More men know about the function of the ovary than they do the position, purpose and possible complaints of their own prostate gland. Liz Gill clears some of the clouds of ignorance and embarrassment.
When Francois Mitterrand, the French president, went into hospital a few days ago for an operation on his prostate gland he was sharing an experience common to 30,000 Britons every year, as well as at least one of his predecessors Charles de Gaulle and Ronald Reagan and Lord Wilson.
Yet despite its prevalence, prostate disease is still surrounded by ignorance and either concealed altogether details of M Mitterrand’s operation were released only after rumors started to spread that he was dying or referred to euphemistically as “a spot of trouble with the waterworks”.
As Clive Gingell, consultant urologist at Southmead Hospital in Bristol, says: “People seem to know almost nothing about it. I even had the proofs of an article returned to me recently with prostate corrected to `prostrate’. Not only do we not know where it is or what it does, we don’t even know how to spell it.
“The symptoms can be very embarrassing, but sometimes men think they are just a normal part of aging, and adjust their lives accordingly. The trouble is that as the years go by and the symptoms worsen they have to make more and more adjustments. They really become slaves to their bladders. It’s only after they’ve had treatment that they realize just how bad it had become. It can be very rewarding to treat because patients are often like new men afterwards.”
Mr. Gingell was one of the speakers at yesterday’s launch of Better Prostate Health, a campaign aimed at raising public awareness of the gland which lies at the base of the male bladder, surrounding the urethra, and which produces vital fluid to help transport and nourish sperm. With a grant from the pharmaceutical company Merck Sharp and Dohme, the campaign organizers plan to distribute posters and leaflets to health centers and chemists. They have also produced a video and set up a telephone information line with Hilary Jones, the GP who broadcasts on medical matters for TV-am.
“I feel it’s time we focused more attention on men’s health,” Dr. Jones says. “A recent Mori poll found that men know less about their own bodies than they do about women’s. For instance, 87 per cent of men know the function of the ovary. But only 32 per cent know about the prostate gland.
“At the same time men are very reluctant to visit their doctor. But although the campaign is about men’s health we know that educating women is just as important. It’s the men’s wives or partners who often finally succeed in encouraging a visit to the GP for help.”
The most common condition is benign prostatic hyperplasia (BPH), which could affect up to 2.4 million men in the UK, or one in three aged between 50 and 79, according to a study carried out in Stirling by Edinburgh University. The study also found a wide disparity between the number of men troubled by symptoms and those who actually consulted a doctor. Even those who did seek help had frequently had the symptoms for a year or more.
In BPH the prostate normally the size of a chestnut enlarges, sometimes to the size of an orange, gradually narrowing the urethra, the channel through which urine passes to the outside, and leading to difficulties in urinating. Symptoms include impairment of the size and force of the urinary stream; difficulty in starting, interruption of the stream and dribbling afterwards; a frequent need to urinate; a feeling of urgency; a sensation that the bladder has not been emptied.
The symptoms tend to be troublesome rather than painful unless the enlargement is so severe as to lead to urinary retention an inability to pass water at all which is what led to M Mitterrand being rushed to hospital.
Roger Kirby, consultant urologist at St Bartholomew’s Hospital in London and author of a book on BPH out next month, says “A lot of men do let it get to this stage. We still get five or six such cases a week. Bladder disturbances can really affect quality of life. Sufferers can be obsessed, they become expert in toilet logistics and become panicky if there isn’t one nearby. You hear wives say their husbands cannot drive for more than an hour or they have to keep getting up in the night and disturbing them. Yet the men are often afraid to seek help because they are embarrassed or worried about the stigma of incontinence. Or they think they’ve got cancer or they are worried that they’ll have to have an operation.”
In fact, although the trans-urethral prostatectomy (removal of the prostate gland through the urethra) is still a common procedure, there is increasing interest in medical and other alternatives. Drug treatment may use alpha blockers which relax the smooth muscles in the gland, or Proscar, which shrinks it. Mr. Kirby often uses both in combination as an alternative to or a way of postponing surgery. However, alpha blockers are not suitable for men with low blood pressure as they can cause fainting. Other alternatives include stretching the urethra by inflating a balloon-like device inside it, although this is not considered very successful in most cases; or inserting metal “stents”, or springs, into the urethra to hold it open (the drawback here is that they encourage the formation of stones); heating the gland with hyperthermia, using microwave energy to kill the portion of the prostate immediately adjacent to the urethra (the process is expensive, with machines costing up to Pounds 400,000); or using lasers to vaporize or shrink the gland.
“There is a lot of enthusiasm for and interest in these alternatives because the problem is such a common one that patients do not want surgery if it can be avoided,” Mr. Kirby says. “What you get, though, depends on where you live whether you are near a big teaching hospital for instance or whether you can go private: they are keen to try these new things. At the same time the risk-benefit ratio of these new treatments still needs careful evaluation.”
Surgery usually involves the removal of about a third of the prostate in a procedure where a cutting loop is pushed down the urethra and the enlarged tissue pared away and washed out. The risk of dying from the operation within 90 days is about 1.5 per cent, mainly because, Mr. Kirby says, it is performed on a lot of very elderly men who often have other diseases as well.
The other drawback is that surgery interferes with the neck of the bladder, rendering it incapable of shutting off during ejaculation. The likely result is that the patient will suffer retrograde ejaculation afterwards when sperm remain within the bladder instead of leaving the penis.
However, the ability to have an erection is not usually lost, nor the sensations of orgasm, although fertility is likely to be substantially impaired. “You get occasional cases of impotence,” Mr. Kirby says, “although this is more likely to be psychological rather than physical.”
Tissue that is removed during the operation is checked for signs of malignancy, which are found in about 10 per cent of cases as they have been in M Mitterrand’s.
Prostate cancer is the second most common cancer among men in this country and claims about 8,000 lives a year. Treatment is either palliative, or involves radiation, drug therapy or surgery: a radical prostatectomy involves the removal of the whole gland. “It is a big operation which means impotence and infertility and would really only be countenanced to save the life of a young man with a localized cancer,” Mr. Kirby says.
As tumors require supplies of the male hormone to sustain them, sufferers are sometimes given chemical or physical castration.
Nobody knows what causes prostate disease, which seems to be slightly on the increase although this may be due to increased longevity. Environmental and lifestyle factors may play a part.
At the moment there is much debate, particularly in America, over the value of screening: earlier discovery increases the likelihood of cure. “Prostate cancer is very unusual in men under 50,” Mr. Kirby says, “but quite common in the over-sixties. A man of 60 will not consider himself old, and he may well expect to live another 15 years or so, but screening involves blood tests and rectal examinations and would cost time and money.”