The Prostate:
An Owner’s Manual

How to keep this small gland from causing big problems.


April 2013

By Lisa James

 

Location and Function: The prostate is just below the bladder, right in front of the rectum; it is wrapped around the urethra, which carries urine out of the body, and empties into it. (This explains the gland’s name, which comes from a Greek word meaning “guardian” or “protector.”) The prostate produces a slightly alkaline fluid that helps protect sperm cells as they make their way through the female reproductive tract to the egg.

Structural Components: Made up of two primary kinds of tissue: glandular epithelial cells, which produce prostatic fluid, and stromal connective and smooth muscle cells, divided among four zones and wrapped in a thin band of fibrous tissue.

Potential Hazards: Men of any age can develop an infection of the prostate, or bacterial prostatitis, either short-term (acute) or long-term (chronic), or a poorly understood condition called chronic nonbacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS), pelvic pain of undetermined origin lasting at least three months that in some cases is linked to inflammation.

However, a man’s risk of developing prostate problems rises as he gets older. The two most common age-related prostate disorders are:

• Benign Prostate Enlargement (BPE): Also referred to as benign prostatic hyperplasia (BPH), this non-cancerous condition can cause the prostate to go from about the size of a walnut to, in some cases, that of an apple. Researchers aren’t sure why some men develop BPE as they age while others don’t; some studies indicate that such cardiovascular risk factors as obesity, diabetes and high blood pressure may increase BPE risk.

• Prostate Cancer: Growths capable of spreading beyond the prostate to other organs; most develop in the peripheral zone closest to the rectum. Prostate cancer may be proceeded by a pre-cancerous condition called prostatic intraepithelial neoplasia (PIN). Age is a major risk factor; others include smoking, family history and a diet rich in red meat and low in fresh produce. Prostate cancer is also much more common among African-Americans than among Americans of other ethnic backgrounds.

Statistic: 241,740—Estimated new cases of prostate cancer this year in the United States (Cancer Facts & Figures 2012, American Cancer Society)

Statistic: 241—Incidence per 1000,000 men of prostate cancer among African-Americans, compared with 149 in 1000,000 for white Americans (Cancer Facts & Figures)

Symptoms: Early prostate cancer is often symptomless. Symptoms of advanced malignancies can include weakness or swelling in the legs, loss of weight and appetite, fatigue and a deep, dull pain or stiffness in the lower back, ribs, pelvis or upper thighs. Surprisingly, BPE may also produce few symptoms, and prostate size is not always an indicator of the discomforts a man may experience.

The best-known of those discomforts involve problems in urination. One look at the gland’s anatomy explains why; since the prostate surrounds the urethra, an increase in prostate volume may cause the passageway to narrow, making it more difficult to pass urine.

Urinary symptoms associated with prostate problems include nocturia, the need to urinate, sometimes repeatedly, during the night (daytime bathroom breaks may also increase); hesitancy, difficulty in starting the urine stream, and intermittency, interruptions in flow; urgency, the need to urinate immediately, which can lead to episodes of incontinence; and straining. Because such symptoms can also occur as the result of bladder dysfunction, doctors now use the overall term lower urinary tract symptoms (LUTS).

Statistic: 75%—Men between the ages of 60 and 69 who report experiencing nocturia; rises to 83% among men 70 and older (National Institutes of Health)

Diagnostics: BPE does not lead to prostate cancer. But because both conditions can cause LUTS, symptoms should be evaluated by a practitioner.

In addition to a taking a medical history, the practitioner will ask detailed questions to determine how severe the symptoms are. A physical examination will often include a digital rectal exam (DRE), in which the prostate is palpated to check its size and texture. Urine will be taken for analysis. In addition, blood may be taken to test for the presence of prostate-specific antigen (PSA), a protein made by the prostate; levels rise in response to any irritation of the gland, including cancer. If cancer is suspected a biopsy, in which samples are taken through a needle, will be done. Various imaging tests may be ordered if needed.

The use of PSA for screening—the testing of symptom-free men in an effort to catch cancer early—is more controversial; different professional and public health organizations disagree on which men should be tested and how often. That’s because of the risk of false positives, high PSA scores that don’t result in cancer diagnoses, and the fact that in many men, especially those who are older, prostate cancer grows so slowly that it never becomes life-threatening; such men are more likely to die from other causes, such as heart disease.

Statistic: 90%—Prostate cancers discovered in early stages (Cancer Facts & Figures)

The Expert Says: There’s a growing consensus that the way we use the PSA test results in unacceptably high overtreatment rates for prostate cancer...We screen the elderly at very high rates, and that’s just not rational.

H. Ballentine Carter, MD
Brady Urological Institute, Johns Hopkins Medicine, Baltimore, Maryland

Treatments such as surgery, radiation or hormone therapy are routinely recommended for aggressive malignancies, especially those in younger men. Such treatments carry considerable side effect risks, including incontinence and erectile dysfunction. (Surgery, as well as medication, is also used for BPE.) However, men with slow-growing cancers also receive such recommendations. For these men, active surveillance—carefully tracking the cancer for signs of aggressive growth—may be an option.

Statistic: $32 million—Cost of prostate cancer overtreatment per year (2013 Genitourinary Cancers Symposium)

The Expert Says: There is a one in four chance that treatment will not help the patient in any way. Active surveillance is an underutilized alternative.
—Carter

When to start, and how often, to undergo PSA testing for screening purposes should be discussed with one’s practitioner based on such factors as age, family history and lifestyle risks.

The Expert Says: I think every asymptomatic man should know that about one prostate cancer death will be prevented for every thousand men screened over a decade. But that could be much, much higher over a lifetime of screening—as many as four to six deaths may be prevented...The physician and the patient ought to be discussing these facts together. There’s no right or wrong answer.
—Carter

Preventive Maintenance: While age is the single biggest risk for developing prostate problems (and one that can’t be reduced), researchers agree that lifestyle factors can influence a man’s chances of being diagnosed with either BPE or prostate cancer.

The Expert Says: Prostate disease is a chronic disease of age and I don’t think we’ve really thought of it that way.
—Carter

According to an April 2010 study in the Ameri­can Journal of Public Health, men who are heavy smokers increase their risk of developing prostate cancer by 22% and their risk of dying from it by 30%. The researchers analyzed data from 24 studies involving 21,600 men.

On the other hand, regular exercise has been linked to a reduction in prostate cancer risk; it is believed that being active helps modulate hormone levels. What’s more, some evidence indicates that a healthy sex life (another form of exercise) may reduce prostate cancer risk by serving as a form of prostatic “housekeeping.”

The Expert Says: The more physically active you are, the less time you may spend looking for
bathrooms.
—Carter

Exercise also helps reduce obesity. Excess body fat, especially that which accumulates in the abdomen, leads to the types of hormonal and meta­bolic disturbances linked to prostate troubles. Countries with the highest obesity rates also have the highest prostate cancer rates.

The Expert Says: Abdominal obesity is like adding an organ to your body. It secretes substances that increase chronic inflammation.
—Carter

Diet is the other factor in weight. Asian men who eat a traditional diet of produce, soyfoods and fish have lower cancer mortality rates than men eating a Western diet. Once Asian men move to Western countries and start eating the local diet, their mortality rates go up. Fried foods, a prominent part of the Western diet, have been particularly linked to cancer risk.

Adopting a diet that more closely reflects that of Asia and other parts of the world known for healthy eating (the Mediterranean, for example) helps lower one’s risk of prostate problems, including cancer, as well as a slew of other health hazards. Fish contains omega-3 fats, which have been linked to greater prostate cancer survival. (Krill is a supplemental source of omega-3.)

The Expert Says: The one diet I’m in favor of is ELF—eat less food.
—Carter

Fresh produce, along with green tea, also contain antioxidants that fight free radicals, substances that damage cells. One study found an association between a diet rich in such antioxidants and a reduced risk of the most aggressive forms of prostate cancer. Green tea has also been linked to slower cancer progression.

Antioxidants help fight chronic inflammation, which may be linked to prostate cancer survival and the development of BPE. Researchers have found that certain plant extracts, such as those taken from green tea, turmeric and olive fruit, help quell inflammation.

One theory behind BPE is that the enzyme 5-alpha-reductase turns testosterone into a form called DHT, which stimulates excessive prostate growth. The herb saw palmetto inhibits 5-alpha-reductase, as does astaxanthin, an antioxidant and anti-inflammatory found in krill and other marine animals. Re-Settin is a supplement that combines both, along with pumpkin seed, lycopene, and apple and grape polyphenols. It is designed to help regulate hormonal activity to lower DHT levels and raise those of testosterone. (The amino acids L-alanine, L-glutamine and L-glyceine also support healthy hormone production.)

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