Dr. Patrick Walsh's Guide to Surviving Prostate Cancer

Dr. Patrick Walsh's Guide to Surviving Prostate Cancer

by Patrick C. Walsh

ISBN: 9781455504183

Publisher Grand Central Life & Style

Published in Calendars/Diet & Health, Calendars/Astrological

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Sample Chapter


  • The Short Story: The Highly Abridged Version of This Chapter

    • What Is the Prostate?

    • If It’s Not a Vital Organ, Why Is It Important?

    • What Else About Prostate Anatomy Do I Need to Know?

  • The Prostate’s Strategic Location

    • Nothing About the Prostate Is Easy

    • To Sum Up the Prostate

  • A Brief Anatomy Lesson

    • Reproductive Tract

    • Prostate

      • How Do Hormones Affect the Prostate?

      • The Prostate Is Not Required for Potency

    • Testes

    • Epididymis

    • Vas Deferens

    • Seminal Vesicles

    • Penis

  • How the Urinary Tract Works

    • Kidneys

    • Ureter

    • Bladder

    • Urethra

THE SHORT STORY: The Highly Abridged Version of This Chapter

There’s a “Short Story” in every chapter of this book. This is because prostate cancer—the last thing most men would ever choose to think about—is not just a scary subject to deal with, it’s tough to understand. The disease itself is complicated, and the decisions about what to do next can be agonizing. Before you can chart your next course, you’ve got to sort through and attempt to make sense of many things.

If this were a potboiler novel, the kind of page-turner you start on page one and don’t put down until you’ve savored the last word on the last page, you wouldn’t need any guidance on how to read it; you’d just get going. If, on the other hand, this were an academic textbook, you might approach it with a highlighter in hand, emphasizing key points and take-home messages in bright yellow marker. This book falls somewhere in between, and people read it in different ways. They kick the tires, in effect—flip through the pages; maybe they head directly to a specific section, such as impotence or biopsy, then backtrack and read about how prostate cancer gets started or jump ahead to chapters on treatment.

With this in mind, in every chapter we’ve done our best to give you the highlights—what you really need to know—up front, in a highly abridged form. Consider this your briefing, or your “headline news.” All of these overviews will familiarize you with the main ideas you’ll be covering on the next pages.

That said, this is what you need to know about the anatomy of the prostate.


The prostate is a small and probably expendable organ. Men can live quite comfortably without it. The prostate’s biggest job, as far as we know, is to provide part of the fluid that makes up semen. But even this contribution does not appear to be crucial for reproduction—which is why some scientists think the prostate’s main role may be to safeguard the reproductive tract from infection in the urinary tract. (In fact, its name in Greek means “protector.”) It is not a vital organ. Thus, the major importance of the prostate is not what it does but what goes wrong with it—the problems it causes for nearly all men who live long enough. These are

  • Cancer of the prostate, the most common cancer in men;

  • BPH (benign prostatic hyperplasia, also called enlargement of the prostate), one of the most common benign tumors in men and a major source of misery as men get older; and

  • Prostatitis, the most common cause of urinary tract infections in men.


Although it’s only as big as a walnut, the prostate is a miniature Grand Central Station, a busy hub at the crossroads of a man’s urinary and reproductive tracts. It’s at a highly strategic location, right at the outlet to the bladder. Urine and semen cannot leave the body without passing through the prostate. It is also tucked away, deep within the pelvis, surrounded by vulnerable structures—the bladder, the rectum, the sphincters responsible for urinary control, major arteries and veins, and a host of delicate nerves, some of them so tiny that we’ve only recently discovered them. This is why any form of treatment for prostate cancer can produce side effects including incontinence, impotence, and rectal bleeding.


The prostate is like a complicated sponge, with five distinct parts called zones. The two most important for our discussion are the peripheral zone, which is located next to the rectum, contains most of the glands in the prostate, and is the main site where cancer develops; and the transition zone, which surrounds the urethra and is the principal site where BPH begins. The prostate’s growth and function are stimulated by hormones: testosterone, produced in the testicles, is converted to another hormone, called dihydrotestosterone (DHT)—the most active male hormone—in the prostate.

The bottom line: The prostate is a gland that does much more harm than good and is located in a terrible area that complicates any attempt to treat it. Despite this, as you will learn in this book, there has never been more hope in the treatment of all prostate disorders—especially cancer.

The Prostate’s Strategic Location

Welcome to the prostate—the bustling, walnut-sized hub at the crossroads of a man’s urinary and reproductive tracts. What makes such a small, relatively obscure gland so important to men? The answer is not immediately obvious: the prostate is not, for example, a vital organ like the heart. Its biggest job, as far as we know, is to provide about one-third of the fluid that makes up semen. But even this contribution does not appear to be crucial for reproduction, leading some scientists to theorize that the prostate’s main purpose actually may be to safeguard the reproductive tract from infection in the urinary tract. (In fact, its name in Greek means “stands before” or “protector.”) The prostate has few other redeeming features, isn’t necessary for life or even for sexual function, and is known primarily for the clinical problems it causes to nearly all men who live long enough.

What the prostate does have, however, is a highly strategic location, right at the outlet to the bladder. Urine cannot leave the body without passing through the prostate, via a tube called the urethra. (Think of the urethra as an expressway and the prostate as the Lincoln Tunnel.)

Nothing About the Prostate Is Easy

From a urologist’s standpoint, even a routine checkup—to feel for lumps or hardness with a digital rectal examination—is more complicated and takes more skill than many of our patients realize. (For a detailed discussion of diagnosing prostate problems, see chapter 6.) The prostate is as tucked away—and as surrounded by booby traps—as any of the prizes sought by Indiana Jones in Raiders of the Lost Ark. It lies in the midst of vulnerable structures—the bladder, the rectum, the sphincters responsible for urinary control, major arteries and veins, and a host of delicate nerves, some of them so tiny that we’ve only recently discovered them—that can foil any physician who ventures into the area without exquisitely precise knowledge of the terrain. This is why any procedure to treat prostate cancer—surgery, external-beam radiation therapy, implantation of radiation “seeds,” or attempts to kill cancer cells by cooling or heating the prostate—can produce side effects including incontinence, impotence, and rectal bleeding.

The prostate fits snugly within the pelvis; there isn’t much “breathing room” there. Unfortunately, not only is the prostate packed tightly amid other structures, like pieces of a jigsaw puzzle, it is poorly insulated. The flimsy wall of tissue separating the prostate and the seminal vesicles is thinner than a piece of tissue paper—not much of a buffer zone for cancer. Consequently, once cancer reaches a critical size, it can easily penetrate the wall (also called the capsule) of the prostate and escape into this overcrowded region of the body, spreading to the nearby seminal vesicles or lymph nodes, or even further, into the bloodstream.

This is why—even though treatment for prostate cancer is improving dramatically—a man’s best protection against this disease is to have it detected as quickly as possible. Ideally, for the American man at average risk of prostate cancer, screening should start at age forty with a physical and digital rectal examination (see chapter 5) and a blood test for prostate-specific antigen (PSA) (also see chapter 5). This first prostate checkup should establish a baseline, an essential comparison point for your doctor to refer to in future visits—in other words, it should be no big deal right now, but very important for later.

What happens next depends on your initial PSA level, but your doctor will probably want you to come back for another rectal exam and PSA test every two to five years. Like a suspicious character—but one on whom the police can pin no actual crime—the prostate is best put under observation at age forty and beyond. We used to recommend this only for men at higher risk—African Americans and men with a family history of prostate cancer (see chapter 3). Other men, we believed, didn’t need to start worrying about their prostate until age fifty. But because of research at Johns Hopkins led by scientists including H. Ballentine Carter and Alan Partin, we now believe that this is the best advice for all men.

To Sum Up the Prostate

It’s a gland that does much more harm than good and is located in a terrible area that complicates any attempt to treat it. Despite this, there has never been more hope in our field. At last, we are finding answers to the toughest questions of prostate cancer: Where exactly does it begin, and why? How does it spread? If we can’t cure it, can we contain it—can we make advanced prostate cancer a chronic illness, like diabetes, instead of a fatal one? Can we change our thinking and try drugs that were once considered last-ditch measures sooner? Can we try adjuvant therapy, as doctors use successfully in breast cancer? Can we actually prevent cancer or somehow slow its progress with diet? If PSA comes back after surgery or radiation, what does it mean—and how much time do we have to find a more effective treatment? As for radical prostatectomy and radiation therapy, can we make these treatments even better, with fewer side effects and quicker recovery of potency and continence? How can we help men and their families get their lives back? How can we improve quality of life? All of these areas will be covered in detail in later chapters.

A Brief Anatomy Lesson

Although we’ve tried to keep it brief, this crash course in anatomy may still be more than you ever wanted to know about the prostate and anything even remotely linked to it. But we believe it’s essential that you understand where the prostate is and what it does, the two main systems it influences—the reproductive and urinary tracts—and how they can be affected when something goes wrong.

Reproductive Tract

For the reproductive organs, the basic act of sexual intercourse is as highly choreographed and synchronized as a NASA shuttle launch. First, the climate must be just right—in this case, the weather is a chain of coded chemical messages and hormonal signals. The equipment must be working properly, too. The main vessel, of course, is the penis, a remarkable construction that relies on hydraulic principles for erection, requires a delicate balance between arteries and veins, and is orchestrated by many intricate nerves. Orgasm, the climax of sexual intercourse, involves instantaneous, nearly simultaneous firings of fluid from the prostate, seminal vesicles, and testes (which make sperm). Because the prostate is the focus of this book, we’ll begin there, although as you will see, sexual potency and intercourse really begin in the brain.


The prostate is a complicated, powerful little factory. Its main products, manufactured in numerous tiny glands and ducts, are secretions—components of semen. During orgasm, muscles in the prostate drive these secretions into the urethra (where it is joined by sperm and fluid from the seminal vesicles), which pumps it out of the penis. The prostate’s fluid is clear and mildly acidic, and contains many ingredients, most of them designed to sustain sperm outside the body for as long as possible. (These include citric acid, acid phosphatase, spermine, potassium, calcium, and zinc.) Some prostatic secretions also protect the urinary tract and reproductive system from harmful bacteria that may enter the urethra. Here, the prostate truly lives up to its Greek name of “protector.” Infections in this area can cause scar tissue to form in the ducts that drain the testicles, leading to infertility. If these infections were common, they would pose a serious threat to procreation—and this may be the major reason that all mammals have a prostate.

After ejaculation, the seminal fluid immediately coagulates—a key part of nature’s “safety net” to maximize the odds of reproduction. If semen remained watery, it could not linger in the vagina. (In rats and other rodents, semen actually forms a pelletlike plug that effectively blocks other rats from depositing their semen in the same female.) The semen is gradually broken down again by an important enzyme made by the prostate—prostate-specific antigen (PSA). PSA’s other great value is that it can be detected in a simple blood test. In recent years, this PSA test has become a crucial addition to medicine’s arsenal for detecting prostate cancer and monitoring the success of treatment. (For more on what PSA can do and on other tests for prostate cancer, see chapter 5.)

Like New York City, the prostate is divided into five zones: anterior, which takes up one-third of the space and consists mainly of smooth muscle; peripheral, the largest segment, which contains three-fourths of the glands in the prostate; central, which holds most of the remaining glands; preprostatic tissue, which plays a key role during ejaculation—muscles here prevent semen from flowing backward, into the bladder; and transition, which surrounds the urethra and is the epicenter of trouble in benign prostatic hyperplasia (BPH). For reasons not entirely understood, when a man reaches his mid-forties, the prostate tissue in the transition zone tends to enlarge, begins to push nearby tissue for room, and eventually starts to cramp the urethra. With this slow strangulation—think of a man’s necktie slowly tightening around his collar—the prostate can make it exceedingly difficult for urine to get from the bladder through the prostate and out of the body. (For more on BPH, see chapter 2.) Most prostate cancer occurs in the peripheral zone. Fortunately, this is the region most likely to be felt during a rectal examination and tapped during a needle biopsy of the prostate (see chapter 6).

On a microscopic level, prostatic tissue is like a squishy sponge, riddled with tiny glands. These are the microfactories that produce the secretions, and they’re connected by hundreds of ducts, which transport the fluid into the urethra. When these ducts become obstructed—as they do in BPH—PSA levels begin to rise in the bloodstream. Because prostate cancers don’t make any ducts, glands in cancerous tissue become isolated. But these ducts still churn out fluid, which has nowhere to go—except into the bloodstream. That’s why, gram for gram, prostate cancer contributes ten times more to blood PSA levels than does BPH.

Prostate cells come in two basic models: epithelial cells, glandular cells that make the secretions, and stromal cells, muscular cells that hold the epithelial cells in place. The stromal cells aren’t just passive scaffolding; they also help the prostate grow. From the stromal cells, in fact, spring many growth factors. And growth factors, we have learned, play a pivotal role in the development and function of the prostate when it is healthy and when it is cancerous.

How Do Hormones Affect the Prostate?

The prostate is very sensitive to hormones. In cancer treatment, this is a good thing; cutting off the supply of these sex hormones, or androgens, can shrink prostate cancer and delay its progression. The hormones that control the prostate originate in the brain: the hypothalamus makes a substance called luteinizing hormone-releasing hormone (LHRH), which it transmits using “chemical Morse code,” or signal pulses, to the nearby pituitary gland. In response, the pituitary makes its own chemical signal, called luteinizing hormone (LH). LH, in turn, controls the testes, which make testosterone. Testosterone is the chief “male” hormone, the cause of—among other things—secondary sex characteristics such as body hair and a deep voice, and fertility. Testosterone circulates in the bloodstream and seeps into a prostate cell by diffusion, like water through a coffee filter. To the prostate, testosterone is a raw material: the prostate, using an enzyme called 5-alpha reductase, refines testosterone into another hormone called dihydrotestosterone (DHT). Soon, DHT joins up with a specific protein in the cell’s nucleus and quickly becomes a powerhouse that switches on various genes within the prostate.

The Prostate Is Not Required for Potency

In animals, it’s not even a must for fertility; animals can remain fertile even if they have had their prostate or their seminal vesicles—but not both organs—removed. We didn’t always know this about potency and the prostate (see chapter 8), and the discovery was surprising, considering that the growth of the prostate clearly is linked to a man’s sexual development. Starting at puberty, the prostate enlarges five times in size—from a weight of about 4 grams to 20 grams, the size of a walnut—by about age twenty. (For the rest of a man’s life, the prostate continues to grow and become heavier, but much more slowly.)


The testes, or testicles, are a man’s reproductive organs. They make the hormone testosterone, as discussed above. They also make sperm inside hundreds of tiny tubes and threadlike, winding tubules. (If these miniature pipes were straightened out, each would stretch to a length of 2 feet.) There are two testes, each less than 2 inches long and about 1 inch wide. The testes, attached to blood-supplying lifelines called spermatic cords, are covered by the scrotum. Have you ever wondered why the scrotum is suspended in such a vulnerable position, below the body? Wouldn’t it make more sense—and provide better protection—if the testicles were inside the body? Yes and no. If the testes were tucked away inside the pelvis, they would indeed be better protected—but there wouldn’t be much to protect. The testes are located in the scrotum for the simple but expedient reason that it’s a more temperate climate down there by a couple of degrees. Sperm are delicate; they fare poorly when the temperature is too warm. The scrotum, in effect, is nature’s cooler. (In fact, men who have undescended testicles—which are located inside the abdomen—cannot develop sperm because the normal body temperature is just too hot.)


The sperm-making tubules in each testis converge to form the epididymis. Compared to the tubules, this is a river as large and serpentine as the Amazon: each tubule (one on each side), though only 1 millimeter wide, could be uncoiled to reach a remarkable length of 15 to 20 feet. It is one continuous tube. Thus, it’s easy to see why an infection here could cause scar tissue and blockage that would result in infertility. These tubules are packed side by side, top to bottom, to form the epididymis, an elongated structure about the size of a woman’s pinky finger. This is the greenhouse where sperm mature until orgasm, when they shoot from the tail of the epididymis during a series of powerful muscle contractions. The epididymis clings to one side of each testis before turning yet again and heading upward to meet still another tube, called the vas deferens.

Vas Deferens

This impressive tube (again, one on each side; together they are called the vasa deferentia), now grown to 3 millimeters in diameter, is a hard, muscular cord about 18 inches long. Its job is to pump sperm to the part of the urethra that lies within the prostate (the prostatic urethra). Because it is so thick, it can easily be palpated through the scrotum. (It can also be cut easily in an outpatient procedure—a form of male birth control called a vasectomy. When the cord is cut, sperm cannot exit the penis through ejaculation and instead are reabsorbed by the body.) The vas deferens travels to a space between the bladder and rectum, then courses downward to the base of the prostate, where it meets with the duct of the seminal vesicle to form the ejaculatory duct.

Seminal Vesicles

The lumpy seminal vesicles, each about 2 inches long, sit behind the bladder, next to the rectum, hanging over the prostate like twin bunches of grapes. Arching still higher over them, on either side, are the vasa deferentia, which meet the seminal vesicles at V-shaped angles; these form the ejaculatory ducts, slitlike openings that feed into the prostatic urethra. The seminal vesicles are made up of caves called alveoli, which make sticky secretions that help maintain semen’s consistency. (The vesicles got their name because scientists used to believe they stored sperm; they don’t.) Like the prostate, the seminal vesicles depend on hormones for their development and growth and for the secretions they produce. Although the seminal vesicles are strikingly similar to the prostate in many ways, they’re almost always free of abnormal growth—benign (as in BPH) as well as malignant. (This is covered in more detail in chapter 3.)

Scientists at Johns Hopkins have been exploring the relationship between the prostate and the seminal vesicles. What we have learned from their work is that the saga of human evolution is also a story of two male glands—both of which produce fluid that makes up semen. One gland, the prostate, is prone to cancer. The other, the seminal vesicle, is remarkably free of it. In nature, animals that are carnivores—meat eaters like dogs and lions—don’t have seminal vesicles. The only animals that have both prostates and seminal vesicles are herbivores—veggie-eating animals, like bulls, apes, and elephants. There is only one exception to this rule: humans. Men have seminal vesicles, too. In other words, man, a meat lover, has the makeup of an animal that should be a vegetarian. For more on this research and what it means, see chapter 3.


The penis—an engineering marvel built of nerves, smooth muscle, and blood vessels—has two main functions: sexual intercourse and urination. (Note: There is no bone in the human penis, although this is not the case in dogs and some other animals.) The penis works like a water balloon. Its basic structure is that of a rounded triangle; all three corners have cylinders of tissue (called the corpora cavernosa and the corpus spongiosum) that fill and become engorged with blood. During an erection, as arteries pump a steady supply of blood into the penis, the veins (which normally pump it back out again) clamp down so the blood can’t recirculate, thus keeping the penis “inflated” during sexual activity. All of this is made possible by the delicate nerves that lead to and from the penis. For years, these tiny nerves were poorly understood. The sad result was that removal of the prostate almost always meant impotence (see chapter 8). That is no longer the case.


Semen is the ejaculate, and it’s made up of seminal fluid and sperm. (One-third of the fluid originates from the prostate, two-thirds from the seminal vesicles.) Sperm makes up just a tiny fraction of semen (which is why a vasectomy does not reduce the volume of the ejaculate). Semen is surprisingly rich. Its components include prostaglandins, spermine, fructose, glucose, citric acid, zinc, proteins, and enzymes such as immunoglobulins, proteases, esterases, and phosphatase. These other ingredients probably serve as a buffer to help sperm survive the trip and remain active and, in the case of sugars such as fructose and glucose, as a “snack for the road,” to provide energy for a sperm’s metabolism on its journey. Still other components—the zinc, for example, and proteases and immunoglobulins—may be cleansing agents there to help fend off infections and other harmful substances in the urinary tract.

Semen undergoes extreme chemical transformations after ejaculation, metamorphosing from a viscous liquid to a semisolid and back again. A few minutes after ejaculation, semen coagulates into a gel-like substance; then, within about fifteen minutes, it becomes a sticky liquid. In most animals, a substance made by the seminal vesicles is the cause of the coagulation; then PSA, an enzyme made by the prostate (see above), makes semen runny again. The character of semen varies greatly among species. For example, in bulls and dogs (which don’t have seminal vesicles), semen does not coagulate at all. But in rats and rabbits, semen quickly coagulates to form a pellet; for these animals, a PSA-like enzyme is crucial in helping the sperm reach their destination. Because semen is a bodily fluid, like blood, it is affected by drugs and can be a carrier of sexually transmitted diseases, such as AIDS.

How the Urinary Tract Works


The kidneys are the body’s main filters. With each heartbeat, they cleanse the blood of toxic wastes, excess water, and salts and (among many other chores) help maintain the body’s balance of fluids and minerals. With more than a million tiny, wadded-up filters called nephrons, the kidneys sift through an incredible volume of fluid—about 45 gallons a day for a 150-pound man (see fig. 1.5). Every sip of water we drink is refined, reabsorbed, and then processed again. (If the water and minerals weren’t reabsorbed, our bodies would become seriously dehydrated within hours.) Not all of this material returns to the body, however; much of it passes out as urine. Every day, the average man excretes about 2 quarts of urine (a concentrated mixture of water, sodium, chloride, bicarbonate, potassium, and urea, the breakdown product of proteins).


Urine exits each kidney through a pipeline called the ureter. The ureters work like toothpaste tubes, squeezing or “milking” urine from the kidneys. Each ureter is about a foot long and narrow—less than a half-inch wide at its broadest point. Ureters are one-way streets: urine always flows the same way through them—straight toward the bladder.


The bladder is a big bag. Stretched to its fullest, this muscular tank can hold about a pint of urine (see fig. 1.2). Unlike the kidneys and ureters, the bladder, in normal circumstances, allows us some voluntary control; it generally obeys our decision to eliminate or hold urine. (The inability to control urination is called incontinence.) With intricately woven layers of muscle and connective tissue, the bladder can collapse or expand, depending on the amount of fluid it’s asked to hold at a given time. A sophisticated backup system protects the bladder from extreme distention and the risk of rupture: when the bladder is very full, it signals the kidneys to slow down the production of urine. At the neck of the bladder is a gate called the trigone. The purpose of the trigone is to make sure urine flows only one way—downward, away from the ureters and kidneys. The trigone’s valve makes a tight seal that prevents urine from backing up into the kidneys, even when the bladder is distended.


The next stop on urine’s downward passage is the urethra, another muscular tube, about 8 inches long. This one begins at the neck of the bladder, then tunnels through the prostate at a 35-degree angle and continues into the penis. The urethra is divided into three segments—prostatic (the part that runs through the prostate), membranous (in between the prostate and penis—this is where the external sphincter is located), and penile. Like the prostate, it plays a role in both the urinary and reproductive systems; it serves as a conduit not only for urine but also for sexual fluids. The prostatic urethra has its own gate to prevent fluid backup—a ring of smooth muscle located in the preprostatic zone. During ejaculation, this muscle ring contracts along with the bladder neck. This keeps semen from flowing the wrong way—up into the bladder—and directs its course downward, out the urethra.

That’s it for the anatomy crash course. Throughout this book, as we describe diagnostic procedures, treatments, and complications, you may need to return to this chapter. That’s what it’s for—to give you a working familiarity with the territory we’ll be covering in the next chapters. If it helps, think of these pages as your Michelin Guide to male anatomy. Now that we’ve discussed the context of the prostate—a significant gland in both the urinary and reproductive systems—it’s time to explain why this tiny gland is so important and what can go wrong.



  • The Short Story: The Highly Abridged Version of This Chapter

    • Prostate Cancer

    • BPH, or Enlargement of the Prostate

    • Prostatitis

  • What Can Go Wrong with the Prostate: Cancer, BPH, and Prostatitis

  • Prostate Cancer

  • Benign Prostatic Hyperplasia

    • What Causes It?

    • Does BPH Run in Some Families?

    • What Does BPH Feel Like?

    • How Do You Know If You Have It?

    • How Is BPH Treated?

  • Prostatitis

    • What Causes It?

    • How Do You Know If You Have It?

    • How Is Prostatitis Treated?

THE SHORT STORY: The Highly Abridged Version of This Chapter

At some point in their lives, most men are going to have to come to terms with the prostate, because this little gland is the source of three of the major, common health problems that affect men:

  • Prostate cancer, the most common cancer in men;

  • Benign prostatic hyperplasia (BPH), also known as enlargement of the prostate, one of the most common benign tumors in men; and

  • Prostatitis, a painful inflammation of the prostate and the most common cause of urinary tract infections in men.

This news usually comes as an unpleasant shock, because most men don’t even know that they have a prostate until something goes wrong. Worse, because there is no “statute of limitations” on prostate problems, some men are unlucky enough to endure more than one of these disorders. (In fact, some men find out they have prostate cancer during a routine procedure to treat BPH.) You may suddenly experience a bout of prostatitis or develop urinary problems because of prostate enlargement. Or your “wake-up call” to the prostate may be an abnormal prostate-specific antigen (PSA) blood test, or a suspicious lump felt during a rectal exam, raising the possibility that you have prostate cancer. Thus, it’s important for you to understand all of the “Big Three” prostate disorders.

Here’s what you need to know.


This is the most common cancer in men and the second-leading cause of cancer death in men. Because prostate cancer is the subject of this entire book, the only important point you need to know right now is that when prostate cancer is small, it is curable. However, because it is “silent” and produces no early-warning symptoms, routine testing is very important. How can we save lives from prostate cancer? The rest of this book is devoted to answering this question. The key is a four-pronged approach—prevention, early diagnosis, better treatment for localized disease (cancer confined to the prostate) with fewer side effects, and better control of advanced disease.


BPH is so common that most men, if they live long enough, will develop it. By age seventy, 70 percent of men have it, and one-quarter of men with the disease require treatment. BPH is not prostate cancer, and having it does not mean that a man is more likely to get prostate cancer. BPH and prostate cancer are two different diseases that develop in different regions of the prostate—almost as if the prostate were two glands rolled into one. Prostate cancer begins in the outer, peripheral zone of the prostate and tends to grow outward, invading surrounding tissues; that’s why it rarely produces symptoms until it is far advanced. On the other hand, BPH begins in a tiny area of the inner prostate called the transition zone—a ring of tissue that makes a natural circle around the urethra, the tube through which urine and semen exit the body. In BPH, the growth is inward, toward the prostate’s core, constantly tightening around the urethra and interfering with urination (which is why symptoms are almost impossible to ignore). BPH is a very common condition that affects most men. It is not cancerous, and today, there are many good ways to treat it.


Prostatitis is the most common cause of urinary tract infection in men, and an estimated 25 percent of all men who see a doctor for urological problems have symptoms of it. There are four conditions lumped under the umbrella of prostatitis. The two least common and easiest to treat are caused by bacterial infection: acute and chronic bacterial prostatitis. These conditions are usually associated with fever, chills, severe burning on urination, increased frequency of urination, and, in some cases, a life-threatening infection in the bloodstream. Another category of prostatitis is called chronic prostatitis/chronic pelvic pain syndrome. Nobody knows what causes this form of prostatitis, and antibiotics do not help at all. The treatment here is largely aimed at relieving symptoms, with muscle relaxants such as alpha-blockers and other drugs that ease muscle tension in the prostate and make urination easier. There’s a final, mysterious category known as asymptomatic inflammatory prostatitis. This form produces no symptoms and is usually discovered by chance, when inflammatory cells are found in the prostatic fluid or when inflammation is detected on a prostate biopsy. If it produces no symptoms, is it something we should even worry about? Maybe. We’re still learning about this inflammation, and, although it is not cancer, it may be linked with the formation of cancer. In other words, whatever causes the inflammation may eventually cause cancer as well. (See chapter 3 for more on this.)

The best thing to know about prostatitis is that it is not cancer—although, confusingly, it can cause elevations in the PSA blood test, just like cancer. The treatment for most prostatitis (except the bacterial kind, which responds to antibiotics) is often trial and error; it takes patience to come up with the right plan. There is, however, some exciting new research that may help us find new ways—including changes in diet and lifestyle—to relieve the symptoms of this vexing condition.

What Can Go Wrong with the Prostate: Cancer, BPH, and Prostatitis

For most young men, the prostate falls into the category of “obscure body parts” that includes the spleen—that is, it’s in there someplace, it probably does something useful, but it’s best dealt with on a need-to-know basis.

Unfortunately, most men are going to need to know about the prostate sometime, because this little gland is the source of three of the major health problems that affect men: prostate cancer, the most common major cancer in men; benign enlargement of the prostate (BPH, or benign prostatic hyperplasia), one of the most common benign tumors in men and a source of urinary symptoms for most men as they age; and prostatitis, painful inflammation of the prostate, the most common cause of urinary tract infections in men. Worse, because there’s no “statute of limitations” on prostate problems, some men are unlucky enough to endure more than one of these disorders. For example, men who get BPH or prostatitis may still develop prostate cancer. Although this is a book about prostate cancer, when it comes to making the diagnosis and planning treatment, the other prostate disorders must be considered, too. Thus, it’s important that men know about all of the “Big Three” prostate problems—what they are, how they are treated, and their telltale symptoms.

Fortunately, effective treatment and relief of symptoms is available for all of these prostate disorders. Even prostate cancer, when caught early, is usually curable—generally without causing loss of urinary control or sexual function. Better still, for the first time ever, we are very close to understanding how to keep advanced cancer in check, perhaps even for years.

Prostate Cancer

Prostate cancer is the most common major cancer in men and the second-leading cause of cancer death in men. Because prostate cancer is the subject of this entire book, we’ll use this space only to make one point: when prostate cancer is small and curable, it is also silent—it produces no symptoms. That’s why routine testing is so important—to detect cancer as early as possible. If it’s caught too late, prostate cancer can be deadly, and if the disease is allowed to run its course, it can produce terrible symptoms and excruciating pain. But if caught in time, before the cancer spreads beyond the wall of the prostate, prostate cancer can be cured with surgery or radiation. For some men with small, slow-growing tumors, a process called active surveillance—following the disease closely—may be a safe option (see chapter 7).

Treatments for prostate cancer are better than ever: we are now able to cure prostate cancer in more men, and with fewer side effects, than ever before. And, for the first time, groundbreaking research and novel methods aimed at stopping advanced prostate cancer in its tracks are starting to pay off, with promising new drugs now being tested in patients. Even though in some men we may not be able to cure prostate cancer, we may be able to stop it from growing further—so that some men with advanced disease will die with prostate cancer but not of it.

How can we save lives from prostate cancer? The key is a four-pronged approach:

  • Prevention—to ward off prostate cancer entirely, or at least delay its onset for decades;

  • Earlier diagnosis—with the help of highly sensitive tests and sophisticated models for analyzing the results, detecting prostate cancer at the earliest and most curable stages yet;

  • Better treatment for localized disease—expanding and refining effective treatments, and working to minimize side effects even further; and

  • Better control of advanced disease.

Next, we cover the other two major prostate problems: BPH and prostatitis. Because none of the Big Three prostate diseases precludes the others, it is possible for a man to have more than one, even at the same time. However, if you don’t have one of these problems, you may wish to go on to chapter 3 now and refer to the rest of this chapter on a “need-to-know” basis.

Benign Prostatic Hyperplasia

Benjamin Franklin reportedly suffered from it; so did Thomas Jefferson. So will most men, if they live long enough. This almost inevitable condition is called benign prostatic hyperplasia (BPH), or enlargement of the prostate. The risk of BPH increases every year after age forty: BPH is present in 20 percent of men in their fifties, 60 percent of men in their sixties, and 70 percent of men by age seventy. One-quarter of men with BPH—more than 350,000 a year in the United States alone—eventually will require treatment, some of them more than once, to relieve the urinary obstruction BPH causes.

Before the 1990s, there was no effective medical (as opposed to surgical) treatment for this disorder. Men diagnosed with BPH were usually sent home and told to return when their symptoms were severe enough to warrant surgery. Just a decade ago, an American man had a 25 percent risk of undergoing prostate surgery for benign disease at some point in his life. In fact, BPH is still a common cause of surgery in American men over age fifty-five.

In recent years, as medical therapy has become available, more men have sought treatment to relieve their symptoms. Based on the numbers mentioned above, it’s likely that after age sixty, a majority of men will either be taking medication for BPH or considering it. However, not all of these men will be helped by the medicine; for men with severe symptoms or men who wait until the disease is far advanced before they seek treatment, surgery is still the best option.

Note: Growth is not the same thing as cancer. BPH is not prostate cancer, and having it doesn’t mean a man is more likely to get prostate cancer. They’re two different diseases—and in some ways, the prostate is almost like two different glands rolled into one. However, because both BPH and prostate cancer are associated with aging, scientists are wondering if there are any other connections that we don’t know about and are looking for genes that appear to be altered in both conditions. Prostate cancer begins in the outer peripheral zone of the prostate (see fig. 1.3) and grows outward, invading surrounding tissue. BPH begins in a tiny area of the inner prostate called the transition zone, a ring of tissue that makes a natural circle around the urethra. In BPH, the growth is inward toward the prostate’s core, constantly tightening around the urethra (the tube that carries urine from the bladder through the prostate to the penis) and interfering with urination (see fig. 2.1). This is why BPH produces such annoying, difficult-to-ignore symptoms—but why prostate cancer is often “silent,” producing no symptoms for months or even years. The key word here is benign. (The word hyperplasia simply means an increase in the number of cells in the prostate, which causes it to become enlarged.) By itself, an enlarged prostate causes no symptoms and does no harm. If it weren’t for the fact that the prostate encircles the urethra, BPH might never require treatment.

What Causes It?

The quick answer is, we don’t know. Like wrinkles and gray hair, BPH just seems to come with the territory of aging. For reasons that are not clear, beginning at around age forty—in some men more than others—the inner zone of the prostate begins to grow. But even this is more complicated than it sounds. BPH involves two different kinds of tissue: glandular, made up of epithelial cells (the factories that make the prostate’s secretions) and smooth muscle cells (which contract to squeeze the secretions into the urethra). Somehow, BPH sets these two types of tissue at odds; it’s the epithelial tissue that makes the lumpy lobes, but the smooth muscle tissue reacts to this buildup by tightening around the urethra.

Scientists suspect that the aging prostate somehow becomes more sensitive to testosterone, even though there’s less of it floating around in the bloodstream. Why? As men age, testosterone production starts to fall—but the body’s levels of estrogen (which normally are very low in men) remain about the same. We know that even a slight amount of estrogen can make testosterone more powerful; it may be that this imbalance in androgen and estrogen levels contributes to the disease. Also, the tissue changes in BPH may be triggered by substances called growth factors, possibly those made by muscle cells in the prostate.

Curiously, even though the tissue is growing—which normally would mean a big increase in the number of cells being made—the enlarging prostate makes about the same number of cells as always. How can this be? In any tissue, there is a finely tuned balance between the number of new cells and the number of cells that are dying. Apparently, the population boom in BPH isn’t due to an increase in cell birth but to a decrease in cell death. For some reason, the cells in BPH are living much longer. Some process—perhaps an increase in growth factors—has altered their normal life span, creating a “fountain of youth” for prostate cells. Although the growth is not malignant, the process is similar to what’s happening in prostate cancer—which suggests that once we understand the factors that control cell death in BPH, we may have a better approach for controlling it in cancer as well.

Does BPH Run in Some Families?

Several studies at Johns Hopkins suggest that it does. Hopkins scientists believe that for a small number of men, about 7 percent, age isn’t the only major risk factor. These men probably have inherited one or more genes that somehow make them prone to BPH. In one investigation, scientists studied men aged sixty-four and younger with notable prostate enlargement. They also studied their relatives and family histories. They found that the male relatives of these men were four times as likely as other men to require a prostatectomy to treat BPH. And brothers of these men were six times as likely as other men to need surgery to treat BPH. Understanding how the disease works in these men—specifically, identifying the genes involved—may provide major insight into the far more common form of BPH and one day may even help us prevent it. If you have a strong family history of BPH, scientists at Johns Hopkins would be very interested in hearing from you. (Send inquiries to the Hereditary Prostate Disease Study, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD 21287–2101, Attention: Dr. Patrick Walsh.)

What Does BPH Feel Like?

How does what’s happening on the inside translate to the outside—into symptoms and their impact on a man’s life? It varies; BPH is a different disease in every man, depending on a delicate interplay of factors, including the shape of the growth, the specific tissue involved, and how these variables affect the bladder. As the cell growth progresses, the tissue becomes lumpy. Bulbous nodules begin sprouting like mushrooms, forming characteristic clusters, or lobes.

These lobes tend to arrange themselves in one of three basic configurations. Lateral lobe enlargement features big knobs that sandwich the urethra, one on either side. When a man urinates, these lobes can swing open and shut like double doors (think of a saloon in a cowboy movie), so despite their size, they may not produce much urinary obstruction. In middle lobe enlargement, however, the lobe sticks up, plugging the bladder neck like a cork in a bottle and causing a man great difficulty with urination. (Because this form of BPH is much harder to ignore than lateral lobe enlargement, men who have it are far more likely to seek medical relief for their symptoms.) And in trilobar enlargement, both areas are affected; there can be obstruction at the bladder neck as well as in the urethra.

As the prostate squeezes the urethra, it impedes urine flow. This may manifest itself as frequent urination, needing to go to the bathroom several times an hour; hesitancy, or having to wait for the urinary stream to start; urgency, or the sudden sensation of needing to urinate, which may culminate in involuntary urine leakage before you reach the bathroom; repeatedly awakening in the night to urinate; starting and stopping during urination; and a constant feeling of fullness in the bladder. BPH can also lead to urinary tract infections and, rarely, can cause damage to the bladder or kidneys. It is often frustrating, annoying, and disruptive.

Think of a man’s necktie slowly starting to tighten around his collar. This is what happens, over time, as the prostate’s inward growth toward the urethra takes its toll. At first, or in mild cases, this can mean an irritating but still tolerable change in quality of life. However, when it progresses beyond the nuisance point—when the bladder is never completely empty, or when the kidney or bladder become damaged—it needs to be treated.

At first, BPH is invisible. It causes few symptoms, because the powerful bladder muscle compensates for the narrowed urethra by making more vigorous contractions and forcing urine through the prostate. But over time, this extra effort takes its toll on the bladder, making it less efficient. This is when a man may notice a decreased flow rate and obstructive symptoms. The bladder, after months of heavy duty, also becomes a victim of its own powerful muscles. The muscle-bound bladder wall thickens and loses its elasticity. With all that extra muscle, the bladder can’t hold as much as it used to; it becomes unstable and overly reactive. When this happens, a man feels the need to urinate more often—unfortunately, sometimes spontaneously. These are irritative symptoms: urge incontinence (when a man knows he has to urinate but can’t make it to the bathroom in time) and nocturia (the need to urinate often during the night). These symptoms are worse if a man is unable to empty his bladder completely. If the bladder is always partly full with leftover urine, it doesn’t take much—half a glass of water, even—to fill it all the way. Some of our patients joke that they’ve spent the first half of their lives making money, and they’re spending the second half making water. Imagine how disruptive and frustrating it is for a man to have to go to the bathroom twice as often as he normally would.

How Do You Know If You Have It?

Some men go right to a specialist, a urologist, for help with their urinary problems, but most men start out with a generalist—their family doctor or internist. Most likely, all of these doctors will approach your symptoms the same way: there should be a digital rectal examination and a PSA blood test. (These and other diagnostic tests are discussed in chapter 5.) You should be referred to a urologist if your doctor suspects BPH (or, for that matter, prostatitis or prostate cancer).

Because other conditions can mimic BPH, your doctor will probably begin by taking a detailed medical history and performing a physical exam. It is very important for your doctor to know your entire medical history, even if you have what appears to be a classic case of BPH. For example, an injury to the urethra (from having a catheter inserted into the bladder during a surgical procedure, perhaps) can create a urethral stricture—scar tissue that narrows the urethra—that has nothing to do with the prostate but does a great impersonation of BPH. Blood in the urine or pain in the bladder or penis could point to a bladder tumor or mean that a stone has developed in the bladder, prostate, or kidney. If you have a history of urologic trouble—recurrent urinary tract infections, for example, or prostatitis—it could be that an old problem has returned, but in disguise. BPH symptoms can also be produced by bladder cancer, prostate cancer, and neurogenic bladder (trouble with bladder function caused by a neurological problem, such as Parkinson’s disease or stroke).

You will also be asked to score the severity of your symptoms and how much they bother you on a questionnaire called the International Prostate Symptom Score (IPSS), which appears on pages 38–39. This is a series of seven questions that can be answered on a scale from 0 to 5. (Briefly, symptoms are considered mild if the score total is 0 to 7, moderate if it’s 8 to 19, and severe if it’s 20 to 35.) The last question is the most important of all: How much do the symptoms bother you? This is critical, because BPH is not life-threatening. All of its treatments are directed at relieving symptoms—which means this symptom score will be the main basis for selecting therapy. (Thus, it is essential that you be brutally honest—rather than stoic and long-suffering or overly optimistic that this problem will go away by itself—in answering these questions.) The big question your doctor needs answered, and the one only you can decide, is whether you could live the rest of your life this way. Are you changing your life to accommodate BPH—giving up seats to a basketball game, for instance, so you won’t have to tough it out in the long lines at the men’s room? Are you planning your day around trips to the bathroom? If not—if you can put up with it for now—then you may choose to delay treatment. But if this problem is driving you crazy and disrupting your life, it may be time to seek treatment.

The physical examination is discussed in detail in chapter 5. Because BPH affects only the innermost core of the prostate, your doctor may not be able to feel anything out of the ordinary. It’s important to keep in mind that the size of the prostate may have nothing to do with the degree of symptoms. Some men with major prostate enlargement have no urinary tract trouble, while other men with seemingly minor enlargement or even a small prostate can suffer terrible problems from obstruction. Again, it all depends on where the trouble is (see above for a discussion of the types of BPH).

You may also need other tests, including the following:


This test measures the speed of your urinary stream and the amount of urine you pass, and is done as you urinate (while you’re alone in a testing room) into an electronic machine. (It’s a urological version of the radar gun used to measure professional baseball pitchers’ throws.) To ensure an accurate result, it’s important that you urinate at least 5 or 6 ounces. This test can identify men whose maximum flow rate is diminished and who may benefit most from treatment. (The normal peak urinary flow rate is 15 cubic centiliters or more per second.)


This is a painless imaging technique. It creates a picture by bouncing high-frequency sound waves off an object, like sonar on a submarine. It can be performed from the outside, through the abdomen, or transrectally, using a wand inserted in the rectum. Though not recommended for most men with BPH, ultrasound may be helpful in diagnosing such problems as obstruction of the kidney, stones, or a hidden tumor in the upper urinary tract; in estimating how well the bladder is emptying; and in determining the size of the prostate.

Residual Urine Measurement

If you’re not emptying your bladder completely, this important test will find out. Further, it will show how much urine you’re leaving behind. This can be done indirectly by an ultrasound examination of the lower abdomen immediately after you urinate or directly by inserting a small catheter into the bladder (like a dipstick) and measuring what’s there. These measurements can be a helpful means of following the course of BPH and spotting any change for the worse. If it turns out that you have large amounts of residual urine, your doctor will probably suggest that you seek treatment to avoid chronic urinary tract infection or damage to your kidneys.

Urodynamic Studies

Your urologist may want to do these studies if there is evidence that the primary problem is with the bladder, not the prostate. Cystometry is a way to measure bladder pressure and function. It’s performed by threading a tiny catheter into the penis, through the urethra, and into the bladder to monitor pressure changes as the bladder is filled with water. Pressure-flow studies, using a small catheter, check bladder pressure as you urinate. (Note: Any time a catheter is inserted into the urethra, there is a slight risk of a urinary tract infection developing a few days later. Be sure to tell your doctor if you experience any subsequent fever or discomfort.) In these tests, pressure within the bladder is compared with the rate at which urine is flowing. This can determine whether men with high peak urinary flow rates have obstruction. Imagine squeezing water out of a balloon with a small opening. If you can squeeze hard enough, you can make the water flow, not just trickle. Similarly, some men with significant obstruction can produce reasonable urinary flow rates because they can generate high bladder pressure. These men will have relief of symptoms if their obstruction is treated. However, in some men, low urinary flow rates are caused by diseased bladders that can’t produce much pressure. Relieving the obstruction in the prostate won’t help these men, because the true problem is the bladder.


This test, usually performed in an outpatient setting, is uncomfortable but not painful; it is often used to assess the situation before an invasive procedure. A cystoscope is a slender, lighted tube (often flexible) that works like a small telescope. It is inserted into the tip of the anesthetized penis and threaded through the urethra into the bladder. This allows the urologist to see the bladder, prostate, and urethra and spot anything abnormal—such as a stone, stricture, or enlargement. With cystoscopy, your doctor may also be able to see thickened muscle bands in the bladder. Like rings in a tree trunk, these tell a story—that a condition of bladder obstruction has probably evolved over months or even years. (Note: As with insertion of a catheter into the urethra, this test carries a small risk of urinary tract infection. Some men also experience blood in the urine or a temporary inability to urinate. Be sure to tell your doctor if you develop a fever or feel any discomfort.) Cystoscopy can also be used to rule out other conditions, such as the presence of a bladder stone or bladder tumor.

How Is BPH Treated?

The first option is observation, particularly for men with mild symptoms—those who say they can live with it for the time being. The course of BPH is often hard to predict. Your symptoms could stay the same, improve, or get worse. Men who choose observation must make an extra effort to avoid any condition (such as constipation) or medication (including over-the-counter cold remedies) that could aggravate the problem. Beyond observation, there are two basic approaches: medical and surgical.

For men with moderate symptoms, the initial treatment should be medical. Here again, there are several approaches. One class of drugs is called alpha-blockers. Remember the two kinds of tissue involved in BPH? One is glandular, made up of epithelial cells that secrete the prostate’s fluids. The other is smooth muscle tissue—stromal cells that contract and squeeze this fluid into the urethra. As the glandular tissue enlarges and begins to narrow the urethra, the smooth muscle tissue tightens around it like a fist. In the normal prostate, there are two stromal cells for every epithelial cell. But in BPH, this ratio shifts. It’s five to one, leading some scientists to describe BPH as a “stromal process.” In other words, it’s a smooth muscle problem. Alpha-blockers (the same drugs often used to treat high blood pressure) counteract this by causing this muscle tissue to relax. These drugs are helpful in men with small prostates and moderate symptoms.

For men who have a significantly enlarged prostate, it is reasonable to try another class of drugs called 5-alpha reductase inhibitors. These drugs block 5-alpha reductase, the chemical that changes testosterone into dihydrotestosterone (DHT), the active form of male hormone within the prostate. This is important because, scientists have learned, the trouble in BPH starts after testosterone is converted by 5-alpha reductase into DHT. There are two drugs—dutasteride (Avodart) and finasteride (Proscar)—that block the activity of this enzyme. Both appear to work equally well in shrinking the prostate and in decreasing obstructive symptoms. They may also halt the progression of BPH. These drugs neatly manage to block a hormonal process without affecting a man’s levels of testosterone (the hormone responsible for libido and sexual function). However, the problem with these drugs is that the effect is gradual and very slow. To some men, the pace of change is agonizingly slow, with significant improvement coming only after several months to a year of taking these medications. Also, these 5-alpha reductase inhibitors work well only if the prostate is significantly enlarged (men with smaller-sized prostates can have BPH symptoms, too). If the prostate is small, a prostate-shrinking drug isn’t going to solve the problem. And the relief of symptoms lasts only as long as a man takes these drugs.

Testing a Combined Approach

Could 5-alpha reductase inhibitors and alpha-blockers work better together? Is it possible that, for some men, two drugs are better than one? This idea was tested in a large, double-blind, placebo-controlled trial. Indeed, long-term use of both an alpha-blocker and a 5-alpha reductase inhibitor proved safe and reduced the risk of clinical progression—of symptoms getting worse—more than either treatment alone. Men taking both drugs had a lower risk of developing acute urinary retention (the inability to urinate) and were less likely to need invasive therapy. However, combined therapy is not the miracle answer for every man with BPH. It’s expensive, results are not immediate, and although the outcomes of this study were statistically significant, they amounted to only a few percentage points. Further, there is some concern that long-term use of 5-alpha reductase inhibitors may, by artificially lowering a man’s PSA level, delay the diagnosis of prostate cancer until it has progressed into high-grade disease (this is discussed in chapter 4).


    Symptoms of urinary obstruction…

  • Weak flow

  • Hesitancy in starting urination; a need to push or strain to get urine to flow

  • Intermittent urinary stream (starts and stops several times)

  • Difficulty in stopping urination

  • Dribbling after urination

  • A sense of not being able to empty the bladder completely

  • Not being able to urinate at all

    … could be caused by

  • Benign prostatic hyperplasia (BPH)

  • Urethral stricture

  • Prostate cancer

  • Medication

  • Neurogenic bladder (bladder trouble caused by a neurological problem, such as Parkinson’s disease)

    Symptoms of irritation…

  • Pain or burning during urination

  • Frequent urination, especially at night

  • A strong sense of urgency in urination; inability to postpone urination

  • Sleep disrupted by the need to urinate

  • Urgency incontinence

    … could be caused by

  • Thickened bladder, caused by obstruction from BPH

  • Infection in the bladder or prostate

  • Bladder tumor

  • Stone

  • Neurogenic bladder

Surgical Options

For men with severe symptoms or men who do not respond to medical therapy, there are many effective surgical options. The gold standard is a procedure called transurethral resection of the prostate (TUR or TURP), also described by patients (although it makes urologists cringe) as the “Roto-Rooter” procedure. It is a proven, effective way to improve BPH symptoms quickly and keep them at bay for years. The TUR is performed under anesthesia (usually spinal anesthesia). Although it is a surgical procedure, the abdomen is not opened up. (Only in rare cases—usually in men with very large prostates—is it necessary to perform an open surgical procedure for BPH to remove the prostate tissue surrounding the urethra.) In a TUR, surgeons reach the prostate via the urethra by placing an instrument similar to a cystoscope through the penis. This instrument, called a resectoscope, allows surgeons to view the prostate as they chip away at excess tissue from inside, removing the prostate’s core in fragments. These tissue chips are then flushed out, collected, and sent to a pathologist, who examines them and checks for prostate cancer. Because the resectoscope is threaded through the urethra, no skin incision is needed. In recent years, several promising new techniques have been developed using alternate forms of energy—heat, radio waves, ultrasound, microwaves, and laser—to kill the obstructive cells on the spot (instead of removing the extra tissue, as in TUR). These energy waves are generated, focused, aimed, and fired at the overgrown tissue. Some waves work like a shotgun, blasting holes in the prostate. Others are as sensitive as a scalpel, delicately nibbling away at overgrown tissue until the urethra is free of obstruction. These procedures, which sound like they’re right out of a science fiction movie, include GreenLight photoselective vaporization and holmium laser ablation.

To sum up: BPH is a common condition that affects most men. It is not cancerous, but it can mimic cancer. Today, there are many effective ways to treat it, and most of them have few side effects.


Prostatitis hurts. This painful condition—an inflamed, swollen, and tender prostate—can be caused by a bacterial infection or by other factors. The major complaint in men with prostatitis is pain in the perineum (the area between the rectum and the testicles). They may also experience aches, pain in the joints or muscles and lower back, blood in the urine, pain or burning during urination, and painful ejaculation. In its own way, prostatitis is every bit as difficult and frustrating as BPH—not only because of the symptoms but because there is not always an apparent cause. Prostatitis is a benign ailment—it is not cancer, and it does not lead to cancer. It is not always curable, but it is almost always treatable (although some forms respond better than others to treatment).

The National Center for Health Statistics estimates that about 25 percent of all men who see a doctor for urological problems have symptoms of prostatitis. An estimated half of all men will experience some of these symptoms during their lifetime. Prostatitis is the most common cause of urinary tract infections in men; in fact, American men make about two million trips to the doctor each year seeking help for the symptoms of prostatitis or its siblings, “irritative prostatic conditions.”

What Causes It?

Sometimes we know, sometimes we don’t. As one urologist commented in a review of this disorder, “Prostatitis is one of the most difficult clinical problems for men who suffer from it, as well as for the families of those men and their physicians. It is a particularly perplexing problem for urologists, who see many men with prostatitis and have difficulties with diagnosis and treatment.” Fewer than 8 percent of men with prostatitis actually have a urinary tract infection (symptoms caused by bacteria, which can be helped by antibiotics). What about the rest of these men? There are actually four conditions lumped under the umbrella of prostatitis. Each one has distinct characteristics and responds differently to treatment. That’s why getting the right diagnosis is so important.

The two least common forms of prostatitis are caused by bacterial infection. Note: Although these are sometimes referred to as “infectious” prostatitis, neither form is contagious, and neither form can be transmitted to your sex partner. Acute bacterial prostatitis is a severe, debilitating condition that hits with all the subtlety of a Mack truck. No mystery here; men who have it know something is wrong, and they require immediate treatment. In addition to the symptoms described above, acute bacterial prostatitis is usually distinguished by chills and fever, and extreme pain. It’s difficult for a man to be stoic and try to “ride out” this condition. It’s also a big mistake: if not treated, acute bacterial prostatitis can lead to more serious problems, such as urinary retention (the inability to urinate), a life-threatening infection in the bloodstream (called sepsis), and development of an abscess (an accumulation of pus under pressure, like a pimple) within the prostate.


Not at all

Less than 1 time in 5

Less than half the time

About half the time

More than half the time

Almost Always

Your score

1. Incomplete emptying

Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?







2. Frequency

Over the past month, how often have you had to urinate again less than two hours after you finished urinating?







3. Intermittency

Over the past month, how often have you found you stopped and started again several times when you urinated?







4. Urgency

Over the past month, how often have you found it difficult to postpone urination?







5. Weak stream

Over the past month, how often have you had a weak urinary stream?







6. Straining

Over the past month, how often have you had to push or strain to begin urination?








1 time

2 times

3 times

4 times

5 times or more

7. Nocturia

Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?







Total IPSS Score

Quality of Life Due to Urinary Symptoms



Mostly satisfied

Mixed; about equally satisfied and dissatisfied

Mostly dissatisfied



If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?








If your total score is:

  • 0 to 7 your symptoms are considered mild

  • 8 to 19 your symptoms are considered moderate

  • 20 to 35 your symptoms are severe

Acute bacterial prostatitis is really an acute urinary tract infection (UTI). Fortunately, because the inflammation is so intense, this enables certain antibiotics, which normally wouldn’t be able to penetrate the blood-prostate barrier—a shield designed to protect prostatic fluid—to reach the prostate. (Usually, in keeping out bad things like infection, this barrier also blocks helpful agents.) Acute bacterial prostatitis responds dramatically to antibiotics. However, many men are undermedicated—they either don’t think they need (and therefore don’t take) or aren’t prescribed enough antibiotics to hit the infection hard and knock it out for good. A week to ten days of treatment may ease all signs of infection, and a man may even feel back to normal within a few days. But doctors have learned the hard way—from watching acute bacterial prostatitis return as a chronic infection—that it takes much longer, about six weeks of antibiotics, to get rid of the infection. In this sense, bacterial prostatitis is a lot like another stealthy infection, tuberculosis. The prostate is like a sponge, and if all traces of bacteria are not obliterated right away, acute bacterial prostatitis becomes much more difficult to cure. Eradicating acute bacterial prostatitis the first time around by relentless treatment with antibiotics is the best way to avoid developing chronic bacterial prostatitis.

Chronic bacterial prostatitis is also caused by bacteria, and it’s also treated with antibiotics. It can be a recurring illness, coming back periodically for years after an initial episode of acute bacterial prostatitis. Its symptoms are usually milder versions of those seen in the acute form. Here, too, treatment with antibiotics should continue for six weeks. In many cases, the infection goes away every time with treatment; if, a few months later, it returns, it will vanish again after another round of antibiotics.

Both acute and chronic bacterial prostatitis are associated with UTIs, positive urine cultures that pinpoint the bacteria’s location to the prostate, and the presence of inflammatory cells in prostatic secretions. (The hallmark of chronic bacterial prostatitis is that when the infection returns, it’s caused by the same type of bacteria that caused the previous infection.)

Chronic bacterial prostatitis, in fact, is so closely tied to UTIs that many doctors believe that if you don’t have a UTI, and if you’ve never had one, you probably don’t have chronic bacterial prostatitis. One explanation for persistent bacterial prostatitis may be lingering infection in tiny stones, called calculi, in the prostate. Prostatic calculi (the prostate’s version of gallstones or kidney stones) are harmless and very common; about 75 percent of middle-aged men and 100 percent of elderly men have them.

The next category is called chronic prostatitis/chronic pelvic pain syndrome, and the cause here is a diagnostic puzzler: Nobody knows what causes the two forms of prostatitis in this group (which used to be called nonbacterial prostatitis), and antibiotics don’t help at all. Men with chronic prostatitis/chronic pelvic pain syndrome may have many of the same symptoms as those with chronic bacterial prostatitis. However, in some men, the prostate may not even be the problem. The pain and other symptoms may be a result of spasms elsewhere in the pelvis, rectum, or lower back. This category has two subgroups: inflammatory and noninflammatory, based on whether any white blood cells (also called inflammatory cells) can be found in the prostatic fluid.

Treatment here is largely symptomatic. Your doctor may prescribe one or several medications, including antibiotics, alpha-blockers, 5-alpha reductase inhibitors, anti-inflammatory agents, and pentosan polysulfate sodium (Elmiron). All of these have been shown to help some men with these forms of prostatitis; the problem is determining which men will be helped by which drug or drugs. This may take a while—and plenty of patience—for you and your doctor to figure out. This is the “art” of medicine—your doctor thinking creatively, juggling and fine-tuning various treatments to find the best ones for you, and you hanging in there while this happens. Some doctors recommend anti-inflammatory drugs and sitz baths to ease muscle discomfort and make urination easier, and many men have been helped by changing their diet. Some foods—particularly spicy dishes, red wine, and caffeine—seem to make symptoms worse.

Finally, there’s the mysterious “bonus” category known as asymptomatic inflammatory prostatitis. This condition produces no symptoms and is usually found by chance during a biopsy or when prostate tissue is removed for other reasons (for example, during surgery for BPH or cancer). If it produces no symptoms, is this inflammation something we should even worry about? Maybe. We’re still learning about this form of prostatitis and, although it is not cancer, it may be linked with the formation of cancer. In other words, whatever causes the inflammation may eventually cause cancer as well. (This will be discussed at length in the next chapter.)

How Do You Know If You Have It?

As described above, acute bacterial prostatitis causes severe symptoms that leave little room for guesswork. Other forms of prostatitis, however, cause milder symptoms (and asymptomatic inflammatory prostatitis doesn’t cause any symptoms at all) that may not immediately suggest that the prostate is to blame. The constellation of symptoms of prostatitis includes pain in the perineum (the area between the rectum and testicles), testicles, the tip of the penis, the lower legs and back, and during or after ejaculation, as well as blood in the urine, the need to urinate frequently, and incomplete emptying of the bladder.

You are at higher risk of developing prostatitis if you recently have had a urinary catheter or other medical instrument inserted into your penis; have engaged in rectal intercourse or oral sex; have had a recent bladder infection; or have other urinary problems, including BPH or an abnormal urinary tract. Stress also seems to play a role in prostatitis. (Note: If you have undergone recent surgery or any other surgical procedure, be sure to tell your doctor.)

How Is Prostatitis Treated?

The easiest to treat is the most dramatic form, acute bacterial prostatitis. (The most likely cause of infection is E. coli, a form of bacteria that’s common in the colon.) This can be cured with a course of antibiotics—usually one of a class called fluoroquinolones—that lasts for six weeks. Men with chronic bacterial prostatitis are helped by low maintenance doses of antibiotics. This is called chronic suppressive therapy and, as its name suggests, it is designed to prevent new UTIs from developing, instead of treating them after the fact. Men who do not have infections may be helped by drugs such as alpha-blockers (often used to treat high blood pressure; described above in the BPH section), antidepressants, and antispasmodics (drugs that help calm muscle spasms). The treatment for most prostatitis is often trial and error, and it helps if men and their doctors can work together, with much patience, to come up with the right plan. New evidence suggests that some nonbacterial prostatitis may actually be caused by an autoimmune condition that mimics the symptoms of prostatitis. This exciting new research may help us find new ways to manage the condition.

Finally, many men with prostatitis have found that their symptoms improve when they change their diet—eating a good balance of fruits and vegetables; avoiding spicy foods, alcohol, caffeine, and soft drinks that contain saccharin; and drinking enough water to keep urine running clear—and their lifestyle. A thirty-minute hot bath or sitz bath twice a day can relieve pain and make it easier to urinate. Getting daily exercise (but not riding a bike or an exercise bike, which can irritate symptoms) and resuming normal sexual activity may also be helpful.



  • The Short Story: The Highly Abridged Version of This Chapter

  • Who Gets Prostate Cancer?

  • What Causes Cancer?

    • All Cancers Are Caused by Damage to DNA

    • What Causes DNA Damage?

  • Molecular Causes of Prostate Cancer: The Double Attack of Oxidative Damage and Inflammation

    • Putting Out Fires

    • The Silence of the Genes

    • Genetic Fire Starters

    • What Causes Inflammation in the Prostate?

  • Risk Factors for Prostate Cancer

    • Age

    • Race

    • Genetic Susceptibility

    • Hormones and Race

    • Environment: Prostate Cancer and What You Eat

      • Eat More Fish

      • The Asian Diet: East vs. West

      • Does Diet Trump Race?

    • Family History

      • Confoundingly Common

      • Wrongly Stereotyped

    • The Genetics of Prostate Cancer

      • The Genes In Question: What We’ve Learned So Far

      • Inherited Risk: Am I Just “More Likely” to Get Cancer, or Is It Already a Done Deal?

      • What Can We Learn from Twins?

      • Association with Other Tumors

    • What About Hormones?

      • What About Hormone Replacement?

      • Supplemental Testosterone: The Fountain of Youth?

    • Other Risk Factors

      • Occupation: Farming and Exposure to Agent Orange

      • Cigarette Smoking

    • Things That Do Not Increase the Risk

      • Vasectomy

      • Sexual Activity

      • Alcoholic Beverages

      • Physical Inactivity

      • Other Prostate Problems

THE SHORT STORY: The Highly Abridged Version of This Chapter

For American men, and men from all western countries, prostate cancer is something to worry about, because so many of us get it. This year, more than 200,000 American men will be diagnosed with prostate cancer, and 28,000 will die from it. An American boy born today has a 17 percent risk of developing prostate cancer and a nearly 3 percent risk of dying from it.

Although these numbers are high, the picture of prostate cancer today is far brighter than it’s ever been—much more hopeful than it was even a generation ago. Consider these statistics: Of men diagnosed with prostate cancer in the late 1970s who did not die of other causes, only 70 percent survived five years, and more than half died of prostate cancer within fifteen years. How far we have come since then! Today, thanks to early diagnosis and screening, more than 95 percent of men diagnosed with prostate cancer are alive ten years later.

And yet, in terms of sheer numbers, there’s a massive cloud on the horizon—the aging baby boom generation, which makes up about 27 percent of the U.S. population. By some estimates, unless we can do something to prevent prostate cancer over the next twenty to forty years, the number of new cases will double. And unless we can find a better way to cure the disease, the number of men dying from it may triple. It’s not that we’re not doing a good job of treating prostate cancer, it’s that we’ll have so many more men to do a good job on!

That’s why this book is more important now than ever. We hope to teach men and their families as much as we know about what causes prostate cancer, how to prevent it, and how we can treat it better.


  • Age: Why is prostate cancer the bane of older men? Because, like many cancers, it takes years to develop. Mutations occur gradually, over decades, as oxidative damage—tiny changes within your cells—takes its toll. An American man in his mid-to late-seventies is seven times more likely to develop prostate cancer than is a man in his forties. What a difference a few decades makes: In men aged forty to fifty-nine, the risk of developing prostate cancer is one in fifty. In men aged sixty to seventy-nine, it’s one in seven. And over the course of his lifetime, an American man’s risk of developing prostate cancer is one in six.

  • Race: African American and Afro-Caribbean men have the highest risk of prostate cancer of any ethnic group in the world. Worse, black men seem to get more severe forms of prostate cancer, are more likely to have cancer recur after treatment, and are more likely to die from the disease than white men. Exactly why this is remains uncertain, although it may relate to genetic susceptibility, dietary and lifestyle factors, and inadequate exposure to vitamin D (see below).

  • Family history: If your father or brother has had prostate cancer, your risk of developing the disease is two-and-a-half times greater. If three family members (such as a father and two brothers) have developed prostate cancer, or if the disease occurs in three generations in your family (grandfather, father, son), or if two of your relatives have developed the disease at an early age (younger than fifty-five), then your family meets the criteria for hereditary prostate cancer, and your risk of developing prostate cancer may be as high as 50 percent. The genes responsible for this are under intense investigation, with the hope that when they are found, genetic testing will be available. Up to this point, about thirty different areas in the human genome have been identified, but each of these just adds a little bit to a man’s risk of developing the disease. The search continues to find the big ones—the genes that account for the strong increased risk we see in families with hereditary prostate cancer.


Although you can’t do anything about your age, race, or family history, there’s another part of your life where you can make a difference: your environment, which includes everything that you are exposed to, and also certain lifestyle choices. We know this from studies of identical twins. Genetically, they look just the same, but their risk of prostate cancer varies, depending on the choices they make every day. Their risk of developing prostate cancer turns out to be 50 percent genetic and 50 percent environmental.


Why is it that prostate cancer is so common in western cultures and much less so in Asia? And why, when Asian men migrate to western countries, does their risk of prostate cancer increase over time? Scientists believe environment—including diet and lifestyle—must play a large role in determining who gets prostate cancer.


Go to an all-you-can-eat buffet or even to your local mall, and see for yourself: As a country, we’re hefty. About two-thirds of American adults have too much body fat, and being overweight doesn’t just affect your heart and blood pressure, and your risk of stroke, diabetes, or premature death. It also makes you more likely to develop certain cancers. We suspected it but didn’t know it before. Over the last decade, it has become clear that having too much body fat also increases a man’s risk of developing prostate cancer that is more aggressive and more likely to cause death. Chances are good that if you have a “spare tire,” you’ve been told this before by well-meaning family members or your doctor, and you’ve gotten pretty good at saying, “Yeah, yeah, I know,” truly intending to do something about it one of these days, and wishing people would find something else to worry about and leave you in peace. Most of us have been in that place, for one reason or another. Well, “one of these days” might as well be today.


We’ll just put it right out there: Men who eat a lot of red and processed meats and dairy products are more likely to develop advanced prostate cancer and die from it. Men who eat tomatoes and cruciferous vegetables, such as broccoli, seem to have a lower risk of prostate cancer. Why? We don’t know yet, but we can speculate: There is an enzyme in prostate cancer cells that craves the fatty acids in dairy products and red meat. It just loves them. Consequently, when a man with prostate cancer consumes a diet high in these foods, his cancer cells get nine times more energy than normal cells. Further, these cells produce hydrogen peroxide, which causes still more oxidative damage to DNA and more mutations, leading to further progression of the disease.


Excerpted from "Dr. Patrick Walsh's Guide to Surviving Prostate Cancer" by Patrick C. Walsh. Copyright © 0 by Patrick C. Walsh. Excerpted by permission. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher. Excerpts are provided solely for the personal use of visitors to this web site.
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