1. Introduction: What Is the Prostate?

Hidden deep within the male pelvis is a small gland the size of a walnut known as the prostate. The prostate is an essential part of the male reproductive and urinary systems. But there is a serious design fault.

Similar to a rubber ring, the prostate surrounds the thin, soft urethra, the pipe that transports urine from the bladder to the outside world. The prostate rests silently and unsung for many years until one day it begins to expand inwards. Slowly but surely it constricts the urethra, wreaking everything from mild unpleasantness to outright havoc on the unsuspecting owner.

The urethra is like a hosepipe: Any outside pressure affects the passage of urine, causing poor stream, unpredictable flow, pressure above the blockage and, in the worst case, total obstruction. But that only describes what happens during enlargement of the prostate—what many men experience as benign prostatic hyperplasia.

Prostate cancer is like having an invasive weed growing inside the rubber ring: Over time it expands out into the surrounding area, causing destruction and inward erosion of the hose itself, further narrowing the urethra.

Prostate Anatomy

So where is the prostate, and what is it made of? The prostate lies deep within a crowded part of the pelvis. Forming a funnel-shaped ring around the urethra, it sits immediately beneath the bladder, above the penis and in front of the rectum. The urethra is the thin tube that carries urine from the bladder to the penis and out of the body. Its inconvenient position makes investigation and treatment of prostate diseases problematic.

The prostate contains glandular, ductal, and muscular tissue. It has three lobes and an outer casing. The glandular tissue produces seminal fluid. The muscular tissue provides structure to the prostate and causes it to contract, expelling the seminal fluid. The prostate also contains the ejaculatory duct that carries mature sperm into the urethra for ejaculation.

In young boys, the prostate is the size of a small pea. Then a surge of male hormones in adolescence sparks growth to the size of a walnut. From the age of 25, the prostate enters a second, slower growth phase that, due to its location, may cause urinary symptoms in many men as they age.

Function: What Does the Prostate Do?

The prostate secretes a fluid that protects, carries, and nourishes sperm and is essential for healthy reproductive function. This fluid contains sugars, enzymes, and chemicals that are essential for the health of sperm as it travels within the male body and during sexual intercourse and into the female reproductive system. The fluid ejected during ejaculation is known as seminal fluid or semen. It contains sperm mixed with the fluids from the prostate, the seminal vesicles, and the bulbourethral glands.

The prostate has a second function: During orgasm, muscle fibers in the prostate contract, forcing the seminal fluid out of the urethra and, in the process, closing off the outlet to the bladder so that semen flows out and not up into the bladder.

Diseases of the Prostate

The prostate is infamous and troublesome due to its location. Any enlargement of the prostate causes pressure on, or narrowing of, the urethra. Untreated prostate enlargement may cause damage to the bladder and kidneys. Its awkward position and complex anatomy make investigations and surgical interventions difficult, and the risk of complications must be carefully weighed.

The three most common diseases of the prostate are:

  • Benign prostatic hyperplastic (BPH): A common condition caused by an enlarged but healthy prostate. While not a disease as such, it can cause significant urinary symptoms and secondary disease. BPH affects:
    • 10 percent of men in their 30s
    • 20 percent of men in their 40s
    • 50 to 60 percent of men in their 60s
    • 80 to 90 percent of men aged 70 and over
  • Prostate cancer: The second-most-common cancer in men, affecting 1 in 6 men in their lifetime. The incidence rises with age; however, many cases are so slow-growing that they are not life-threatening: Only 1 in 39 men with prostate cancer die of the disease.
  • Prostatitis: Inflammation of the prostate, sometimes due to infection. Unlike BPH and prostate cancer, prostatitis can affect young and middle-aged men, with a lifetime risk of 5 to 10 percent.

Prostate Medicine: Past, Present, and Future

The word “prostate” comes from the ancient Greek word “prostat¯es,” meaning “president.” Despite the fact that men have likely been suffering from prostatic symptoms for thousands of years, the organ was first reported in medical literature in 1536 by Venetian anatomist Niccolò Massa. Illustrations were first drawn in 1538 by Andreas Vesalius, a Flemish anatomist. It was originally called the “glandulous body.”

Prostate Disease: Past

Prostate cancer was first described in 1853 by J. Adams, a surgeon at The London Hospital. He discovered prostate cancer during histological examination and described it as rare: How wrong he was! Radical perineal prostatectomy—a procedure removing the whole gland—was first performed in 1904 by Hugh H. Young, of Johns Hopkins Hospital, and for many years was used as palliative care for men with advanced cancer. This involved accessing the prostate via the perineum, the area between the anus and the scrotum.

In 1945, Terence Millin developed the abdominal “retropubic” approach. This allowed lymph node dissection and more accurate staging of the disease. In 1983, Dr. Patrick Walsh, also of Johns Hopkins, modified the technique to develop the radical retropubic prostatectomy that allowed nerve-sparing and reduced impotence following surgery.

The hormone connection: In 1785, John Hunter’s research made the link between male hormones and the size of the prostate gland, finding that castrated animals had smaller prostate glands. In 1893, Philadelphia surgeon W. White replicated the finding in dogs and went on to recommend castration for urinary obstruction in men. White’s work produced mixed results, probably because urinary obstruction is often caused by benign prostatic hypertrophy (BPH). In 1935, researchers at Yale, led by Clyde Deming, reported similar findings in primates, also reporting no effect on human BPH.

Radiation and chemotherapy: Radiation therapy was developed in the early 20th century, with the refinement of external beam radiotherapy (EBRT) in the 1950s. Brachytherapy (seed therapy) was introduced in 1983. Chemotherapy was first researched in the 1970s but its use is only just gaining traction in prostate cancer.

Screening and diagnosis: The PSA test (prostate specific antigen) was rolled out in 1986 in the United States, when the FDA approved it for monitoring patients with prostate cancer. It was later approved for screening in 1994. Biopsy of the prostate became more accessible in the 1980s with the introduction of ultrasound-guided biopsy.

Statistics: The incidence rate of prostate cancer peaked in 1992, with a rate of 237.5 new cases per 100,000 men and 39.2 deaths per 100,000 men. The incidence and death rates have decreased steadily since then. The latest CDC data from 2014 reveals an incidence of 96.1 new cases per 100,000 men and 19.1 deaths per 100,000. The cause of this dramatic drop is not fully understood, but is largely due to overdiagnosis following the introduction of the PSA test in 1986 and the subsequent reduction in use of the test.

TURP: The transurethral resection of the prostate (TURP) has been used to treat benign prostatic hypertrophy (BPH) since 1909. It was the first successful minimally invasive surgical procedure.

Remarkably, TURP remains the standard therapy for urinary obstruction in BPH, though thankfully the procedure has been much refined since the early days, significantly reducing unpleasant complications.

The introduction of symptom-relieving medications (5-alpha reductase inhibitors and alpha-adrenergic blockers) has allowed many men to delay or avoid surgery for BPH.

Prostate Disease: Present

The prostate was considered a taboo subject until very recently. Cancer awareness was largely focused on breast cancer, which predominantly affects women. In 1999, American Foundation for Urological Disease (AFUD) designated September as “National Prostate Health Month.”

A Senate resolution in 2001 confirmed that Prostate Health Month would be observed annually. In 2003, President George W. Bush designated September as “National Prostate Cancer Awareness Month.”

Over the past few years, prostate cancer has gained more attention, with many men taking part in “Movember”—a month of awareness and fundraising for the Movember Foundation—“the only global charity focused solely on men’s health.” Men are encouraged to grow mustaches and take part in fundraising activities—a great way to reduce the stigma of prostate disease, raise funds for research, and increase awareness.

Prostate Disease: Future

Biomarkers: Researchers are pursuing the development of a test that can precisely predict clinically significant prostate cancer and more accurately guide treatment. Biomarkers are specific molecules that indicate a process, normal or abnormal, taking place in your body. PSA is the standard biomarker for prostate not specific or accurate enough. Current screening techniques are known to be problematic, over-diagnosing many men with insignificant disease and missing others with advanced or aggressive disease.

Active surveillance: Clinical trials are ongoing to compare “active surveillance” with immediate treatment for men with low-grade prostate cancer. The hope is that the research will result in clear guidelines to help determine which men are good candidates for active surveillance and which men need more aggressive treatment.

Genetics: Ongoing research aims to identify genetic mutations that may be responsible for prostate cancer, with the aim of identifying those at most risk. Epigenetics research is looking at the interaction between prostate cancer and genes, lifestyle, and environment, with the aim of preventing disease.

Metastatic cancer: This is the most aggressive form of prostate cancer, with the lowest survival rates. Research continues into treatments to improve outcomes in this form of the disease. Combinations of hormone therapies, radiation, and chemotherapy are being trialed to determine which improve outcomes.

Symptoms of Prostate Disease

As the prostate grows, it expands internally and externally. Internal expansion presses on the urethra and causes the following symptoms:

  • Frequent urination
  • Dribbling of urine
  • Trouble urinating, otherwise known as poor stream or inability to urinate
  • Pain or burning before or during urination or ejaculation
  • Blood in semen or urine
  • Erectile dysfunction
  • Pain in mid or lower back, hips, upper thighs, pelvis, or lower abdomen
  • Cloudy urine
  • Fever or chills with no obvious cause (prostatitis)

Consult your doctor if you have symptoms, especially if they are of sudden onset. Men are notoriously slow to seek medical help. It is important to know that all common prostate diseases are easier to treat and have much better outcomes when treated early, so don’t delay in seeking a medical opinion.

When you see your doctor, he or she may ask you to complete a symptoms checklist, like the American Urological Association Symptoms Score.

Reducing Your Risk 

While you cannot change your age, race, or family history, you can change your lifestyle and environment. Prostate health is closely related to general health. Men who are very healthy tend to get less prostate disease.

There are no guarantees, however: Lifestyle changes are about shifting the odds in your favor. There is a huge amount of conflicting health advice, especially regarding diet. Most research is on prostate cancer risk.

As a general rule, it is good to listen to your body. If a food or activity makes you feel vibrant, energetic, and healthy, it is probably good for you. If a food or activity gives you pain, discomfort, a foggy head, and an energy crash, it is probably not good for you.

Try the following recommended lifestyle changes and monitor how they affect you.

  • Improve your diet. Switching away from the traditional Western diet high in red meat and processed foods toward a healthier diet can reduce the risk and symptoms of prostate disease. Improving diet may have multiple effects, including reducing inflammation, optimizing weight, reducing abdominal fat, and improving blood sugar control. In people with metabolic syndrome or diabetes, dietary changes should be discussed with your medical practitioner.
    • Decrease red meat, dairy, and processed foods, especially those high in sugar, trans fats and artificial food additives (colors, flavors, sweeteners, flavor enhancers). If you eat red meat, reduce your intake to twice a week and opt for higher-quality, leaner cuts, and go for organic, grass-fed meat if you are able.
    • Increase your intake and variety of fresh fruits and vegetables—these will give you a broad spectrum of vital vitamins, minerals, antioxidants, and fiber. Switch to healthier sources of protein and fat such as beans, pulses, avocados, and fish (two to three times a week). Opt for healthy fats and avoid heating them at high temperatures (olive oil, avocado oil, sesame oil). Fish oil supplements are good for brain health and may reduce inflammation.
  • Exercise. Regular exercise may reduce the risk of prostate disease and the impact of symptoms. Gentle walking, yoga, or abdominal exercises are a great place to start—under medical supervision if you have other health problems. Exercise helps optimize metabolism, maintain a healthy weight, gain muscle, improve pelvic floor tone, and stay flexible and mobile. Good pelvic floor health can help reduce urinary symptoms as you age.
  • Maintain a healthy weight. Being overweight significantly increases the risk of prostate cancer and BPH.
  • Regular ejaculation has been shown to reduce the risk of prostate cancer.
  • Stress reduction Chronic psychological stress releases harmful neurochemicals into your system and has been shown to increase the risk of cancer death, including prostate (relative risk: 2.42). Stress reduction strategies include exercise, mindfulness practice, and counseling.
  • Stop or at least reduce smoking. Cigarette smoking increases the risk of all cancers. Research shows that the heaviest smokers have a 24 to 30 percent higher risk of death from prostate cancer than do men who have never smoked.
  • Treat medical conditions such as metabolic syndrome and diabetes, which increase the risk of prostate cancer and  BPH.

In the following chapters we take a closer look at the principal diseases of the prostate, with special consideration for screenings, symptoms, and treatments.

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