The Prostate: a growing problem

Most men will develop prostate problems as they get older.

The endocrine gland, situated in the pelvis at the base of the bladder, produces seminal fluid that nourishes and protects sperm. Unfortunately it also almost universally enlarges with age, resulting in obstructive urinary symptoms due to pressure on the urethra, which passes through the prostate, and the bladder.

The numbers are sobering. It is estimated that approximately 70 per cent of men in their 60s and 80 per cent of men over the age of 70 have some degree of benign prostatic hyperplasia (BPH).

And the numbers for prostate cancer are just as bad. In 2019 prostate cancer was the second most commonly diagnosed cancer in Australia. There were over 19 000 cases (comprising a quarter of all male cancers) and over 3300 men have died from the disease in 2019. By the age of 85 it is estimated that one in six men will have developed prostate cancer.  

Unfortunately erectile dysfunction and anorgasmia (inability to have an orgasm) are common side-effects of prostate cancer treatment. The incidence varies depending on the man’s age and pre-morbid sexual function but long-term erectile dysfunction is estimated to affect anywhere from 20 to 70 per cent of men following nerve-sparing prostatectomies or pelvic radiotherapy.

The side-effects of androgen deprivation therapy – which is often required if the cancer has spread beyond the prostate – are even more profound. In addition to sexual dysfunction the hormone injections can cause loss of muscle, reduced body hair, hot flashes, gynaecomastia (breast enlargement) and penile and testicular shrinkage.

Studies have shown that sexual dysfunction can negatively impact a man’s quality of life, causing reduced self-esteem, embarrassment and depression.

The pros and cons of prostate cancer screening has always been a contentious issue within the medical community, with long-standing concerns regarding potential over-diagnosis and over-treatment of early prostate cancer cases which are often slow growing, resulting in unnecessary morbidity and excessive health care costs.

In 2016 the Cancer Council of Australia released a new set of guidelines that recommended against routine screening for prostate cancer for most men. Somewhat confusingly the guidelines, which were endorsed by both the Urological Society of Australia and New Zealand and the Royal Australian College of General Practitioners, still left the onus about whether or not to undergo screening on each individual person.

Given that men are urged to be more proactive about their health, these somewhat ambiguous guidelines have left many men feeling confused about what to do.

“Most men still want screening to be done, but it is a very controversial thing,” Surfers Health Practice Principal Dr Mark Jeffery says. He acknowledges the concern about unnecessary prostate biopsies, but is reluctant to recommend against screening.       

Dr Aneta Suder, medical oncologist at the Royal Brisbane and Women’s Hospital, advises men to remain proactive despite the new guidelines. “There is that misconception that prostate cancer is a disease of older men but we do see a younger cohort of patients as well,” she says. “Eighty-five per cent of patients can be cured if their prostate cancer is picked up early, so we always encourage men to make sure they listen to their bodies and look out for symptoms like persistent back pain or weight loss.”

Sydney-based urological surgeon Professor Henry Woo says that there are things that can be done to minimise sexual dysfunction following prostatic surgery. These include pelvic floor exercises, penile rehabilitation, medications to aid with erections as well as therapeutic treatments like penile massage and sexual therapy.

“We have an ageing population and the general fitness level of an average 70-year-old is the same as a 60-year-old’s was twenty years ago,” says Woo. “So it’s not surprising that, as we get fitter, any impact on sexual function is going to be of greater concern than it would have been to the previous generation.”    

Woo continues to believe that men should have screening. “The PSA [prostate specific antigen] blood test is a very useful risk assessment tool. If a man’s PSA is below the median for his age group, that positions him in a low-risk group for getting prostate cancer, and you could actually quite reasonably not check him again for another ten years,” he says.

“Once upon a time we used to treat all men diagnosed with prostate cancer but we now know that that is wrong. Many men diagnosed with prostate cancer will die with the disease, rather than from it, and some of the low-grade prostate cancers do not have to be treated at all. We can manage them via active surveillance and find the right balance between avoiding the over-treatment of prostate cancer yet at the same time not losing that window of opportunity to treat a prostate cancer that might later declare itself as being more significant.”

Many of the complications seen with prostate cancer therapy also commonly occur when BPH, which causes difficulty with urination, is treated. The medications used can cause loss of libido, erectile dysfunction and gynaecomastia. If medications are unsuccessful surgery, in the form of a transurethral resection of the prostate (TURP), is often required. Approximately 20 per cent of men who undergo this procedure will experience erectile dysfunction and 75 per cent will experience retrograde ejaculation.

An alternative to surgery, called Rezum, which appears to preserve sexual function, has recently become available in Australia. In this procedure a tube is inserted into the urethra and small volumes of sterile steam are injected into the prostate causing shrinkage of the tissue.

Retired businessman Kerry Hayes, 64, was the first man to undergo this procedure in Australia after years of suffering difficulty in urinating, poor sleep and the sensation of always having a full bladder.

“I’m quite sexually active so I didn’t want to risk that function,” said Hayes, who had his procedure done at the Sydney Adventist Hospital by Professor Woo. “The results have been everything I hoped for.”

If you are experiencing symptoms of urinary obstruction, such as difficulty initiating voiding, prolonged dribbling, or a persistent sensation of a full bladder, or if you are undecided about whether or not to undergo prostate cancer screening, then please speak to your general practitioner.

“We are here to help and guide you to an informed decision,” Dr Jeffery says. “Screening isn’t for everyone but it will certainly save some lives.”

Lifestyle factors and risk of prostate cancer:

• Studies indicate that animal fats, red meat and dairy appear to increase the risk of prostate cancer;
• Vegetables, tomatoes, coffee and soy-based products appear to decrease the risk;
• Vitamin D may offer some protection against prostate cancer but multivitamin use may actually increase the risk;
• Other less well-established but potential modifiable risk factors include sexually transmitted diseases (increase), certain insecticides (increase), aspirin and non-steroidal anti-inflammatory drugs (decrease), sun exposure (decrease), vasectomy (increase) and frequent ejaculation (decrease);
• Always follow your doctor’s advice.

Watch this video about how exercise medicine has the potential to improve the life expectancy for men with prostate cancer:

---

Suvi Mahonen is a Surfers Paradise-based journalist. Her work appears in The Australian, HuffPost, Mamamia and other health and lifestyle publications. Follow her on Facebook and online art-selling platform Redbubble

Feature photo credit: Darko Djurin