September is men’s “Prostate Health Month.” My bet is that most people are unaware of the disorders that can affect the prostate gland, except for prostate cancer. So, here goes.
First of all, where is the prostate (not prostrate – which means lying stretched on the ground with one’s face downward) and what is its function? The prostate gland is about the size of a walnut, situated at the base of the bladder, and encircles the urethra (the tube through which urine travels from the bladder to the outside, as well as the path of spermatic fluid with ejaculation). It produces prostatic fluid, an alkaline fluid that mixes with the seminal fluid containing sperm with ejaculation.
In the U.S, about 50% of men 51-60 years old have prostate conditions, and this increases to about 90% by age 80. There are three major categories of prostatic disorders:
- inflammation (called prostatitis)
- benign prostatic hypertrophy (thickening or overgrowth of the prostate)
- prostate cancer
Prostatitis
Prostatitis, inflammation of the prostate gland, can be caused by bacteria
or be non-bacterial. It can be acute (sudden onset) or chronic (continuing or occurring again and again for a long time). Prostatitis is most commonly seen in the 20 to 50-year-old age group and those over 70 years old.
Acute infections (about 10% of all cases) are often associated with urinary tract infections caused by bacteria or by gonorrhea and chlamydia, which are sexually transmitted infections. The patient frequently presents with urinary tract infection symptoms (pelvic pain, pain or burning on urination, an urgent feeling of having to urinate, having to go frequently). Sometimes there can be fever, chills, nausea, malaise. Treatment generally consists of antibiotics.
Non-bacterial prostatitis is more common. An inflamed prostate can be caused by a variety of prior issues. These can include past infection, chemical irritation, nerve problems, pelvic floor muscle problems, sexual abuse, and chronic anxiety. This kind of prostatitis is the most difficult to treat because of the many possible causes.
Benign Prostatic Hypertrophy
Overgrowth or thickening of the prostate, without evidence of cancer, is called benign prostatic hypertrophy. This disorder causes the gland to get larger. This narrows the urethra and can lead to a variety of urinary problems. It causes some degree of obstruction to the flow of urine. The worse case scenario is complete urinary obstruction; the person cannot pass urine at all. In rarer circumstances, there can be chronic urinary retention, causing increased pressure in the bladder and upwards, causing kidney damage.
The main symptom is usually difficulty urinating, especially starting the urine flow, combined with a feeling that the bladder is not empty. Added to this can be a sense of having to go urgently, sometimes with painful urination, and there can also be blood in the urine. On physical exam, the prostate can be palpably enlarged.
Factors that increase a person’s chance of developing benign prostatic hypertrophy are: family history of the disorder, obesity, heart disease or circulatory disorders, type 2 diabetes, and decreased physical activity.
There are some drugs that are currently being used in the management of this problem. When symptoms are severe, surgical procedures through the urethra are generally performed. These types of procedures enlarge the diameter of the urethra and makes it easier to pass urine.
Possible side effects of the surgical procedures can be:
- retrograde ejaculation (semen flows back into the bladder rather than out the urethra with ejaculation)
- urinary incontinence especially associated with the sensation of having to urinate immediately (called “urge” incontinence)
- scarring and narrowing of the urethra
- erectile dysfunction
If someone is contemplating a surgical procedure for benign prostatic hypertrophy, it is essential to discuss all the side effects and their management with the doctor.
Prostate Cancer
Cancer is the most dreaded disorder of the prostate. It is most common in men who are 50 years old or older, however, it can be found in younger men. According to the American Cancer Society, 1 in 8 men will develop prostate cancer at some point in their lives.
Race plays a part in occurrence. In the US, there is an increased incidence in African-American and Caribbean men of African ancestry and a lower incidence in Asian-American and Hispanic/Latino men. It is less common in Africa, Asia, Central and South America.
It is important to know family history. If a father or brother has/had prostate cancer, the risk can be doubled or more. In a study by Lauren Barker et al published in 2018 in the journal “Chemical Cancer Research,” males with a family history of breast cancer had a 21% increased risk of prostate cancer and a 34% increased risk of lethal disease. Those with a family history of prostate cancer had a 68% increased risk and a 72% increased risk of lethal disease.
Besides ethnicity and family history, some inherited genetic changes can increase the risk of prostate cancer, such as genetic mutations to the BRCA1 and BRCA2 genes, and also an inherited condition called Lynch syndrome.
Chemical exposure, such as those experienced by firefighters, might put a person at increased risk. Obesity is another risk factor, and there is some data that diets high in animal protein, including dairy, might increase the risk.
A majority of prostate cancer is identified by screening with the Prostate Specific Antigen (PSA) test, although there is conflicting advice about PSA testing. There is no cut-off between normal and abnormal, which can be confusing. Most men without prostate cancer have levels less than 4 ng/ml (nanograms per milliliter). Borderline is 4-10 ng/ml, with a one in four (25%) chance of having prostate cancer. With a result of greater than 10 ng/ml, a person has a 50% chance of having prostate cancer.
To add to the confusion, some prostate tumors are slow growing, called indolent. These do not require immediate surgery or radiation, and should be monitored regularly. This is called “active surveillance.” Other tumors can be aggressive and necessitate more immediate surgery or radiation.
Diagnosis of prostate cancer is usually made based on biopsies of the prostate gland, done with ultrasound guidance. A urologist is usually the physician who does these biopsies and would be the physician advising the patient about active surveillance, surgery, or radiation. If the disease is advanced when the physician first sees the patient, there might be symptoms such as pain and stiffness in the back, hips, or upper thighs. The evaluation, under those circumstances, might begin with imaging such as CT scans or MRIs.
Treatment options vary with the age and general condition of the patient, as well as the extent of the tumor. Two main ways of treating prostate cancer are surgery (radical prostatectomy) and radiation therapy. Side effects of a radical prostatectomy can include urinary incontinence, erectile dysfunction, changes in orgasms, and loss of fertility. Side effects of radiation can be urinary urgency and burning, blood in the urine, loose stools, urinary incontinence, erectile dysfunction, weaker bones, and vitamin B12 deficiency. All of these should be discussed thoroughly with the urologist before making any treatment decision.
Dietary Considerations
There is bound to be some controversy when discussing diet in relation to decreasing the risk of prostate cancer (and other cancers also). Part of the problem is that it is challenging to do dietary studies. Another issue is that it takes cancer time to develop and so studies that manipulate dietary factors need adequate time to be carried out, years, not months.
Here is some helpful information. Most advice from reputable sources emphasizes a diet low in fat, sugar, red and processed meats, dairy foods, and charred meat from frying or grilling. There is some evidence (from the Harvard University prostate cancer progression and mortality data) that indicates eating eggs and poultry increases prostate cancer progression.
There is also some evidence that eating flaxseed regularly may reduce the rate of tumor growth. The recommended amount is three tablespoons of ground flaxseed a day. This can be added to cooked cereals, sprinkled on salads, incorporated into a nut butter on toast, and milled into flour form to be used in baking at a 1:1 ratio with whole wheat flour. Flaxseed might also help with benign prostatic hypertrophy.
Cruciferous vegetables like broccoli, cabbage, Brussels sprouts, and cauliflower are loaded with antioxidants, as are berries. Cooked tomatoes contain lycopene, the frequent intake of which has been shown to be associated with a reduced risk of prostate cancer. The consumption of soybeans and other soy products, legumes (beans), and green tea have also been associated with better prostate health.
Good general health practices can help prevent many cancers. They include avoiding obesity, exercising regularly, and not smoking or using other tobacco products. And, as your grandmother said, “eat your vegetables!!!”
