The Complete Book of Men's Health - Part 1: Sexual Health

The prostate gland is a time-bomb ticking away deep in the plumbing of every male. The World Health Organization (WHO) estimates that 80 per cent of men will eventually need treatment for prostate problems. One in three will need an operation.

Despite these appalling statistics, few men know where their prostate gland is, what it does, or the symptoms that occur when it starts to go wrong. More importantly, few men realize that a prostate-friendly diet can reduce their risk of developing the three major prostate diseases: benign prostatic hyperplasia, prostatitis, and prostate cancer.

THE HEALTHY PROSTRATE GLAND

A healthy prostate gland weighs around 20 g and is the size and shape of a large chestnut. It is made up of millions of tiny glands that secrete a thin, milky, acidic fluid. The prostate also contains muscle and fibre cells which help the gland to contract.

Figure 13: A healthy prostate gland

The prostate is hidden away between the bladder and the penis, wrapped around the urethra ­ the tube through which urine flows from the bladder. This is a major design flaw: with increasing age the prostate naturally starts to enlarge. This squeezes the urethra and interferes with urinary flow.

WHAT DOES THE PROSTRATE GLAND DO?

The function of the prostate gland is not fully understood. What is known is that the prostate:

• secretes fluids that make up 30­40 per cent of semen volume.

• secretes nutrients such as zinc, amino acids, citric acid, vitamins and sugars that are thought to keep sperm healthy, but are not essential for reproduction. Sperm which have not come into contact with prostate fluid can still fertilize an egg.

• helps to direct semen outwards during ejaculation so sperm don't reflux up into the bladder.

• contains substances that give semen its characteristic smell.

• secretes enzymes such as acid phosphatase and prostatic specific antigen (PSA) which help to increase semen fluidity so sperm can swim away.

• secretes hormone-like chemicals (prostaglandins) which have effects on the female genital tract, such as making the cervix 'pout' slightly so sperm can swim through more easily, and perhaps causing the female tract to contract. In theory this may help 'suck' sperm higher up towards the egg, and may also make the female orgasm more intense. As prostate secretions are the first fluids released during ejaculation, these effects may be important.

Three main things tend to go wrong with the prostate gland; each occurs at a different stage in a man's life:

1. Prostatitis, in which the gland becomes infected or inflamed. This is most common between the ages of 25 and 45.

2. Benign prostatic hyperplasia (BPH), in which the gland slowly enlarges. This commonly causes symptoms after the age of 45.

3. Prostate cancer, which tends to occur over the age of 55 ­ though it can occur much earlier.

PROSTATITIS

When looked at under a microscope, the prostate gland contains more canals and blind passageways than Venice. These can become infected, inflamed or clogged ­ either with thickened secretions or tiny, gravel-like stones ­ to produce prostatitis. It is estimated that one in three men will suffer from prostatitis at some stage between the ages of 20 and 50 years.

There are four main types of prostatitis:

1. acute (recent onset) bacterial infection

2. chronic infection, of one of two kinds:

a. (long-term, grumbling) bacterial infection

b. (long-term) non-bacterial inflammation

3. prostatodynia ­ symptoms of prostate pain without obvious signs of inflammation or infection.

Acute Bacterial Prostatitis

This is usually caused by bacteria from the intestines which find their way into the urinary system either through the urethra or by travelling in the bloodstream or lymphatic fluids.

Sometimes, organisms causing sexually transmissible diseases (e.g. gonorrhoea, Chlamydia) are involved. Occasionally, the fungus that causes thrush (Candida) is responsible too.

Symptoms strike suddenly and can include:

• feeling unwell

• chills or fever

• low back pain

• aching round the thighs and genitals

• deep pain between the scrotum and anus

• pain and difficulty on passing water

• frequency of passing water

• pain on ejaculation

the prostate gland will also usually be hot, swollen and tender when the doctor examines it (by gently inserting a finger in the back passage).

Sometimes, infection persists in the nooks and crannies of the prostate gland, despite treatment. When this happens, chronic prostatitis results.

Chronic Prostatitis

Chronic prostatitis is common in developed countries. Post-mortem studies show that one in five men under the age of 40 years and as many as three in five older males demonstrate evidence of having had the condition. This suggests that chronic (ongoing) inflammation of the prostate gland is often present without causing symptoms.

Studies show that there are two main types of chronic prostatitis, those due to a microbial infection and those in which inflammation is present without any signs of infection.

Chronic Bacterial Prostatitis

Micro-organisms can enter the prostate gland to set up a localized infection with pus and even micro-abscesses. Swelling rapidly occurs, which traps the bacteria in the gland as the usual drainage channels become blocked off.

In some cases, bacteria become coated in prostatic secretions that harden to form tiny crystals or stones. This protects them from attack by the body's immune system and antibiotics and accounts for the repeated flare-ups that are common in chronic bacterial prostatitis.

Symptoms vary, but may include:

• pain and discomfort in the prostate, scrotum, testes, rectum or tip of the penis

• aching in the lower back, lower abdomen or inner thighs

• watery discharge from the penis

• urinary problems such as urgency, getting up at night to pass water, pain on passing water

• pain on ejaculation

• premature ejaculation

• blood in the semen

• infection and swelling of the testes.

Unfortunately, this condition can be difficult to eradicate. Some men suffer recurrent symptoms throughout their life.

Chronic Non-bacterial Prostatitis

This can occur at any time after puberty but is commonest between the ages of 30 and 50. It is an inflammatory condition in which prostate secretions contain white pus cells but no bacteria.

One of the most popular theories is that non-bacterial prostatitis is due to abnormal emptying of the bladder. This forces urine into the prostate channels and ducts, to cause chemical irritation and inflammation. This is sometimes triggered, or made worse, if a man jogs or plays active sports on a full bladder.

Another theory is that some men produce prostate secretions that are thicker, and perhaps more acid than normal. They cannot drain away through the narrow ducts quite so easily and build up to produce swelling and irritation.

The most common symptoms of chronic non-bacterial prostatitis are:

• pain/ache in the testicles, penis or rectum

• low backache, especially after intercourse

• burning on passing water

• urinary frequency

• discharge from the urethra, especially after sex.

Prostatodynia

Prostatodynia is characterized by pain and symptoms of prostate problems, but with no evidence of inflammation or infection in the gland. Prostate secretions look normal and do not contain pus cells.

Prostatodynia is surprisingly common, accounting for a third of cases where men experience chronic prostatic symptoms.

These symptoms often include sexual problems such as:

• pain on erection or ejaculation

• low sex drive

• low semen volume

• impotence.

As a result, some doctors have labelled it a psychosexual problem. It is likely to have a physical cause, however, such as spasm of the pelvic muscles ­ perhaps brought on by stress and anxiety. Symptoms are often made worse when ejaculation is infrequent, which suggests that the pain may be due to prostatic gland engorgement, perhaps with secretions that are thicker than normal.

Both non-bacterial prostatitis and prostatodynia are sometimes relieved by increased frequency of ejaculation, either through sexual intercourse or masturbation. This drains the gland of excess secretions and temporarily increases blood supply. Both effects help to flush away toxins. In some cases, however, increased frequency of ejaculation just makes the problem worse.

Another possibility is that prostatodynia is due to the irritation or malfunction of the nerves supplying the prostate gland.

How Prostatitis Is Investigated

Prostatitis is frequently difficult to diagnose accurately. It is best investigated by doctors specializing in urology or genito-urinary medicine.

You may well be referred to a special (genito-urinary or VD) clinic, but this doesn't necessarily mean your doctor thinks you have a venereal disease. It's just that genito-urinary clinics have the equipment and expertise to investigate and treat your symptoms sympathetically and in confidence. The tests you are likely to have will include:

• a full genital and rectal examination

• swabs from the end of the penis

• urine cultures and a 'three-glass' test (see below)

• prostatic massage

• a blood test to check for signs of infection (raised white cell count)

• routine screening for sexually transmissible diseases such as Chlamydia.

During examination, the doctor will look for a discharge from the end of the penis and signs of inflammation such as redness or soreness. The testicles may be gently examined for lumps or tenderness.

A rectal examination is usually performed to assess the gland's size and texture, but this is not always helpful. In acute prostatitis the prostate is usually hot, swollen or tender. In chronic prostatitis it may feel boggy and soft, but often seems perfectly normal.

Swabs are taken by gently inserting a sterile cotton bud into the end of the penis. This collects fresh discharge which is then examined under the microscope before being sent for bacterial culture.

A second swab is sent for special analysis to detect signs of Chlamydia infection. Unlike normal bacteria, Chlamydia are too small to be seen under a light microscope and cannot be grown in culture.

Urine tests for Prostatitis

You will be asked to provide a urine sample by passing a small amount of water into one glass jar, and more into a second jar.

These samples are checked for cloudiness, signs of protein or blood, and for threads of cellular material. Threads are fished out for examination under the microscope, as the presence of pus cells or bacteria can help with the diagnosis. The remaining urine is sent for culture to see if any bacteria grow.

Usually, a 'three-glass' test is done. After passing urine into the second jar, you are asked to stop voiding and retain some urine. The doctor then inserts a gloved finger into your rectum and gently massages the prostate gland.

Massaging the gland releases secretions which can be milked down to the tip of the penis and collected. If no fluid appears, you will be asked to pass a small sample of urine into a third glass jar to flush the released prostate fluids through.

Analysis of the Three Glass Test

The three-glass test aims to distinguish between infection in different parts of the male urogenital tract. The results are not always clear cut, but in general they may be summarized as follows:

• If bacteria are found in the first glass jar, this suggests infection of the urethra (the tube leading from the bladder to the tip of the penis).

• If bacteria are present in the second sample, this suggests you might have a bladder infection (cystitis).

• If more bacteria are found in the third glass jar than in the first, this suggests prostatitis.

• If pus cells are present, but no significant bacteria are found in any sample, this suggests non-bacterial prostatitis.

• If no bacteria and very few pus cells are found, the diagnosis may be prostatodynia.

Treatment of Prostatitis

Acute Prostatitis

Once the diagnosis is made, a prolonged course of antibiotic tablets are prescribed, usually for at least four weeks. Symptoms should start to improve within a few days.

Occasionally, infection causes the gland to swell enough to squeeze the urethra shut. This causes urinary outflow obstruction, and admission to hospital is required. A catheter is inserted into the bladder under local anaesthetic to ease the urinary flow.

Chronic Prostatitis

Chronic infection can be difficult to treat, as inflammation and swelling traps infection inside the gland. Once the diagnosis is made, antibiotics are prescribed for at least six weeks. Sometimes, they are needed for three months or more.

Anti-inflammatory painkillers such as ibuprofen also help to damp down swelling, inflammation and pain.

Chronic non-bacterial prostatitis can be treated with a natural food supplement derived from rye pollen extracts. This has been shown to reduce inflammation, irritation and swelling. First signs of improvement usually show within three months, and there is a progressive improvement over a six-month period.

Prostatodynia

This can be difficult to treat. Painkillers are not usually very helpful and some patients end up on tranquillizers to reduce muscular spasm in the gland. These are not a good idea for long-term use as they can become addictive.

Recent studies suggest that prostate pain is relieved by microwave hyperthermia. The prostate gland is warmed from 37 to 42.5°C (98.6 to 108.5°F) by a special instrument inserted into the back passage. This increases the blood supply and speeds up the body's natural healing reactions. An hour's treatment is given for six weeks.

Similar relief is sometimes obtained by sitting in a hot bath for half an hour.

Other treatments which have been tried for prostatodynia include:

• acupuncture

• laser irradiation

• muscle relaxant drugs (e.g. diazepam)

• anti-spasmodic drugs

• psychotherapy and counselling

• relaxation techniques

Regular exercise and a high-fibre diet to keep the bowels regular are important for men with prostatodynia, especially if they sit at a desk for most of the day. Both sitting and constipation increase prostate congestion.

The nicotine in cigarettes causes spasm of smooth muscle and may exacerbate the symptoms of prostatodynia. Alcohol or caffeine can also trigger attacks of prostate pain, and it might be worth seeing an allergy specialist to identify foods you should avoid.

Prostatitis and Sex

If you suffer from prostatitis it is best to avoid sex while you have symptoms or are taking treatment. If the problem is due to infection, it is theoretically possible to pass this on to cause cystitis or vaginal infection in a female partner. Your doctor will advise on when you can resume normal sexual relations.