You may be reading this article because you are having prostate problems. The article can help answer your questions about prostate changes that happen with age, such as:

• What are common prostate changes?
• How are these changes treated?
• What do I need to know about testing for prostate changes, including cancer?

What Is the Prostate?
The prostate is a small gland in men. It is part of the male reproductive system.

The prostate is about the size and shape of a walnut. It sits low in the pelvis, below the bladder and just in front of the rectum. The prostate helps make semen, the milky fluid that carries sperm from the testicles through the penis when a man ejaculates.

The prostate surrounds part of the urethra, a tube that carries urine out of the bladder and through the penis.

How does the prostate change as you get older?

The prostate gland surrounds the tube (urethra) that passes urine. This can be a source of problems as a man ages because:

• The prostate tends to grow bigger with age and may squeeze the urethra (see drawing).
• A tumor can make the prostate bigger.

What Prostate Changes Should You Be Aware Of?
Growing older raises your risk of prostate problems. The three most common prostate problems are:

• Infection (prostatitis)
• Enlarged prostate (BPH, or benign prostatic hyperplasia)
• Prostate cancer

What Are Common Tests for Prostate Changes?
Abnormal findings from any of these tests can help diagnose a problem and suggest the next steps to take:

• DRE (digital rectal exam) — a test to feel the prostate
• PSA (prostate-specific antigen) test — a blood test
• Biopsy — a test to check for cancer

What Is Prostatitis and How Is It Treated?
Prostatitis is an inflammation or infection of the prostate gland. It affects at least half of all men at some time in their lives. Having this condition does not increase your risk of any other prostate disease.

Prostatitis Symptoms

• Trouble passing urine or pain when passing urine
• A burning or stinging feeling when passing urine
• Strong, frequent urge to pass urine, even when there is only a small amount of urine
• Chills and high fever
• Low back pain or body aches
• Pain low in the belly, groin or behind the scrotum
• Rectal pressure or pain
• Urethral discharge with bowel movements
• Genital and rectal throbbing
• Sexual problems and loss of sex drive
• Blocked urine
• Painful ejaculation (sexual climax)

Several tests, such as DRE and a urine test, can be done to see if you have prostatitis. Getting the right diagnosis of your exact type of prostatitis is the key to getting the best treatment. Even if you have no symptoms, you should follow your doctor's suggestion to complete treatment.

There are four types of prostatitis:

• Acute Bacterial Prostatitis
  This infection comes on suddenly (acute) and is caused by bacteria. Symptoms include severe chills and fever. There is often blood in the urine. You must go to the doctor's office or emergency room for treatment. It's the least common of the four types, yet it's the easiest to diagnose and treat.

  Treatment: Most cases can be cured with a high dose of antibiotics, taken for seven to 14 days, and then lower doses for several weeks. You also may need drugs to help with pain or discomfort.

• Chronic Bacterial Prostatitis
  Also caused by bacteria, this condition doesn't come on suddenly, but it can be bothersome. The only symptom you may have is bladder infections that keep coming back. The cause may be a defect in the prostate that lets bacteria collect in the urinary tract.

  Treatment: Antibiotic treatment over a longer period of time is best for this type. Treatment lasts from 4 to 12 weeks. This type of treatment clears up about 60 percent of cases. Long-term, low-dose antibiotics may help relieve symptoms in cases that won't clear up.

• Chronic Prostatitis or Chronic Pelvic Pain Syndrome
  This disorder is the most common but least understood form of the disease. Found in men of any age from late teens to elderly, its symptoms go away and then return without warning. There can be pain or discomfort in the groin or bladder area.

  Treatment: There are several different treatments for this problem, based on your symptoms. These include antibiotics and other medicines, such as alpha-blockers. Alpha-blockers relax muscle tissue in the prostate to make passing urine easier.

• Asymptomatic Inflammatory Prostatitis
  You usually don't have symptoms with this condition. It is often found when your doctor is looking for other conditions like infertility or prostate cancer. If you have this problem, often your PSA test will show a higher number than normal. It does not necessarily mean that you have cancer.

  Treatment: Men with this condition are usually given antibiotics for four to six weeks, and then have another PSA test.

BPH Symptoms
BPH symptoms usually start after the age of 50. They can include:

• Trouble starting a urine stream or making more than a dribble
• Passing urine often, especially at night
• Feeling that the bladder has not fully emptied
• A strong or sudden urge to pass urine
• Weak or slow urine stream
• Stopping and starting again several times while passing urine
• Pushing or straining to begin passing urine

• A weak bladder
• Backflow of urine causing bladder or kidney infections
• Complete block in the flow of urine
• Kidney failure

The prostate starts out about the size of a walnut. By the time a man is 40, it may have grown slightly larger, to the size of an apricot. By age 60, it may be the size of a lemon.

As a normal part of aging, the prostate enlarges and can press against the bladder and the urethra. This can slow down or block urine flow. Some men might find it hard to start a urine stream, even though they feel the need to go. Once the urine stream has started, it may be hard to stop. Other men may feel like they need to pass urine all the time or are awakened during sleep with the sudden need to pass urine.

Early BPH symptoms take many years to turn into bothersome problems. These early symptoms are a cue to see your doctor.

How Can BPH Be Treated?
About half the men with BPH eventually have symptoms that are bothersome enough to need treatment. BPH cannot be cured, but drugs or surgery can often relieve its symptoms. BPH symptoms do not always grow worse.

There are three ways to manage BPH:

• Watchful waiting (regular follow-up with your doctor)
• Drug therapy
• Surgery

Watchful Waiting
Men with mild symptoms of BPH who do not find them bothersome often choose this approach.

Watchful waiting means getting annual checkups. The checkups can include DREs and other tests. Treatment is started only if symptoms become too much of a problem.

If you choose to live with symptoms, these simple steps can help:

• Limit drinking in the evening, especially drinks with alcohol or caffeine.
• Empty the bladder all the way when you pass urine.
• Use the restroom often. Don't wait for long periods without passing urine.

• Over-the-counter cold and cough medicines (especially antihistamines)
• Tranquilizers
• Antidepressants
• Blood pressure medicine
• Drug therapy

There are two main types of drugs used. One type relaxes muscles near the prostate while the other type shrinks the prostate gland. There is evidence that shows that taking both drugs together may work best to keep BPH symptoms from getting worse.

Alpha-blockers
These drugs help relax muscles near the prostate to relieve pressure and let urine flow more freely, but they don't shrink the size of the prostate. For many men, the drug can improve urine flow and reduce symptoms within days. Possible side effects include dizziness, headache and fatigue.

5 Alpha-reductase Inhibitor
This drug, known as finasteride, shrinks the prostate. It relieves symptoms by blocking an enzyme that acts on the male hormone, testosterone, to boost organ growth. When the enzyme is blocked, growth slows down. This helps shrink the prostate, reduce blockage and limit the need for surgery.

Taking this drug for at least six months to one year can increase urine flow and reduce your symptoms. It seems to work best for men with very large prostates. You must continue to take the drug to prevent symptoms from coming back.

This drug also is used to treat baldness in men. It can cause these side effects in a small percentage of men:

• Decreased interest in sex
• Trouble getting or keeping an erection
• Smaller amount of semen with ejaculation

BPH Medications
Category	Activity	Generic Name	Brand Name
Alpha-blockers	Relax muscles near prostate	doxazosin tamsulosin terazosin prazosin	Cardura Flomax Hytrin Minipres
5 alphareductase inhibitor	Slows prostate growth, shrinks prostate	finasteride	Proscar or Propecia

BPH Surgery
The number of prostate surgeries has gone down over the years. But operations for BPH are still one of the most common surgeries for American men. Surgery is used when symptoms are severe or drug therapy has not worked well.

Types of surgeries include:

• TURP (transurethral resection of the prostate) is the most common surgery for BPH. It accounts for 90 percent of all BPH surgeries. It takes about 90 minutes. The doctor passes an instrument through the urethra and trims away extra prostate tissue. A spinal block is used to numb the area. Tissue is sent to the laboratory to check for prostate cancer.

  TURP generally avoids the two main dangers linked to other prostate surgeries:

  • Incontinence (not being able to hold in urine)
  • Impotence (not being able to have an erection)
  • The recovery period for TURP is much shorter as well

• TUIP (transurethral incision of the prostate) is similar to TURP. It is used on slightly enlarged prostate glands. The surgeon places one or two small cuts in the prostate. This relieves pressure without trimming away tissue. It has a low risk of side effects. Like TURP, this treatment helps with urine flow by widening the urethra.

• TUNA (transurethral needle ablation) burns away excess prostate tissue using radio waves. It helps with urine flow, relieves symptoms and may have fewer side effects than TURP. Most men need a catheter to drain urine for a period of time after the procedure.

• TUMT (transurethral microwave thermotherapy) uses microwaves sent through a catheter to destroy excess prostate tissue. This can be an option for men who should not have major surgery because they have other medical problems.

• TUVP (transurethral electroevaporation of the prostate) uses electrical current to vaporize prostate tissue.

• Open prostatectomy means the surgeon removes the prostate through a cut in the lower abdomen. This is done only in very rare cases when obstruction is severe, the prostate is very large or other procedures can't be done. General or spinal anesthesia is used and a catheter remains for three to seven days after the surgery. This surgery carries a higher risk of complications than medical treatment. Tissue is sent to the laboratory to check for prostate cancer.

Prostate Cancer

Things to Know
Prostate cancer means that cancer cells form in the tissues of the prostate. It is the most common cancer in American men after skin cancer.

Prostate cancer tends to grow slowly compared with most other cancers. Cell changes may begin 10, 20 or 30 years before a tumor gets big enough to cause symptoms. Eventually, cancer cells may spread (metastasize) throughout the body. By the time symptoms appear, the cancer may be more advanced.

By age 50, very few men have symptoms of prostate cancer, yet some precancerous or cancerous cells are present. More than half of all American men have some cancer in their prostate glands by the age of 80.

Most of these cancers never pose a problem. They either give no signs or symptoms or never become a serious threat to health.

A much smaller percentage of men are actually treated for prostate cancer. Most men with prostate cancer do not die from this disease.

• About 16 percent of American men are diagnosed with prostate cancer at some point in their lives.
• 8 percent have serious symptoms.
• 3 percent die of the disease.

Prostate Cancer Symptoms

• Trouble passing urine
• Frequent urge to pass urine, especially at night
• Weak or interrupted urine stream
• Pain or burning when passing urine
• Blood in the urine or semen
• Painful ejaculation
• Nagging pain in the back, hips, or pelvis

Prostate cancer can spread to the lymph nodes of the pelvis. Or it may spread throughout the body. It tends to spread to the bones. So bone pain, especially in the back, can be another symptom.

Risk Factors
There are some risk factors linked to prostate cancer. A risk factor is something that can raise your chances of having a problem or disease. Having one or more risk factors doesn't mean that you will get prostate cancer. It just means that your risk of disease is greater.

• Age. Being 50 or older increases risk of prostate cancer.

• Race. African American men are at highest risk of prostate cancer — it tends to start at younger ages and grows faster than in men of other races. After African American men, it is most common among white men, followed by Hispanic and Native American men. Asian American men have the lowest rates of prostate cancer. Aside from race, all men can have other prostate cancer risk factors (aging, family history and diet).

• Family history. Prostate cancer risk is two to three times higher for men whose fathers or brothers have had the disease. For example, risk is about 10 times higher for a man who has three immediate family members with prostate cancer. The younger a man is when he has prostate cancer, the greater the risk for his male family members. Prostate cancer risk also appears to be slightly higher for men whose mothers or sisters have had breast cancer.

• Diet. The risk of prostate cancer seems to be higher for men eating high-fat diets with few fruits and vegetables.

Prostate Cancer Screening
Screening means testing for cancer before you have any symptoms. A screening test can often help find cancer at an early stage. When found early, cancer is less likely to have spread and may be easier to treat. By the time symptoms appear, the cancer may have started to spread. Remember, even if your doctor suggests prostate cancer screening, this doesn't necessarily mean that you have cancer.

Screening tests are most useful when they have been proven to find cancer early and lower a person's chance of dying from cancer. For prostate cancer, doctors don't yet know these answers and more research is being done.

Large research studies, with thousands of men, are going on now to study prostate cancer screening. The National Cancer Institute is studying the combination of PSA testing and DRE as a way to get more accurate results.

Some cancers never cause symptoms or become life-threatening. If they are found by a screening test, the cancer may then be treated. For prostate cancer in its early stages, it isn't known whether treatment would help you live longer than if no treatment were given when a screening test detects prostate cancer.

Talk with your doctor about your risk of prostate cancer and your need for screening tests.

Talking to Your Doctor

Different kinds of doctors and other health care professionals manage prostate health. They can help you find the best care, answer your questions and address your concerns. These health care professionals include:

• Family doctors and internists
• Physician assistants (PAs) and nurse practitioners (NPs)
• Urologists, who are experts in diseases of the male reproductive and urinary tract systems
• Urologic oncologists, who are experts in treating cancers of the male urinary and reproductive systems such as prostate cancer
• Radiation oncologists, who use radiation therapy to kill cancer cells
• Medical oncologists, who treat cancers with medications such as hormone treatments and chemotherapy
• Pathologists, who are doctors who find diseases by studying cells and tissues under a microscope

Types of Tests
These types of tests are most often used to check the prostate:

Health History and Current Symptoms
This first step lets your doctor hear and understand the "story" of your prostate concerns. You'll be asked about whether you have symptoms, how long you've had them, and how much they affect your lifestyle. Your health history also includes any risk factors, pain, fever, or trouble passing urine. You may be asked to give a urine sample for testing.

Digital Rectal Exam
DRE is the standard way to check the prostate. With a gloved and lubricated finger, your doctor feels the prostate from the rectum. The test lasts about 10 to 15 seconds.

• The size, firmness and texture of the prostate
• Any hard areas, lumps or growth spreading beyond the prostate
• Any pain caused by touching or pressing the prostate

PSA (Prostate-Specific Antigen) Test
PSA is a protein made by normal cells and prostate cancer cells. It is found in the blood and can be measured with a blood test. PSA tests are often used to follow men after prostate cancer treatment. PSA testing is still being studied to see if finding cancer early lowers the risk of dying from prostate cancer.

PSA levels can rise if a man has prostate cancer, but a high PSA is not proof of cancer. Other things also can make PSA levels go up. These may give a false positive test result. These include having BPH or prostatitis, or if the prostate gland is disturbed in any way (riding a bicycle or motorcycle, a DRE, orgasm within the past 24 hours, and prostate biopsy or surgery can disturb the prostate). Also, some prostate glands naturally produce more PSA than others. PSA levels go up with age. African American men tend to have higher PSA levels in general than men of other races.

Researchers are trying to find more answers about:

• The PSA test's ability to tell cancer from benign prostate problems
• The best thing to do if a man has a high PSA level

What Do PSA Results Mean?
PSA levels are measured in terms of units per volume of fluid tested. Doctors often use a score of 4 nanograms (ng) or higher as the trigger for further tests, such as a prostate biopsy.

Your doctor may monitor your PSA velocity, which means looking at the rate of change in your PSA levels over time. Rapid increases in PSA readings can suggest cancer. If you have a mildly elevated PSA, you and your doctor may choose to check PSA levels on a scheduled basis and watch for any change in the PSA velocity.

Prostate Biopsy
If your symptoms or test results suggest cancer, your doctor will refer you to a specialist (a urologist) for a prostate biopsy. A biopsy is usually done in the doctor's office.

For a biopsy, small tissue samples are taken directly from the prostate. Your doctor will take samples from several areas of the prostate gland. This can help lower the chance of missing any areas of the gland that may have cancer cells. Like other cancers, doctors can only diagnose prostate cancer by looking at tissue under a microscope.

Most men who have biopsies after routine exams do not have cancer.

Deciding About Repeat Biopsy
A test that can help your doctor decide if you need a repeat biopsy is called free PSA. This test is used for men who have higher PSA values. The test looks at a form of PSA in the blood. Free PSA is linked to BPH but not cancer.

Free PSA is figured as a percentage of the total PSA:

• If both total PSA and free PSA are higher than normal, this suggests BPH rather than cancer.

• If regular PSA is high but free PSA is not, cancer is more likely. More testing should be done.

If a Biopsy Is Positive
A positive biopsy means prostate cancer is present. A pathologist will check your biopsy sample for cancer cells and will give a Gleason score. The Gleason score ranges from 2 to 10 and describes how likely it is that a tumor will spread. The lower the number, the less likely the tumor is aggressive and may spread.

Treatment options depend on the stage (or extent) of the cancer (stages range from 1 to 4), Gleason score, PSA level, and your age and general health. These items will be available from your doctor and are listed on your pathology report.

Reaching a decision about treatment of your prostate cancer is a complex process. Many men find it helpful to talk with their doctors, family, friends and other men who have faced similar decisions. There are many organizations that can provide more information and support to you, your partner and family.

It is a good idea to get a copy of your pathology report from your doctor and carry it with you as you talk with your health care providers.

Checklist of Questions for Your Doctor

• What type of prostate problem do I have?
• Is more testing needed and what will it tell me?
• If I decide on watchful waiting, what changes in my symptoms should I look for and how often should I be tested?
• What type of treatment do you recommend for my prostate problem?
• For men like me, has this treatment worked?
• How soon would I need to start treatment and how long would it last?
• Do I need medicine and how long would I need to take it before seeing improvement in my symptoms?
• What are the side effects of the medicine?
• Are there other medicines that could interfere with this medication?
• If I need surgery, what are the benefits and risks?
• Would I have any side effects from surgery that could affect my quality of life?
• Are these side effects temporary or permanent?
• How long is recovery time after surgery?
• Will I be able to fully return to normal?
• How will this affect my sex life?
• How often should I visit the doctor to monitor my condition?

National Cancer Institute
Cancer Information Service (CIS)
1-800-4-CANCER (1-800-422-6237)
TTY: 1-800-332-8615
Internet: www.cancer.gov

U.S. Centers for Disease Control and Prevention
1-888-842-6355
FAX: (770) 488-4760
E-mail: cancerinfo@cdc.gov
Internet: www.cdc.gov/cancer/prostate

Posted: March 2005

Source: National Cancer Institute, National Institutes of Health

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