With an ageing population in the United States, many baby boomers are coming of “age”. Estimates are that 10,000 of them reach the age of 65 daily. Prostate problems in general are very common and confusing. No doubt, the confusion will increase due to so many more men experiencing prostatic enlargement and possible cancers. More than 50% of men over age 50 years are affected by prostate enlargement. By the age of 80 years, 90% of men will have an enlarged prostate. The diagnosis and treatment of prostate problems has changed a great deal over the last 20 years but continues to lack clarity or consensus. Benign enlargement of the prostate gland causes urinary frequency, urinary retention and incomplete emptying of the bladder. Similar symptoms may be initial signs of prostate cancer as well. Early detection of any cancer is key to successful treatment. The confusion is with testing procedures that are less than perfect. A wide variety of treatments none of which achieve dominant success over other modalities and some evidence that many of these cancers do not need to be treated because of their slow growth, confound diagnosis and management of prostate problems. Let’s examine what we know.
Enlargement of the prostate is suspected when urinary symptoms such as the following are experienced urinary frequency, stopping and starting urinary stream, straining to urinate, and getting up at night to urinate regularly. A weak urinary stream and dribbling may also indicate enlargement is choking off the urethra and blocking the outflow of the urine from the bladder. The challenge is that prostate cancer, prostate infections or common urinary tract infections can also cause similar symptoms. Discovery of prostate cancer can be as simple as the basic urine analysis, digital rectal exam, and PSA blood test. Normal findings in all of these tests are reliable in eliminating possible cancer. However, positive results raise the suspicion of cancer in men over fifty and need to be carefully evaluated. PSA tests in particular are well known for false positives due to the ability of benign prostatic enlargement to cause elevations in the results. Blood in the urine could be an early clue of cancer requiring further evaluation or biopsy.
Treatment of benign prostatic hypertrophy is usually with medications that can slowly reduce some of the problem of obstruction of urine outflow from the bladder by the prostate enlargement. Some herbal remedies have had some limited success as well. However, studies are unable to prostate protocol reviews reproduce consistent benefit. Medications can help most men who struggle with small frequent urination but side effects like dizziness and low blood pressure occur in some. When medical treatment does not work or seem suitable surgical procedures may be helpful. There are several minimally invasive treatments that can achieve good results with low risks and good improvement in urinary flow. Each case must be evaluated on an individual basis with a urology specialist to tailor the appropriate option to the individual patient.
Cancer detection in the prostate is still a challenge. It can be difficult to diagnose the presence of prostate cancer as well as whether it is a more aggressive or slow spreading type. The Prostate-specific Antigen (PSA) blood test is still the best screening test even though it has limitations. Following the progression of this test value with consideration for the individual, age, family history, along with other risk factors has the best predictive value. We know that there are significant false positives of a PSA test. Benign enlargement causes elevations in the PSA results. There remains a difference of opinion among experts regarding watchful waiting for screening and active surveillance for cancer. There is additional uncertainty in prostate cancer treatment as many of these are very slow growing. An old adage suggested that older men died “with” prostate cancer rather than “of” prostate cancer. The amount and location of cancer detected (whether it has spread outside of the prostate gland), age of the patient, risk factors and other illness will strongly influence how aggressive treatment should be. Because of the variations of slow and more aggressive prostate cancer, treatment needs to be an individualized decision between each patient and his treating providers. Surgery, radiation, and chemotherapy are all tools that can bring a best outcome for any given individual. With aging baby boomers, benign prostate enlargement and cancer will increase in prevalence. There have been many new developments in treatment. The particulars of screening and detection remain a controversial area. Being informed and vigilant is the best way to protect yourself or the aging males in your family.