Prostate Problems

Benign enlargement of the prostate gland, also known as Benign Prostatic Hyperplasia (BPH), is a common but incompletely understood consequence of aging. The clinical symptoms of frequency, urgency and decreased force of urinary stream, also known as lower urinary tract symptoms (LUTS) are also associated with advancing age.

For a detailed discussion of the diagnosis and management of BPH, click here for the American Urological Association’s clinical guidelines.

That an enlarging prostate and the development of LUTS are both age dependent is indisputable. Autopsy studies have demonstrated that up to 80% of 80-year-old men will have historic evidence of BPH. Approximately 40% of those same men will demonstrate an enlarged prostate on physical examination; however, only 25-30% of 80 year old men will have symptomatic BPH and pursue treatment.

CAUSES

Two conditions are necessary for the development of BPH; namely, aging and the presence of testes. It is well known that human males who are castrated prior to the time of puberty never develop BPH. Benign prostatic hyperplasia (BPH) is a common but incompletely understood consequence of aging.

• That an enlarging prostate and the development of LUTS (lower urinary tract symptoms) are both age dependent is indisputable. Autopsy studies have demonstrated that up to 80% of 80-year-old men will have historic evidence of BPH. Approximately 40% of those same men will demonstrate an enlarged prostate on physical examination; however, only 25-30% of 80 year old men will have symptomatic BPH and pursue treatment.
• The development of BPH requires the presence of testosterone. The cascade of hormonal events leading to this phenomenon begins with the release of luteinizing-releasing hormone (LHRH) by the hypothalamus. LHRH acts on the anterior pituitary gland to stimulate the production of luteinizing hormone (LH). LH circulates in the bloodstream and induces the testicular Leydig cells to produce testosterone. Testosterone, in turn, acts on individual prostatic epithelial cells where it binds at the cell membrane with a surface receptor and is a substrate for the enzyme 5a -reductase. The primary product of 5a -reductase activity on testosterone is the metabolite, 5a -dihydrotestosterone (DHT). DHT binds with a receptor in the cytosol and becomes a hormone-receptor complex which is then transported to the nucleus. It is DHT which seems to be critical for the development of BPH.

The static component of bladder outlet obstruction may be attributed to the physical enlargement of the prostate as it encroaches on the prostatic urethra and bladder outlet. The dynamic portion of the obstruction is more likely related to the relative tension of prostatic and bladder neck smooth muscle. It is particularly useful when formulating a strategy for the treatment of bladder outlet obstruction to consider whether the detrusor itself is intact. A variety of conditions, most notably diabetes mellitus, may result in a detrusor muscle that is ineffective in generating pressures high enough to overcome even normal resistance at the bladder outlet.

CAUSES

The most common cause of a bladder outlet obstruction is an enlarged prostate. Additional causes include can include prostate cancer, narrowing of the urethra or bladder outlet scarring from infection, injury or surgery or bladder stones. Bladder outlet obstruction may also occur as a side effect of certain medications, such as antihistamines and decongestants.

Once bladder outlet obstruction has been confidently diagnosed it is helpful to think of this concept as being attributable to both static and dynamic factors. The static component of bladder outlet obstruction may be attributed to the physical enlargement of the prostate as it encroaches on the prostatic urethra and bladder outlet. The dynamic portion of the obstruction is more likely related to the relative tension of prostatic and bladder neck smooth muscle. It is particularly useful when formulating a strategy for the treatment of bladder outlet obstruction to consider whether the detrusor itself is intact. A variety of conditions, most notably diabetes mellitus, may result in a detrusor muscle that is ineffective in generating pressures high enough to overcome even normal resistance at the bladder outlet.

Adenocarcinoma of the prostate is the clinical term for a cancerous tumor on the prostate gland. As prostate cancer grows, it may spread to the interior of the gland, to tissues near the prostate, to sac-like structures attached to the prostate (seminal vesicles), and to distant parts of the body (e.g., bones, liver, and lungs). Prostate cancer confined to the gland often is treated successfully.

For a detailed discussion of the diagnosis and management of prostate cancer, click here for the American Urological Association’s clinical guidelines. The prostate gland is located in the pelvis, below the bladder, above the urethral sphincter and the penis, and in front of the rectum in men. It is made up of glandular tissue and muscle fibers that surround a portion of the urethra. The gland is covered by a membrane (called the prostate capsule) that produces prostate-specific antigen.

According to the American Cancer Society (ACS), prostate cancer is the most common type of cancer in men in the United States, other than skin cancer. The ACS estimates that about 230,900 new cases will be diagnosed in 2004 and about 29,900 men will die of the disease. Prostate cancer is the second leading cause of cancer death in men, exceeded only by lung cancer.

Prostate cancer occurs in 1 out of 6 men. Reports of diagnosed cases have risen rapidly in recent years and mortality rates are declining, which may be due to increased screening.

African American men have the highest incidence of prostate cancer, and Asian and Native American men have the lowest incidence. Rates for Asian and African men increase sharply when they emigrate to the United States, suggesting an environmental connection (e.g., high-fat diet, smoking).

In 2009, it was estimated that 27,360 men would die from prostate cancer and 192,280 men would be diagnosed with it (American Cancer Society Facts & Figures 2009). The incidence of prostate cancer increases with age, with nearly two out of three prostate cancer cases being diagnosed in men over the age of 65. The prostate is a gland in the male reproductive system located just below the bladder (the organ that collects and empties urine) and in front of the rectum (the lower part of the intestine). It is about the size of a walnut and surrounds part of the urethra (the tube that empties urine from the bladder). The prostate gland produces fluid that makes up part of the semen.

Prostate cancer is found mainly in older men. As men age, the prostate may get bigger and block the urethra or bladder. This may cause difficulty in urination or can interfere with sexual function. The condition is called benign prostatic hyperplasia (BPH), and although it is not cancer, surgery may be needed to correct it. The symptoms of benign prostatic hyperplasia or of other problems in the prostate may be similar to symptoms for prostate cancer.

A doctor should be consulted if any of the following problems occur:

• Weak or interrupted flow of urine.
• Frequent urination (especially at night).
• Difficulty urinating.
• Pain or burning during urination.
• Blood in the urine or semen.
• Nagging pain in the back, hips, or pelvis. Painful ejaculation.

CAUSES

• Age – The most common risk factor for prostate cancer is age. The incidence of prostate cancer increases greatly after age 50. Nearly 2 out of 3 prostate cancers are found in men over the age of 65.
• Race – Prostate cancer is most prevalent in African-American men. Additionally, advanced stage prostate cancer diagnosis is more likely for African-American men and because of this they are more than twice as likely to die of prostate cancer as white men. Non-Hispanic whites are more likely to be diagnosed with prostate cancer than Asian-American and Hispanic/Latino men. The reasons are unclear for these racial and ethnic differences.
• Genetic – Prostate cancer appears to run in some families, which suggests there may be an inherited or genetic factor. A man whose father or brother has prostate cancer is more than twice as likely to develop the disease. The risk is much higher for men with several relatives affected by prostate cancer, especially if their relatives were young at the time the cancer was found.
• Diet – While the role of diet in prostate cancer has been studied, the exact correlation is unclear. A number of studies have shown that men who consume a lot of calcium (through food or supplements) may have a higher risk of developing advanced prostate cancer. The majority of studies have not found such a link with the calcium levels found in the average diet, and it’s important to remember that calcium is known to have other important health benefits.