Health News and Information

There’s also medical therapy—new drugs designed to attack the problems of BPH in a couple of ways. One strategy is targeted at shrinking the enlarged prostate; the other is aimed at keeping smooth muscle tissue in the prostate from tightening around the urethra.

A drug called finasteride shrinks the prostate by blocking the formation of a powerful hormone called DHT. Because finasteride doesn’t affect the body’s production of the male hormone testosterone, impotence is a rare complication. About one-third of men taking finasteride have a significant improvement in symptoms, but this doesn’t happen right away; it generally takes six months to a year for the drug to reach its maximal effect.

Drugs called alpha blockers relax the smooth muscle tissue within the prostate. For many men, they can provide immediate relief. Because these drugs can also lower blood pressure, the dose needs to be increased gradually, and these medications are best taken at night.

The degree of improvement in symptoms is similar to the results achieved with finasteride.

Which BPH treatment is right for you? Be your own advocate; learn as much as you can about the disease itself, and about the pros and cons of each treatment. Before committing to any treatment, you owe it to yourself to find answers to some basic questions, including: What are the odds that my symptoms will improve? How long will the effects of the treatment last? And, what are the risks of complications?

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It’s important to understand that no form of prostatectomy stops BPH; these procedures only treat the disease that’s present. It’s a bit like mowing the lawn, in that, depending on how fast the prostate grows back, the procedure may have to be performed again.

In a recent study of more than 400 men who had the TUR procedure, symptoms improved markedly in 93 percent of those with severe manifestations of BPH, and in 79 percent of those with moderate problems. None of the men died as a result of the procedure, none had a heart attack, and only 5 percent reported impotence. In other research on men who’ve undergone the TUR, the improvement in urinary flow has been shown to last longer than seven years after surgery in most men.

Despite generally excellent results, TURhas come under fire recently. Some research has suggested that it’s less effective, in the long run, in fighting urinary obstruction than open prostatectomy. One such study examined the long-term progress of men in Denmark, England, and Canada, who underwent either open prostatectomy or TUR: 13 percent of those who had TUR needed a second procedure, as opposed to 3.5 percent of men who’d had open prostatectomy. (The proportion of men having had a TUR who need a repeat TUR amounts to about 1 percent to 2 percent a year.) However, from this and other studies, it’s clear that, given the choice, many men would rather have two TURs over ten years than one open prostatectomy.

In the same controversial study, investigators raised another issue: The statistics suggested that, four or five years after surgery, TUR might be associated with a higher likelihood of death from heart attacks than open prostatectomy. (The likelihood of a man dying from a TUR itself is almost nonexistent—less than 0.5 percent.) Further research, however, brought an explanation—that men undergoing open prostatectomy were healthier to start with. Men with heart disease and a large prostate were excluded from undergoing open prostatectomies; the more complicated nature of this procedure demanded healthier patients. With the simpler TUR procedure, however, nearly all men—including those with heart disease—were still considered eligible for surgery. Thus, the increased number of deaths from heart disease four or five years after surgery can be fully explained by the fact that more men with heart disease underwent a TUR than underwent open prostatectomy.

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Libido is stimulated by the male hormone, testosterone, which is produced mainly by the testicles. When testosterone levels drop, the sex drive is diminished.

Erections are controlled by nerves that lead to and from the penis; particularly important are the nerves in two bundles that sit on either side of the prostate. In normal erection, sexual stimulation causes these nerves to release chemicals that increase blood flow into the penis. As the penis becomes engorged with blood, veins clamp down—shutting themselves off, so the blood can’t leave the penis. This keeps the penis erect during sexual activity. But sometimes these nerves are damaged—during a surgical procedure, for instance. Sometimes the arteries that pump blood into the penis are injured—after radiation therapy, perhaps. Or sometimes, for various reasons, the veins that are supposed to keep blood trapped inside the penis just don’t do their job. When a man has trouble with an erection, doctors call this “erectile dysfunction.”

Ejaculation involves powerful muscle contractions in the epididymis, vas deferens, prostate and seminal vesicles. During orgasm, a muscular valve in the bladder neck slams shut, forcing semen out the only possible exit—through the urethra and penis to the outside world, rather than backward into the bladder. But certain prostate treatments can result in the loss of this fluid. In a TUR procedure to treat BPH, for instance, the valve in the bladder neck is sometimes destroyed—so, because there’s no barrier to keep sperm from going back into the bladder, it isn’t forced out the urethra. After radical prostatectomy, there’s usually no emission of fluid because the prostate and seminal vesicles, which make most of it, are gone and the vas deferens has been shut off. After radiation therapy, many men also have a loss of ejaculate fluid because the glands responsible for making it are “dried up.”

Orgasm doesn’t really have much to do with the prostate. Orgasm happens primarily in the brain; as long as sensation is intact, orgasm can occur even in the absence of an erection and ejaculation. This is the key reason why normal sexual function can be restored to most men who are impotent after prostate treatment. (The one exception here is men receiving hormone therapy; because this causes a loss of libido, there is a general lack of interest in sexual activity.)

The most common sexual problem that troubles men after prostate treatment is the loss of erection, and there are several good ways to restore this, including vacuum erection devices, penile injections (injecting tiny amounts of erection-producing drugs into the penis), and penile prostheses.

The take-home message here is that after treatment for prostate disease (except for men treated with hormone therapy), recovery of sexual function is almost certain. Take heart!

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This varies from man to man. Ten percent of men with M+ (D2) disease— metastatic prostate cancer—live less than six months. Ten percent live longer than ten years. The rest fall somewhere in the middle; statistics show that half of these men live three years or less, and only 25 percent are alive after five years. What accounts for the extreme disparity in these numbers? It all has to do with the ratio of hormone-sensitive cells to hormone-insensitive cells, and how fast the cancer grows. In some men, nearly every cell is responsive to hormones; in other men, very few cells are hormone-sensitive. Some cancers take hundreds of days to double in size; others double every few weeks.

There is a mathematical model of how these cancer cells grow, called tumor kinetics. A tumor must double in size thirty times before a doctor can even feel it—before there’s a centimeter of cancer. This growth is logarithmic—two cells, then four, then eight, etc. Say a tumor is at its tenth doubling; it has 1,024 cells. And say that three-fourths of these cells are responsive to hormones. The patient is castrated, and all the hormone-responsive cells drop out of the picture, leaving only 256 cells. What happens? These cells aren’t affected by the hormones; they continue to grow. The now-smaller tumor doubles. There are 512 cells. It doubles again—1,024 cells. It’s back to where it started. And when it doubles again, there will be twice as many cells as before.

Now say only 1 percent of this cancer is not responsive to hormones. It’s going to take many more doublings before this tumor becomes dangerous. So how long hormones work depends on two things: The ratio of hormone-resistant cells to hormone-dependent cells, and how long it takes for the cancer to double in size. Relapse will come a lot sooner in a man whose cancer doubles every 30 days, for example, than in a man whose cancer takes 100 days to double.

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Several transperineal procedures don’t require open surgery at all. One is done just with fluoroscopy (an X-ray image that appears live on a TV screen instead of as a still photograph). Another involves a perineal template like the one described above, and uses CT scanning for extra precision in placing the needles. Over the course of several CT scans, doctors are able to create a three-dimensional image of the prostate. A computerized guidance system helps determine where the seeds should go, how deeply they should be inserted, and how strong their radiation should be.

Many doctors are encouraged by new techniques that use transrectal ultrasound and a sophisticated grid to guide placement of the implants. Like the CT scanner, the transrectal ultrasound enables doctors to develop beforehand a three-dimensional map of the prostate; this guarantees a much more even distribution of radiation throughout the gland. During the procedure, a Foley catheter is inserted through the urethra into the bladder, an ultrasound probe is inserted in the rectum, and needles are placed according to the electronic grid. In this approach, long stabilizing needles are used that don’t have anything to do with placement of the seeds. Because there’s no abdominal incision here, and therefore doctors don’t have full access to all sides of the prostate, they use these needles basically to skewer the prostate and move it around so the seeds can be placed in the appropriate spots. Doctors also use fluoroscopy and ultrasound to double-check the position of the seeds. In some studies, this has been shown to ensure a more accurate, even distribution of the seeds.

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