The prostate is a walnut sized gland found beneath the bladder, in front of the rectum in men. The urethra passes through the centre of the prostate gland. Ducts coming from the sexual organs (testicles) also enter the prostate gland and join the urethra.
Many of the functions of the prostate are unknown. It is known that the prostate produces part of the semen fluid that keeps the sperm healthy and supported prior to ejaculation.
Cancer develops when the cells of the body divide and reproduce in an uncontrolled manner to form a mass of tissue that can invade the surrounding organs and also spread to distant parts of the body (metastases).
Prostate cancer usually develops in the outer part of the gland and can spread locally to the bladder and also to other organs such as liver and commonly to bones. It is not known exactly why prostate cancer occurs, however, it appears to occur as a result of faults in the genes controlling growth and division of the prostate gland cells.
Some known risk factors are as follows:
Initially, prostate cancer may have no symptoms at all. Most men see their GP because of urinary symptoms such as hesitancy, urgency, frequency, nocturia, dribbling, weak stream and incomplete emptying. You will be assessed and investigated if prostate cancer is suspected.
The PSA, Prostate Specific Antigen, is a protein substance produced by the prostate under normal circumstances.
If your PSA is elevated on the blood test, it may indicate that there is a cancer within your prostate. It is important to note that an elevated PSA does NOT diagnose cancer of the prostate.
It merely enables your specialist to decide whether further investigation of the prostate is necessary to look for cancer (for instance, TRUS biopsy).
The normal range for PSA is 0-4.0ng/ml, but this varies according to your age and the reference range used by the pathology laboratory.
Trans Rectal UltraSound of the prostate and biopsy is used to obtain very small samples of prostate tissue so that they can be looked at under the microscope to see if cancer cells are present.
If prostate cancer is found, you will probably be asked to have the following further tests:
If the cancer is localised to the prostate, the following options are available:
These treatment options have many advantages and disadvantages, which should be discussed with you on an individual basis with your urologist at the time of consultation.
If the cancer has spread, some of the following options are available:
Clinical examination and testing of your PSA levels will be carried out at regular intervals. For example, after radical prostatectomy, your PSA should drop to almost un-recordable levels, ideally to below <0.1. Be aware that different laboratories have different reference ranges and therefore the actually PSA number may be slightly higher than the above.
If after treatment of a localised prostate cancer, your PSA remains at this low level for three years, you can usually assume that the cancer will not come back and that you are cured
Much research continues into the causes and treatments of prostate cancer. Attempts have been made to identify the possible genes responsible for prostate cancer development and therapies directed at altering the function of these genes may give rise to effective treatments in the future.
This is part of the normal ageing process in men where the prostate gland increases in size. The prostate grows to its normal size around the time of puberty, however, it then starts to slowly increase in size in the third decade and onwards.
As the prostate gland is somewhat contained by its outer layers, an enlargement of the prostate tends to impinge upon the urethra, narrowing the channel for urine in the process.
This can lead to some of the symptoms of BPH. Around 10% of men in their 40’s have BPH and this figure rises to 50% of men in their 50’s and 90% of men over the age of eighty.
The symptoms of BPH are caused as a result of the narrowing of the urethral channel, which obstructs the flow of urine from the bladder outwards. Symptoms can be:
Strangely, some men with a large prostate have no symptoms at all, whereas small prostates can cause severe symptoms.
If the urethra is blocked completely, the patient may not be able to pass urine at all and this results in acute urinary retention, requiring immediate medical attention.
Patients usually see their GP’s complaining of urinary symptoms. These include having a weak stream, having to wait to get started to pass urine, a feeling that the bladder isn’t emptying, frequent and urgent desire to pass urine along with having to get up during the night to do so.
Examination of the prostate demonstrates whether it is enlarged or not. Your doctor may request a blood test to check your PSA. This can be used as a possible indicator for prostate cancer in some circumstances.
If a diagnosis of BPH is made, the GP will then refer you to a urologist. Your urologist will confirm your symptoms history and repeat the prostate examination to confirm your GP’s findings. Your urologist then may order the following tests:
Men are often concerned that their symptoms are indicative of a risk of prostate cancer. If their GP or urologist is able to reassure them that this is not a particular concern they may feel that the symptoms aren’t sufficiently bothersome to warrant treatment.
Drug treatments are available to try and relieve your symptoms. There are two main classes of drugs that are in use:
i) Alpha-blockers. These act by relaxing the smooth muscle of the prostate and bladder neck outlet to improve your urinary flow. Drugs in this group include tamsulosin, alfuzosin, terazosin and doxozacin.
ii) Drugs that stop the production of dihydrotestosterone (DHT) produced from testosterone. The main drug in this group is finasteride. Finasteride takes longer to work and has been shown to be of most benefit in patients with larger prostates.
Your urologist will discuss the side effects of these drugs with you at your consultation.
Operative treatments for BPH include TURP, laser prostatectomy and other minimally invasive therapies.
What is a TURP?
Trans Urethral Resection of Prostate (TURP) involves “coring out” the prostate to create a wide channel through the prostate to enable you to pass urine more freely. Over the years, TURP had assumed the position of the gold standard treatment for bladder outflow obstruction due to prostatic enlargement. In recent years laser technology has been increasingly successful in replacing traditional TURP.
After traditional TURP some 10% of men may require a second coring out of the prostate at 8 years. In some instances, the scar tissue forming around the bladder neck can give rise to the need for earlier operation, soon after TURP. This is called bladder neck stenosis and can occur in up to 15% of patients undergoing TURP.
HIFU is high intensity focused ultrasound. The technology has been developed as a curative treatment for localised prostate cancer.
It is indicated as a first choice therapy for localized prostate cancer in suitable patients.
Additionally, it can be used as salvage therapy of local recurrence after a radical prostatectomy operation or radiotherapy.
A transducer probe emits a powerful ultrasound wave that can be focused and concentrated to a point a small distance away from the probe.
This is similar to the way in which a magnifying glass can be used to focus the power of the sun’s rays to a point, causing a burn.
Similarly, the concentration of the HIFU beam can create maximum pressure at a point (the focal point), creating temperatures of between 85° and 100°C at this point.
At the point of ultrasound concentration, two main effects occur:
Clinically, this causes a small cigar shaped lesion within the prostate, destroying the prostate cancer cells and surrounding tissue.
Yes. The operating surgeon uses computer software to treat the prostate and the cancer within.
The HIFU beam is concentrated at different points within the prostate, in three dimensions, to ensure that destruction of the tissue is complete.
Depending on the size of the prostate, the average treatment takes 2-3 hours to complete.
The patient requires either a spinal anaesthetic or general anaesthetic for the duration of the procedure
Contraindications for HIFU treatment
Preparation before HIFU treatment