Thursday, September 23, 2010

7.15 Prostate Cancer & Other

Physician's Notebooks 7  - - See Homepage 

Update 24 December 2018
 Includes in scroll-down order, general info, prostatitis, benign prostatic hypertrophy and prostate cancer.

15. The Prostate –
a male organ, surrounds the outlet of the urinary bladder and when enlarged, it narrows the outlet, slowing and then stopping urine flow. A man's semen, the fluid part of his sexual come, is partly from prostate.

occurs in young men. Its symptom is uncomfortable, frequent small urination and a discomfort in the seat area between anus and scrotum. It is caused by infection, allergy and excessive sexual intercourse. With first episode, check Dipstick urinalysis (3.2 Secrets of Urine Testing)If its Bact test is negative, relax and do one week no sexual intercourse and sit in hot bath 15 minutes twice a day. If Bact positive, have culture & sensitivity test at University-HMO and take best antibiotic. Eventually prostatitis burns out. I know. It happened to me and here I am - still standin -  60 years later. In my case it was caused by a chemical I injected up my penis while in the Army in Japan as part of preventive against sexually transmitted disease.
Benign Prostatic Hypertrophy (BPH)
Every man who lives past 60 will get it. I got it. If it blocks the urine, a man may, one day, become unable to pee. It does not become cancer but men with BPH also develop cancer. The BPH symptom is gradual and cannot be missed. If male and age 50s, you note your urine stream does not start forcefully as it did at age 20. Instead of an arc from tip of penis, the urine at first dribbles before building up force. Or it makes a weak double stream. Even the sound of the urine hitting the water in toilet bowel is less. And when you stand to urinate, at first it does not come.
   You do not need a doctor or a test to diagnose it. For quite a few men there comes a day when the urine stops. After a beer party or some other spree that makes much pee, one gets up from bed needing to pee and - Emergency!
   First a catheter (thin rubber tube) is pushed up the penis from its tip opening, then a urologist is called and – Lo! – the patient gets a TUR (trans-urethral resection, in which the prostate opening to bladder is enlarged by shaving its tight edges thru a cystoscope). Many do well after TUR but a few get reverse ejaculation into bladder, ending sex life. A fewer get urethral stenosis (too narrow to pass the urine) after TUR and are back at square one. And some TUR cases need another TUR because the prostate is still in place and the shaved area re-grows and re-obstructs.

My Personal Experience: I noted my BPH in 1980 at age 47. I am motivated against the TUR surgery because I feared it might stop sex so I got a urethra-dilating cystoscopy once a year for 6 yrs. My purpose of these cystoscopies, in which a finger-thick hollow metal tube is inserted into and up the penis and through the prostate opening into the bladder was to stretch and widen the narrowed prostate canal to reduce the narrowing and keep my urine flowing. I also got rectal ultrasound test of my prostate to check cancer and measure the size and consistency of prostate. My prostate shrank after the stretching and my symptom became less, and here I am at 85, still standin’ without TUR. I tolerate a slow-to-start urine stream, especially at night after sleep and after certain medications. Also, I have leaky urine with a filling/filled bladder. This leaky urine is not a peeing in pants; it is an un-felt slow leak and it is lessened by frequently emptying my bladder by pressing my fist or open hand into my low abdomen just above pubic bone while I sit to pee. Also it can be an almost uncontrollable, not unpleasant feeling of wanting to pee when the bladder is nearly filled to capacity.
   But advice to get TUR should not be ignored. Especially in case of more than one urinary stoppage that requires catheter, or in case of kidney disease that may end in dialysis. (Prostate obstruction can further damage weakened kidney)
   Every older man should know how to handle his peeing so as not to have urine stoppage. (Or if it stops, to know how to avoid emergency) Make it a routine to go to pee as soon as you have first urge. With BPH, a full bladder increases risk of pee stoppage. Also go to pee before lying down, since a problem time for urine stoppage is getting up from sleep with overfull bladder.
   Do not strain to start or continue pee; it will only make it worse. Allow pee to come out naturally, and if it does not come, press your fist deeply in, just above pubic bone. (Best done sitting to pee) Also, pee while sitting in a warm bath or standing in the shower and using your fist in the supra pubic pressure. It works when pee won't come any other way.
   If you need an emergency room or hospital insertion of a rubber catheter to get out the urine, it is important not to be panicked into having quick surgery. It is a good time to get a urology check and a urologist opinion.
    It is a good idea for anyone with prostate obstruction to carry a size (french size-numbers. eg, 12Fr) 12 or 14 catheter. 
This catheter folded up, a little more than 12 inches (c.30 cm) long, has insertion tip at your left end and urine outflow opening at right
And to use it as follows: In an emergency, sterility is not important. Just clean hands and catheter. Any lubricant OK; if none just use water. Sit on toilet seat, grasp penis in left hand in full hand grip, elevating shaft of penis c.15 degrees. Hold catheter between thumb and forefinger 1 inch (c.2.5 cm) from its rounded tip opening and advance the tip of the catheter into the opening in the head of penis and keep advancing it until urine flows out, which should be a c.7 inch (c.18 cm) advance. Sometimes the tip may get hung up at the base of penis shaft. In that case, withdraw and push it forward again. And if it does not work, go to emergency room. You should not wait until you are in extreme need to do your own catheter. The sequence is: you need to pee moderately: first try on toilet seat for a minute; if no go, try in hot bath for a minute; then, while in the bath, if no go, the catheter.
Prostate Cancer
develops after age 50. Prostate cancer differs from many other cancers in that it is multicentric (from more than 1 cell compared to the single clone for many other cancers) and hard to predict its course. Many prostate cancers are so slow-growing that the patient lives with the cancer without treatment or discomfort or other symptom. But some give terrible deaths. And the curative treatments for prostate cancer may harm life quality. Therefore with prostate cancer decisions, it is best to go slow. Also life expectancy is important. An 80-year-old who discovers prostate cancer will only rarely need treatment and will die naturally with the cancer still in his prostate. Oppositely, a 55-year-old needs to act quickly.

 The blood test for prostate cancer is prostate specific antigen (PSA). If the PSA goes high, get expert doctor digital rectal exam and, if it is suspicious, get an ultrasound scan of prostate and if suspicious bump or area, then get ultrasound-directed core needle biopsies, done by expert in prostate cancer at top University-HMO.
  The prostate normally produces a small amount of PSA that circulates in the blood. But when prostate starts to transform into cancer it increases its PSA and ups the PSA test number. The test does not have a high sensitivity (ie, some slightly high PSA tests may be found without cancer due to enlarging prostate of BPH). But it is easy to repeat, and inexpensive, and when combined with the yearly digital rectal exam, very useful.
  Take me? In July 2011 I decided after years of denial to get my prostate checked. First I got a PSA test. Then I was referred to the urologist. He put his finger up my asshole and said "You have a firm area, I am not sure what it is, but if your PSA is high, I need to biopsy." And a week later when I went back I was happy to see my PSA test was normal low so I did not biopsy. My urologist advised a recheck after one year. And now my PSA test remains normal. 
  Some more info about the PSA test: Its number in blood (nanogram, or ng, per ml) directly relates to size of prostate - bigger prostate, higher PSA. So the latest is to get your prostate size in volume and gram estimates by ultrasound and then use the number as denominator of the PSA blood test number to give the density PSA/gram value. Another new twist is to get a velocity PSA rise after 3 or more consecutive PSA tests, using the months or weeks interval as denominator to get a +PSA rise per month rate. This has added an accuracy to predicting prostate cancer and helping in the decision to biopsy or not. But simple PSA test is OK for routine check.
Approach to Preventing Prostate Cancer: Start PSA test at age 45 once every year. Be sure it is done more than one week after your last rectal exam, and more than 24 hours after your last sexual orgasm & ejaculation. Also do not take any sex steroids (includes testosterone and sports steroids) for at least one week before the blood is drawn. Keep a record of all results and if you note a trend upward, even if in normal range, calculate a +PSA velocity. The PSA will slowly increase with age; values below 2 nanog/mL are good against anxiety of cancer. Two to 4-mgm are a reason to get a rectal prostate ultrasound sizing. Four mgm or more you should consult a urologist experienced in prostate cancer. Discuss the PSA numbers and trends with your Urology consultant.
Prostate Biopsy today is by needle. Two types of needle biopsy exist: fine needle biopsy (FNB) and Core Needle Biopsy (CNB)  For adequate decision-making in prostate cancer the CNB is better because it gives a thicker tissue specimen.  
  In contrast to single biopsies in other types of cancer, in prostate it should be a minimum of 10 CNB performed at the same time over the suspicious areas of prostate. The biopsies are done through rectum under ultrasound guidance. The CNB should be done by a urology specialist in prostate cancer in an HMO-university hospital or clinic. Mild sedation and strong antibiotic are given. Doing biopsy may delay prostate or rectal surgery for 6 weeks. Thus, where high suspicion of a bad type prostate cancer and where surgery is preferred, the surgeon may do open biopsies through skin incision and quick sections used to diagnose and evaluate the cancer and if serious cancer is confirmed, the surgery is done immediately.
  From the above it can be understood that prostate CNB is a decision not made lightly. It must be preceded by strong evidence. (high or rising PSA tests, MRI or US imaging suggesting bad cancer, or x-ray of distant metastases)

Prostate CA treatment: as with all Cancer in my book, it should be at world-class institution. First the prostate cancer should be staged for curability. Generally, curability means the cancer is limited to the prostate gland; anything beyond that is treated for life prolongation and palliation. For cure, the treatment is radical prostatectomy surgery. The  x-ray treatments or radiation implant, or hormonal treatment are life prolonging rather than curative. Some cases of prostate cancer, especially in men over the age 70, are best treated by watchful waiting, which means reliance on PSA blood testing to decide if treatment will be necessary and when it should be done. Which treatment to choose depends on age, stage of cancer, other illnesses and including attitude toward prolonging one’s own life. In Notebooks 10, I deal with a general philosophy of cancer care that can be applied to particular case. Do not rush into treatment of prostate Cancer. It is a slower grower. But in the cases with fast growth, often speed does not translate into cure. The key is early diagnosis and careful consideration by world-beater consultants.
END OF CHAPTER. To read next now, click 7.16 Incontinence of Urine

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