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

A tube (catheter) is passed into the bladder, through the penis (under local anaesthetic) to drain trapped urine and bring instant relief. Very rarely the catheter cannot be passed through the urethra due to gross swelling of the prostate gland. If this happens, the urethra can sometimes be gently dilated with special rods. If this fails, a suprapubic catheter can be passed into the bladder through the overlying abdominal wall.

Hopefully, with increased awareness of prostate problems, fewer men will present at this late stage with urinary retention ­ an extremely embarrassing, unpleasant and painful condition.

BPH and Lifestyle

The symptoms of BPH can have a drastic effect on lifestyle. Common complaints are:

• having to avoid drinking at certain times, such as before an outing or before going to bed

• having to reduce total fluid intake

• having to make sure that you always know where the nearest toilet is

• not participating in social or leisure activities because of fear of embarrassment

• feeling depressed, with low self-esteem.

A recent poll of around one thousand men over the age of 50 found that 27 per cent had to get up at night to pass water. Of these, 13 per cent had put up with the problem for over 10 years. Twenty per cent had difficulty in starting to pass water, and 15 per cent reported frequency. Many men suffered limitation of their social, leisure and sexual activities because of their symptoms.

A MORI poll of 800 men over the age of 50 years showed that:

• Almost half of sexually active males with symptoms of prostatism experience a lowered sex drive, difficulty in sustaining an erection and ejaculatory problems.

• 20 per cent of men with symptoms of BPH had sex at least once per week, compared with 40 per cent of men without symptoms.

• Men with two or more symptoms of prostatism said they would like to have sex more often than their symptoms allowed.

What to Do If You Think You Have BPH

If you suspect you have symptoms of prostatism it is important to consult your doctor straightaway. Don't wait until the symptoms start interfering with your life. Early screening will help to prevent future problems with your kidneys ­ and will also increase the likelihood that the more serious problem, prostate cancer, is picked up and treated early.

Rectal Examination

Some men admit to not going to their doctor with prostate symptoms because they dread the thought of a rectal examination.

The size, shape, texture and tenderness of the prostate gland can be assessed by the doctor gently inserting a finger into your back passage. This is called a digital rectal examination, usually abbreviated to DRE, and it is nowhere near as unpleasant as many men think. Most patients describe the sensation as similar to slight constipation.

The doctor uses a colourless, odourless, water-based jelly as a lubricant. Only the index finger is inserted ­ which, if you think about it, is much thinner than the width of the average bowel motion.

Investigation of an Enlarged Prostate Gland

Blood Tests

• Full Blood Count to check for anaemia or infection

• Urea and Electrolytes ­ to check how well your kidneys are working.

• Prostate Specific Antigen (PSA) ­ which may be raised if there is a hidden prostate tumour (see PSA)

• Prostatic acid phosphatase (PAP) ­ which may be raised in prostate cancer if secondary cancers have spread to the bones

Urine Tests

• Urine 'dip-stick' test ­ to check for sugar and protein

• Mid-Stream Urine (MSU) ­ to check for bacterial infection (cystitis), red blood cells, pus cells and casts (minute threads of tissue shed from the kidney)

• Urinary flow rate ­ to assess how badly your stream is affected. This involves passing urine into a bottle with a special by-pass, or into a funnel with an electronic device attached. The speed you pass urine and the total amount passed are printed out in the form of a graph. This will show how much your urinary outflow is obstructed.

Ultrasound

Ultrasonography passes high-frequency, inaudible sound waves through your body. These bounce back off tissue planes and are analysed by a computer which produces an image on a screen. Ultrasound can check:

• the size of your prostate gland

• the size of your kidneys

• how much residual urine stays in your bladder after voiding

• trans-rectal ultrasonography, in which a lubricated, finger-shaped probe is gently inserted in the back passage, can give a better assessment of the prostate gland and whether enlargement is due to benign hyperplasia or cancer.

Cystoscopy

A narrow telescope (cystoscope) is inserted through the penis into the bladder, under general anaesthetic. This allows assessment of the urethra, the bladder, and the degree of prostate obstruction.

Intravenous Pyelogram (IVP, IVU, excretory urogram)

This test, used only occasionally, involves injecting a radio-opaque form of iodine into a vein, which is then concentrated by the kidneys. X-rays are taken which outline the urinary tract and reveal abnormalities.

Treatment of BPH

Treatment depends on the severity of your symptoms and how much they interfere with your life. The WHO Prostate Symptoms Score (see Figure 15) now allows an objective assessment.

Mild Symptoms

If prostatic enlargement is slight, the treatment approach is one of 'wait and see', so long as the assessment has ruled out malignancy. In some cases symptoms will not get dramatically worse. A prostate-friendly diet and rye pollen extracts may help.

Moderate Symptoms

Anti-Spasmodic Drugs

These drugs (e.g. oxybutinin; flavoxate; propantheline) reduce irritation and spasm of the bladder and help symptoms such as frequency of passing urine, urgency and incontinence. They should not be used if the prostate is greatly enlarged, however, so are of limited value in treating BPH.

Alpha-Blocker Drugs

These (e.g. prazosin; terazosin; indoramin) damp down activity in the nervous system, which would normally trigger contraction of muscle fibres in the prostate and urethra. By relaxing the muscles, the urethral bore is widened to improve symptoms.

5-Alpha-Reductase Inhibitors

These drugs (e.g. finasteride) block the enzyme that converts the male hormone testosterone to dihydro-testosterone ­ the hormone responsible for BPH (see below). This can help an enlarged prostate gland to shrink by over 20 per cent and is particularly beneficial to men with severe symptoms. Treatment needs to be taken continuously as the prostate can start to enlarge within a few weeks of stopping the tablets. Condoms should be used during intercourse while taking these drugs to protect female sexual partners from exposure to the drug, which may be present in the semen.

Hormones

Hormonal factors influencing prostate symptoms are not fully understood. Treatment with a synthetic progestogen (gestronol) is sometimes given as an injection every five to seven days. It is not commonly used, however, as few men welcome regular injections. Other hormone preparations (e.g. flutamide, cyproterone) have been shown to shrink the prostate gland by 25 per cent but do not significantly improve urinary flow rate or reduce the amount of residual urine remaining in the bladder after voiding. Experts believe it is unlikely that a single hormone treatment will work against BPH.

Natural Treatments

Several natural plant products, collectively known as phyto- therapy, are used to treat BPH. Like conventional drugs, these have different actions on the prostate gland to improve symptoms. Some shrink or soften the gland to open up the urethra; others relax muscle fibres and reduce spasm of the prostate and bladder.

Europeans have led the field in natural prostate treatments. In Germany, phytotherapy is prescribed for 95 per cent of patients undergoing medical treatment for BPH. In France and Italy, natural plant extracts are used by around 40 per cent of men with symptoms that warrant intervention.

These natural treatments include preparations of:

• South African stargrass ­ Harzol

• Golden Rod (Solidago)

• African prune (Pygeum africanum) ­ Tadenan

• American Dwarf palmetto (Serenoa repens) ­ Permixon

• Rye pollen extracts ­ Cernilton, ProstaBrit

The two latter plant extracts are interesting as they are thought to inhibit the enzyme 5-alpha- reductase, and reduce inflammation. Sixty-nine per cent of men using rye pollen extracts notice an improvement in symptoms, and their prostate volume shrinks by up to 30 per cent.

Severe Symptoms

Traditionally, surgery is the gold standard treatment for moderate to severe benign prostatic hyperplasia. Removal of part or all of the prostate gland has been practised for over a hundred years.

Catheteriszation

Catheterization is the insertion of a flexible tube into the bladder to release trapped urine. This can be left in place to provide continual drainage into a bag worn attached to the leg. This option is useful for treating dribbling incontinence but is not acceptable to many men except as a temporary measure. Catheterization is also used as an emergency procedure to release trapped urine in the bladder if the urethra becomes completely blocked.

Transexual Prostatectomy (TURP)

Over 45,000 men in the UK undergo a TURP each year. In the US, over 400,000 are performed every year, at an annual cost of $4 billion.

During a TURP, an instrument (resectoscope) is inserted through the penis while the patient is under a general anaesthetic. A fibre-optic light and lens system allows the surgeon to view the urethra and bulging inner surface of the prostate gland. A high-frequency electric arc is used to trim excess tissue and cauterize bleeding points at the same time. The surgeon pares away the enlarged central portion of the prostate gland from the inside out. A continuous fluid irrigation system flushes the trimmings away and allows some to be collected for examination under a microscope. Histology reveals a hidden tumour in about 5 per cent of cases.

The latest refinement of the TURP is the use of a right-angled laser-fibre. This allows the surgeon to target the prostate tissue for removal more accurately, reducing the risk of complications such as absorption of irrigation fluid, bleeding, incontinence and retrograde ejaculation (see below). Endoscopic laser ablation, as this procedure is known, is currently undergoing trials and may eventually replace the classic TURP.

After a TURP

It usually takes several weeks for symptoms of prostatism to settle down after the operation. Up to 20 per cent of men will have post-operative problems, including intermittent, dribbling incontinence of urine. In about 5 per cent of cases, this problem is continual. Incontinence after the operation is not necessarily irreversible or permanent, however. It generally improves with time and often improves with medication. If necessary, artificial valves may be implanted to relieve the problem.

The prostate gland can still continue enlarging after the operation, so that symptoms eventually recur. Around 15 per cent of men need a second TURP within eight years of the first.

TURP and Sex

It is important to know that at least a third of men undergoing a TURP will suffer retrograde ejaculation after the operation. Some studies suggest the figure is as high as 90 per cent. With retrograde ejaculation sperm are passed backwards into the bladder during orgasm, so very little is ejaculated from the penis. This in itself is not harmful, however, and the sperm will be voided next time you empty your bladder. What it does mean, though, is that you are likely to be subfertile. While it is possible to aspirate sperm from the bladder and use these for artificial insemination techniques, if you think you might want more children in the future it is worth having sperm samples frozen and stored in a sperm bank before the operation. Marie Stopes and The British Pregnancy Advisory Service (see Useful Addresses) offers this facility.

There is no obvious reason why a TURP should affect a man's sex drive or ability to maintain an erection. Nevertheless, a few men do seem to experience sexual problems after the operation. Fifty per cent report noticing a change in the intensity of their orgasms, and this may of course make some less interested in sex.

As a general rule, however, you should not fear having erectile problems after a prostate operation. If any do occur, you will be treated as if you haven't had a prostate operation ­ that is, other causes will be sought.

Open Prostatectomy

An open prostatectomy, in which the entire prostate gland is shelled out through an incision over the pubic bone, was the standard prostate operation until TURP was perfected. It is now more widely used in the US than in the UK, where it makes up around only 4 per cent of prostatectomies.

It is still sometimes performed if:

• the prostate is very much enlarged (over 70 g)

• the hip joints are badly affected by arthritis and cannot be placed up in stirrups as required for TURP

• a suspected early tumour might be cured through removal of the entire gland

• large bladder stones also need removal.

The risk of retrograde ejaculation with open prostatectomy is around 80 per cent.

Other Options

Many new procedures have been developed to treat BPH. Not all are widely available and some are still at the clinical trial stage:

Tulip

Trans-urethral, Ultra-sound guided, Laser-Induced Prostatec-tomy. A laser probe is inserted into the urethra as far as the prostate gland. A water-filled balloon is inflated to fix it in place and to help drain blood out of the gland. The bloodless prostate is trimmed and sealed using the laser, which cuts down blood flow even further, causing the gland to shrivel. The procedure causes relatively little bleeding. Only 5 per cent of treated males suffer retrograde ejaculation after this operation.

Stent Implants

A tubular metal mesh implanted in the prostatic urethra is expanded to hold the urethral walls open. Positioning is a minor procedure that takes less than 15 minutes. Two types of stent are available:

1. a fine, tubular wire mesh (Wallstent) that stays in permanently

2. a gold- or silver-plated metal spiral (Fabian urospiral) that is replaced every few years.

Balloon Dilation

A balloon is inserted into the urethra and inflated to dilate the passage through the prostate gland. Initial results seemed promising, but some doubt was recently cast on the effectiveness of this procedure.

Microwave Hyperthermia (Prostatron)

For this technique a microwave coil within a catheter is inserted into the urethra and heated to a temperature of 42°C (107.6°F). A cooling system protects surrounding tissues. The procedure is performed under local anaesthetic and takes between one and two hours. It improves symptoms of BPH by two-thirds and cuts in half the number of times the sufferer has to get up in the night to pass urine.

Transrectal Hyperthermia (Prostathermer)

A probe is introduced into the rectum to heat the prostate gland to a temperature of 42°C (107.6°F) using microwaves. This procedure must be repeated six times to be effective.

Thermex

A radio-frequency device that is still under trials. This only needs to be used once and can treat two patients simultaneously.

TUNA: Trans-Urethral Needle Ablation

Needles are inserted into the prostate gland (under a local anaesthetic) to achieve greater precision and higher temperatures during thermal treatment to shrink the prostate gland.

Sonoblate

A device is inserted via the rectum to focus ultrasound waves on the prostate gland. Temperatures high enough to shrink the gland are produced.

Cryotherapy

Deep Freeze Treatment. A cryoprobe is inserted into the penis as far as the prostate gland. The tip of the instrument is then frozen using liquid nitrogen. This forms a ball of ice that envelops and freezes the prostate gland. After five to 10 minutes the probe is electrically rewarmed and the water content of the gland melts and is flushed away. This produces dramatic shrinkage.