- ABP, acute bacterial prostatitis, adrenal, androgen, antiandrogen, apoptosis, benign prostate hyperplasia, benign prostatic hypertrophy, bicalutamide, biologic therapy, biopsy, BPH, brachytherapy, CAP, Casodex®, catheter, chemotherapy, chronic bacterial prostatitis, chronic nonbacterial prostatitis, chronic pelvic pain syndrome, chronic prostatitis, cryosurgery, Davinci, digital rectal exam, enlarged prostate, erectile dysfunction, estrogen, flutamide, genitourinary, goserelin acetate, HIFU, hormonal, hormone, hyperplasia, hypogonadism, impotence, incontinence, laparoscopic prostatectomy, leuprolide acetate, Lupron, metastasis, metastasize, Nilandron, nilatamide, nocturia, obesity, oncologist, pelvic lympadenectomy, perineal prostatectomy, perineum, prostadynia, prostatectomy, prostate enlargement, prostate gland, prostate infection, prostate-specific antigen, prostatic acid phosphatase, prostatic hyperplasia, prostatitis, PSA, radical prostatectomy, resectoscope, retropubic prostatectomy, robotic prostatectomy, RRP, seminal fluid, testosterone, transperineal, transrectal, transrectal ultrasound, transurethral, transurethral microwave thermotherapy, TUMT, TURP, ultrasound, urologist, urology, vaccine, Zoladex®.
- The prostate is part of a man's reproductive (genitourinary) system and is located in front of the rectum and under the bladder. It surrounds the urethra, the tube through which urine flows.
- A healthy prostate is about the size of a walnut. Male hormones (androgens, particularly testosterone) normally produced by the body stimulate the growth of the prostate. The testicles are the main source of male hormones, including testosterone. The prostate changes size very little from birth until puberty, but at puberty it increases in weight and doubles in size. In general, the size of the prostate remains constant after puberty for the next 30 or more years. In some men, in fact, the prostate never again increases in size. Unfortunately, however, this is not the case for most men, who will develop some form of non-cancerous enlargement of the prostate, medically known as benign prostatic hyperplasia or BPH. Half of all men in their 50s and 80% of men in their 80s have some symptoms of BPH.
- The prostate makes part of the seminal fluid. During ejaculation, seminal fluid helps carry sperm out of the man's body as part of semen. In the adult male, the glandular tissue of the prostate secretes a fluid that contributes 20-30% of the total volume of the seminal fluid released when a man ejaculates. This prostate fluid is continuously generated by the prostate but increases during sexual excitement. The combination of spermatozoa, seminal vesicle fluid, and prostatic fluid, in addition to a tiny amount of fluid from some minor glands, constitutes semen. The prostate gland fluid is a thin, milky substance that gives semen its characteristic color and odor.
- Some common prostate problems include prostatitis (inflammation of the prostate, usually caused by bacterial infection), benign prostatic hyperplasia or BPH (an enlarged prostate, which may cause dribbling after urination or a need to urinate often, especially at night), and prostate cancer (a common cancer that responds best to treatment when detected early).
- Pain relievers and several weeks of treatment with antibiotics are typically needed for category 1 and 2 prostatitis, which are bacterial infections. A variety of treatments as well as self-care measures also can provide relief. Treatment for category 3 prostatitis (nonbacterial) is less clear and mainly involves relieving symptoms. Category 4 prostatitis is usually found during examination for another reason and often does not require treatment.
- Acute bacterial prostatitis (infectious prostatitis) is treated with oral antibiotics for one to two weeks. The commonly used antibiotics include quinolones, such as norfloxacin (Noroxin®), ciprofloxacin (Cipro®), or levofloxacin (Levaquin®). In severe cases, treatment with intravenous (IV) antibiotics may be necessary. Chronic bacterial prostatitis is also treated with oral antibiotics for 4-12 weeks. Other medications used to treat infectious prostatitis include: stool softeners, such as docusate sodium (Colace®); anti-inflammatory medications, such as ibuprofen (Motrin®); analgesics or pain medications, such as hydrocodone (Vicodin®, Lortab®); alpha-blockers such as tamsulosin (Flomax®); and 5-alpha reductase inhibitors, such as finasteride (Proscar®) or dutasteride (Avodart®).
- If the individual has noninfectious prostatitis, he/she will not need antimicrobial medication. Treatment depends upon the symptoms that are present. If the condition responds to muscle relaxation, the individual may be given an alpha blocker, a drug that can relax the muscle tissue in the prostate and reduce the difficulty in urination.
- Asymptomatic inflammatory prostatitis and chronic prostatitis may respond to multidisciplinary approaches incorporating exercise, progressive relaxation, and counseling.
- Benign prostatic hyperplasia (BPH):
- Drug therapy: The U.S. Food and Drug Administration (FDA) has approved multiple drugs to relieve common symptoms associated with an enlarged prostate. Finasteride (Proscar®), FDA-approved in 1992, and dutasteride (Avodart®), FDA-approved in 2001, inhibit the production of the hormone dihydrotestosterone (DHT), which is involved with prostate enlargement. The use of either of these drugs can either prevent the progression of growth of the prostate or actually shrink the prostate in some men.
- The FDA also approved the drugs terazosin (Hytrin®) in 1993, doxazosin (Cardura®) in 1995, tamsulosin (Flomax®) in 1997, and alfuzosin (Uroxatral®) in 2003 for the treatment of BPH. All four drugs act by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and to reduce bladder outlet obstruction. The four drugs belong to the class known as alpha blockers. Terazosin and doxazosin were developed first to treat high blood pressure. Tamsulosin and alfuzosin were developed specifically to treat BPH.
- Because drug treatment is not effective in all cases, researchers in recent years have developed a number of procedures that relieve BPH symptoms, but are less invasive than surgery.
- Transurethral resection of the prostate (TURP): This is a surgical procedure to remove tissue from the prostate that may be blocking urine flow using a resectoscope (a thin, lighted tube with a cutting tool) inserted through the urethra. This surgery is sometimes performed to relieve symptoms caused by benign (non-cancerous) tumors. Transurethral resection of the prostate may also be done in men who cannot have a radical prostatectomy because of age or illness.
- Transurethral microwave procedures:
In May 1996, the U.S. Food and Drug Administration (FDA) approved the ProstatronT, a device that uses microwave generated heat to destroy excess prostate tissue. In the procedure, called transurethral microwave thermotherapy (TUMT), the ProstatronT sends computer-regulated microwaves through a catheter to heat selected portions of the prostate to at least 111 degrees Fahrenheit. The temperature becomes high enough inside the prostate to kill some of the tissue. As this part of the prostate heals, it shrinks, reducing the blockage of urine flow. A cooling system protects the urinary tract during the procedure.
- A similar microwave device, the Targis SystemT, received FDA approval in September 1997. Like the ProstatronT, the Targis SystemT delivers microwaves to destroy selected portions of the prostate and uses a cooling system to protect the urethra. A heat-sensing device inserted in the rectum helps monitor the therapy.
- Both procedures take about one hour and can be performed on an outpatient basis without general anesthesia. Neither procedure has been reported to lead to impotence or incontinence.
- While microwave therapy does not cure BPH, it reduces urinary frequency, urgency, straining, and intermittent flow. It does not correct the problem of incomplete emptying of the bladder. Ongoing research will determine any long-term effects of microwave therapy and who might benefit most from this therapy.
- Transurethral needle ablation: In October 1996, the U.S. Food and Drug Administration (FDA) approved the minimally invasive Transurethral Needle Ablation (TUNA) System for the treatment of benign prostate hyperplasia (BPH). The TUNA System delivers low-level radiofrequency energy through twin needles to burn away a well-defined region of the enlarged prostate. Shields protect the urethra from heat damage. The TUNA System improves urine flow and relieves symptoms with fewer side effects compared with transurethral resection of the prostate (TURP, see below). No incontinence or impotence has been observed.
- Prostate cancer:
- Overview of management options: When prostate cancer is localized (not spread beyond the prostate), most practitioners will discuss options with patients that include surgical removal of the prostate (prostatectomy), radiation treatment, or active surveillance (also called watchful waiting or observation). The goal of prostatectomy or radiation treatment is to cure the patient by eradicating the cancer. There are other, less well-established approaches including cryotherapy and high-intensity focused ultrasound (HIFU), for which there is less scientific evidence available compared to prostatectomy or radiation therapy.
- Prostatectomy: Radical prostatectomy is a surgical procedure to remove the prostate, surrounding tissue, seminal vesicles, and pelvic lymph nodes. Prostatectomy is performed by a urologist. The traditional open surgery is also called "radical retropubic prostatectomy," during which a 3-4 inch incision is made below the belly button, through which the prostate and nearby lymph nodes are removed. Less common is the perineal prostatectomy, which is an open surgical procedure to remove the prostate and nearby lymph nodes through an incision made in the perineum (area between the scrotum and anus). More recently, laparoscopic prostatectomy and robotic laparoscopic prostatectomy approaches have become more common. For these procedures, several small incisions are made in the abdomen, through which instruments are inserted to perform the surgery. For non-robotic prostatectomy, the surgeon operates these instruments by hand, while in robotic prostatectomy the surgeon operates controls that move a robotic arm to perform the surgery. Most likely, these approaches are all equivalent in terms of effectiveness and side effects, although the least scientific evidence is available on robotic prostatectomy as it is a recently developed technique. Most scientific evidence suggests that the most important factor when selecting a surgical approach is the experience of the surgeon, not the specific surgical technique. Several studies show that the more prostatectomies a surgeon does each year, the better the outcomes for patients. Therefore, patients are advised to undergo surgery with a physician with a lot of experience removing prostates.
- Surgery complications: Surgery for prostate cancer can cause problems such as erectile dysfunction (impotence) and leakage of urine from the bladder (incontinence). Levels of severity are highly variable. In many cases, doctors may use a technique known as nerve-sparing surgery to save the nerves that control erection. These surgeries are performed under general anesthesia, which may also cause complications. The risk of complications should be discussed with the surgeon during initial meetings. Pre-operative clearance by an internal medicine physician or cardiologist should be considered and discussed with the surgeon.
- Radiation therapy: Radiation therapy is a cancer treatment that uses high-energy radiation to kill cancer cells and shrink tumors. It is performed by a radiation oncologist. There are two main types of radiation therapy. External beam radiation therapy (EBRT) uses a machine outside the body to send radiation toward the cancer. Most commonly, EBRT is performed using "conformal" approaches that customize the radiation to the shape of each patient's prostate and location of tumor, and particularly "intensity modulated radiation therapy" (IMRT). Internal radiation therapy (or "brachytherapy") involves surgically implanting tiny, radioactive capsules (called "seeds") into the cancerous prostate gland. The seeds emit radiation that kills the malignant tumor. The type of radiation therapy used depends on the type and stage of the cancer being treated. For some prostate tumors, a combination of EBRT and seeds may be considered by the radiation oncologist. For cancers that are higher-risk (higher Gleason grades, higher PSA scores, and/or greater amounts of cancer in the prostate or surrounding area), hormone therapy may be recommended by the radiation oncologist to be given during treatment and for a period of time after the radiation is completed. Recently, proton beam therapy has been suggested for localized prostate cancer, but evidence is limited and this approach is generally reserved for other types of cancers, such as small tumors in children.
- Radiation complications: Side effects during radiation treatment can include diarrhea, skin burns, sexual dysfunction, and urinary discomfort or urgency. Normal tissue can be damaged by radiation. Like prostatectomy, possible long-term complications include urinary incontinence (leakage) and erectile dysfunction (impotence). There is also a very small chance of long-term blood in the stool due to radiation damage to the lining of the rectum (radiation proctitis). New developments in radiation delivery have decreased the chances of these complications. The risks of these complications should be discussed with the radiation oncologist during an initial meeting.
- Active surveillance, watchful waiting, observation: For selected patients with low-grade cancers (Gleason 3+3=6 in few cores with low prostate specific antigen or PSA), active surveillance may be appropriate. Surveillance is usually under the supervision of a urologist and involves regular follow-up of the PSA, digital rectal exam, periodic re-biopsy, and consideration of periodic imaging with MRI or CAT scans. If concerning changes occur suggesting that the cancer is progressing, then proceeding with prostatectomy or radiation treatment will be considered. For older patients with limited life-expectancy (less than 5-10 years) and low-grade cancers, observation may be considered if the potential risks of treatment are felt to outweigh potential benefits.
- Cryosurgery: Cryosurgery is a treatment that uses an instrument to freeze and destroy prostate cancer cells. This type of treatment is also called cryotherapy. There is less scientific evidence available to support this therapy than there is for prostatectomy or radiation. It is sometimes used for cancer that has recurred after radiation or surgery, but it is associated with high levels of incontinence.
- High-intensity focused ultrasound (HIFU): High-intensity focused ultrasound is a new treatment that uses ultrasound (high-energy sound waves) to destroy cancer cells. To treat prostate cancer, an endorectal (inside the rectum) probe is used to make the sound waves. Scientific evidence supporting this approach is limited.
- Choosing a management approach: Selecting between the available options for localized prostate cancer can be very difficult, especially because for many men there may be no clear advantage of one approach over another. The choice of treatment should be made after discussion with physicians and reading about the different options. Regardless of the approach selected, it should be under the care of a physician with experience treating prostate cancer.
- Metastaticprostate cancer:
- Overview of management options: When prostate cancer has spread beyond the prostate, it is said to be "metastatic" or to have metastasized. The most common areas of metastasis are the bones (especially ribs, spine, skull, and pelvis) and lymph nodes, and less commonly the lungs and liver. Once the cancer spreads to the bones, liver, or lungs, it cannot be cured, and treatments are aimed at controlling the growth of the cancer for as long as possible. The standard initial treatment for metastatic prostate cancer is hormonal therapy. Chemotherapy is generally not given unless the cancer becomes resistant to the effects of hormonal therapy. Generally, the prostate area itself is not treated if the cancer has metastasized, although in some cases if there is a lot of cancer in the prostate area, radiation may be given for "local control" to avoid complications from the cancer growing too large in the pelvis area.
- Hormonal therapy: "Hormone therapy" is a potentially confusing term, as the goal of this treatment approach is actually to block the effects of the normal male hormone, testosterone, on prostate cancers. This is because testosterone stimulates the growth of prostate cancer cells. There are several stages of hormone therapy that can be used as the cancer becomes resistant to each prior stage.
- Castration (surgical or with medications): The initial stage of hormonal therapy involves blocking most of the body's production of testosterone ("castration"). This can either be done by surgical castration (surgical removal of the testicles) or with injected medications ("pharmacologic" or "chemical" castration). The medications are called luteinizing hormone-releasing hormone (LHRH) agonists or gonadotropin releasing hormone (GnRH) antagonists and include leuprolide (Eligard®, Lupron®, Lupron Depot®, Viadur®), goserelin (Zoladex®), and buserelin (Suprefact®). Side effects most commonly include hot flashes, erectile dysfunction (impotence), loss of sexual desire, weight gain, and fatigue. Less commonly men may experience diminished concentration and skin changes. Bone loss occurs and therefore a baseline bone mineral density test should be conducted, treatment with calcium and vitamin D should be started, and a bone-strengthening medicine such as a bisphosphonate should be considered. Recently, hormonal therapy has been linked to a possible increased risk of diabetes or heart disease, although further studies are necessary to determine if a link truly exists. Therefore, people with increased risk of these conditions should discuss the risks vs. potential benefits of this therapy with a doctor. Patients who begin hormone therapy may experience an increase in prostate cancer symptoms for approximately two weeks after starting this treatment due to a temporary increase in testosterone levels, and therefore 2-4 weeks of a different medication (antiandrogen) may be given initially to mute this effect.
- Antiandrogens: Antiandrogens are pills that block the action of testosterone on prostate cells. Examples are bicalutamide (Casodex®), nilutamide (Nilandron®, Anadron®), and flutamide (Eulexin®). They are often added when a prostate cancer becomes resistant to castration treatment alone. Breast enlargement and tenderness can occur, and to prevent breast enlargement, some patients undergo a single radiation treatment to the breast area (which should be given before starting the antiandrogen). Patients taking antiandrogens should undergo periodic liver function tests and should report symptoms such as nausea, vomiting, stomach pain, fatigue, appetite loss, dark urine, or yellowing of the eyes to a physician immediately. Diabetic patients should follow blood sugars closely when beginning therapy. If a cancer progresses during treatment with an antiandrogen, withdrawal of the antiandrogen should be done to see if the action of taking away the antiandrogen shrinks the cancer. If the cancer grows again, then a different antiandrogen may be considered.
- Adrenal agents: Drugs that can prevent the adrenal glands from making androgens (male sex hormones) include ketoconazole. An adrenal agent can be considered if a cancer progresses despite treatment with castration plus an antiandrogen. The adrenal agent should be started at a low dose and gradually increased by the treating physician as appropriate. At higher doses, a steroid pill such as hydrocortisone should be given with the adrenal therapy. Side effects can include drowsiness, dizziness, headache, weakness, nausea, or loss of appetite especially during the first few weeks of treatment. If these symptoms are severe, a physician should be contacted immediately. Liver function tests should be monitored during this treatment.
- Estrogens: Estrogens (hormones that promote female sex characteristics) were previously used to treat prostate cancer, but are seldom used today because of the risk of serious side effects, including blood clots.
- Chemotherapy: Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy is often used to treat advanced prostate cancers that are resistant to hormonal treatments. A medical oncologist (cancer specialist) will usually recommend a single drug or a combination of drugs. As of 2008, the only U.S. Food and Drug Administration (FDA)-approved chemotherapy for prostate cancer shown to lengthen life and improve quality of life is docetaxel (Taxotere®). Mitoxantrone (Novantrone®) has also been approved by the FDA for prostate cancer, but has not been shown to lengthen life and is only beneficial in a small percent of patients. Other chemotherapy medications sometimes used to treat prostate cancer include paclitaxel (Taxol®), carboplatin, and, less commonly, doxorubicin (Adriamycin®) or oral etoposide. For rare cases of "small cell" or neuroendocrine prostate cancer, intravenous etoposide and a platinum agent may be used. Side effects of chemotherapy depend on the type of drug used, dosage, and length of treatment. The most common side effects are fatigue, nausea and vomiting, diarrhea, hair loss, anemia, and increased susceptibility to infection due to lowered white blood cell counts. Radiopharmaceuticals such as samarium (Quadramet®) may be used as a palliative measure to treat bone pain.
- Clinical trials: Many new drugs including "targeted" agents, vaccine-type therapies, and new chemotherapies are in development. A treating oncologist may offer enrollment in a trial to patients with prostate cancer. An "informed consent" document will be given to a patient that explains the potential risks and benefits of the trial. Information from clinical trials is used to improve therapies for future patients and is an opportunity to receive a new treatment approach that is not otherwise available.
- Hospice and end-of-life care: When a patient has not responded to treatment methods, is too frail to receive further therapy, or the prognosis is not good, palliative care can be started with a goal of comfort and to provide symptomatic relief and dignity. Hospice services are available as inpatient facilities or in the home with hospice nurses visiting as necessary. Hospice options can be discussed with an oncologist's office.
- This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).
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Types and causes of prostate conditions
Prostatitis is inflammation of the prostate gland usually caused by an infection that often affects younger men. With treatment, prostatitis should generally be alleviated within several days to two weeks. Treatment of chronic (long-term) bacterial prostatitis usually involves antimicrobial medication for four to 12 weeks. This type of prostatitis is difficult to treat and recurrence is possible.
- Prostatitis usually results from blockage or irritation of some of the ducts within the prostate gland, and the cause may be mechanical (such as narrowing of the urethra) or infectious. The infectious causes may be viral or bacterial, including E. coli or sexually transmitted infections such as Chlamydia.
- There are four types of prostatitis: acute bacterial prostatitis (the least common of the four types, but the most common in men under 35); chronic bacterial (not very common, but affects mostly men between 40-70 years); asymptomatic inflammatory prostatitis (produces no outward symptoms and occurs mainly in men aged 60 and over); and chronic nonbacterial/prostadynia (most common type). Prostadynia, also known as chronic pelvic pain syndrome, is a condition associated with similar symptoms as chronic nonbacterial prostatitis, but which has no evidence of prostate inflammation.
- Benign prostatic hyperplasia (BPH): Benign prostatic hyperplasia (BPH) is a normal, gradual enlargement of the prostate caused by hormonal fluctuations, such as decreases in testosterone and increases in dihydrotestosterone (DHT) and estrogen in prostate tissue. BPH usually beings in middle age. BPH does not lead to cancer. BPH does not generally cause pain, but discomfort (a feeling of pressure) in the groin area is generally found.
- As the prostate enlarges, it presses against the urethra and interferes with urination. At the same time, the bladder wall becomes thicker and irritated and begins to contract, even when it contains small amounts of urine, which causes more frequent urination. And, as the bladder continues to weaken, it may not empty completely leaving some urine behind. Blocking or narrowing of the urethra by the prostate and partial emptying of the bladder cause many of the problems associated with BPH.
- BPH affects about half of men aged over 60 and 80% of men aged 80 or older; it is considered to be a condition related to aging. Almost every man over 45 has some prostate enlargement, but symptoms are rarely felt before the age of 60. BPH affects all men differently and therefore treatment varies.
- Prostate cancer: As men get older (after age 50), their risk of prostate cancer increases. Men above 50 years of age should be checked for prostate cancer routinely by their doctor, and men with risk factors for developing prostate cancer (including family history of prostate cancer, multiple family members with prostate cancer, and/or African heritage), should talk to their doctor about starting this screening at a younger age such as 40.
- Prostate cancer exhibits tremendous differences in incidence among populations worldwide. Asian men typically have a very low incidence of prostate cancer, with age-adjusted incidence rates ranging from 2-10 per 100,000 men. Higher incidence rates are generally observed in northern European countries. African men, however, have the highest incidence of prostate cancer in the world. In the United States, African American men have a 60% higher incidence rate compared with Caucasian men.
- Prostate cancer is the most common non-skin cancer in America, affecting one in six men. More than 218,000 men in the United States will be diagnosed with prostate cancer in 2007. Healthcare professionals recommend men 50 years of age and older get screened for prostate cancer.
- If an immediate family member such as a father or brother has prostate cancer, the risk of developing the disease is greater than that of the average American man. Between 5-10% of prostate cancer cases are believed to be due primarily to high-risk inherited genetic factors or prostate cancer susceptibility genes. The survival rate indicates the percentage of patients who live a specific number of years after the cancer is diagnosed. For prostate cancer, the 10-year survival rate is 93% and the 15-year survival rate is 77%.
- A high-fat diet and obesity may increase the risk of prostate cancer. Researchers theorize that fat increases production of the hormone testosterone, which may promote the development of prostate cancer cells. Obese men who are diagnosed with prostate cancer have more than two-and-a-half times the risk of dying from the disease as compared to men of normal weight at the time of diagnosis. Scientists believe that obesity increases the risk of prostate cancer by increasing inflammation and steroid hormones, such as testosterone.
- Because testosterone naturally stimulates the growth of the prostate gland, men who have high levels of testosterone and men who use testosterone (steroid) therapy are more likely to develop prostate cancer than are men who have lower levels of testosterone. Long-term testosterone treatment could cause prostate gland enlargement (benign prostatic hyperplasia or BPH). Also, doctors are concerned that testosterone therapy might fuel the growth of prostate cancer that is already present.
Copyright © 2011 Natural Standard (www.naturalstandard.com)
The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.