Prostatic disorders: Awareness for cure

Introduction:

Dr NK Mohanty

Lower urinary tract symptoms (LUTS) are common in men, affecting up to 78 per cent of the elderly population. The most common LUTS are urinary frequency, urgency, hesitancy, weak stream and nocturia. The increase in the prevalence of LUTS with advancement of age is an accepted fact. The prevalence of LUTS was lowest in France (14 per cent) and Scotland (18 per cent) and highest in the US (38 per cent) and Japan (46 per cent). The preliminary data reported in one Indian study indicate that LUTS, due to specific diseases in Indian male population, is around 36 per cent (480 out of 1329). About 14 per cent of the total subjects had benign prostatic hyperplasia (BPH).

Anatomy of the prostate gland

Prostate Gland and Surrounding Structures

The prostate is a gland about the size of a walnut that is only present in men. It is located just below the bladder neck and surrounds the proximal part of urethra, the tube through which urine flows from the bladder and out through the penis.

BPH: Pathophysiology

A man’s prostate gland usually starts enlarging after 40 years of age. This condition is called benign prostatic enlargement (BPE). As the prostate gland enlarges, the urethra is pinched tighter and tighter within the prostate. As the tube narrows, urine has a much harder time making its way through the urethra and out of the body. This results in obstructive and irritative LUTS.

Symptoms and signs

Many men with an enlarged prostate have no symptoms. Common symptoms may include:

• Frequency
• Urgency
• Urge incontinence
• Nocturia
• Poor flow of urine
• Hesitancy
• Intermittency
• Sense of incomplete void
• Blood in the urine dribbling after voiding.
• Leakage of urine
• Pushing or straining to begin urination

In severe cases of BPH, another symptom i.e. acute urinary retention (inability to urinate) or chronic urinary retention can result, causing severe pain and discomfort. Catheterisation may be necessary to drain urine from the bladder to obtain immediate relief.

Diagnosis

Various methods are used to diagnose problems in the prostate. Some of them are:

• Digital rectal examination (DRE)
• Prostate specific antigen (PSA ) test
• Uroflowmetry test
• Post-void residual (PVR)
• Urodynamic study (UDM)

Treatment for enlarged prostate (BPH)

• Self-care and precautions at home: Some precautions can help to avoid worsening of symptoms caused by prostate enlargement and complications till you see the urologist. Do not delay to urinate once you experience an urge. Urinate as soon as you feel the urge, and empty the bladder completely. Avoid alcohol and caffeine, especially after dinner. Don’t drink a lot of fluid all at once. Avoid drinking fluids within two hours of bedtime. Cold weather and lack of physical activity may worsen symptoms.
• Medical (non-surgical) treatment of BPH are:
  1. alpha-blockers
  2. 5-alpha-reductase inhibitors
• Surgical treatment for BPH: Generally, surgery is considered for men who don’t get relief from symptoms using drug treatments or have absolute indications of surgery ie. hematuria, recurrent urinary retention, bladder stone, recurrent uinary tract infection (UTI) etc. The surgical treatment techniques include:

1. Transurethral resection of the prostate (TURP, Mono-polar) is traditionally the most common endoscopic operation for BPH. But with advent of newer technologies, it is done far less frequently because of its limitation of use up to only 70 to 80 gms of gland and associated multiple serious complications like fluid overload, electrolyte disbalance, TUR syndrome and need for long time catheterisation (3-5 days).
2. Transurethral resection in saline (TURIS) with the BIPOLAR technology is the latest alternative to TURP. It is safe, effective and quick with comparable results to all other techniques used to treat BPH. In this technique, normal saline is used instead of distilled water to prevent electrolyte disbalance and TUR syndrome. Its faster technology makes it applicable to larger glands and for the patients with multiple co-morbidities and on antiplatelets.
3. HoLEP is holmium laser enucleation of prostate where prostatic lobes are first enucleated with laser fibre and then the lobes are removed piecemeal with the help of morcellator.
4. KTP green-light laser prostatectomy is an upcoming laser technique which has an advantage over HoLEP and all other techniques that can be used safely to treat patients with cardio-vascular co-morbidities and on antiplatelets.
5. Open prostatectomy is only rarely recommended now for men whose prostate is very large and bipolar or laser technology is not available.

Other benign prostate conditions

Prostatitis: Prostatitis is an infection or inflammation of the prostate gland that presents as several syndromes with varying clinical features. The term prostatitis is defined as microscopic inflammation of the tissue of the prostate gland, which spans a broad range of clinical conditions. Prostatitis most commonly affects men in their 30’s and 40’s, but can also affect men of an older age. About 40 per cent of men will suffer from some sort of prostatitis at some time in their life.

Management

Treatment of prostatitis can be done with long-term antibiotics, alfa blockers, and anti-inflammatory medications.

Prostate cancer: Magnitude of the problem in India

Incidence rates show that prostate cancer is the fifth most common malignancy worldwide and the second most common in men (Parkin et al, 2005). Prostate cancer makes up 11.7 per cent of new cancer cases overall, 19 per cent in the developed countries, and 5.3 per cent in the developing countries. However, the actual number could be much more as it is reported far less frequently in developing countries, secondary to poor data recording system and patient’s inaccessibility to a healthcare system. According to a recent study, Asian Indians have a greater tendency for higher Gleason scores (seven or more) in both the pre-operative prostate biopsy and final histopathological analysis and a significantly higher incidence of extra prostatic extension was found in Asian-Indians versus Caucasians (32.3 per cent versus 16.5 per cent, respectively). Another study regarding prostate cancer in Asian-Indians suggests that the incidence in five major Indian cities including Delhi appears to be rising.

Causes of prostate cancer

The specific causes of prostate cancer remain unknown. The primary risk factors are age and family history. Men who have first-degree family members with prostate cancer appear to have double the risk of getting the disease compared to men without prostate cancer in the family. This risk appears to be greater for men with an affected brother than those with an affected father.

Symptoms of prostate cancer

Patient may present with LUTS as found in BPH. Depending on the growth of the malignancy and its local spread, it may cause irritative and obstructive LUTS. Other less common symptoms are:

• Blood in the urine
• Blood in the semen
• New-onset erectile dysfunction (impotence)
• Bone pain (especially in the lower back, hips, or ribs) in cases of metastasis

Diagnosis of prostate cancer

Following tests are done to diagnose prostate cancer:

• Digital rectal exam (DRE)
• Prostate specific antigen (PSA)
• Abdominal ultrasound
• Transrectal ultrasound and prostate biopsy
• MRI and CT scan – for staging of cancer
• Bone scan

Management of prostate cancer

Management of the disease depends upon the stage of the disease atwhich patient presents to the urologist.

Prostate cancer staging

Staging is a method to describe how advanced a cancer is. Prostate cancer staging is done in the following ways:

• Stage I (or A): The cancer cannot be felt on a digital rectal exam, and there is no evidence that it has spread outside the prostate.
• Stage II (or B): The tumour is larger than a stage I and can be felt on a digital rectal exam. There is no evidence that the cancer has spread outside the prostate.
• Stage III (or C): The cancer has invaded other tissues neighbouring the prostate
• Stage IV (or D): The cancer has spread to lymph nodes or to other organs

Stage 1 and 2 prostate cancer (organ confined prostate cancer) can be treated with curative intent by the following methods:

• Open radical prostatectomy
• Laparoscopic radical prosatatectomy (LRP) and lap assisted robotic radical prostatectomy (LRRP)
• Radiation therapy for localised prostate cancer
• High intensity focused ultrasound (HIFU)

Stage 3 or more (advanced prostate cancer) cannot be cured. Progression of the disease is inevitable but treatment is available to slow its progression and to alleviate the symptoms.

Treatment of hormone sensitive prostate cancer

• Hormone therapy
• Medical castration
• LHRH analogues
• GnRH analogues
• Surgical castration (Orchiectomy)

Treatment of castration resistant prostate cancer

• Chemotherapy: First line and second line chemotherapy

Treatment of metastatic CRPC

• Immunotherapy
• Palliative therapy for bone pain and other symptoms

Conclusion

With better understanding of the disease, the survival of patients has increased significantly over the last few decades due to early detection and improved therapy. Improved socioeconomic status and better access to health care has also played a major role in countries like India.