Managing your prostate

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On 09 Sep, 2023, Seniors Today hosted their weekly Health Live Webinar with Dr Prakash Sankapal who spoke on and answered questions about prostate management in seniors and dealing with prostate cancer.

About Dr Prakash Sankapal:

Dr Prakash Sankapal is an MBBS from KIMS, Hubballi, Karnataka, and has done his MS in General Surgery. He specialised in MCh Urology from the prestigious Grant Government Medical College and Sir J J Group of Hospitals, Mumbai. He has also completed his DNB Urology.

He was selected for the Olympus International Travel Fellowship conducted by the Urological Society of India (USI), in 2020-21. He also attended and presented a paper at the 18th Urological Association of Asia (UAA) Congress in conjunction with 72nd Annual meeting of the Korean Urological Association (KUA) – Seoul, South Korea.

He aims to use his expertise and knowledge to serve his patients. His areas of expertise included endoscopic procedures like URSL, PCNL, TURP, TURBT, RIRS, HOLEP, minimally invasive, open, reconstructive surgeries, etc.

September is marked as Prostate Cancer Awareness month.

Urology is a super specialisation which includes the diseases of the male and female genito- urinary tract and their management.

This urinary tract of the male encloses the kidney, ureter, bladder, as well as the male reproductive system- prostate, seminal vesicles and testis.

There is a confusion on the subject of whom to consult- a urologist or a nephrologist.

Urologists deal with and treat the surgical aspect of the urogenital which affects the renal/ urinary system- such as cancers, stones in the kidney, ureter, bladder. Urologists also deal with male infertility in men and prostate diseases.

Nephrologists on the other hand deal with the medical conditions which affect the kidney and renal system such as renal nephropathy, hypertensive nephropathy. Individuals who have a deranged urea/ creatinine should consult with a nephrologist.

The prostate is a small walnut shaped gland which is present between the bladder and urethra. It surrounds the urethra and produces a fluid that transfers the sperm during ejaculation.

Till 50 years of age, the weight of the prostate is 18-20 gm

After 50 years of age, as the age increases, the size of the prostate gland also increases.

This increase in the size of the prostate is called Benign Enlargement of the Prostate or (BPH) Benign Prostate Hyperplasia.

Since the prostate is positioned just below the bladder, and it also encompasses the urethra all around, when it increases in size, it causes lower urinary tract symptoms. These symptoms can be:

1. Voiding symptoms

– Thin stream

– Poor flow

– Intermittency of flow

– Strain while passing urine

– Sense of incomplete voiding

2. Storage symptoms- these can be secondary to bladder issues

– Increased frequency

– Urgency

– Nocturia

– Dribbling after passing urine

– Some patients may also present with overflow incontinence

When a patient presents with any of the above symptoms, he is evaluated clinically. If the patient is over 50 years of age, the clinical evaluation is done using digital per rectal examination wherein the following points are noted, examined and looked for:

• Size of the prostate
• Structure and the surface of prostate- if it is smooth, rough, hard or has any nodules

Blood investigations are also done- PSA (Prostate Specific Antigen) is done for screening of prostate cancer.

The recommendation is for a male, over 50 years of age to undergo PSA annually.

Urine routine, microscopy and culture tests are also done to rule out any urinary tract infection

Urine flow test/ Urine Flowmetry is a test where in the patients flow of urine is checked- whether it is normal or abnormal.

For this investigation, the patient has to pass urine/ void in a special commode once he has reached the sensation of full bladder. Once the patient urinates, there is a graph which is generated.

Ideally, a normal graph is bell shaped.

If the flow is reduced/ obstructed/ abnormal it is represented in the graph accordingly.

Ultrasonography (KUB)- to know better about the size of the prostatic enlargement, post void residue (the amount of urine the patient retains even after evaluating his bladder), bladder wall thickness.

Treatment for prostate enlargement can be

1. Medical treatment- this is operated for the prostate and bladder.

For the prostate, drugs are given to relax the bladder neck and to shrink the prostate size.

For patients with issues with the flow and other lower urinary tract symptoms- alpha blockers is the class of drug which is prescribed

For patients with a significantly enlarged prostate- 5- alpha Recuctase Inhibitors is the class of drugs prescribed.

For patients with storage symptoms- bladder muscle relaxants are advised- anticholinergics/ beta agonists

In case the patient does not get the symptoms treated, it can cause:

– More urine retention and back flow of urine into the kidneys, leading to obstruction- causing increased creatinine, renal failure, etc.

– It can also lead to diverticulum formation.

– Recurrent UTIs

• Bladder stones

2. Surgical treatment: this should be sought when:

• Prostate enlargement is causing urinary retention.
• Recurrent episodes of blood in urine (hematuria) due to the enlarged prostate
• Recurrent UTIs
• Bothersome voiding symptoms which are not relieved after taking medication
• Bladder stones
• Diverticulum
• Renal insufficiency

Surgical procedure done for an enlarged prostate is called TURP (Trans- Urethral Resection of the Prostate)- most commonly done procedure for elderly male with clear indications for surgery.

If the size of the prostate is more that 150gms, HOLEP is the procedure performed- this is laser surgery for prostatectomy. This can be done up to 300 gms of size with very few complications.

Tips for a healthy prostate:

• Empty the bladder properly and completely
• Avoid water and fluid intake 2 hours before bed time
• Avoid alcohol and caffeine
• Avoid cold climates- cold weather can cause contraction of the bladder leading to increased frequency in passing urine
• Comply to the medications, if and whenever prescribed

The most commonest cause for/ risk factors for  Prostate Cancer include:

• Obesity
• Age
• Family history
• Lower levels of Vit D
• Repeated attacks of prostatitis
• Elevated levels of testosterone

Prostate cancers can present to the hospital with the following symptoms:

• Majority of the times, in the early state, the patients might not have any symptoms
• Blood in urine
• Symptoms of enlarged prostate
• Urinary retention

Investigations:

• Clinical evaluation using digital per rectal examination
• Trans rectal ultrasound
• Biopsy
• PSA screening blood test (Normal values- 0-4 mg/dL; Borderline: 5-10mg/ dL; High Suspicion: >10mg/ dL)
• Trans Rectal Ultrasound guided Biopsy

Possible treatment measure:

Depends on the PSA value, the score on the biopsy and the stage of the prostate cancer.

Options available include-

• Active surveillance- PSA< 10mg/dL, age- 80-85 years, healthy male, early stage
• Prostate surgery, like radical prostatectomies with lymph node dissections- early stage, confined to the prostate
• Radiation therapy after surgeries
• Hormonal therapies
• Chemo and immunotherapy