Prostate Problems: Diagnosis & Therapy

Have you been diagnosed with prostate cancer recently?

If so, it is important for you to have access to comprehensive, in-depth information about your disease and all the treatment options available. In this section, we will give you an overview of what you or a family member should know, in order to help you feel well-prepared for when you speak with your doctor. Knowing your options may help you approach decisions with peace of mind.

The Prostate

The prostate is part of the male reproductive system. The prostate is a small gland located in the pelvis below the bladder and surrounds the urethra (the tube that carries urine out of the body). Its rear side lies next to the rectum.

What does the prostate do?

The prostate gland produces a secretion during ejaculation. This secretion plays a crucial role in fertility by nourishing and helping sperm to move. During ejaculation, the muscles of the prostate contract to push the secretion into tubes which lead to the urethra. Simultaneously, secretions from the seminal vesicles and sperm from the testicles enter the urethra.

A healthy prostate performs its biological task unnoticed. In a healthy state, it measures approximately four centimetres in length and is the shape of a walnut. In a healthy 20-year-old man, the prostate weighs around 20 grams. The prostate gland grows over time and can reach 100 grams or more in some men. Prostate-Specific Antigen (PSA) is produced in the prostate gland. PSA levels are detectable in the blood and in the semen. The PSA value is important for the early detection of prostate cancer. If this value is increased, it may be a sign of cancer.

What problems can occur?

Prostate issues can fit into three categories: They can be benign, inflammatory or malignant. These conditions are all associated with an increase in the PSA value, which means further tests are needed to verify the diagnosis. No conclusions can be drawn as to the underlying cause on the basis of an abnormal PSA value alone. Urologists, therefore, make use of further testing methods to make a diagnosis. For example, MRI scans (an imaging procedure) are becoming more widely used.

One common benign disorder that affects many older men is prostate enlargement. Medically, this is known as Benign Prostatic Hyperplasia or BPH. In men with this disorder, the prostate is found to increase in volume. One of the first indicators of benign prostate enlargement is an increased urge to urinate.

Inflammatory processes can develop in the prostate, regardless of the patient’s age. Urologists refer to this as prostatitis. One common first indicator of this disorder is a burning sensation when urinating. This disorder may be acute or chronic. In some men, this form of inflammation may also result in an increase in PSA value.

Prostate cancer is also associated with raised PSA values. The likelihood of developing prostate cancer increases with age. Prostate cancer is categorized into different stages depending on how aggressive and advanced it is. Based on these stages, different treatment plans are used by your physician. At first, the malignant change in the prostate usually goes unnoticed by patients, and this means the PSA values in the blood often provides the first signs of the disease.

Prostate cancer

Symptoms

Prostate cancer typically develops unnoticed in the early stages; there are typically no complaints from the patient. Symptoms only occur at later stages.

Symptoms of prostate cancer can include an increased urge to urinate, especially at night, trouble starting the flow of urine or a complete inability to urinate. This may happen when the prostate has become so large because of the malignant tissue growth that it encroaches on the urethra.

Prostate cancer can also cause pain during ejaculation, and a weak or interrupted flow of sperm. In addition, blood may also be seen in the urine or semen. Impotence, decreased erection, and decreased ejaculation can also be the result of prostate cancer.

People with the disease may also report pain in the prostate, lower back, pelvis, hips and thighs, and may experience sciatica pain. This may happen when metastases have formed outside of the prostate, for example in the bones.

Diagnosis

Doctors use various diagnostic procedures to determine whether a patient has prostate cancer. The most common tests are listed below.

The aim of the multiple diagnostic procedures is to find out how aggressive the tumour is, how large it is, whether it has spread into the surrounding tissue and to assess the patient’s overall condition.

To get the most detailed picture possible, various examinations may need to be carried out several times.

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A doctor uses their finger to feel the prostate from inside the rectum. Due to its anatomical position, the prostate is easily accessible via the rectum. A DRE does not take long and is not usually painful, however, many men find it uncomfortable. The doctor will determine the size, shape and boundaries of the prostate gland, check whether it reacts painfully to contact, record its consistency and fluctuation, and examine whether there are any lumps or hardened areas. Only 1 in 3 tumours can be picked up by a digital rectal examination, so further diagnostic procedures are necessary to exclude cancer. (Source)

If cancer is suspected, the next step is to determine the PSA value through a blood test. An elevated PSA value may indicate prostate cancer but is not enough to confirm the presence of the disease. If the value is elevated, doctors will carry out a biopsy.

In addition, the doctor may perform a transrectal ultrasound examination. However, this is not a reliable diagnostic method and is only recommended as an additional measure. It allows conclusions to be drawn as to the size, position and extent of a tumour.

MRI offers a more accurate representation of the prostate. In an MRI scan, strong magnetic fields are used to produce cross-sectional images in which the various tissues of the body can easily be differentiated. MRI is becoming increasingly important as it can be used by doctors to identify, localise and delineate clinically significant tumours within the prostate.

If the digital rectal examination, the PSA value and other examinations provide indications of prostate cancer, the doctor will perform a biopsy. This is performed by inserting a thin, hollow needle through the rectum and piercing the prostate at specific points. Around ten to twelve fine tissue samples are taken during this procedure. Alternatively, the hollow needles are inserted in a targeted fashion, specifically into the suspected tissue areas, guided by MRI imaging. The tissue samples are examined in the laboratory by a pathologist, who will check whether tumour cells can be seen in the tissue samples, how many samples contain tumour tissue, and the extent to which the individual samples are affected by cancer.

In addition to determining the presence of tumour cells, the laboratory examination can provide an indication of how aggressive the tumour cells are. This is done using a Gleason score. A score of 6 suggests low aggressiveness, while 7 would indicate moderate aggressiveness. If the score is higher than this, the tumour is considered to be highly aggressive.

Stages

Prostate cancer is a change in the tissue of the prostate and can be characterised by ‘more’ or ‘less’ aggressive growth. In many cases, especially when the disease is at an early stage, the tumour is limited to the prostate and is referred to as localised cancer. In later stages, it can extend out into the surrounding tissue, which is referred to as locally advanced cancer. Alternatively, the cells can spread throughout the body via the bloodstream and lymphatic system, and form metastases in other places.
Doctors assign a stage to each patient’s prostate cancer, which helps them in recommending appropriate treatment options. Staging is based on the extent of the tumour, whether lymph nodes are affected and whether the tumour has already spread to other organs.

The stages are classified as follows:

  • T1: The tumour cannot be felt in a digital rectal examination, and cannot be seen using imaging techniques
  • T2: The tumour is limited to the prostate — localised tumour
  • T3: The tumour has broken through the capsule — locally advanced tumour
  • T4: The tumour is growing in surrounding organs

The “N” category describes whether the tumour has affected the nearby lymph nodes, and the “M” category indicates whether metastases are present. Doctors assign a stage of cancer by combining the T, N, M classifications and PSA levels.

Conventional treatments

The following conventional treatments can be found in treatment guidelines for prostate cancer:

In active surveillance, no steps are taken to treat the disease. Instead, the patient is checked at regular intervals using the diagnostic procedures described above – PSA test, digital rectal examinations, MRI and repeated biopsies. If this testing shows that the disease has advanced, your doctor will recommend a treatment procedure. Active surveillance can therefore be seen as postponing treatment.

Surgery to remove the prostate, or Radical Prostatectomy (RP), is one of the most common treatments when prostate cancer is diagnosed. In this procedure, the prostate is completely removed; in the case of a localised tumour in stages T1 or T2, this removes the cancer too. RP can be performed as open, minimally invasive or robot-assisted surgery. The aim of the surgery is to cure the prostate cancer. However, side effects such as urinary incontinence and impotence frequently occur, which limit the patient’s quality of life considerably on a permanent basis.

For localised prostate cancer, radiation therapy (also known as radiotherapy) with the aim of curing the prostate cancer is also an option. This approach is also used in patients with a metastatic tumour, to provide local tumour control. The most common and most likely side effects of this treatment include bowel problems, impotence and incontinence. In LDR (low dose-rate) brachytherapy and HDR (high dose-rate) brachytherapy, radiation sources are implanted directly into the prostate. These treatment methods can also be accompanied by the side effects for patients described above.

In hormone therapy, the body is deprived of testosterone to slow down or stop the tumour growth. It is used in patients with advanced prostate cancer and is often used as an additional treatment after surgery or radiation therapy.

What alternative/further treatment options exist?

Maintaining quality of life after prostate cancer treatment is a key concern for many patients when choosing a treatment method. Many patients look for a treatment option that affects urinary and erectile function as little as possible after treatment. In recent years, medical science has made significant advancements to develop prostate cancer procedures that protect the surrounding anatomy and their associated bodily functions. One such procedure is TULSA, a prostate therapy that uses high-intensity ultrasound.

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