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Prostate Health

The prostate gland isn't big—about the size of a walnut—but its location virtually guarantees problems if something goes awry. The prostate gland is located just below the bladder and in front of the rectum. It also wraps around the upper part of the urethra, the tube that carries urine from the bladder out of the body. That means prostate problems can affect urination and sexual function.

The prostate is prone to three main conditions: Prostatitis: infection or inflammation of the prostate; Benign prostatic hyperplasia (BPH): aging-related enlargement of the prostate gland; and Prostate cancer: the growth of cancerous cells inside the prostate, which may break out of the gland and affect other parts of the body.

Prostate function - What does my prostate do?

Your prostate plays a key role in reproduction. Although it’s the testicles that produce sperm, the prostate (along with tiny neighboring organs called seminal vesicles) helps produce semen—the viscous fluid in which sperm travel. Sperm owe to the prostate their ability to survive after they enter the vagina: The prostate lends to semen an alkaline quality that neutralizes acids in the vagina that would otherwise be deadly.

Here’s what happens when you ejaculate. Within the prostate, a series of ducts lined with fluid-producing cells pushes prostatic fluid out into the urethra (the tube that carries urine from the bladder) where it joins both the sperm produced by the testicles and the fluids generated by the seminal vesicles (narrow glands located on each side of the prostate).

For your prostate to function properly, it needs the right levels of hormones from three other glands in your body: The adrenal glands, which rest on top of your kidneys, the testicles, which produce testosterone; and the pituitary gland, located at the base of the brain.  

The prostate consists of two lobes, right and left, and it’s wider at its base. Counterintuitively, the base of the prostate is higher up in your body, where the gland nestles against the bladder. The “apex” is the lower end, closer to the rectum. Between the apex and the base lies the mid-gland. These terms are important in discussions about prostate cancer, since the area of the prostate in which a cancer appears can affect symptoms, treatment options and outcomes. Apex-sited cancers are hard to remove without damaging the muscle that controls urination and the blood vessels and nerves (called neurovascular bundles) that help you get erections. If a cancer is at the base of the prostate, it may spread into nearby tissue, including the seminal vesicles. 
prostate bladder

What are common prostate problems?

Unfortunately, most men will experience some kind of prostate problem during their lifetime. The effects of these problems can range from mild inconvenience to life-threatening cancers. Prostate problems are generally associated with three conditions: prostatitis, BPH, and cancer.

Prostatitis refers to an inflamed prostate. Men with this condition often experience pain or burning when they urinate, an increased urge to urinate, difficulty emptying their bladders, painful ejaculation and pain in the perineum or lower back. Prostatitis cases are divided into four categories depending on their causes and symptoms: acute bacterial prostatitis; chronic bacterial prostatitis; chronic nonbacterial prostatitis; and asymptomatic inflammatory prostatitis.

Benign Prostatic Hyperplasia (BPH), commonly called “enlarged prostate,” refers to the excessive growth of the gland that usually occurs after age 50; it can double or triple in mass during the latter decades of life. BPH is not caused by cancer (though it can occur alongside it), and should be considered an expected part of the aging process for most men. About half of cases are asymptomatic, but some men will experience problems in their lower urinary tracts. As the prostate expands in size, it effectively pinches off the urethra (the tube carrying urine from the bladder to the penis), making the muscular walls of the bladder have to work harder and causing problems with urination.

As with other cancers, prostate cancer is the abnormal growth of cells. Prostate cancer can either be localized (limited to the prostate itself) or regionally advanced, meaning it has spread to surrounding tissue. Recent years have seen great advancements in prostate-cancer screening, testing and treatment, including new hormone therapies as well as the ability to treat the disease at the genetic level and to harness the body’s own immune system to defeat cancer. Survivability statistics continue to trend upward.
 

What causes prostate problems?

While some prostate problems can be traced to infections, it’s usually difficult, if not impossible, to nail down the exact causes of most such illnesses. Instead, it usually makes sense to talk about risk factors rather than causes. For example, age, poor diet and race have been associated with some prostate problems but cannot be said to cause them outright. 

Around 5-10% of cases of prostatitis, or an inflamed prostate, are clearly attributable to easily detected bacteria. But as for the remaining 90-95% of cases, what causes them is hard to say. One possibility is that the immune system mistakenly targets the prostate, blasting the gland with inflammatory compounds. Another possibility is bacterial or fungal infections that go undetected by standard testing methods. Certain foods may also trigger symptoms, as might stress and depression, chronic pain conditions, trauma to the genitourinary area, and repeated biopsies.

By far, the greatest risk factor for benign prostatic hyperplasia (BPH), or enlarged prostate, is age. However, prostatitis, a sedentary lifestyle, obesity, high blood pressure and diabetes have all been associated with the condition. And researchers have found correlations between BPH and a diet high in sugar, red meat and refined grains.

No exact cause of prostate cancer has been identified, although genetic defects (either inherited or uninherited) play a key role. Age is an important risk factor, as is family history: Men whose fathers or brothers had prostate cancer are two to three times likelier to get it themselves. Race appears to matter, as well—rates among African Americans are 60% higher than in white men. A diet high in red meat and saturated fats has been associated with increased risk, and obesity is a separate risk factor. Some studies suggest that men who ejaculate infrequently are at higher risk.
 

Who develops prostate problems and how common are they?

Most men who live into old age will develop some form of prostate problem, although symptoms can range from mild inconvenience, like having to get up during the night to urinate, to invasive cancers that can cause debilitating changes or even death. 

Between 9% and 16% of men develop prostatitis (inflamed prostate) at some point during their lives. Unlike other prostate problems, prostatitis affects younger and older men equally. Each year, prostatitis leads to nearly 2 million doctor visits in the US. Men suffering from depression, anxiety and stress may struggle more with prostatitis symptoms, and men with other chronic pain conditions may be more susceptible. Prostatitis is not contagious or sexually transmitted.

Benign prostatic hyperplasia (BHP),or an overgrown prostate, is extremely common in older men. Although the majority of men with the condition (50-60%) never develop symptoms, the remainder seek treatment for a range of problems that may include a weak urine stream, leaking and dribbling, and a dangerous inability to empty the bladder. These symptoms are caused when the enlarged prostate effectively constricts the urethra, the tube that carries urine from the bladder.

In 2020, around 191,130 men were diagnosed with prostate cancer, with more than 33,000 dying from it, making it the second leading cause of cancer deaths among men in the US. Still, 98% of men survive for 10 years after diagnosis and 96% survive 15 years. Nine out of 10 cases are diagnosed early enough to achieve a nearly 100% five-year survival rate. Nearly a quarter of men with aggressive prostate cancers have defects in certain inherited genes. The median age for diagnosis is 66, with cases rarely occurring in men under 40, and tapering off after age 75. African Americans are at greater risk for prostate cancer than any other group in the US.
heath and inflamed prostate

What are the symptoms of prostate problems?

Prostatitis (inflamed prostate) is characterized by a group of symptoms including frequent urge to urinate, burning and pain during urination, inability to empty the bladder, pain or difficulty ejaculating, and pain in the pelvis, lower back or perineum (the area between the scrotum and the rectum). Prostatitis caused by bacteria entails symptoms typical of infections, such as fever, chills, fatigue and muscle pain. Some men report a feeling of fullness in the rectum, and blood may appear in the semen. Some forms of prostatitis can cause spasming of the pelvic-floor muscles. Although not an observable symptom to the patient, prostatitis can increase blood levels of prostate-specific antigen (PSA).

The hallmark of BPH (benign prostatic hyperplasia, or enlarged prostate) is a cluster of symptoms known by the acronym LUTS (lower urinary tract symptoms). They include a weak, interrupted urine stream, more frequent urination (especially during the night), frequent urge to urinate, leaking or dribbling, and the feeling that you can’t quite empty the bladder. Over time, those symptoms may escalate to the point that the bladder can no longer push urine past the obstructing prostate, causing what’s known as acute urinary retention. The bladder may undergo structural changes that prevent it from adequately collecting urine from the kidneys. An inability to urinate at all is not just painful but a true medical emergency.

Most prostate cancer diagnoses do not come from patients reporting symptoms but rather from blood tests that show high PSA levels, followed by biopsy. Patients with low-risk, non-aggressive cancers typically experience no symptoms at all. However, their cancer should be monitored to make sure it doesn’t grow and become more difficult to treat. When men do notice signs of cancer, those symptoms tend to be difficulty urinating or bone or back pain because the cancer has spread.
 

When to see a doctor if you have symptoms?

Talk to your doctor if you experience any of the lower urinary tract symptoms (LUTS), which include a weak urine stream, increased urgency to urinate, inability to void the bladder completely, and more frequent urination. Other symptoms that should prompt a doctor’s visit are pain during or after ejaculation, blood in the semen, and pain around the base of the penis, the perineum, the lower back or the rectum. With your doctor, you’ll want to weigh the risks versus the benefits of treatment. A major consideration is the extent to which your symptoms are interfering with your lifestyle. For example, if you work in an office or need to travel frequently, then having to use the bathroom often is probably disruptive to your lifestyle in a way that it wouldn’t be if you were retired or worked from home. If your symptoms prevent you from engaging in enjoyable activities or if they’re noticeably worsening, discussing treatment options with your doctor is wise.

You can gauge the severity of your symptoms by completing a simple, seven-question, multiple-choice questionnaire to get what’s called an International Prostate Symptom Score (IPSS).  You’ll be asked questions such as, “Over the past month, how often have you had to push or strain to begin urination?” and, “Over the past month, how often have you had a weak urinary stream?” Based on your responses, you’ll be able to tally up an overall score. If yours falls in the range of moderate to severe, you should talk to a doctor about treatment.

If you are unable to urinate, you’re experiencing a medical emergency and should seek prompt urgent care.

Unexplained pain—especially worsening pain—in the bones or lower back could be a symptom of an advancing prostate cancer, and should certainly prompt a doctor visit.
 

Do prostate problems cause other problems?

Thanks to the prostate’s immediate proximity to the bladder, urethra and rectum, prostate problems can have damaging effects on those other organs. For example, an enlarged prostate may encroach on the urethra and lower bladder, making it harder for the bladder to expel urine. As a result, the bladder may thicken and stretch, impeding the kidneys from emptying into it. At the extreme, this can cause kidney failure. 

Chronic non-bacterial prostatitis may affect the entire pelvic floor, meaning not just the prostate gland but the system of muscles and nerves that support the bladder, the rectum and other organs involved in sexual, bowel and bladder functions.

Men with severe BPH (benign prostatic hyperplasia, or enlarged prostate) are at risk of frequent urinary tract infections, bladder stones and ruptured blood vessels in the urethra.

Sometimes the side effects of treatments for prostate conditions lead to other problems. For example, alpha blocker drugs prescribed against BPH can cause retrograde ejaculation, in which semen flows back into the bladder instead of out the penis. The same condition also sometimes affects men who undergo a procedure to correct BPH called transurethral resection of the prostate. BPH drugs such as finasteride and dutasteride can cause erectile dysfunction and even metabolic changes that raise diabetes risk.

Similarly, prostate cancer surgeries can lead to such problems as sexual dysfunction and urinary incontinence, and radiation can cause bowel problems. Hormonal therapy can cause hot flashes, loss of muscle mass, and breast enlargement, and may increase the risk of heart disease, liver disease, diabetes and cognitive decline. Bone disease is both a side effect of hormonal therapy and a result of metastasized cancer. And chemotherapy is associated with a host of problems including hair loss, loss of fingernails and toenails, fatigue, nausea, mouth sores, infertility and digestive issues.
 

prostate resectoscope

How can I prevent a prostate problem?

Since the causes of most prostate problems are unknown, you should think in terms of lowering risk rather than preventing problems. Certain lifestyle considerations have been associated with lower risk of enlarged prostate and prostate cancer. These include maintaining a healthy body mass, exercising, and eating a Mediterranean-style diet.

One study found that men who ejaculated more than 21 times per month were 20% less likely to get prostate cancer than those who ejaculated four to seven times per month. 

Some research suggests that a class of drugs known as 5-alpha reductase inhibitors, which include the drugs finasteride and dutasteride, could lower risk of prostate cancer by inhibiting an enzyme that fuels tumor growth. However, while the drugs do seem to lower rates of low-risk cancers (and can be effective against benign enlarged prostate), some studies indicate they may have an opposite effect on more aggressive cancers. 

Although it’s not the same as preventing cancer, regular screening is the best way to ensure that if you do have it, you catch it early and vastly increase your chances of a good outcome. This is especially important if you have a family history of prostate cancer. The primary screening method is the digital rectal exam, in which the doctor inserts a lubricated, gloved finger into the rectum to feel the prostate for abnormal texture, swelling and lumps. 

Another screening method is the PSA (prostate-specific antigen) test. However, many conditions besides cancer might cause an elevated PSA score, so PSA tests often produce false-positive results. There are concerns in the medical community that PSA screening leads to excessive unnecessary biopsies and potential overtreatment. At any rate, it’s advisable to get a PSA test before you have any problems so that you and your caregivers will have a baseline score to compare to.


 

What is prostate cancer?

All cancers begin when cells somewhere in the body start to grow out of control. Prostate cancers get their start in the prostate gland and may spread from there to other body parts. When the cancer remains limited to the prostate, it is known as localized prostate cancer and is often treated with surgery or radiation. Localized cancer has the best chances for a good treatment outcome. 

Cancer that has spread from the prostate to surrounding tissue is called regionally advanced prostate cancer. It, too, can be treated using surgery or radiation, but may also be treated with a hormonal therapy called androgen deprivation therapy (ADT) to block production of testosterone, a key hormone for the promotion of cancer growth. In the past, doctors removed the testicles to block testosterone (castration); today, ADT serves the same purpose but is only temporary.

Doctors use the label “non-metastatic castration-sensitive prostate cancer” to describe localized cancers in which ADT treatment has caused levels of PSA (prostate-specific antigen) in the blood to fall. If the cancer remains localized after ADT yet PSA levels continue to rise, the cancer is dubbed “non-metastatic castration-resistant prostate cancer.” When the cancer has spread beyond the prostate but appears to respond to ADT, it’s called “metastatic castration-responsive prostate cancer.” And when ADT appears not to affect a metastasized cancer, doctors label it “metastatic castration-resistant prostate cancer.” 

Prostate cancers are further classified according to the stage of the disease, using the tumor-node metastasis (TNM) system. Its “T” categories range from Stage T1a, for low-grade localized tumors, to Stage T4, in which the cancer has spread to the bladder or rectum. In Stage N, the cancer has spread to the pelvic lymph nodes, and in the three substages of Stage M, it has metastasized to more distant parts of the body.
 

What is the main cause of prostate cancer?

No single cause of prostate cancer has been identified—nor can researchers conclusively state that any given factor causes the disease per se. But DNA-damaging chemicals in our environment likely play an important role, as do inherited genetic defects.

Radiation, chemicals and inflammation can all cause mutations to cells’ DNA. When the cells divide, the mutations are repeated and can produce prostate cancer. Such mutations occur within a man’s body after exposure to the stimulus and are not inherited.

Other genetic defects are indeed inherited from a man’s parents; these mutations are called germline defects. Two of the most common germline defects are found in the BRCA1 and BRCA2 genes, whose job is to repair damage to cells’ DNA. When the BRCA genes are defective, DNA damage inside cells can accumulate and form tumors. About 25% of men with aggressive prostate cancers have defective BRCA genes (more commonly BRCA2). BRCA genes are not alone, though—recent research has found 16 DNA-repair genes that may be implicated in prostate cancer. Other cancer-related germline defects include mutations to the ATM gene, which regulates cell growth; the HOXB13 gene, which is involved in prostate development; and the CHEK2 gene, which blunts the effect of testosterone on the growth of cancer cells.  

You can contextualize the importance of inherited genetic defects by considering the weight of family history as a risk factor for prostate cancer: A man with two or more first-degree male relatives (father and brothers) who have developed prostate cancer has five to 10 times greater risk than a man with no affected first-degree relatives.

While other factors (such as age, race, diet, obesity and exercise) no doubt contribute to a man’s overall risk profile, genetic defects are probably the strongest single predictor of who will and will not develop prostate cancer.
 

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