Posts Tagged ‘BPH’

Prostate Arterial Embolization To Treat Prostate Enlargement

February 18, 2017

Andrew Siegel MD  2/18/17

Note: Today’s entry was supposed to be on the topic of female stress incontinence, but this very interesting prostate topic presented itself to me, so the female incontinence entries will be continued next week.

Benign prostate enlargement (BPH) is a common condition of the middle-aged and older male in which the enlarging prostate gland obstructs urinary flow. It causes a number of annoying lower urinary tract symptoms, including a hesitant, weak and intermittent stream, prolonged emptying time, incomplete emptying, frequent urinating, urgency, nighttime urinating, and at times, urinary leakage. 

There are numerous treatment options available and one of the newest minimally invasive options is “super-selective prostate artery embolization”—a.k.a. “PAE”—a  procedure that is done by an interventional radiologist (a specialist x-ray doctor who does internal procedures without using conventional surgical techniques).  The blood supply to the prostate is purposely blocked (embolized) using micro-particles that are injected into one or more of the arteries to the prostate.  As a result of this embolization of the prostate artery, the part of the prostate served by the artery shrinks, opening up the obstructed urinary channel and improving the lower urinary tract symptoms.

Urinary difficulties attributable to BPH are commonly quantified using the International Prostatic Symptom Score (IPSS), a questionnaire consisting of seven symptom categories, with a range of increasingly severe symptom scores from 0 through 35. The score is based on the severity of each of the following lower urinary symptoms: hesitancy, decreased urinary stream, intermittency, sensation of incomplete emptying, nighttime urination, frequency, and urgency. The questionnaire responses are graded, with each of the seven symptom categories contributing a maximum of 5 points, for a total possible score of 35. Symptoms can be ranked as mild (0–7), moderate (8–19), and severe (20–35).  This IPSS is a useful metric both before and after a procedure like PAE, in order to document clinical symptomatic improvement.

Before pursuing PAE, a CT angiogram of the prostate is performed to determine prostate arterial anatomy, to help plan the PAE and to exclude patients with severe arterial disease or anatomic variations that will not allow PAE to be a consideration. Prior to pursuing a PAE procedure, it is vital to check PSA, perform a digital rectal examination and rule out prostate cancer.

 Technique of PAE

The PAE procedure takes place in the radiology department of the hospital under the supervision of the interventional radiologist. The femoral artery (thigh artery) is cannulated and by using an injection of contrast, the arterial supply to the prostate gland is identified. The prostate artery most commonly branches off the internal pudendal artery. Embolization of the anterolateral prostate artery, the main blood supply to the benign prostate growth, is attempted on both sides. The most challenging aspect is to identify and catheterize the tiny prostate arteries that are often only 1-2 mm in diameter.  Micro-particles (polyvinyl alcohol, trisacryl gelatin microspheres or other synthetic biocompatible materials) are injected into the prostate arteries to purposely compromise blood flow and cause partial necrosis (death of prostate cells) and shrinkage. After the embolization on one side, an angiogram (x-ray of pelvic arterial anatomy) is done before the sequence is repeated on the other side.

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Because of variation in prostate arterial anatomy and the types of micro-particles used, the extent of necrosis and shrinkage of the prostate is quite variable. Furthermore, prostate volume reduction does not precisely correlate with symptom improvement.  Although ideally performed on both sides, when done only on one side (left or right prostate artery) it still results in improvement of symptoms without as significant a reduction in prostate volume.

Although clinical improvement in urinary symptoms is less predictable after PAE as compared to standard treatments including surgical removal or laser treatment of the obstructing part of the prostate, the PAE has numerous points in its favor. Advantages of this new procedure are avoidance of general anesthesia and surgery an preservation of ejaculation, as opposed to surgical treatments of BPH, which commonly cause retrograde ejaculation (ejaculating backwards into the bladder with semen following the path of least resistance).  The PAE procedure is ideal for the older male with symptomatic BPH and significant prostate enlargement who for one of a variety of reasons is not a good candidate for conventional surgery.

Side effects of the PAE include urethral burning, fever, nausea and vomiting and perineal pain from prostate ischemia (damage to the blood supply), short-term inability to urinate as well as the radiation exposure necessary to perform the procedure.

Bottom Line:  Growing evidence supports the use of prostate arterial embolization to treat benign prostate enlargement.  Selectively occluding the prostate arterial supply results in damage to the prostate blood supply and ischemic necrosis (prostate tissue death) with reduction in the volume of the prostate gland with improvement in symptoms.  Safe and effective, it is a promising minimally invasive option that is an attractive alternative to surgery for symptomatic patients with large prostates and concomitant medical problems who have failed to respond well to pharmacological treatments.

 Dr. John DeMeritt is an interventional radiologist at Hackensack University Medical Center in Hackensack, New Jersey, who has particular expertise and experience in PAE.  He reported the first case study of PAE in the USA, has conducted numerous studies on the topic as well as written several medical journal articles and has been interviewed on the subject by Dr. Max Gomez on CBS news: https://www.youtube.com/watch?v=SdV8ZxtLqZU

Thank you to Dr. DeMeritt for provided me with information on the subject matter, both verbally and in the form of several excellent articles, including his original case report.  He also provided me with the PAE image.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

 

Prostate Steaming For Better Urinary Streaming

November 12, 2016

Andrew Siegel MD 11/12/2016

A new, minimally invasive procedure for treating symptomatic prostate enlargement has been tested in clinical trials and has been shown to be safe and effective. I was informed about it at a recent urology meeting in Prague and was intrigued because of its simplicity. The prostate steaming procedure–called “Rezum”–takes less than 15 minutes and uses convective heat energy in the form of steam to open up the obstructed prostate gland. 

Convection Versus Conduction

Convection is the transfer of thermal energy by heating up a liquid, resulting in currents of thermal energy traveling away from the heating source.  This type of energy is used for the Rezum prostate steaming procedure.

This is as opposed to conduction, which is heat transfer via molecular agitation. Thermal energy that is directly applied to tissues heats up molecules and is transferred through tissues as higher-speed molecules collide with slower speed molecules. Conduction energy is commonly used in surgery to cut or coagulate tissues.

Benign Prostate Enlargement (BPH)

BPH is a common condition in men above the age of 50. Based upon aging, genetics and testosterone, the prostate gland enlarges to a variable extent. As it does so, it often compresses the urinary channel (like a hand around a garden hose), causing urinary obstructive and irritative symptoms that can be quite annoying.  Obstructive symptoms include: a weak, prolonged stream that is slow to start and tends to stop and start (to quote my patient: “peeing in chapters”) and incomplete emptying. Irritative symptoms include: strong urges to urinate, frequent urinating, nighttime urinating and possibly urinary leakage before arrival at the bathroom.

pre-treatment_v2

BPH (note the tissue compressing the urinary channel)

Medications or surgical procedures are often used to alleviate the symptoms of BPH.  One class of medication relaxes the muscle tone of the prostate (Flomax, Uroxatral, Rapaflo, etc.); another class shrinks the prostate (Proscar, Avodart). The erectile dysfunction medication Cialis has also been used (daily dosing) to help manage symptomatic BPH. Commonly performed procedures to improve the symptoms of BPH include Greenlight laser photovaporization of the prostate, Urolift procedure and TURP (transurethral resection of the prostate). The Rezum prostate steam procedure is a new addition to the BPH armamentarium.

Rezum Prostate Steaming

The prostate is a compartmentalized organ with discrete anatomical zones (compartments). The transition zone is the area responsible for benign enlargement. In the Rezum procedure, radio-frequency energy is used to convert a small volume of water to steam, which is injected within the  transition zone of the prostate via a retractable needle under direct visual guidance (cystoscopy). The steam adheres to the anatomy of the prostate zones, its spread limited by the zonal anatomy. Each steam (convective water vapor thermal energy) injection takes less than 10 seconds and utilizes no more than a few drops of water. The number of injections necessary is based upon the size of the prostate gland, but it generally requires only a few.

watervaportreatment

Steam being injected into prostate tissue via a retractable needle

Convection uniformly disperses the steam, causing targeted cell death of prostate cells. This slowly and gradually will un-obstruct the prostate and alleviate the symptoms of BPH.

It is unusual for the actual procedure to take much longer than a few minutes, although the patient will need preparation time before and recovery time after the procedure. After the Rezum is completed, a catheter is placed for a few days. Common temporary side effects include inability to urinate (the reason for the catheter), discomfort with urination, urinary urgency, frequency, and blood in the urine or semen. Symptomatic improvement may be noted as early as two weeks after the procedure, but it may take up to 3 months before maximal benefits are derived.

tissue_resorption_v2

Prostate anatomy 3-months following Rezum procedure

A multi-center, randomized, controlled study was recently reported in the Journal of Urology. 200 men were randomized to active treatment with Rezum versus control. The study concluded that convective water vapor energy provides durable improvements in the symptoms of BPH, preserving erectile and ejaculatory function.

Bottom Line: This quick outpatient procedure for BPH  is safe and effective, can be performed in an office setting using sedation and can treat certain anatomical variations (e.g. middle lobe prostate enlargement) that cannot be treated by some of the alternative methods. Erectile and ejaculatory functions are preserved in most patients, which is often not the case with the BPH medications, Greenlight laser and TURP. A disadvantage is that the Rezum is not immediately effective, requiring a catheter for several days and a period of several weeks before symptomatic improvement is evident. Our urology practice is now offering this procedure to patients.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

http://www.TheKegelFix.com

 

 

Breast Lift, Face Lift…Prostate Lift

April 1, 2016

Andrew Siegel MD 4/2/16

“Prostate lift” a.k.a. “Urolift,” is a new rather clever means of improving a man’s ability to urinate when it is compromised by obstruction of the urinary channel because of enlarged lateral prostate lobes.

Prostate 101

The prostate is a male reproductive organ that produces prostate fluid, a milky liquid that serves as a nutrient vehicle for sperm. Similar to the breast, the prostate consists of glands that produce this milky fluid and ducts that convey the fluid into the urethra (urine and semen channel). The prostate completely surrounds the urethra, enabling its many ducts to drain into the urethra. However, this necessary anatomical relationship between the prostate and the urethra can potentially be the source of many troubles for the aging male.

The Enlarging Prostate

Benign prostatic hyperplasia (BPH) is one of the most common conditions of the aging male  often causing bothersome lower urinary tract symptoms (LUTS)—urinary frequency, urgency, nighttime urination, weak and intermittent stream and the sensation of incomplete bladder emptying—that affect quality of life by interfering with normal daily activities and sleep patterns. The relationship between BPH and LUTS is complex because not all men with BPH develop LUTS, and LUTS are neither specific to nor exclusive to BPH. Urinary tract infections, prostate cancer, urethral scar tissue, and impaired bladder contractility (underactive bladder) are other problems that can mimic BPH.

Why Does The Prostate Enlarge?

Aging, genetic, and hormonal factors cause the prostate gland to gradually enlarge, with the process typically starting at about 40 years of age. As the prostate grows (hypertrophies), it puts pressure on the urethra, much
 as a hand squeezing a garden hose can affect the flow through the hose. Although larger prostates tend to cause more of this “crimping” than smaller prostates, this relationship is not precise.

UroLift (Prostate Urethral Lift)

UroLift is a new, minimally invasive means of treating prostate obstruction using a cystoscope (a small telescope that is positioned in the urethra to view the urethra, prostate and bladder) to place implants within the prostate to compress the obstructing prostate tissue. It opens the urethra so that the prostate no longer blocks the outflow of urine. It does so while leaving the prostate intact, not requiring cutting, heating, lasering or removal of prostate tissue. It is advantageous because of reduced bleeding and the preservation of erectile and ejaculatory function. It is important to know that it is not applicable to all men with prostate enlargement as it is only appropriate for certain prostate anatomies and sizes.

The technique uses mechanical compression of the encroaching lateral lobes of the prostate, creating an open channel. The implants are similar in action to molly bolts, resulting in crimping and tufting of the prostate tissue. The implants are deployed under direct visual guidance at the 2 o’clock and 10 o’clock positions using a needle that houses the components of the implant. The needle is passed through the full thickness of the prostate and upon retraction of the needle, the prostate capsule is engaged by a nitinol tab that is attached to an adjustable suture. The suture is placed under tension and a stainless steel urethral end piece is attached to the suture, securing the compression. Between two and ten implants may be used, depending on the size of the prostate gland.

Urolift color with text 2

Because the procedure does not remove tissue and avoids thermal energy, it has minimal  — if any– adverse effects on erectile and ejaculatory function, a major advantage over many of the alternative treatments of BPH, both medical and surgical. Minor side effects include short-term urinary burning, urgency and blood in the urine. The procedure was pioneered in Australia in 2005, received FDA approval in 2013 and Medicare approval in 2016.

Bottom Line: The UroLift is a clever new procedure that is effective in alleviating the annoying symptoms of prostate obstruction in men with certain prostate anatomies and sizes.  It alleviates obstruction without removing tissue by compressing the obstructing lateral (side) prostate lobes and does so without adversely affecting sexual or ejaculation function. 

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Arnold Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.  

Pelvic Rx can be obtained at http://www.UrologyHealthStore.com, an online store that is home to quality urology products for men and women.  Use code UROLOGY10 at check out for 10% discount. 

 

5 Things Every Woman Should Know About Her Man’s Pelvic Health

November 28, 2015

Andrew Siegel MD   11/28/15

4910841630_d096720d0d_o (1)

(Attribution: Pier-Luc Bergeron, A happy couple and a happy photographer; no changes made, https://www.flickr.com/photos/burgtender/4910841630)

Since this is Thanksgiving weekend and a broadly celebrated family holiday, I cannot think of a better time to blog about how wives/girlfriends/partners can help empower their men’s pelvic health.

  1. His Erections
  2. Prostate Cancer
  3. Bleeding
  4. Testes Lumps/Bumps
  5. Urinary Woes

 

Erectile Dysfunction: A “Canary in the Trousers”

If his erections are absent or lacking in rigidity or sustainability, it may just be the “tip of the iceberg,” indicative of more serious underlying medical problems. The quality of his erections can be a barometer of his cardiovascular health. Since penile arteries are tiny (diameter of 1-2 millimeters) and heart arteries larger (4 millimeters), it stands to reason that if vascular disease is affecting the penile arteries, it may affect the coronary arteries as well—if not now, then perhaps soon in the future. Since fatty plaque deposits in arteries compromise blood flow to smaller blood vessels before they do so to larger arteries, erectile dysfunction may be considered a genital “stress test.”

Bottom Line: If your man is not functioning well in the bedroom, think strongly about getting him checked for cardiovascular disease. His limp penis just may be the clue to an underlying more pervasive and serious problem.

Prostate Cancer

One in seven American men will develop prostate cancer in their lifetimes and most have no symptoms whatsoever, the diagnosis made via a biopsy because of an elevated or accelerated PSA (Prostate Specific Antigen) blood test and/or an abnormal rectal exam that reveals an asymmetry or lump. Similar to high blood pressure and glaucoma, prostate cancer causes no symptoms in its earliest phases and needs to be actively sought after.

With annual PSA testing, he can expect a small increase each year correlating with prostate growth. A PSA acceleration by more than a small increment is a “red flag.” The digital exam is simply the placement of a gloved, lubricated finger in the rectum to feel the size, contour and consistency of the prostate gland, seeking hardness, lumps or asymmetry that can be a clue to prostate cancer. It is not unlike the female  pelvic exam.

Bottom Line:  As breast cancer is actively screened for with physical examination and mammography, so prostate cancer should be screened for with PSA and digital rectal exam. In the event that prostate cancer is diagnosed, it is a treatable and curable cancer. Not all prostate cancers demand treatment as those with favorable features can be followed carefully, but for other men, treatment can be lifesaving.

Bleeding

Blood in the urine can be visible or only show up on dipstick or microscopic exam of the urine. Blood in the urine should also be thought of as a “red flag” that mandates an evaluation to rule out serious causes including cancers of the kidney and bladder. However, there are many causes of blood in the urine not indicative of a serious problem, including stones, urinary infections and prostate enlargement.

Blood in the semen is not uncommonly encountered in men and usually results from a benign inflammatory process that is usually self-limited, resolving within several weeks. It is rarely indicative of a serious underlying disorder, as frightening as it is to see blood in the ejaculate. Nonetheless, it should be checked out, particularly if it does not resolve.

Bottom Line: If blood is present when there should be none—including visible blood in the urine, blood stains on his undershorts or blood apparent under the microscope—it should not be ignored, but should be evaluated. If after having sex with your partner you notice a bloody vaginal discharge and you are not menstruating, consider that it might be his issue and make sure that he gets followed up.

Testes Lumps and Bumps

Most lumps and bumps of the testes are benign and not problematic. Although rare, testicular cancer is the most common solid malignancy in young men, with the greatest incidence being in the late 20s, striking men at the peak of life. The excellent news is that it is very treatable, especially so when picked up in its earliest stages, when it is commonly curable.

A testicular exam is a simple task that can be lifesaving. One of the great advantages of having his gonads located in such an accessible locale—conveniently “gift wrapped” in the scrotal satchel—is that it makes them so easy to examine. This is as opposed to your ovaries, which are internal and not amenable to ready inspection. This explains why early testes cancer diagnosis is a cinch as opposed to ovarian cancer, which most often presents at an advanced stage. In its earliest phases, testes cancer will cause a lump, irregularity, asymmetry, enlargement or heaviness of the testicle. It most often does not cause pain, so his absence of pain should not dissuade him from getting an abnormality looked into.

Your guy should be doing a careful exam of his testes every few weeks or so in the shower, with the warm and soapy conditions beneficial to an exam. If your man is a stoic kind of guy who is not likely to examine himself, consider taking matters into your own hands—literally: At a passionate moment, pursue a subtle, not-too-clinical exam under the guise of intimacy—it may just end up saving his life.

Bottom Line: Have the “cajones” to check his cajones. Because sperm production requires that his testes are kept cooler than core temperature, nature has conveniently designed mankind with his testicles dangling from his mid-section. There are no organs in the body—save your breasts—that are more external and easily accessible. If your man is not willing to do self-exams, at a moment of intimacy do a “stealth” exam under the guise of affection—it just might be lifesaving.

Urinary Woes

Most organs shrink with the aging process. However, his nose, ears, scrotum and prostate are the exceptions, enlarging as he ages. Unfortunately, the prostate is wrapped precariously around the urinary channel and as it enlarges it can constrict the flow of urine and can cause a host of symptoms. These include a weaker stream that hesitates to start, takes longer to empty, starts and stops and gives him the feeling that he has not emptied completely. He might notice that he urinates more often, gets up several times at night to empty his bladder and when he has to urinate it comes on with much greater urgency than it used to. He might be waking you up at night because of his frequent trips to the bathroom. Almost universal with aging is post-void dribbling, an annoying after-dribble.

Bottom Line: It is normal for him to experience some of these urinary symptoms as he ages. However, if he is getting up frequently at night, dribbling on the floor by the toilet, or has symptoms that annoy him and interfere with his quality of life, it is time to consider having him looked at by your friendly urologist to ensure that the symptoms are due to benign prostate enlargement and not other causes, to make sure that no harm has been done to the urinary tract and to offer treatment options.

Wishing you the best of health and a wonderful Thanksgiving weekend,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.

Her Breasts and His Prostate…So Similar, So Mysterious

July 18, 2015

Andrew Siegel MD  7/18/15

prostate breast

(Thank you, Wikimedia, for above image)

The female breasts and the male prostate are both sources of fascination, curiosity, and fear. Hidden deep in the pelvis at the crossroads of the male urinary and reproductive systems, the prostate is arguably man’s center of gravity. On the other hand, the breasts—with an equal aura of mystery and power—are situated in the chest superficial to the pectorals, contributing to the alluring female form and allowing ready access for the hungry infant, curiously an erogenous zone as well as a feeding zone.

Interestingly enough, the breasts and prostate share much in common, both serving important “nutritional” roles. Each functions to manufacture a milky fluid; in the case of the breasts, the milk serving as nourishment for infants and in the case of the prostate, the “milk” serving as sustenance for sperm cells, which demand intense nutrition to support their arduous  marathon journey traversing the female reproductive tract.

Breasts are composed of glandular tissue that produces milk, and ducts that transport the milk to the nipple. The remainder of the breast consists of fatty tissue. The glandular tissue is sustained by the female sex hormone estrogen and after menopause when estrogen levels decline, the glandular tissue withers, with the fatty tissue predominating.

The prostate—on the other hand—is made up of glandular tissue that produces prostate “milk,” and ducts that empty this fluid into the urethra at the time of sexual climax. At ejaculation the prostate fluid combines with other reproductive secretions and sperm to form semen. The remainder of the prostate consists of fibro-muscular tissue. The glandular tissue is sustained by the male sex hormone testosterone and after age 40 there is a slow and gradual increase in the size of the prostate gland because of glandular and fibro-muscular cell growth.

Access to the breasts as mammary feeding zones is via stimulation of the erect nipples through the act of nursing. Access to the prostate fluid is via stimulation of the erect penis, with the release of semen and its prostate fluid component at the time of ejaculation.

Both the breasts and prostate can be considered to be reproductive organs since they are vital to nourishing infants and sperm, respectively. At the same time, they are sexual organs. The breasts can be thought of as accessories with a dual role that not only provide milk to infants, but also function as erogenous zones that attract the interest of the opposite sex and contribute positively to the sexual and thus, reproductive process. Similarly, the prostate is both a reproductive and sexual organ, since sexual stimulation resulting in climax is the means of accessing the prostate’s reproductive function.

Both the breasts and prostate are susceptible to similar disease processes including infection, inflammation and cancer. Congestion of the breast and prostate glands can result in a painful mastitis and prostatitis, respectively. Excluding skin cancer, prostate cancer is the most common cancer in men (accounting for 26% of newly diagnosed cancers with men having a 1 in 7 lifetime risk) and breast cancer is the most common cancer in women (accounting for 29% of newly diagnosed cancers with women having a 1 in 8 lifetime risk). Both breast and prostate tissue are dependent upon the sex hormones estrogen and testosterone, respectively, and one mode of treatment for both breast cancer and prostate cancer is suppression of these hormones with medication, e.g., Tamoxifen and Lupron, respectively. Both breast and prostate cancer incidence increase with aging. The median age of breast cancer at diagnosis is the early 60’s and there are 232,000 new cases per year, 40,000 deaths (the second most common form of cancer death, after lung cancer) and there about 3 million breast cancer survivors in the USA. The median age of prostate cancer at diagnosis is the mid 60’s and there are 221,000 new cases per year, 27,500 deaths (the second most common form of cancer death, after lung cancer) and there are about 2.5 million prostate cancer survivors in the USA.

Both breast and prostate cancer are often detected during a screening examination before symptoms have developed. Breast cancer is often picked up via mammography, whereas prostate cancer is often identified via an elevated or accelerated PSA (Prostate Specific Antigen) blood test. Alternatively, breast and prostate cancer are detected when an abnormal lump is found on breast exam or digital rectal exam of the prostate, respectively.

Both breast and prostate cells may develop a non-invasive form of cancer known as carcinoma in situ—ductal carcinoma-in-situ (DCIS) and high grade prostate intraepithelial neoplasia (HGPIN), respectively—non-invasive forms in which the abnormal cells have not grown beyond the layer of cells where they originated, often predating invasive cancer by years.

Family history is relevant with both breast and prostate cancer since there can be a genetic predisposition to both types and having a first degree relative with the disease will typically increase one’s risk. Imaging tests used in the diagnosis and evaluation of both breast and prostate cancers are similar with both ultrasonography and MRI being very useful. Treatment modalities for both breast and prostate cancer share much in common with important roles for surgery, radiation, chemotherapy and hormone therapy.

In a further twist to the relationship between breast and prostate cancer, a recent study showed that women with close male relatives with prostate cancer are more likely to be diagnosed with breast cancer. Compared to women with no family history of breast or prostate cancer, those with a family history of both were 80% more likely to develop breast cancer.

Breast and Prostate Cancer Myths and Facts

“Only old people get breast or prostate cancer.

Fact: 25% of women with breast cancer develop it before age 50, whereas less than 5% of men with prostate cancer develop it before age 50; however, many men in their 50s are diagnosed with the disease.

“Men can’t get breast cancer and women can’t get prostate cancer.”

Fact: 1700 men are diagnosed with breast cancer with 450 deaths on an annual basis.  Women have structures called the Skene’s glands, which are the female homologue of the male prostate gland. On very rare occasions, the female “prostate” can develop cancer. The Skene’s glands are thought to contribute to “female ejaculation” at the time of sexual climax. 

“All lumps in the breast or prostate are cancer.”

Fact: 80% of breast lumps are due to benign conditions as are 50-80% of prostate “nodules.”  If an abnormality is found, further evaluation is necessary.  

“It’s not worth getting screened for breast cancer because of the USPSTF (United States Preventive Services Task Force) recommendation against routine screening mammography in women aged 40 to 49 years and against clinicians teaching women how to perform breast self-examination.  It’s not worth getting screened for prostate cancer because the USPSTF also recommended against prostate-specific antigen (PSA)-based screening for prostate cancer.”

Fact: In my opinion, the USPSTF has done a great deal of harm to public health in the USA with their recommendations. The goal of screening is to pick up cancers in their earliest stages at times when treatment is likely to be most effective. Not all cancers need to be treated and the treatment can differ quite a bit based upon specifics, but screening populations at risk is a no-brainer.  For breast cancer and prostate cancer–the most common cancer in each gender–it is important to screen aggressively to obtain the necessary information to enable doctors and their patients make sensible decisions, which are individualized and nuanced, depending on a number of factors.

The reader is referred to a terrific recent article in the NY Times concerning screening for prostate cancer: http://www.nytimes.com/2015/07/06/opinion/bring-back-prostate-screening.html

Wishing you the best of health,

2014-04-23 20:16:29

AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in your email in box go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: http://www.MalePelvicFitness.com.  Work in progress is The Kegel Fix: Recharging Female Sexual, Urinary and Pelvic Health.

Co-creator of Private Gym pelvic floor muscle training program for men: http://www.privategym.com—also available on Amazon.

The Private Gym program is the go-to means of achieving pelvic floor muscle strength, tone, power, and endurance. It is a comprehensive, interactive, easy-to-use, medically sanctioned and FDA registered follow-along exercise program that builds upon the foundational work of Dr. Arnold Kegel. It is also the first program designed specifically to teach men how to perform the exercises and a clinical trial has demonstrated its effectiveness in fostering more rigid and durable erections, improved ejaculatory control and heightened orgasms.

Prostate: Bigger Is Not Better

November 24, 2013

Blog #129

The following quote from Gabriel Garcia Marquez’s Love in the Time of Cholera colorfully sums up the aging prostate:

“He was the first man that Fermina Daza heard urinate. She heard him on their wedding night, while she lay prostrate with seasickness
in the stateroom on the ship that was carrying them to France, and
 the sound of his stallion’s stream seemed so potent, so replete with authority, that it increased her terror of the devastation to come. That memory often returned to her as the years weakened the stream, for she never could resign herself to his wetting the rim of the toilet bowl each time he used it. Dr. Urbino tried to convince her, with arguments readily understandable to anyone who wished to understand them, that the mishap was not repeated every day through carelessness on his part, as she insisted, but because of organic reasons: as a young man his stream was so defined and so direct that when he was at school he won contests for marksmanship in filling bottles, but with the ravages of age it was not only decreasing, it was also becoming oblique and scattered, and had at last turned into a fantastic fountain, impossible to control despite his many efforts to direct it. He would say: “The toilet must have been invented by someone who knew nothing about men.” He contributed to domestic peace with a quotidian act that was more humiliating than humble: he wiped the rim of the bowl with toilet paper each time he used it. She knew, but never said anything as long as the ammoniac fumes were not too strong in the bathroom, and then she proclaimed, as if she had uncovered a crime: “This stinks like a rabbit hutch.” On the eve of old age this physical difficulty inspired Dr. Urbino with the ultimate solution: he urinated sitting down, as she did, which kept the bowl clean and him in a state of grace.”

The prostate gland is that mysterious, deep-in-the-pelvis male reproductive organ that can be the source of so much trouble.  It functions to produce prostate fluid, a milky liquid that serves as a nutrient and energy vehicle for sperm. Similar to the breast in many respects, the prostate consists of numerous glands that produce this fluid and ducts that convey the fluid into the urinary channel. At the time of sexual climax, the smooth muscle within the prostate squeezes the fluid out of the glands through the prostate ducts into the urethra (urinary channel that runs from the bladder to the tip of the penis), where it mixes with secretions from the other male reproductive organs to form semen.

The prostate gland completely envelops the urethra, enabling its many ducts to drain into the urethra. However, this necessary anatomical relationship between the prostate and the urethra can potentially be the source of many issues for the aging male. In young men the prostate gland is the size of a walnut; under the influence of three factors—aging, genetics, and adequate levels of the male hormone testosterone—the prostate enlarges, one of the few organs that actually gets bigger with time when there is so much atrophy (shrinkage) and loss of tissue mass going on elsewhere.

Who Knew?  As we age our muscles atrophy, our bones lose mass, our height shrinks and our hairlines and gums recede.  So why is it that our prostates—strategically wrapped around our urinary channels—swell up?

Prostate enlargement can be very variable; it can grow even to the size of a large Florida grapefruit!  As the prostate enlarges, it often—but not always—squeezes the sector of the urethra that runs through it, making urination difficult and resulting in a number of annoying symptoms and sleep disturbance.   It is similar to a hand squeezing a garden hose that affects the flow through the hose. The situation can be anything from a tolerable nuisance to one that has a huge impact on one’s daily activities and quality of life.

The condition of prostate enlargement is known as BPH—benign prostate hyperplasia—one of the most common plagues of aging men. It is important to identify other conditions that can mimic BPH, including urinary infections, prostate cancer, urethral stricture (scar tissue causing obstruction), and impaired bladder contractility (a weak bladder muscle that does not squeeze adequately to empty the bladder).

Although larger prostates tend to cause more “crimping” of urine flow than smaller prostates, the relationship is imprecise and a small prostate can, in fact, cause more symptoms than a large prostate, much as a small hand squeezing a garden hose tightly may affect flow more than a larger hand squeezing gently. The factors of concern are precisely where in the prostate the enlargement is and how tight the squeeze is on the urethra. In other words, prostate enlargement in a location immediately adjacent to the urethra will cause more symptoms
 than prostate enlargement in a more peripheral location. Also, the prostate gland and the urethra contain a generous supply of muscle and, depending upon the muscle tone of the prostate, variable symptoms may result. In fact, the tone of the prostate smooth muscle can change from moment to moment depending upon one’s adrenaline (the stress hormone) level.

Typical symptoms of BPH include an urgency to urinate requiring hurrying to the bathroom that gives rise to frequent urinating day and night and sometimes even urinary leakage before arriving to the bathroom.  As a result of these “irritative” symptoms, some men have to plan their routine based upon the availability of bathrooms, sit on an aisle seat on airplanes and avoid engaging in activities that provide no bathroom access.  One symptom in particular, sleep-time urination—aka nocturia—is particularly irksome because it is sleep-disruptive and the resultant fatigue can make for a very unpleasant existence.

The other symptoms that develop as a result of BPH are “obstructive” as the prostate becomes “welded shut like a lug nut.”  These symptoms include a weak stream that is slow to start, a stopping and starting quality stream, prolonged time to empty, and at times, a stream that is virtually a gravity drip with no force.  One of my patients described the urinary intermittency as “peeing in chapters.”  Many men have to urinate a second or third time to try to empty completely, a task that is often impossible. There may be a good deal of dribbling after urination is completed, known as post-void dribbling.  At times, a man cannot urinate at all and ends up in the emergency room for relief of the problem by the placement of a catheter, a tube that goes in the penis to drain the bladder and bypass the blockage. BPH can be responsible for bleeding, infections, stone formation in the bladder, and on occasion, kidney failure.

Not all men with BPH need to be treated; in fact, many can be observed if the symptoms are tolerable. There are very effective medications for BPH, and surgery is used when appropriate. There are three types of medications used to manage BPH: those that relax the muscle tone of the prostate; others that actually shrink the enlarged prostate gland; and Cialis that has been FDA approved to be used on a daily basis to treat both erectile dysfunction as well as BPH.  There are numerous surgical means of alleviating obstruction and currently the most popular procedure uses laser energy to vaporize a channel through the obstructed prostate gland.

In terms of the three factors that drive prostate growth: aging, genetics and testosterone: There is nothing much we can do about aging; in fact, it is quite desirable to live a long and healthy life!  We cannot do a thing about our inherited genes.  Having adequate levels of testosterone is actually quite desirable in terms of our general health.

So what can we do to maintain prostate health? The short answer is that a healthy lifestyle can lessen one’s risk of BPH.  Regular exercising and maintaining a physically active existence results in increased blood flow to the pelvis, which is prostate-healthy as it reduces inflammation. Sympathetic nervous system tone tends to increase prostate smooth muscle tone, worsening the symptoms of BPH; exercise mitigates sympathetic tone.  Maintaining a healthy weight and avoiding abdominal obesity, will minimize inflammatory chemicals that can worsen BPH.   Vegetables are highly anti-inflammatory and consumption of those that are high in lutein, including kale, spinach, broccoli, and peas as well as those that are high in beta-carotene including carrots, sweet potatoes, and spinach can lower the risk of BPH.  

Bottom Line: BPH is a common problem as one ages, oftentimes negatively impacting quality of life.  There are medications as well as surgery that can help with this issue; however, a healthy lifestyle that includes exercise, avoidance of obesity, and a diet rich in vegetables can actually help lower the risk for developing bothersome prostate symptoms.

Ten Steps To A Healthy Prostate 1. Decrease the amount of animal fat in your diet 2. Eat less meat and dairy 3. Eat more fish 4. Eat more tomatoes 5. Increase the amount of soy in your diet 6. Eat more fruits, veggies, beans, cereals and whole grains 7. Drink a cup of green tea daily 8. Maintain a healthy weight 9. Exercise regularly 10. Manage stress

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health

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Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in January 2014.

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