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You and Your Annual Prostate Exam

What is the purpose of a Prostate Exam?
During a Prostate Exam our physicians are able to determine any irregularity within your prostate gland. Irregularities might be an enlarged prostate, a lesion on the prostate or a lump on the prostate. With early detection our physicians are able to treat, in most cases, successfully.

How is a Prostate Exam performed?
At Urology Consultants our physicians perform Digital Rectal Exams (DRE) which is also known as the prostate exam. Utilizing a gloved index finger our physician will access the prostate gland through the rectum. This technique allows the physician to feel the prostate for any irregularities. The exam takes approximately 2 minutes.

Who needs a Prostate Exam?
As recommended by the American Cancer Society Men 42 years of age or older with either a history or family history of prostate cancer are recommended to undergo a Prostate Exam annually. Men 50 years of age or older with no history are recommended to undergo a Prostate Exam once a year.

What type of symptoms would I have if I had prostate problems?
In addition to your age, symptoms that may be encountered would be;

  • not completely emptying your bladder
  • frequent urination
  • not being able to hold your urine
  • having to strain to urinate
  • a weak urine stream
  • awaken several times during the night with an urgency to urinate

At any age these are warning signs of a problem with your health and you should consult your physician right away!

If the doctor finds abnormalities, what steps are taken?
Generally, when our physicians encounter abnormalities during a prostate exam, depending on the findings he may elect the patient to undergo all or one of the following: ultrasound of the prostate, Prostatic Specific Antigen (PSA) - a blood test to determine if cancer is present, drug therapy or surgery.

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The Facts About Prostate Cancer

Could you have prostate cancer?

If you're a man over 40 or someone in your family is, one of the most important things you can do for yourself or recommend to that family member is to get tested for prostate cancer. Prostate cancer is the most common form of cancer in men and the second leading cause of cancer deaths. For 1996 the projected number of new cases of prostate cancer is 317,100. This number is expected to rise in coming years with more widespread and routine use of PSA tests for screening. Who is at risk? Almost all men will get prostate cancer if they live long enough. The risk of developing prostate cancer increases as men get older. Eighty percent of prostate cancer cases are diagnosed in men who are over the age of 65. However some men develop it when they are younger. For unknown reasons, African Americans have a higher risk of developing prostate cancer than white Americans. Asian immigrants are among those men with the lowest risk.

Get tested: Early detection pays off Prostate cancer is usually very slow growing. Symptoms may not appear for many years. Many men will die without ever knowing they had prostate cancer. Others will find out they have early, middle, or late stage prostate cancer.

Because prostate cancer is so prevalent and symptoms may not exist, it is extremely important that you and male family members over 40 get tested for the disease.

The goal of each treatment is to extend life and allow life to be lived as it always has - remaining active, spending time with family and being part of the community.

But the definition of successful treatment changes as the disease advances. Successfully treating early-stage prostate cancer often means curing it. Successfully treating advanced prostate cancer means delaying its symptoms (sometimes for many years).

Awareness is the first step to successful treatment. This booklet provides an introduction to prostate cancer and its treatment options. It is meant to make you aware that all males are at risk; that prostate cancer is a disease you can battle and win; that patients can lead an active life while undergoing treatment; and that testing is crucial, because you need to know you have the disease before you can get treated.

What You Need to Know about Prostate Cancer

Where and what is the prostate?

Prostate ImageThe prostate is a gland, the size and shape of a walnut. It's located below the bladder, just in front of the rectum. Passing through the center of the prostate is the urethra. During ejaculation, muscles surrounding the prostate squeeze the seminal fluid into the urethra and out through the penis.

The urethra also carries urine. When the prostate becomes enlarged, it squeezes the urethra and interrupts the flow and control of urine. Consequently, one of the symptoms of prostate cancer is urinary difficulties. Surgery, an effective treatment for the early stages of prostate cancer, can also cause urinary difficulties.

Alongside the prostate is a group of nerves that go to the penis and control erections. Surgery can damage these nerves, with impotence as the result. In recent years, a nerve sparing" technique has been practiced by surgeons to help patients maintain the ability to achieve an erection. Success depends on the size and location of the tumor. If surgery is an option for you, the chance of becoming impotent may affect your decision to undergo surgery.

Bear in mind, though, that both urinary difficulties and impotence are treatable.

What is prostate cancer?
In any body tissue, cells normally reproduce themselves in an orderly and controlled manner; worn out tissue is routinely replaced. Cells growing out of control form a growth, which is called a tumor. Some tumors grow, but always stay at the same site without invading adjacent tissues, and these are called benign tumors. Other tumors not only grow but also have the potential to invade and destroy surrounding tissue, as well as to spread to distant parts of the body. These are called malignant tumors, or cancer. Cancer cells can detach from malignant tumors and travel to other parts of the body and begin to grow. Tumors that develop in another organ or structure as a result of spreading in this manner are called metastases.

What are its causes?
No one knows exactly what causes prostate cancer. Some researchers think environmental factors, such as high-fat diets, may be the culprit; some attribute prostate cancer to genetics. Regardless of the cause, the greatest risk factor for prostate cancer is age. The likelihood of developing prostate cancer starts to increase after the age of 40.

Diagnosing Prostate Cancer

How can you know if you have prostate cancer?
There are a variety of ways to detect prostate cancer. Some of these are described below.

Symptoms of the disease:
While some patients have no symptoms, others may experience frequent, difficult or painful urination; dribbling urine; blood or pus in the urine; or blood or pain on ejaculation. Such symptoms may also indicate prostate problems other than cancer. To be sure, a doctor will have to perform a thorough examination. The severity of symptoms does not necessarily relate to the severity of the tumor.

Digital rectal examination (DRE):
In this test a gloved finger is inserted in the rectum. The physician feels for the size, shape and texture of the prostate. Cancer feels hard. However, more tests will be needed to make sure that cancer is present.

PSA test:
This is a blood test that measures the levels of prostate specific antigen (PSA). PSA is a protein found in the blood and produced by the prostate. PSA levels rise in the presence of prostate cancer. Although the test is not 100% accurate, PSAs have become an important step in diagnosing prostate cancer and following the course of disease.

Transrectal ultrasonography (TRUS):
With a probe inserted in the rectum, TRUS shows sound waves bouncing off the prostate and other parts of the body. It is sometimes used along with PSAs and DREs to diagnose prostate cancer. It may also be used to help the biopsy process.

This a surgical procedure in which a few cells are removed for microscopic examination. Biopsies are usually done using a local anesthetic. The biopsy allows for an accurate assessment of the presence and types of cancer cells within the prostate.

Be on the lookout
The highest risk groups for prostate cancer are African-American men and men with a family history of the disease. However, every man aged 40 and older is at risk. Therefore, the American Cancer Society recommends that:

  • All men aged 40 and older should get a digital rectal exam (DRE) as part of their regular, annual physical checkup.
  • All men aged 50 and older should get a PSA test as part of their annual physical, in addition to a DRE.
  • If the DRE or PSA test is suspicious, a transrectal ultrasound should be performed.

Remember, prostate cancer often occurs without any symptoms. Regular testing can lead to life-saving therapy.

Stages of prostate cancer
Doctors characterize the extent of prostate cancer with what is called staging. Either of two staging systems are used.

A-through-D system:
In the early stages (A and B), only a few cells of the prostate are cancerous and are confined to the prostate. Over time, the cancer takes over more of the prostate. In the advanced stages, the cancer spreads to surrounding tissues (C), then to lymph nodes, other organs and the bones (D).

>TNM system:
In this system, T stands for tumor size, N for lymph node involvement and M for degree of metastases. All designations are included in staging. For example, T3c,Nl,M0 means that the tumor has extended into the seminal vesicles (T3c), one lymph node is cancerous (N 1) and there is no sign of cancer in other areas of the body (MO). The TNM system corresponds closely to the A-through-D system but not exactly.

In addition to staging, physicians rate how life-threatening the tumor is by using the Gleason system. The biopsied tumor is put under a microscope, and the cells are assigned a grade according to how closely they resemble normal cells. Tumors with a Gleason score of 2 to 4 contain more normal looking cells and are generally slow growing. Tumors rated S to 10 are the most aggressive types


Treating Prostate Cancer

How can you treat prostate cancer?
How prostate cancer is treated depends on the stage of the cancer, the aggressive nature of the cancer, the age of the patient, the patient's overall health, and the side effects of the different treatments. Because so many treatment options exist, your treatment should be a carefully weighed decision involving you, your family, and your doctor.

One of the treatment options is watchful waiting. Because prostate cancer usually grows so slowly, symptoms may not appear for years, and men generally develop the disease late in life, a period of observation is one of your choices. Watchful waiting avoids the side effects and discomfort caused by any treatment. However, as the disease progresses, more active treatments may seem appropriate.

Treatment depends on the stage of prostate cancer. In early stages, getting rid of the cancer or destroying tumor cells is the primary objective. If the cancer has reached an advanced stage, there is too much tumor to eradicate. Therefore, the goal becomes slowing the cancer's growth.

Prostate cancer grows with male hormones such as testosterone, which is primarily made in the testicles. Treating advanced prostate cancer depends on stopping the male hormones from "feeding" the tumor cells. This strategy is called hormonal therapy. Recently, studies have shown that hormonal therapy can also provide benefits in the early stages of prostate cancer.

How do you treat the early stages of prostate cancer?
In the beginning stages, when prostate cancer is localized (confined to the prostate), treatment options generally include:

This is the surgical removal of the prostate. The objective is to stop the growth of the tumor by removing the prostate. Side effects may include impotence and difficulty controlling urination.

Radiation therapy:
This treatment shrinks tumors that are still in the prostate either by 1) directing radiation (x-rays) at the tumor from outside the body, or 2) implanting tiny radioactive seeds directly into the prostate. Radiation can cause impotence, diarrhea, cramps, rectal irritation, and difficulty with urination.

The benefits of radiation therapy can be improved with complete hormonal therapy (CHT). Recent studies have shown that patients given CHT in conjunction with radiation therapy remained cancer-free for an average of 21 months longer than patients given only radiation therapy. CHT is the combination of two drugs, EULEXIN® (flutamide) and an LHRH agonist (Lupron®* or Zoladex®t). The two drugs work together to stop male hormones from "feeding" cancer cells. CHT does not add substantial side effects to radiation therapy alone.

*Lupron® (leoprolide) is a registered trademark of TAP Pharmaceuticals Inc.
Zoladex® (goserelin acetate) is a registered trademark of Zeneca Pharmaceuticals.

How do you treat advanced prostate cancer?
Symptoms may not be present even in advanced prostate cancer. The goal of treating advanced prostate cancer is to slow further growth of the disease, even before symptoms begin. Slowing the growth will delay the onset of symptoms or drastically reduce their severity. Hormonal therapy is usually used for slowing the spread of prostate cancer.

Partial Hormonal Therapy
Most testosterone is made in the testes. With partial hormonal therapy, testes stop producing testosterone. Examples of partial hormonal therapy include the following:

Estrogen (DES) is a female hormone that is used occasionally in the treatment of prostate cancer. When men take estrogen their testosterone levels fall. However, the use of estrogens is limited due to their many side effects. Taken as a pill once a day, estrogen can cause nausea, vomiting, breast tenderness or enlargement, serious heart or blood vessel problems (such as stroke, clots, fluid retention), and lower sex drive.

Orchiectomy is also known as surgical castration, which is the removal of the testicles by surgery. Without testicles, the main source of male hormones is absent, which slows the growth of the tumor. Side effects usually include impotence and hot flashes. The surgery can be performed without an overnight hospital stay.

Medical Castration:
The ability of the testicles to make testosterone can also be stopped without surgery. Medical castration shuts off the supply of testosterone by the testicles and achieves the same result as surgical castration. Medical castration involves injections of Lupron®* (leuprolide) or Zoladex®t (goserelin) once a month or once every three months. These medications are also referred to as LHRH agonists. An LHRH agonist helps reduce the amount of testosterone similar to the surgical procedure. Side effects usually include hot flashes, impotence, breast enlargement and tenderness, loss of sex drive, and nausea.

*Lupron® (leuprolide) is a registered trademark of TAP Pharmaceuticals Inc.
Zoladex® (goserelin acetate) is a registered trademark of Zeneca Pharmaceuticals.

Complete hormonal therapy
While the regular injections of LHRH agonist stop the testicles from making testosterone, they do not eliminate all testosterone in the body. A medicine called EULEXIN® (flutamide) prevents the remaining testosterone from reaching prostate cancer cells.

The combination of LHRH agonists (Lupron® or Zoladex®) plus EULEXIN is called complete hormonal therapy. Complete hormonal therapy virtually shuts off the body's supply of male hormones and slows the growth of the tumor.

Prostate cancer support groups
Prostate cancer treatments can help you physically. Staying active and talking about your feelings can help you feel good mentally. To keep a positive attitude, joining a support group may help.

In a support group you can talk with prostate cancer patients who know exactly what you and your family are going through. In addition, support groups teach various coping mechanisms for stress, depression and anxiety. Many prostate cancer patients have greatly benefitted from support groups.

The organizations listed below provide support for men with prostate cancer and their families. You can call them for details about their organization.

930 North York Road, Suite 50
Hinsdale, IL 60521-2993
Tel: 800.80-USTOO

Patient Advocates for Advanced Cancer Treatments (PAACT)
1143 Parmelee, NW
Grand Rapids, MI 49504
Tel: 616.453.1477

American Cancer Society, Inc.
1599 Clifton Road, NE
Atlanta, GA 30329-4521
Tel: 800.ACS.2345

Local chapters of the ACS provide literature, counseling, and guidance for cancer patients and their families. The ACS sponsors a number of programs, including:

CanSurmount, which brings together patients or families with trained volunteers who can provide one-on-one help.

I Can Cope, an 8-week course that addresses practical and emotional needs of people with cancer.

American Foundation for Urologic Disease
300 W. Pratt St.
Baltimore, MD 21201

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Prostate Surgery and Sex

Male Reproductive DiagramMany men worry about whether surgery for benign prostate hyperplasia (BPH) will affect their ability to enjoy sex. Some sources state that sexual function is rarely affected, while others claim that it can cause problems in up to 30 percent of all cases.

However, most doctors say that even though it takes awhile for sexual function to return fully, with time, most men are able to enjoy sex again.

Complete recovery of sexual function may take up to one year, lagging behind a person's general recovery. The exact length of time depends on how long BPH surgery was postponed despite symptoms and on the type of surgery that was done.

Here is a summary of how surgery may affect the following aspects of sexual function, according to the National Institutes of Health.

  1. Erections: Most doctors agree that if an individual was potent (able to maintain an erection) shortly before surgery, he will probably be able to have erections afterward. Surgery rarely causes a loss of potency. However, surgery cannot usually restore potency that was lost before the operation.

  2. Ejaculation: Although most men are able to continue having erections after surgery, a prostatectomy frequently makes them sterile (unable to father children) by causing a condition called "retrograde ejaculation" or "dry climax."

    During sexual activity, sperm from the testicles enters the urethra near the opening of the bladder. Normally, a muscle blocks off the entrance to the bladder, and the semen is expelled through the penis. However, the coring action of prostate surgery cuts this muscle as it widens the neck of the bladder.

    Following surgery, the semen takes the path of least resistance and enters the wider opening to the bladder rather than being expelled through the penis. Later it is harmlessly flushed out with urine.

  3. Orgasm: Most men find little or no difference in the sensation of orgasm, or sexual climax, before and after surgery. Although it may take some time to get used to retrograde ejaculation, men should eventually find sex as pleasurable after surgery as before.

Many people have found that concerns about sexual function can interfere with sex as much as the operation itself. Understanding the surgical procedure and talking over any worries with the doctor before surgery often help men regain sexual function earlier. Many men also find it helpful to talk to a counselor during the adjustment period after surgery.

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