273 ‒ Prostate health: common problems, cancer prevention, screening, treatment, and more

KEYPOINTS

• 01

  Urinary symptoms are the norm with age, not the exception

  Ted Schaeffer, a Northwestern urologist, says 50–60% of men over 50 have lower urinary tract symptoms, rising to 75–80% by 60, and these almost always involve the prostate. A normal prostate is about 20–30 g at 40–50 and grows with age. Size doesn't predict symptoms well: men can have severe symptoms with a 35 g gland.

• 02

  Waking at night to urinate is often about fluid handling, not just the prostate

  Antidiuretic hormone normally rises in the evening to cut overnight urine production. That rhythm weakens with age, and alcohol inhibits the hormone. Fluid that pools in the legs during the day (look for sock marks in the morning) returns to the circulation when you lie down. Schaeffer says changing when you drink, plus knee-high compression stockings, can often cut nighttime trips from two to one without drugs.

• 03

  Medications: alpha blockers first, then 5-alpha-reductase inhibitors for large glands

  Modern selective alpha blockers relax smooth muscle in the prostate to widen the urethra, without the steep blood-pressure drops of the first generation. Finasteride (5 mg) or dutasteride (0.5 mg) shrink the prostate by 20–30% over time. Their half-lives are long, so Schaeffer notes that a weekly 5 mg finasteride tablet roughly matches the 1 mg daily hair-loss dose.

• 04

  HoLEP has changed surgery for large prostates

  TURP, still the gold standard, scrapes out tissue in roughly 1 g chunks. Holmium laser enucleation (HoLEP) shells out the gland along its natural plane. His colleague Amy Krambeck has removed 400 g from a 450 g prostate, about the size of a big grapefruit, and can operate on glands as small as 25–30 g. He estimates only about 10 surgeons in the US work at her level.

• 05

  Chronic prostatitis is often not an infection

  The four-glass test cultures the first void, bladder urine, prostatic fluid and urine after massage. Bacteria found only in the prostatic fluid point to a true prostate infection. Many men instead have pelvic-floor tightness, which Schaeffer treats with transrectal myofascial release, which he says can change lives. He is wary of repeated 30–60-day antibiotic courses. In bed-bound or dementia patients, he warns that indwelling catheters drive urosepsis.

• 06

  Finasteride hides PSA, and that can kill

  After about five years on a 5-alpha-reductase inhibitor, PSA falls about 2.5-fold. If patients and doctors don't adjust for this, a rising PSA gets missed. A UCSD study of veterans found markedly higher prostate cancer death rates in men taking these drugs, which Schaeffer attributes to this neglect. He also takes post-finasteride syndrome (lasting sexual and neurological effects) seriously and thinks young men at hair-loss clinics aren't properly warned.

• 07

  The deadliest prostate cancers may thrive without testosterone

  In about 100,000 tumour gene-expression profiles (the Decipher database now has 140,000+), Schaeffer's group found luminal-like and basal-like cancers. Fewer than 10% of metastatic tumours are luminal. Basal tumours survive without androgens, which makes them most likely to spread and least hurt by androgen deprivation. That is why he is comfortable treating genuinely low testosterone in men diagnosed with or recovering from prostate cancer.

• 08

  Know your PSA relative to the median for your age

  Median PSA is about 0.5 at 40 and about 1.0 at 50. Being above the median signals a much higher risk over the next 20–30 years and calls for closer follow-up. PSA density (PSA divided by prostate volume) refines this: he gets concerned above about 0.1–0.12 in men under 60 and 0.15 in men over 65–70. A free PSA above 18–20% is reassuring. Screening trials showed PSA cut prostate cancer deaths by 20–25%, yet about 35,000 US men still die each year.

• 09

  Use MRI to decide on a biopsy, and go through the skin

  PI-RADS 3–5 lesions generally warrant a biopsy unless PSA density is very low (around 0.02). Transrectal biopsies carry about a 1–4% infection rate even with antibiotics. Transperineal biopsies go through the skin with buffered lidocaine and nearly eliminate infection. Schaeffer leads a 16-centre randomized trial comparing the two. A good biopsy takes 12 systematic cores plus targeted samples.

• 10

  Gleason 6 can usually be watched; pattern 4 changes the picture

  Grade 3+3=6 is the least aggressive type. In the Johns Hopkins active-surveillance cohort started in 1996, about 30–35% of men were upgraded within five years, with roughly 2–3% added per year after that, about one in five overall over 10 years. Gleason 4+3, meaning more than 50% pattern 4, behaves worse than 3+4, and 3+5 behaves like 4+4. About 95–96% of prostate cancers are diagnosed while still localized.