently investigating whether using finasteride might reduce the risk of prostate cancer. (See the article "New findings show prostate cancer can be prevented.")

Side effects: About 5 per cent of men on finasteride have reported a decreased sex drive or more difficulty getting an erection. Some research reports, however, that men who used a placebo experienced a similar number of these negative side effects as did men on finasteride. Men on finasteride may also experience a reduction in the amount of ejaculate. Your doctor will advise you about other things to consider before taking this drug: for example, it should not be used by men who may father a child because it may cause birth defects. Also, because finasteride reduces prostate-specific antigen levels, which are used to detect early-stage prostate cancer, men who take the drug should ask about early detection processes geared specifically to their situation.

Herbal remedies: Always consult your physician before using any remedy. Remember, some of our most powerful drugs originate from plants, so, even though a remedy is called "natural," it may not be safe. That said, a number of herbal remedies are currently being studied (and sometimes prescribed) for the treatment of BPH. One is saw palmetto, a dwarf palm tree native to the southern United States and the Caribbean. Its berries are used to produce an extract that is currently prescribed for BPH therapy in Europe. The saw palmetto brand sold in Europe (Permixon) contains no other ingredient, unlike the various preparations available on North American store shelves. Currently, Leonard S. Marks of the Urological Sciences Research Foundation is undertaking a clinical trial to determine the effectiveness of saw palmetto in the treatment of BPH. In 2001, his results corroborated "existing data that suggest that saw palmetto may be an effective treatment for reducing the symptoms of BPH." (See "Herbal Therapy for BPH" for more details.)

SURGICAL THERAPY
Surgery is usually recommended only when men's lives are severely affected by BPH. Here are some of the reasons that men undergo surgery:

They cannot urinate;
A partial blockage of the urethra causes repeated urinary tract infections, bladder stones, or extreme urinary retention;
There is evidence of kidney damage, or they have blood in the urine that persists.

Surgical options include procedures that are designed mainly to improve symptoms (TUIP, TUMT, TUNA, HIFU) and ones designed to remove all or most of the overgrown cells (open prostatectomy, TURP, TUVP, Laser therapy). As many of these procedures are also used in the treatment of prostate cancer, they will be described only briefly here.

Transurethral Incision of the Prostate (TUIP): Using a special scope inserted into the patient's urethra, the surgeon makes small incisions in the prostate where it meets the bladder. When the scope cuts muscles in this area with an electric current or laser beam, the opening of the bladder relaxes, and urine can flow more easily. No BPH is removed.

Transurethral Microwave Thermotherapy (TUMT): The surgeon inserts an instrument into a patient's prostate through his urethra. This instrument, called an antenna, sends out microwave energy, and this energy heats up the inside of the prostate, essentially cooking excess prostate tissue. (The urethra and penis are protected by cooling fluid, which circulates around the antenna.) The "cooked" tissue is expelled over time (usually in three to six months), and the prostate shrinks as it heals, improving urine flow.

Transurethral Needle Ablation (TUNA): This operation is similar to the one previously described in that it uses heat to destroy cells. In this operation, however, a needle-like device is placed into areas of the prostate where there is a large amount of BPH. The surgeon uses a cystoscope, basically a light that is inserted up the urethra, and a transrectal ultrasound to enable exact placement of needles. The needles themselves are inserted up the urethra inside a tube (catheter), which protects the urethra and other areas from the heat. The heat destroys specific blockages, which helps to relieve BPH symptoms and which kills some overgrown cells.

High-Intensity Focused Ultrasound (HIFU): In this procedure, a probe placed into the rectum sends a beam of high intensity ultrasound to one very focused spot in the prostate where there is considerable BPH. This area is quickly heated for about a second, destroying targeted cells. (See this report from the BC Cancer Agency on the use of High-Intensity Focused Ultrasound for prostate cancer treatment.)

Open Prostatectomy: This major surgical procedure removes the enlarged portion of the prostate that is obstructing urination. Usually, the surgeon makes an incision in the lower abdomen and approaches the prostate through the bladder or through the prostate itself. The overgrown portion of the prostate is usually removed in one piece, leaving the "shelled out" prostate behind. This operation should not be confused with a "radical prostatectomy," which removes the entire prostate.

Transurethral Resection of the Prostate (TURP): This operation is one of the most common surgeries recommended in the treatment of BPH. In it, an instrument is inserted up the urethra to remove the section of the prostate that is blocking the flow of urine.

Transurethral Electrovaporization of the Prostate (TUVP): In this procedure, an instrument called a roller-ball electrode heats the overgrown tissue in the prostate, turning it into steam. The procedure does destroy BPH cells, and there is minimal bleeding because remaining tissue is cauterised by the electrical current.

Laser therapy: Various laser therapies are currently in use to remove portions of the prostate. Transurethral laser vaporization, laser prostatectomy, or photoselective vaporization of the prostate [PVA] all use laser beams to remove the part of the prostate that is blocking urine flow.

For more on these various treatments, see the section detailing the treatment of prostate cancer.