Men and their prostates

THE recent controversy about exorbitant surgical fees highlighted, as one of the chief offenders, robotically assisted laparoscopic prostatectomy, or “robotic prostatectomy” (as it is more colloquially quoted.

While this practice is quite rightly criticised in terms of cost, one can only hope that men don’t use this publicity as an excuse to ignore their prostate – especially with regard to the symptoms it can cause, not to mention the effect it can have on the quality of life of themselves and their partners.

Benign prostatic hyperplasia (BPH) is an age-related, progressive condition that is highly prevalent, with a significant negative quality of life and lifestyle-related impact on men. Prostate issues are a fact of life for men and are just as relevant now as they have been through the ages. From the times of the village elder passing a reed into the bladders (every morning and evening in the village square) of the men who could not void, to the “must-have” fashion accessory for the proper 19th century gentleman – namely, the walking cane, which often housed a catheter for those with an obstructed bladder – the prostate has exerted a significant burden on the day-to-day life of men.

The prevalence of BPH increases with age – 50% of men in their 50s, increasing to 80% of men in their 80s, have BPH. While not all men with BPH will experience symptoms, we do know that more than 30% of men older than 50 years of age will experience moderate to severe lower urinary tract symptoms (LUTS), two-thirds of those symptoms will be due to BPH. In turn, that means that more than a million Australian men have significant symptoms due to BPH. This, of course, allows that not all men with LUTS have BPH, but after 50 years of age, the majority do.

LUTS are usually considered in three broad categories: storage (frequency, urgency, nocturia), voiding (hesitancy, slow or interrupted stream) and post-micturition (dribble, incomplete emptying), and they can occur either singly or in any combination. It seems the storage symptoms cause a man much more bother than either voiding or post-micturition symptoms, but all tend to progress in both severity and bother even in the relatively short term. There is a significant impact on the quality of life of those men who have symptomatic BPH, and activities of daily living (such as driving, sport, sleep and social activities) are considerably worse in these men. It is not just the men themselves who are affected but also their partners and families, who experience an adverse effect on their relationships and quality of life.

There is solid evidence that BPH is a progressive disease. The prostate volume increases at a rate of just over 2% per year, which has an obvious corollary that the bigger the prostate, the more rapidly it grows. The symptoms increase, as previously stated, but the rate of deterioration also increases with age, hence increasing the impact at a time when the ability to adapt is lessening. The flow rate decreases equally with age, and while it causes less bother as an individual symptom to a man, once the flow rate falls below 12 mL/s, it is generally regarded as an indicator of bladder outlet obstruction, one step closer to urinary retention and surgery.

So, why should men have their prostates checked?

I am not going to reference prostate cancer in this article – though I would like to point out that not checking for prostate cancer does not influence whether you get it (and it could be the aggressive type), only when you find out about it!

We have a much better knowledge of the natural history of BPH, and most importantly, we do have many tools and methods at our disposal to ameliorate the symptoms of BPH, and perhaps prevent its progression. These techniques fall far short of any surgical intervention – usually the tantamount point of concern with most men regarding their prostate.

Many recent studies have confirmed and allowed a list of factors that all independently predict the clinical progression of BPH. These are:

• age 62 years;
• flow rate £6 mL/s;
• prostate volume 31 cc;
• prostate-specific antigen 6 ng/mL; and
• post-void residual 39 mL (usually extrapolated to 100 mL).

While we obviously do not need to refer to the above as exact determinants of intervention, in a man presenting with LUTS, or who wants to undertake some self-introspection, they are a good starting point.

Of far more importance, in my opinion, are the implications for general or total body health that may result from management of prostate symptoms. Mark Moyad, who works in the Department of Urology at the University of Michigan Medical Centre, has coined a wonderful phrase that is a truism, highlighting the potential benefits of addressing BPH issues in men: “heart healthy = prostate healthy”.

It seems that nearly all documented interventions or lifestyle changes beneficial for heart health can prevent, or lessen, the impact of some aspect of BPH and LUTS. So, adopting a behaviour that will have a positive effect on the prostate will have a probably more important benefit on the heart. Hypertension, higher caloric intake (especially fats), cardiovascular disease, metabolic syndrome (dyslipidaemia, waist circumference, blood sugar levels and blood pressure), lipid levels (low high-density lipoprotein, high triglycerides, high low-density lipoprotein) all have an adverse effect on BPH. Whereas moderate exercise, regular vegetable consumption, fibre and omega-3 intake and weight control are all beneficial. It has also become well documented that male sexual function and BPH are related – the higher the prostate symptom score, the more severe the erectile dysfunction. Phosphodiesterase type 5 inhibitors (PDE5is) have been found to have a beneficial effect on LUTS due to BPH – tadalafil is approved by the Therapeutic Goods Administration for this indication.

We also have a number of drugs that can effectively relieve LUTS, with only small side-effect profiles (most commonly, sexual dysfunction and dizziness). a-Blockers work rapidly and well to bring symptomatic relief to men with LUTS due to BPH. The addition of a 5-a-reductase inhibitor (5ARI) can lead to a 30% reduction in prostate size and a significant decrease in the chance of BPH progression. Combination a-blocker and 5ARI is a Pharmaceutical Benefits Scheme-listed therapy. We know that the addition of an antimuscarinic medication to any of the above combination of drugs is effective in relieving residual storage symptoms without significant additional side effects. Likewise, introducing a PDE5i, especially in the presence of erectile dysfunction, is a welcome addition.

So, men should be encouraged not to ignore their prostate. There are lifestyle and behaviour modifications that can prevent and alleviate symptoms, with substantial general and cardiac health benefits in addition. Numerous medications are available that can also provide effective relief of LUTS due to BPH.

BPH is not an automatic one-way street to a surgical intervention, whether it be a traditional transurethral resection of the prostate-based technique (electrocautery, bipolar or laser) or ablative “trend” techniques that use energy sources such as microwave, radiofrequency or steam.

The take-home message is “heart healthy = prostate healthy”.

Associate Professor William Lynch, MB BS MMed MSc FRACS FRCSEd (Hons), is a Fellow of the Royal Australasian College of Surgeons and Associate Professor of Urology at Macquarie University.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.

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