PROSTATE POWER: What men must know NOW
John Hopkins Medicine - Health Tip
The prostate is a gland that sits below a man’s bladder and in front of his rectum. This gland is the size and shape of a crab apple and surrounds the urethra, the tube that carries urine away from the bladder.
The prostate has several functions. First, it produces prostatic fluid, which is a component of semen. Second, it serves as a valve to keep both urine and semen flowing in the proper direction. Finally, it pumps semen into the urethra during orgasm.
When a man reaches his mid-40s and beyond, the inner portion of the prostate begins to enlarge and may put pressure on the urethra, a condition called benign prostatic hyperplasia (BPH). BPH affects about 50% of men age 51 to 60 and about 90% of men older than age 80. Although it can cause a variety of symptoms, BPH is not life-threatening.
Prostate cancer is a much more serious health problem. It is the second leading cause of cancer-related deaths among American men.
In 2005, about 230,000 men were diagnosed with prostate cancer, and about 30,000 died of the disease. Although the exact cause of prostate cancer is still unknown, new research has begun to identify possible risk factors while ruling out factors once thought to play a role. Moreover, improved diagnostic tests and numerous treatment options are available for prostate cancer, and death rates from prostate cancer are on the decline.
The following is a wealth of information on how to manage your prostate health. Learn about your risk for prostate cancer, how to choose a course of treatment if cancer strikes, how to treat related sexual dysfunction, and what it could mean if you see blood in your urine.
Are You at Risk for Prostate Cancer?
Knowing the facts will help you to protect your prostate.
Unlike some other cancers, the causes of prostate cancer are not well understood. As a result, doctors have been unable to give many recommendations to men who wish to reduce their risk of prostate cancer. However, within the past decade, new research has begun to identify the possible risk factors for this common disease. On pages 3 and 4 you’ll find a list of the established risk factors, those with some degree of evidence, and those that have been ruled out as causes of prostate cancer. While some of these risk factors can be modified (for example, selenium and vitamin E intake), others (like age and race) cannot be changed.
Getting a Second (or Third or Fourth) Opinion
Getting a balanced view of all your treatment options for prostate cancer may involve consulting with several specialists.
Determining a course of treatment for prostate cancer is one of the most harrowing decisions in modern medicine. Not only do treatments such as surgery and radiation therapy have troubling side effects, doctors can’t agree on which treatments work best—and are more likely to recommend the option that they specialize in. Hence, to be in the best position for making decisions about your own treatment, it’s vital to get more than one opinion.
Three Types of Specialists
In an often-cited study published in the Journal of the American Medical Association in 2000, researchers asked more than 1,000 specialists what treatment they would recommend for a man with early-stage prostate cancer who was expected to live at least 10 more years. Nearly all the urologists (93%)—who perform surgery—chose surgery as the preferred treatment, while most of the radiation oncologists (72%) responded that radiation therapy and surgery were equally effective treatments. The study authors’ conclusion? Patients should schedule a consultation with a member of each specialty before making a decision.
If these specialists don’t agree, one option is to schedule a consultation with a medical oncologist, a specialist in cancer treatment who does not perform radiation or surgery. Another option is to see a second urologist or radiation oncologist. Doctors of the same specialty often have different approaches to treatment: For example, some radiation oncologists will recommend external beam radiation therapy; others, brachytherapy; and still others, a combination.
The Importance of the Pathologist
A final but not-to-be-overlooked reason to seek a second opinion is that if done at a center that specializes in prostate cancer treatments, it involves having another pathologist review the slides from your biopsy specimen. An accurate pathology reading is essential because it forms the basis for treatment decisions.
Unfortunately, spotting cancerous cells and determining how abnormal they appear are difficult, and pathologists sometimes make errors. In one study, pathologists at Johns Hopkins reviewed biopsy samples of 535 men who had been referred for radical prostatectomy and reclassified 7 (1.3%) as benign. Upon subsequent clinical workup, 6 of 7 men were considered not to have prostate cancer, and their surgery was canceled. Getting an incorrect reading can limit your treatment options—or lead to having treatments that you don’t need.
How To Get a Second Opinion
Some patients are reluctant to bring up the matter of second opinions, thinking that their doctor may not be receptive to involving another physician. Today, however, doctors in step with current medical standards welcome such discussions and support their patients’ desire for additional information whenever appropriate. Health insurers generally pay for second opinions, and some even require them before certain procedures.
Your primary care doctor and the urologist who performed the biopsy are the best sources for referrals. Request that, if possible, they suggest a colleague affiliated with a different hospital. Although this is not absolutely necessary, the practice is prudent, because doctors who work at the same institution often share similar views and may be reluctant to contradict one another. Also check to be certain the consultant is board certified in the appropriate specialty. The American Medical Association (www.ama-assn.org) and the American Urological Association (www.urologyhealth.org) offer referral services. Hospitals, local health departments, family, and friends are other possible resources.
If your referring doctor is unwilling to discuss the possibility of a second opinion or makes you feel uncomfortable about the matter, strongly consider changing doctors.
Before meeting with you, the consultant will require all relevant medical records. The first doctor’s office can send written reports and test results directly to the consultant. Be sure to call before your appointment to confirm their arrival, as it will be impossible to proceed without proper documentation; you can also choose to collect the records and deliver them personally.
During the consultation, the doctor will review the information and may perform a physical examination or order more tests. A written report of recommendations will be sent to the referring physician— and also to you if you request them.
Be sure that the specialists address all treatment options—surgery, radiation therapy, and watchful waiting—and discuss the advantages and disadvantages of each. If your doctors don’t agree and you don’t know what to do, one or more of the following approaches can help you reach a decision:
• Have the specialists explain to you why they came to their respective conclusions.
• Suggest that the specialists discuss the matter with each other; sometimes such conversations produce an acceptable consensus.
• Ask your general practitioner—or, if you wish, another specialist— to help you sort through the options.
• Consider seeking an opinion at a nationally recognized cancer center, such as one affiliated with the National Comprehensive Cancer Network (www.nccn.org).
• Try talking to men who have been treated for prostate cancer. Don’t panic if you’re having trouble making a decision. Prostate cancer is generally a slow-growing malignancy, which means that most people can safely spend up to three months learning about the disease and consulting with the appropriate specialists.
Finding Help for Sexual Function Problems
A visit to a urologist or mental health professional may benefit your sex life.
Nearly all of the treatments for benign prostatic hyperplasia (BPH) and prostate cancer have the potential to cause sexual problems. For instance, surgery and radiation therapy can result in erectile dysfunction, and BPH medications and hormone therapy can produce both erectile dysfunction and reduced sex drive. Even the anxiety and stress associated with having a prostate disorder can affect erectile function and interest in sex. Fortunately, help is available. Making an appointment with your urologist, a mental health professional, or both can help you regain a satisfying sex life.
Seeing a Urologist
If you have been treated for BPH or prostate cancer, you probably already have a urologist. Many urologists who treat BPH and prostate cancer also treat sexual function problems, particularly problems that have a physical cause such as damage to the nerves or blood vessels that control erections.
To determine the cause of your sexual problem, the urologist will take a detailed medical and sexual history, perform a physical examination, and conduct tests. If the cause is found to be physical, several treatment options are available. They include oral medications like sildenafil (Viagra) or vardenafil (Levitra), vacuum pumps, drugs that are injected into the penis or placed in the urethra, and penile implants. The choice of treatment depends on the cause and severity of your sexual dysfunction as well as personal preference (both yours and your partner’s). Some men try a number of treatments before finding the one that works best for them.
If your urologist doesn’t specialize in sexual dysfunction, ask your primary care doctor or current urologist for a referral. You can also check out the website of the American Urological Association (www.auanet.org). Click on the “Patient Info” link and then on “Find a Urologist.” If you do not have Internet access, you can call the organization at 866-RING-AUA or 410-689-3700. Unfortunately, the website does not list the urologists’ subspecialties, so be sure to ask before making an appointment.
Seeing a Mental Health Professional
Sexual dysfunction can cause emotional distress and negatively affect the relationship between you and your partner . So even if your sexual problem has a physical explanation, seeing a mental health professional can be beneficial. Mental health professionals who provide counseling to people with sexual dysfunction include psychiatrists, psychologists, and sex therapists.
Counseling for sexual function problems typically involves both you and your partner meeting with a mental health professional once a week for two to three months. It may also involve homework assignments—putting into practice the skills you learn in counseling each week. The counseling can help relieve the anxiety and depression that often accompany and exacerbate sexual problems, improve communication and strengthen your relationship, and teach new ways that you can enjoy each other sexually, beyond sexual intercourse.
To find a mental health professional who specializes in sexual problems, ask your primary care doctor or urologist for a referral or call the American Psychological Association at 800-964-2000. You can also visit the Web site of the American Association of Sex Educators, Counselors, and Therapists (www.aasect.org). Click on the link “Locate a Certified Sex Therapist/Counselor/Educator Near You.” Before choosing a mental health professional, be sure he or she has experience in dealing with sexual problems related to prostate disease.
When You See Blood in Your Urine
This alarming sign has a variety of possible causes, and not all are serious.
Hematuria is the technical term for blood in the urine. In gross hematuria, red blood cells in the urine are visible to the naked eye, appearing as spots of blood or blood clots in the toilet water or turning the water pink, bright red, reddish-brown, or cola-colored. In microscopic hematuria, the red blood cells can be seen only upon examination of the urine under a microscope. Because hematuria may be caused by a serious condition, all people with gross hematuria and those over age 40 with microscopic hematuria should receive a prompt and thorough medical evaluation.
Causes of the Bleeding
Hematuria is the result of bleeding somewhere in the urinary tract, which is made up of a man’s kidneys, bladder, prostate, and urethra. The bleeding can stem from an infection, inflammation, trauma, cancer, or kidney or bladder stones. It also can be a symptom of benign prostatic hyperplasia or prostatitis. Bleeding disorders and anticoagulant medications such as warfarin (Coumadin) may also cause or contribute to hematuria.
Hematuria is not always indicative of a serious condition. Vigorous exercise can cause blood to be excreted in the urine, but this usually lasts no more than two days. Urethral catheterization can also cause temporary hematuria. Also, pigmenturia—a condition that mimics blood in the urine—results from eating foods or taking medications that discolor the urine but involves no bleeding. (These foods include beets, blackberries, blueberries, fava beans, rhubarb, paprika, and foods and medications containing red or dark food coloring.) Finally, what may appear to be blood in the urine may actually be remnants of blood in the semen, which is usually not a serious condition.
Doctors can find no cause for hematuria in up to 10% of cases, and some 9% to 18% of healthy people have microscopic hematuria.
Diagnosing the Bleeding
Both gross hematuria and microscopic hematuria can be evaluated in a doctor’s office, although some patients with gross hematuria may seek an emergency room evaluation.
Either way, an assessment includes taking a medical history and asking about recent food and drug intake, exercise, and urological procedures. The doctor will ask about specific features of the blood in the urine, including if there is any associated pain or irritation, whether blood appears at the beginning or end of the urine stream, how much blood is in the urine, and if any blood clots are present.
The doctor will then try to determine the cause of the bleeding by performing a number of tests. These can include urinalysis (to look for red and white blood cells, protein, or chemicals), urine culture, blood tests, genital and rectal exams (to look for prostate disease), and a study to image the upper part of the urinary tract (kidney and ureters), which might include an intravenous pyelogram (an x-ray of the urinary tract) or computed tomography (CT). In addition, cytoscopy (inserting a flexible tube through the urethra to view the bladder) is performed to directly visualize the lower part of the urinary tract (urethra and bladder).
Microscopic hematuria usually indicates that a kidney problem is present, and gross hematuria and blood clots typically result from a problem in the bladder, prostate, or urethra. In addition, until they have ruled out malignancy, doctors assume that painless, gross hematuria is the result of cancer.
Stopping the Bleeding
Therapy depends on the exact cause, and treating the underlying cause should stop the bleeding. If the cause involves the bladder, prostate, or urethra, you should seek treatment from a urologist. If the bleeding originates from kidney disease for which surgery would not be corrective (medical renal disease), follow-up with a nephrologist is necessary. Some patients may require catheter irrigation of the bladder to remove any clots that might be blocking urine flow.
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