The prostate is a gland found in men that sits just below the bladder. It normally produces fluid that forms part of the semen or ejaculate. It is normally about the size of a walnut and measures 15-20ml in early adult life. It encircles the urethra, which is a tube that carries urine from the bladder down to the tip of the penis.
The prostate commonly grows in size as men grow older, a condition called benign prostatic enlargement (BPE) or benign prostatic hyperplasia (BPH). This enlargement of the prostate can cause the symptoms of bladder outflow obstruction. These symptoms are often together called Lower Urinary Tract Symptoms (LUTS).
LUTS - Lower Urinary Tract Symptoms+-
LUTS can be divided into storage and voiding types:
Symptoms of impaired bladder storage:
- Frequency (going too often)
- Urgency (having to rush which can’t be deferred)
- Nocturia (getting up at night to void)
- Urge incontinence (leaking urine because you can’t hold on long enough)
Symptoms of impaired bladder voiding:
- Hesitancy (having to wait for the urine to flow)
- Straining (using abdominal muscles to start urinating)
- Poor and/or intermittent flow (stop-start)
- Dribbling (after you think you have finished urinating)
- Incomplete emptying (the sensation that some urine is left behind)
These symptoms, and the effects of treatment on them, can be objectively measured using a questionnaire called the IPSS (International prostate symptom score) (link to IPSS pdf).
PSA and Prostate Assessment+-
Many men over 50 will develop some form of prostate disease that could affect their quality of life. The symptoms from benign prostatic hyperplasia (BPH), prostate cancer and prostatitis can be similar but prostate cancer in particular can progress with no obvious symptoms.
Regular prostate checks allow prostate disease to be detected at a stage when it can often be resolved. It is generally recommended that men should have a prostate health check from 50 years of age, although men with mild symptoms or a family history of prostate problems may be advised to have the test earlier. A prostate health check can be repeated every one to two years; repeat checks can be discussed at your first appointment.
For men with or without symptoms, a prostate health check provides a thorough assessment without any painful or risky procedures, including:
- a medical history is taken to highlight any health risks
- a diary of your fluid input and output called a frequency volume chart is obtained.
- IPSS (International Prostate Symptom Score) questionnaire to rate any symptoms that may be experienced
- discussion with a consultant regarding general health, prostate health and the pros and cons of the tests being performed, as well as the patient’s expectations
- a prostate or digital rectal examination (DRE, using a gloved finger in the back passage) to check for abnormalities
- blood tests for PSA, full blood count and kidney function
- a flow rate test and ultrasound to check whether the bladder is emptying completely
- a urine test to check for infection and other abnormalities in the urine
- all results will be explained immediately and the significance of any abnormalities discussed
- we provide a written report and information pack
- further tests and treatments where appropriate
There is no specific preparation for a prostate health check and you can eat and drink as normal beforehand. You are advised to arrive with a comfortably full bladder in preparation of the urine flow test.
The package price for the prostate health check is £400. This cost is not usually covered on health insurance but subsequent appointments and further tests should be covered.PSA and Prostate Assessment
Tests for prostate problems+-
A urine ‘dipstick’ test can show whether there are any indications of infection or inflammation in the urine. Should it show any abnormalities, the urine can be sent to the laboratory to be tested for infection. A urine infection can affect the result of the PSA test.
Prostate Specific Antigen (PSA) test
A small sample of blood is taken from a vein in your arm and sent to the laboratory to measure the level of PSA. PSA is a protein that helps liquefy semen and is normally made in the prostate. It typically leaks into your blood from your prostate but PSA itself is not a result of cancer. The PSA level rises as men get older mainly due to prostate enlargement.
There are various reasons for a raised PSA level, which include infection, inflammation, benign enlargement, recent instrumentation and cancer. An elevated level does not necessarily mean cancer is present, nor does a lower level always mean it is absent. There is no level of PSA that can totally exclude prostate cancer so when assessing your risk of prostate we need to consider all the factors that help us understand your prostate health.
If you are not sure whether to have a PSA test or not, our advice is as follows:
- You need to be well informed about prostate health and PSA so read up!
- PSA testing can reduce the risk of prostate cancer mortality in screened populations
- PSA screening can lead to over diagnosis (i.e. detection of cancer that will not harm an individual during their natural life).
- PSA screening can lead to over treatment (i.e. surgery or radiotherapy that might treat a cancer that would not have led to an individuals death).
- In men who we diagnose prostate cancer, we are committed to carefully assessing each individual patients risk of having a serious cancer and offering the most appropriate management plan.
- Active surveillance for low risk cancer
- Focal therapy when a localised tumour can be ablated without affecting the rest of the prostate
- Minimally invasive surgery with laparoscopy and robotics for those needing surgery
- Partnership with leading oncologists for patients requiring external beam radiation therapy, seed implant (low dose) brachytherapy and High dose rate brachytherapy.
Other blood tests
Blood tests are also used to check your kidney function as some prostate problems affect the way the kidneys work. A blood test to check your white cell count may be used if infection is suspected.
Digital Rectal Examination (DRE)
A DRE requires the patient to lie on their left side on the examination couch with knees drawn up towards the chin. The doctor or nurse will then use a lubricated and gloved finger to feel the prostate via the rectum (back passage). The prostate can be felt through the rectal wall and will be examined for approximate size and consistency. A DRE should not be painful but may be uncomfortable and embarrassing.
There is some controversy over whether a DRE will affect the PSA reading and therefore your blood tests may be taken prior to the examination.
Urine Flow Rate and Bladder Ultrasound
For this test you will be asked to arrive with a comfortably full bladder and then pass urine into a special machine, which measures the strength of your flow. If your flow is slow, it may mean that your prostate is pressing on the urethra and causing an obstruction. A bladder ultrasound is used following the flow test to check whether you have emptied your bladder completely.
Prostate Cancer Gene 3 (PCA3) Test
The PCA3 assay is a genetic diagnostic test and can be used in conjunction with traditional tests to diagnose prostate cancer. It is a urine test and the sample is obtained after prostate examination. PCA3 is highly prostate cancer specific. It uses urine to measure the PCA3 and PSA messenger RNA; these are then used to calculate the PCA3 score. Prostate volume does not affect the PCA3 score. It is, however, not a definitive test and should be reviewed in conjunction with other investigations.
PSA free to total ratio
This test measures the amount of free and protein bound PSA and may help give a better idea of the risk of prostate cancer than the PSA test alone.
Trans-Rectal Ultrasound (TRUS)
A TRUS is an ultrasound scan of the prostate performed via the rectum. The prostate can be seen clearly through the rectal wall. TRUS images are useful in that they show the shape and consistency of the prostate. Measurements can be taken to calculate the size of the prostate.
You will be asked to lie on a couch on your left side with your knees drawn up towards your chin. The ultrasound probe is lubricated prior to insertion to prevent discomfort. The results of the ultrasound can be explained to you immediately following the test.
If any of the above tests suggest you may be at risk of having prostate cancer, the following tests may also be performed.
The SWOP risk calculator [hj1] incorporates the result of prostate examination, prostate size and any abnormalities seen on examination or ultrasound. SWOP is the acronym for the Dutch for “prostate cancer risk calculator”! This calculator is based on the data from a large European trial of prostate cancer testing and the tool is very useful when assessing men at risk of having prostate cancer.
Multi-parametric MRI (Magnetic Resonance Imaging [hj2] )
MRI is a medical imaging technique used to visualise the internal structure and function of the body. A multiparametric MRI is used to scan the prostate and pelvic area using a special contrast agent that can show up abnormal areas within the prostate. It can also assess the movement of water within tissues – the diffusion scan – highlighting hard areas in the prostate, which may be cancerous. If the MRI is read by an experienced uro-radiologist, it can give valuable information regarding the diagnosis and prognosis of prostate disease.
Transrectal ultrasound (TRUS) and prostate biopsies
Prostate biopsies are taken under ultrasound guidance and sent to a histology laboratory for examination under a microscope. These are taken via the rectum and local anaesthetic is used. The procedure is uncomfortable but not very painful (mostly men report pain scores of 1-3 out of 10). The tissue is examined for evidence of cancer, infection and/or inflammation. You need to take antibiotics prior to the test to prevent infections and these will be provided at the time the test is arranged. It is important to tell your consultant if you are taking any treatment that affects blood clotting e.g. warfarin, heparin, clopidogrel.
Template Guided Prostate Biopsies
These type of biopsies are usually required when there have been diagnostic uncertainties with imaging and trans-rectal biopsies. They are also useful in men with prostate cancer on an active surveillance programme and men being assessed for suitability for focal therapy for prostate cancer.
Prostate biopsies are taken through the perineum using a template to guide the position of the samples taken. This is done under general anaesthetic. The samples are then sent to a histology laboratory for examination under a microscope. The benefits of prostate mapping over TRUS and standard biopsy are a reduced rate of missing the cancer, a reduced rate of infection and bleeding also tends to be minimal. Prostate mapping is nearly always done in conjunction with MRI imaging.
If prostate cancer is diagnosed, a bone scan is sometimes needed to check for metastases (spread of cancer to the bones) but your urologist will discuss this with you.
Treatment of prostate cancer
If you are diagnosed with prostate cancer we will offer you support and the most appropriate treatment. Treatment for prostate cancer is not always required and we are focused on balancing the benefits of treatments against the potential for unpleasant side effects. We do this by making a careful assessment of your health and circumstances. We assess the cancer with imaging and rigorous pathological assessment. Once we know the risk of your disease we can work out the best way of curing or controlling the disease with the minimum of effects on your life. We do this using advanced technology:
- Multi-parametric prostate MRI
- Mapping biopsies of the prostate
- Laparoscopic and robotic prostate surgery
- High intensity focused ultrasound focal therapy
- High dose rate brachytherapy
Laparoscopic and robotic prostatectomy
This procedure involves the removal of the prostate and seminal vesicles and is directed at curing prostate cancer. In men at higher risk a pelvic lymph node removal is also carried out. Once the prostate is removed the bladder neck and urethra are joined together with stitches and a catheter is placed to help drain the bladder while the joined up “anastomosis” heals up. On average, we leave the catheter in place for 10 days, but this may vary slightly.
The main risks specific to this operation are incontinence and erectile dysfunction. These occur due to the proximity of surgery to the urethral sphincter and the nerves and blood vessels that run next to the prostate that support erections. Where possible we help preserve these structures (i.e. nerve sparing, bladder neck and fascial reconstruction) and this allows early functional recovery.
See full information sheet
Active surveillance and Focal therapy with HIFU
At South Coast Urology we, like many Urologists, are concerned about the risk of overtreatment of men with low risk prostate cancer. That is why we always suggest active surveillance for men with low risk disease or focal therapy when a significant lesion can be ablated with energy if the significant cancer is only on one side of the prostate.
Active surveillance is recommended for low volume Gleason score 6 cancers and for some Gleason 3+4 cancers. This process involves a repeat biopsy if the diagnosis has been made only with a TRUS guided trans rectal prostate biopsy. The repeat biopsy is a mapping biopsy under anaesthetic. Imaging with Multiparametric MRI has a growing role and may allow the avoidance or deferral of surveillance biopsies. Imaging, biopsies and PSA checks may need to be repeated periodically, depending on the clinical situation.
Focal therapy is performed using HIFU or Cryotherapy and is undertaken in the context of clinical trials or the UK HIFU registry.
Link to NICE guidance
Prostate seed implant brachytherapy
This treatment is ideal for men with small prostates and intermediate risk disease. It involves a short procedure to insert the radioactive metal seeds and it delivers a high dose of radiation to the prostate without affecting surrounding tissues as much as with external beam radiation therapy. Short-term urinary and rectal side effects are lower than with external beam radiation and surgery. The treatment is not suitable for those with LUTS, bladder outflow obstruction or large prostates.
Benign Prostate Enlargement (BPE)+-
Signs & symptoms
As the prostate grows larger, it can compress the urethra and block the normal flow of urine. With this increased resistance to the urinary flow, the bladder muscles work harder to force the urine through the narrowed urethra. This either leads to the bladder muscle becoming thicker, more sensitive and overactive or it loses its ability to squeeze efficiently, leading to incomplete bladder emptying.
Not everyone with an enlarged prostate experiences symptoms and men with small obstructing glands can also have severe symptoms. However, the following symptoms can occur:
- Weak urine stream
- Stopping and starting during urination
- Having to push and strain to start urinating
- A feeling of not completely emptying your bladder
- Frequent urination
- An urge to urinate
- Getting up often at night to urinate
BPH can be extremely irritating but is very rarely a life threatening condition. In order to understand your treatment options, it helps to have an idea of how severe your symptoms are and how much they are affecting your life. A simple form such as the Prostate Symptom Score Sheet [hj3] can help with this. A detailed diary of your fluid intake and urinary output over a few days is also very useful and may highlight other medical problems unrelated to BPE.
The following are possible complications of untreated BPE that require prompt assessment and treatment.
A small proportion of men may leak urine due to BPE, either from an uncontrollable and strong urge to pass urine or from being unable to prevent urine leaking when straining e.g. coughing/laughing. This can be cured with the correct tailored treatment, which may involve medication and/or surgery.
It is more common for the bladder to become overactive, causing urgency and frequency, but this usually settles once the obstruction has been dealt with, but may require medication.
Acute urinary retention
This is the sudden inability to urinate despite having the desire to do so. It can be very painful and relieved with the insertion of a urinary catheter (tube) through the urethra and prostate in order to drain the urine from the bladder. Patients normally go home with the catheter to convalesce but a few may be required to stay in hospital for a few days to monitor their fluid balance. Once various risk factors for retention have been corrected, we would normally suggest removing the catheter around a week later, helped by taking alpha blocker medication to improve your chances of voiding well, but some men will require prostate surgery to relieve the blockage and restore normal voiding.
Obstruction to bladder drainage can cause back pressure to build up, impeding the drainage of the kidneys and reducing their function. This requires urgent catheterisation and surgery to correct.
If the obstruction to the bladder is chronic, the bladder can overstretch to the point that it loses its ability to squeeze, known as detrusor failure. This may require surgery, self-catheterisation, an indwelling catheter or a combination of the above.
Infections and stones
Chronic retention of urine may lead to the build up of stagnant urine that with time can become infected or promote stone development. This may manifest with bleeding, pain or a urine infection (painful voiding, fever, etc).
The prostate is covered with blood vessels that may bleed and surgery may be required to control recurrent bleeding in the urine (haematuria).
Your urologist may ask you to have some of the following tests, as part of the diagnostic process:
- a PSA (Prostate Specific Antigen) blood test: this may be raised due to a variety of reasons including an enlarged benign prostate.
- A kidney function blood test called creatinine.
- Flow rate and post-void residual: this involves urinating into a specialist machine that records the speed, volume and length of your flow. This, coupled with a bladder ultrasound to check bladder emptying, gives important information that directs treatment.
- TRUS (TRrans Rectal Ultrasound): this is used to measure the size and shape of your prostate and diagnostic samples (biopsies) can be taken this way.
- An IPSS questionnaire to identify the issues of greatest bother and to monitor the effects of treatment (IPSS link).
- A frequency volume chart to record the amount of fluid drunk in a certain time period and the volume and timing of urine passed (F/v chart link).
- A flexible camera (cystoscopy) examination of the urethra, prostate and bladder.
- Urodynamic (pressure/flow) studies or cystometry: This test replicates the act of bladder filling and emptying, using pressure sensors in the bladder and bowel, to determine whether bladder outflow obstruction and/or bladder over-activity is present. It can help identify the cause of incontinence.
The treatment of BPE depends on the severity and type of symptoms and patient preference. This may include:
Fluid advice, lifestyle measures, voiding techniques, reassurance, education and monitoring.
Alpha blockers such as tamsulosin or alfuzosin relax the muscle at the bladder neck and improve flow. They can cause postural hypotension (blood pressure drop on standing), retrograde ejaculation (reflux of semen into the bladder during orgasm) and dizziness. Please tell your doctor if you are due to have cataract surgery as this can be affected by this medication.
5 alpha reductase inhibitors (e.g. finasteride, dutasteride) block the conversion of testosterone, which encourages prostate growth, into its more active and potent form. This results in prostate shrinkage (about 33% over 6 months), a fall in your PSA (about 50%) and symptom improvement. They can cause a reduction in libido, erectile dysfunction and breast enlargement/tenderness.
Combination therapy of the above has been shown to be more effective than either drug alone. These drugs may also be used in conjunction with antimuscarinic agents e.g. oxybutynin that calm bladder function.
PDE5 inhibitors: drugs such as Viagra have been shown to be useful in reducing LUTS, especially in men with erectile dysfunction.
Plant extracts: a variety of these are available e.g. Serenoa repens and Pygeum africanum but the evidence for their use is weak and often no better than placebo (dummy tablets).
Prostate artery embolization
This is a new radiological technique that involves blocking the blood supply to the prostate gland with tiny particles, causing it to shrink. This can be done using fine catheters through the artery in the groin, under local anaesthesia once a TRUS assessment of the prostate and a CT angiogram have been done to assess patient suitability. Results to date suggest that it causes less retrograde ejaculation than surgical techniques, but does not have as strong an effect on urinary symptoms. However, it may enable patients to stop prostate medication. This procedure is currently being done as part of a national trial.
Bladder neck incision involves an operation under spinal or general anaesthetic to cut open the muscle at the bottom of the bladder to widen the channel to urinate through. This is done using a specialized scope passed down the urethra. It is most suitable for men with smaller prostates and typically improves flow rates by 70%. Retrograde ejaculation is relatively common and strictures (scar tissue causing urethral narrowing) can occur in <5%. It is underutilized but in the right patient can be very effective with few side effects.
TURP (Trans Urethral Resection of Prostate)
This remains the “gold standard” treatment of BPE with evidence consistently showing its efficacy and longevity. Similarly to BNI/TUIP, a specialized scope is passed down the urethra up to the bladder, under general or spinal anaesthesia. Shavings of the prostate can then be taken to create a wide channel to void through, with the tissue washed out and sent for analysis. Retrograde ejaculation is common but nowadays, blood transfusion and incontinence are rare. Debate continues about whether TURP causes erectile dysfunction, but this seems more likely to be related to confounding factors such as age, diabetes, heart disease etc. than the procedure itself.
HoLEP (Holmium Enucleation of the Prostate)
This involves using a Holmium laser to dissect the enlarged lobes from the prostate capsule (like “shelling a pea from a pod”) and then morcellating the specimen, which can then be examined under the microscope. Results are similar to TURP and last as long but the procedure causes less bleeding and can be used for patients on anticoagulant medication. As there is less bleeding, catheters can often be removed earlier. It is also more suitable than TURP for very large prostates.
Green light laser (GLL)
In this procedure, a laser is used to vaporise tissue using heat energy. A fibre is continuously swept across the gland causing the tissue to be destroyed. Advances in the power of the laser machine used make comparative studies difficult but in general, the outcomes seem similar to TURP, with a failure rate of about 2% per annum. Patients on anticoagulant medication can continue this and catheterization time is usually shorter. Strictures occur in roughly 7% of men.
This is a new procedure that involves pushing the sides of the prostate apart by compressing them in a staple type device. This is most suitable for smaller prostates that are moderately symptomatic and long-term data is not yet available.
This involves injecting Botox into the prostate via one of three routes, sometimes avoiding a general anaesthetic. How it works is still unclear but it seems to alter the nerve signals to and from the prostate and cause prostate cells to perish. Evidence is limited but suggests moderate improvements in urinary flow (30-120%), reductions in residual volumes and 15-25% gland volume reduction. It is currently best done in clinical trials.
This traditional method of removing the prostate involves an incision in the lower part of the abdomen to allow the surgeon to open the prostate capsule and remove all the benign tissue. The capsule is then closed and this procedure is most suitable for men with very large prostates. Whilst it results in marked improvements in flow, prostate volume reduction and rarely needs repeating, its use is limited by the increased morbidity such as transfusion (7-14%), incontinence (<10%) and bladder neck stricture (6%), especially with more minimally invasive options available.
These devices are designed to splint the prostate and bladder neck open and have been used in elderly men who are not fit for other procedures. They are an alternative to long tern catheters and can be inserted under local anaesthesia. However, they can migrate, become encrusted or cause bleeding/pain and are now rarely used.
There are a whole host of other modalities for treating bladder outflow obstruction but these are not offered by SCU as they are not felt to be as effective as those described above or have limited evidence to support their use.
Prostatitis literally means inflammation of the prostate. However this can be misleading as not all men with prostatitis actually have an inflamed prostate. Prostatitis is a poorly understood condition but is one of the most common complaints involving the urinary system in men aged 18 – 50. Multiple symptoms can be experienced including urinary, sexual, behavioural and emotional. It is now classified as part of a wider spectrum of diseases called urological pain syndromes.
Prostatitis can be acute or chronic, with or without infection, severely affecting quality of life and may lead to anxiety and depression. Seeking medical attention and treating symptoms early can help to prevent long lasting issues. It is often difficult to identify why the condition developed, but a mix of infection, anatomical, neuromuscular and immunological mechanisms have been suggested. Urinary tract infection is a common first event but this is not always the case.
Symptoms of prostatitis
- Pain in the perineum/prostate (area between the anus and scrotum)
- Pain in the penis and/or testicles
- Pain in the lower back, rectum or inner thighs
- Chills and fever
- Frequency and/or urgency of voiding
- Incomplete bladder emptying
- Pain during or after ejaculation
- Blood in the semen
Prostatitis can be confused for other conditions so a detailed history and investigations are required.
Types of Prostatitis
Until recently, prostatitis was classified as being acute or chronic and bacterial or non-bacterial. It is now seen as part of a broader spectrum of pain disorders. These older subtypes can be difficult to accurately diagnose and as the treatments are similar, the management should be tailored to the patients’ symptoms. It is crucial to exclude any infection first, usually caused by bacteria such as E.Coli or Klebsiella.
A detailed history analyzing the type, severity, site and effect of the pain is taken, along with questions about sexual, urinary, bowel and emotional symptoms. This will help to target appropriate investigations to ensure the correct diagnosis and management. A standardized questionnaire such as the NIH-CPSI and IPSS may be used to gauge the effects of treatment. Tests may include:
- A digital rectal examination to determine whether there is swelling or tenderness of the prostate gland. The doctor will also check for pain and discomfort when the muscles and ligaments of the pelvic floor and perineum are pressed.
- A simple urine test to check for white cells is done and the urine sample sent to the laboratory to check for the presence of bacteria
- A Stamey Localisation Test: this test is designed to refine where any infection may reside and involves the collection of 2-3 urine samples and a sample of prostatic fluid following a prostate massage. Its use has declined, as the test can be uncomfortable, with two samples more commonly taken, before and after prostate massage.
- TRUS (transrectal ultrasound of the prostate) can ensure there are no focal abnormalities such as an abscess in the gland.
- Other tests may include a urinary flow test, an ultrasound of the bladder with estimate of bladder emptying, a swab of the lining of the urethra or penis, a cystoscopy (a look at the urethra, prostate and bladder using a telescope) and urodynamics.
There have been numerous trials on the subject but often of poor quality and with conflicting results. Treatment should be tailored to individuals symptoms and may include:
- Alpha blockers to relax prostatic ducts
- Antibiotics if any infection is suspected, for 4-6 weeks
- NSAIDs; non-steroidal drugs such as ibuprofen
- Opioid painkillers to control pain
- Phytotherapy using plant extracts
- Muscle relaxants such as diazepam and baclofen
- Botox A
- Rarely surgery such as TURP unless an abscess is found
- Prostate massage regularly may help
Eating a healthy diet and drinking enough fluids may be beneficial
Avoiding substances which irritate the bladder (alcohol, caffeine, citrus, hot/spicy foods) may alleviate symptoms
Emptying the bladder frequently and completely may decrease urgency
Relaxation techniques such as yoga or pilates may help reduce pain
Good hygiene and hand washing to prevent contamination of the penis/urethra by bacteria from the rectal area. Wearing a condom during anal intercourse will help prevent infection
Warm baths may relieve pelvic pain
Some activities such as cycling may increase symptoms
Some men find acupuncture, meditation, massage therapy and chiropractic therapy to be helpful
A lot needs to be learnt about prostatitis, the causes and treatment. However, it is beneficial to thoroughly investigate symptoms and commence treatment on presentation of symptoms.