Heading towards andropause? (Below) the prostate gland

Forty is the age of change. As men head towards “andropause”, their prostate gradually starts to grow again. It is the embryological male equivalent of the uterus and that is probably why both give trouble at the same age.

The prostate, at birth, is a pea-sized organ at the base of the urethra. In the young adult, it is a walnut-sized, donut-shaped gland. Its secretions actually do little other than contribute to the volume of the male ejaculation.

As the prostate grows, its crucial location partially obstructs urination. The stream is weak and unsatisfactory, and the bladder never feels fully relieved. Also, there is difficulty starting urination as the enlarged prostate acts as a stop valve. Again, attempts to stop may be followed by embarrassing dribbling. The muscles of the bladder eventually hypertrophy, producing ridges and grooves.

These distort the blood supply. Moreover, veins may burst, causing bloodstains in the urine. Stagnation of urine in the bladder may lead to the formation of stones. All these changes increase the susceptibility to infection. The straining produces back pressure and the stagnant and infected urine back tracks into the kidney, leading to renal infection, damage and failure. Uneasiness and a sense of incomplete evacuation of urine thus lead to frequent unsatisfactory visits to the toilet and disturbed sleep.

All men are not affected, although 90 per cent do develop symptoms by the age of 90 years. The symptoms are fairly typical but have to be further evaluated. They may be due to harmless treatable benign prostatic hypertrophy (BPH), cancer, prostatitis (infection), stones or an urinary tract infection.

An enlarged prostate can be easily felt. A smooth, uniform enlargement is characteristic of BPH, a hard and nodular swelling is likely to be cancerous, while a soft, boggy and painful enlargement could be an infection. Once a tentative diagnosis is reached, tests can be done for confirmation.

Key concepts

• Urine test: To differentiate between prostatitis, urinary infection and kidney diseases.

• Prostate-specific antigen (PSA) levels in the blood: A small amount (in nanograms or ng) normally circulates in the blood. High levels indicate prostatitis, BPH or cancer.

• Urinary flow test.

• Post void residual volume test.

• Ultrasound imaging

• Urodynamic studies to measure bladder pressure during bladder filling and urination.

• Cystoscopy: A thin tube with a light called cystoscope is inserted into the urethra to visualise the problem.

• Intravenous pyelogram (IVP): An X-ray image of the urinary tract after injecting a dye.

Age       PSA Level (ng/ml)

40-49       2.5

50-59       3.5

60-69       4.5

70-79       6.5

BPH is likely to occur after the age of 40 years, especially in men with a family history of prostate problems or those who do not have an active sex life. The exact relationship between not having regular intercourse and enlargement of the prostate is not exactly known, but there seems to be a correlation.

Treatment for this condition is usually needed when the patient becomes symptomatic, after the diagnosis has been established with tests. Drugs from the “alpha blockers” group — terazosin, doxazosin, tamsulosin and alfuzosin — can be used. These have the additional advantage of controlling blood pressure. They act quickly to control the symptoms, usually within 48 hours, but have to be taken life long. They can reduce the blood pressure to fatally low levels if they are unwittingly combined with sidenafil (Viagra).

Finasteride is another drug that may be used. This actually shrinks the prostate gland and takes around three months to act. Each of these groups of medication has its own advantages and drawbacks, and thus a synergistic combination of the two is sometimes recommended.

Non-surgical and non-medical treatment like transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), transurethral electrovapourisation and various types of laser therapy can also be opted for. Stents can be inserted into the urethra to keep it open.

Surgical intervention with transurethral resection of the prostate (TURP) used to be the only treatment available for BPH. Now with medications and non-invasive procedures at hand, surgery as an option is fast declining.

By the age of 80 years, 80 per cent of men develop dormant cancerous foci in the prostate gland. It has the same symptoms as BPH. Digital rectal examination reveals a hard nodular gland. Blood PSA levels are very high if metastases are also present. The diagnosis is confirmed by a biopsy and is treated by surgery, radiation, chemotherapy or hormonal therapy.

Acute and chronic infection of the prostate gland is common. It presents itself as a discomfort during urination or ejaculation, pelvic pain, low backache and fever. It may occur as a result of a previous urinary infection or an ascending urethral infection. Bacteria thrive in the prostate and, unfortunately, are difficult to eliminate. Medicationis needed for four to six weeks, followed by low-dose, long-term antibiotic treatment. However, pain may persist. Regular intercourse seems to be the only preventive measure for prostate problems.

Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in