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PROSTATE POWER: What men must know NOW
John Hopkins Medicine - Health Tip

Benign prostate hyperplasia is not life-threatening. For men who develop prostate cancer, numerous treatments are available, and its death rates are declining.

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.

Ranking the Causes of Prostate Cancer
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.   Below, we list 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.
Degree of
Risk Factor Comments
risk factor)
Older age The risk of prostate cancer increases dramatically with age.
Almost all men diagnosed with prostate cancer are older than
age 50, and the average age of diagnosis is between 65 and 70.
Ethnicity The incidence of prostate cancer in the United States varies by
race. The rate for white men is 101 per 100,000 each year .
Black men are at higher risk (137 per 100,000), and Asian-Americans
are at the lowest risk (20 to 47 per 100,000).
Positive family history Men with a father or brother who has had prostate cancer have an
increased risk of the disease.
Elevated insulin growth factor This substance, which circulates in the blood in response to
growth hormone, regulates the growth and death of cancer
cells. Higher levels are associated with an increased risk of
prostate cancer
risk factor)
High alpha-linolenic acid intake Elevated dietary consumption of this polyunsaturated fat, which is found in dairy products and some vegetables, has been linked to a higher prostate cancer risk.
Low lycopene intake Lycopene is an antioxidant found in tomatoes and tomato-based products. A high lycopene intake is associated with a 16% to 21% reduced risk of prostate cancer.
Low selenium intake This trace element may inhibit tumor formation. Taking selenium  supplements reduced the risk of prostate cancer by 66% in one  study.
Low vitamin E intake The antioxidant effects of vitamin E (when taken as alpha-tocopherol supplements) may decrease prostate cancer risk. In one study, the  incidence of prostate cancer was reduced by 34% in men taking  vitamin E supplements.
risk factor)
Androgen receptor genetic variations Certain variations in the genes that code for receptors for  androgens (male sex hormones) may increase androgen  activity, which in turn increases prostate cancer risk.
High dietary fat intake A diet high in fat may increase the risk of prostate cancer. Some experts believe that meat (see below) may be the contributing factor in a high-fat diet.
Meat intake Frying or grilling meat may produce carcinogens that contribute to the development of prostate cancer.
Inflammation within the prostate Men with prostatic inflammation caused by foreign organisms (for example, sexually transmitted diseases) or other causes may be more likely to develop prostate cancer.
Decreased sunlight exposure Higher amounts of sunlight exposure may protect against  prostate cancer by increasing the body’s production of  vitamin D. Low levels of sunlight may result in low vitamin D levels.
(ruled out as
risk factors)
Alcohol intake Low to moderate alcohol intake does not appear to contribute to prostate cancer risk.
Level of physical activity While the evidence has been contradictory, the current consensus is that physical activity has no effect on prostate cancer risk.
Smoking There is no evidence that prostate cancer risk is elevated in smokers, but smokers may be at increased risk for more advanced cancer, as well as for dying of the disease.
Vasectomy Men who have had a vasectomy are at no higher risk for prostate cancer than men who have not undergone this procedure.

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.

Doctors can’t agree on which treatment is best for early prostate cancer, and are more likely to recommend the option in which they specialize. It’s important to get a second opinion, if not more than two.

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

Try to get opinions from doctors who practice at different hospitals. Often those who work at the same institution share the same views. Or they may be reluctant to disagree with one another.

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.

No one trial has compared different forms of treatment directly, and only one modern study has compared treatment with no treatment. In that study, radical prostatectomy reduced more cancer deaths than doing nothing (so-called “watchful waiting”).

Choosing a Treatment for Early Prostate Cancer
One of the most controversial topics in medicine is the best way to treat early prostate cancer. Fueling the controversy is the fact that no trial has directly compared the different forms of treatment, and only one contemporary study has compared treatment with no treatment. In this study, radical prostatectomy reduced deaths from prostate cancer better than watchful waiting.  When deciding on a treatment option, the factors that should be taken into account are age, other health conditions, prostate size, and willingness to accept the  possible risks of erectile, rectal, or urinary dysfunction, which occur at different rates with each form of treatment. Since prostate cancer progresses so gradually, you can usually take a month or two after diagnosis to weigh the options.

Listed below are some of the advantages and disadvantages of the four major treatment options for early prostate cancer.
Treatment Advantages Disadvantages
Watchful waiting • No risk of side effects or complications.

• Non-life-threatening prostate cancers  are not overtreated.

• When men age 70 and older with low- grade prostate cancer choose watchful waiting, overall life expectancy is similar to that of men without prostate cancer.
• Increased risk of cancer progression and death from cancer for some men.

• Reduced chance of a cure if cancer progresses beyond the prostate; in these cases, only symptoms may be treatable.

• Frequent doctor visits to monitor cancer progression.
• Highest cure rates (approximately 70% to 80% after 10 years for men with  localized disease).

• Stage of cancer can be accurately  determined after surgery.

• Return of cancer after surgery can be accurately determined with prostate  specific antigen (PSA) tests.

• Rate of rectal problems (diarrhea, urgency, fecal incontinence, bleeding) is similar to that with brachytherapy, but it is much lower than with external beam radiation therapy.

• Rate of urinary irritative symptoms (urgency and frequency) is lower than with brachytherapy and external beam radiation therapy.
• Risks of the surgery itself (bleeding, deep vein thrombosis, anesthesia complications).

• Hospital stay of three to four days.

• Requires catheterization for two to three weeks.

• Normal activities curtailed for at least one  month.

• Higher rates of incontinence (5% to 20%, depending on patient age and surgeon experi- ence) than for brachytherapy and external beam radiation therapy.

• Rate of erectile dysfunction similar to that with radiation therapy options when surgery is per- formed by an experienced surgeon.

• 20% of men who experience erectile dysfunc- tion after nerve-sparing surgery are not helped by oral drugs such as sildenafil (Viagra).
External beam
radiation therapy
• No hospital stay, risks from surgery, or recovery period.

• Normal activities can be maintained dur- ing treatment period.

• Erectile dysfunction occurs later after treatment compared with surgery (but after two years the rate is similar to that with surgery).

• Erectile dysfunction often can be treated with oral drugs such as sildenafil.

• Urinary incontinence occurs in 1% to 2% of men, which is less often than with radical prostatectomy but similar to the rate with brachytherapy.

• Urinary retention occurs much less often than with brachytherapy but at a rate similar to that with radical prostatectomy.

• Urinary side effects can often be treated with medication.
• Higher recurrence of cancer after 10 years than with radical prostatectomy.

• Requires up to eight weeks of daily treatment.

• Rectal side effects occur in 3% to 10% of men (but rectal problems usually improve after treat- ment is completed).

• Unlike radical prostatectomy, the exact stage of cancer cannot be determined.

• Possibility of fatigue at conclusion of treatment period.

• Bladder irritation (urinary frequency, pain, and urgency) experienced by 5% of men.
Brachytherapy • No hospital stay or risks from surgery.

• Healthy tissue is exposed to less radia- tion than with external beam radiation therapy.

• Shorter procedure (about an hour) than other treatments.

• Quicker recovery than with radical prostatectomy.

• Risks of rectal side effects and erectile dysfunction similar to those with exter- nal beam radiation therapy.

• Erectile dysfunction often can be treated with oral drugs such as sildenafil.

• Urinary incontinence rate much lower than with radical prostatectomy but sim- ilar to that with external beam radiation therapy.
• Poorer long-term cure rate than with radical prostatectomy, even in men with low-grade cancer.

• Not appropriate for men with intermediate or high-risk disease (stage T2 or higher , Gleason score 7 or higher, or PSA 10 mg/dL or higher).

• PSA levels can increase one to two years after treatment, making interpretation of PSA test results and detection of cancer recur- rence difficult.

• Highest rates of urinary retention early on and of irritative urinary symptoms after two years.

• Unable to determine the exact stage of cancer.

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.

Even if a prostate disorder itself or the necessary treatment doesn’t cause sexual disfunction, problems may arise purely from the anxiety and stress involved in having the disorder. Some men try several treatments before finding the one that works best.

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.

Blood in the urine may result from an infection, trauma, or cancer. But it doesn’t always signal that something is wrong. It can result from causes as simple as vigorous exercise. In one case in every ten, doctors never find a cause.

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.

Therapy depends on the exact cause. The bleeding will stop when the underlying cause is treated.

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.

The information contained in this Health Tips is not intended as a substitute for the advice of a physician. Readers who suspect they may have specific medical problems should consult a physician about any  suggestions made.

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