Overcoming the #1 prostate problem

Promising new medical options can beat this common scourge of men over 50

Most men have never heard of it. A lot of men suffer because of it. If you're a man over 50, you've got it. And if you're under 50, you'll get it soon enough.

It's BPH--what doctors call benign prostatic hyperplasia, an enlargement of the prostate gland. It's inevitable, and it sometimes means trouble. But even when it does, there are effective treatments that give relief, including some brand-new therapies.

You may not have heard much about this particular prostate problem because for the first 50 or 60 years of your life, your prostate--this walnut-sized gland below the bladder--behaves like a gentleman. Its only known function is to secrete a fluid-and-enzyme mixture that helps keep sperm healthy and mobile on its way to the egg. As middle age sets in, the prostate still does its duty, but parts of it start to enlarge--BPH arrives. It's not cancer, but it can be almost as serious.

More than half of all men over age 50 have significant enlargement of the prostate; the others have at least some enlargement. This excess growth can cause problems because of the gland's strategic location. It surrounds a section of the urethra, the tube that drains the bladder. The inner core of the prostate is where most of the growth takes place--slowly clamping down on the urethra. In advanced cases, an enlarged prostate can completely block the flow of urine.

The early symptoms of BPH include frequent urination, often accompanied by a sense of sudden urgency. When this happens at night, it's known as nocturia (nock-TOOR-ee-uh). Some men wake up to urinate three, four or more times before morning. A hesitancy or delay in starting the flow and a weak or intermittent stream of urine could also indicate prostate problems. A feeling that the bladder is still partly full after going to the bathroom is also common. Some of these symptoms can indicate other urinary-tract problems, but in men over 50 they most often mean enlargement of the prostate.

Why does the prostate enlarge? "Good question. We don't really know," says Robert P. Huben, M.D., chief of urologic oncology at Roswell Park Cancer Institute, in Buffalo. "Most researchers think that a hormone triggers this unwanted growth. But we don't have enough solid evidence to say more than that it happens as you age, and there doesn't seem to be a way to stop it."

There are, however, men with very large prostates who never complain of serious symptoms. "The fact is, not everyone needs treatment," says Reginald C. Bruskewitz, M.D., professor of surgery at the University of WisconsinMadison. "Virtually all 80-year-old men have some prostate enlargement. But only three out of four notice a problem. Two may begin to wonder if they should seek treatment, and only one of them will actually need something done."

So the questions every man over 50 must answer for himself are not "if," "when" or "how much" his prostate will enlarge, but whether this enlargement bothers him enough to have it corrected and what's the best way to do this. We talked to some of the top urologists in the country to give you an overview of the standard treatment and the latest experimental alternatives. If you're having prostate problems, your urologist can help you decide the best course for you.

STATE-OF-THE-ART SURGERY
Right now, the standard BPH therapy is an operation called transurethral resection of the prostate, known as TURP. About 90 percent of patients treated for BPH currently undergo a TURP--that's around 400,000 operations each year. It's the second most common procedure paid for by Medicare, topped only by cataract lens-replacement.

It's a crude analogy, but TURP is sort of a Roto-Rootering of the prostate. The procedure is made possible by a thin, hoselike device called a resectoscope, similar to the versatile arthroscope used to perform knee surgery on professional athletes. Under local or spinal-block anesthesia, a physician slides the resectoscope through the urethra until it reaches the prostate area. Then, after penetrating the urethral wall, an electric loop at the end of the scope cuts away the surrounding prostate tissue.

Sounds uncomfortable to say the least, but the aftermath of this operation really isn't too bad. "They gave me pain pills in the recovery room, but I didn't feel I needed them," says Robert, age 68, a semiretired oil-well-drilling contractor. Like most men who undergo TURP, Bob had to stay in the hospital for two days after surgery. The main reason: His bladder had to be drained through a catheter while his urethra began to heal. After getting out of the hospital, Bob had some minor discomfort for a few days, and he noticed some blood spotting--all to be expected. He also had to avoid abdomen-straining activities for a month--no heavy lifting, bicycling or even golf.

One major advantage of TURP is that most of the benefits are immediate. "Overall, I'm very pleased with the results, especially during the day. I can sit at my desk till noon without having to go to the bathroom . . . unlike before," says Bob. The operation hasn't helped him much at night. "I still have to get up as many as four times a night," he reports. We spoke to Bob about two months after his operation. Since doctors say it can take up to three months to see all the results, good and bad, Bob has the potential to improve slightly.

"About four out of five TURP patients respond favorably to the operation," says Joseph E. Oesterling, M.D., assistant professor of urology at the Mayo Medical School and a consultant in urology at the Mayo Clinic in Rochester, Minnesota. But the unlucky fifth guy isn't significantly helped or may have serious side effects. About 2 to 4 percent of patients lose control of their bladder. Five to 10 percent become impotent. And some side effects cause the very problems the surgery is supposed to relieve: 3 to 5 percent of all operations result in major scarring or narrowing of the urethra, which can slow urine flow, and 2 to 3 percent result in narrowing of the bladder opening, potentially causing urinary retention. Bob noticed a minor problem with retention and a stinging sensation when he was urinating. His doctor found some minor scarring, which he successfully opened up.

The most common side effect of TURP is "retrograde" ejaculation, in which little or no fluid comes out of the penis during orgasm. It isn't dangerous, and it doesn't interfere with the sensation of male orgasm. But it does take some getting used to. It happens because the tubes carrying sperm from the testicles empty into the urethra. During a normal male orgasm, one end of the urethra--the opening to the bladder--slams shut, leaving the other opening through the penis as the path of least resistance. But in 75 to 80 percent of cases, after TURP operations the bladder neck doesn't close completely during orgasm, according to Dr. Oesterling. The semen now can take two paths, and some or all of it shoots into the bladder, which is closer. This condition, of course, causes infertility, but most men in their 50s and above aren't planning any additions to the family anyway.

"Despite its side effects, TURP is good for men with significant prostate obstruction," says Richard D. Williams, M.D., chairman of urology at the University of Iowa in Iowa City. TURP was introduced as a less-invasive alternative to open prostatectomy, which basically removes the same tissue as TURP but requires general anesthesia and an abdominal incision. Open prostatectomy is still performed in about 6 percent of cases--most commonly when the prostate gets too large (over five times its normal size) for TURP to be done rapidly and safely.

"About 25 percent of men seeking treatment need surgery immediately. When they do, it's usually for dangerous conditions like severe urinary retention, bleeding or rampant infection," says Dr. Bruskewitz. "That doesn't mean the other 75 percent don't need some treatment. But many with moderate problems have the option to wait and see."

Indeed, one alternative under consideration is called "watchful waiting." That means doing nothing--but under a doctor's care to monitor changes in condition. "Because we've been quick to treat the problem in the past, we don't know the precise natural course of the disease. Just seeing a doctor for an exam can make many patients improve," says Dr. Williams.

How many? "Studies suggest that 30 to 50 percent of patients with mild or moderate symptoms improve on their own over three to five years," reports Dr. Oesterling. "Another 20 to 25 percent of those patients remain stable. The rest get worse."

A LOW-TECH OPTION
It makes sense to evaluate less traumatic alternatives for men in the early stages of BPH. Most of the new treatments under investigation have shown early promise. Will they match the long-term success rate of TURP? The bottom line is that we don't know just yet. To find out, the American Urologic Association, the U.S. government's Agency for Health Care Policy and Research, and even the World Health Organization are evaluating these treatments right now. These alternatives are safe and available at many medical centers.

One surgical alternative to TURP is faster, simpler and approved by the Food and Drug Administration. It's called transurethral incision of the prostate. And it's exactly that: One or two incisions are made through the prostate with a resectoscope. The gland splits to each side, relieving pressure on the urethra.

How well does it work? In most cases, it relieves symptoms of difficult or frequent urination dramatically. "I can urinate like a kid again, and my frequent trips to the bathroom are decreasing. That's good after only a month," says Russell, a 72-year-old former high-school counselor. After the operation, Russell had to stay at a hospital overnight attached to a urine catheter, but that beats the two- to three-night stay of most TURP pa-tients. And pain? "They gave me two pain pills that night, so I felt nothing. The next day I was bothered a bit where they'd injected the spinal-block anesthesia for surgery, but otherwise I felt O.K.," he says.

One of the most dramatic improvements of the incision procedure is a much lower rate of retrograde ejaculation--only around 15 to 20 percent are affected. There isn't much data on other side effects, but many doctors think they, too, are probably lower. "Simple incision of the prostate is a grossly underused procedure. Many patients could benefit from it," Dr. Oesterling says. Incision isn't considered the best choice for greatly enlarged prostates, but it has the potential to become a standard procedure for early prostate problems.

HIGH-TECH ALTERNATIVES
When is surgery not surgery? When it's performed with space-age technology instead of cutting. Two procedures currently under investigation strive for the same effect as TURP, but instead of removing prostate tissue, they destroy it and allow the body to eliminate it gradually.

Both techniques--one using a laser, the other using a microwave probe--can be done on an outpatient basis. The newer procedures may be speedy, but the results are slow to be seen. TURP and incision patients see dramatic improvement almost immediately; laser and microwave patients see gradual improvement over a period of two to three months. The delay is caused by the slow rate of tissue elimination.

The microwave probe has been tested two ways: through the urethra and through the rectum. The rectal approach doesn't seem to be as effective. The latest urethral probe is called the prostatron. It has a cooling system that keeps the urethra from being damaged while the surrounding prostate tissue is heated to about 113 degrees F. The probe releases microwaves that destroy tissue. The tissue is then slowly absorbed by the body. This one-time treatment can be done without anesthesia. The older probe without the cooling device requires 10 or more visits to achieve the same effect.

Though it may sound wonderful compared with surgery, the microwave operation is still under investigation. "In our initial trial, 27 out of 30 patients had satisfactory results three months after the procedure. The FDA has approved further trials," reports Charles McKiel Jr., M.D., chairman of urology at Rush Medical College, in Chicago. The continuing study will look at side effects as well as effectiveness.

The laser operation currently has more supporters, probably because lasers are more common in medical technology. The absolute latest thing in laser treatment is called TULIP, which stands for Transurethral Ultrasound-guided Laser-Induced Prostatectomy. The device that performs TULIP is rather complex. It combines a resectoscope-type tube with an inflatable balloon at the tip (to stabilize the device once it gets to the target), an ultrasound probe and a laser. The ultrasound image sent back from the probe helps the physician aim the laser more accurately. The laser beam shoots through the balloon and the urethra (without damaging either one) and heats the prostate tissue. As with the microwave procedure, burned tissue is slowly eliminated over the following weeks.

Chet had to wait nine months before his doctor got an official O.K. to try the laser. "It was worth the wait," says this 67-year-old, retired real-estate broker. "Although I was a little worried afterward. For the first three weeks I didn't see much improvement, but now--two months later--I'm able to `go' with no problem."

Like other forms of laser surgery, TULIP is less traumatic than a regular operation. Because Chet was one of the first patients to undergo the procedure at his hospital, he had to stay overnight with a catheter draining his urine. "One of the interns came in the next morning and was amazed by how clear my urine was. He said after the regular operation there's usually a lot of blood."

While both laser and microwave treatments are still under investigation, we can say a few things in their favor. The machines that perform these procedures are expensive, but they have the potential to cut health-care costs in the long run because they reduce or eliminate hospital time for the patient. More important, supporters of these technologies think they can provide the same relief of symptoms with far fewer side effects than TURP. But only the long-term experiences of men like Chet can provide proof of those suppositions.

DRUGS
Taking a pill once a day might sound more appealing than undergoing any type of surgery, but prostate problems don't disappear so easily. Still, two basic types of drug therapy have given some patients at least temporary relief from BPH symptoms. These drug options work either by relaxing the prostate muscle to relieve pressure on the urethra or by eliminating the hormones that stimulate the prostate to grow.

The muscle tissue of the prostate is very similar to the smooth muscle that makes up veins and arteries. Taking advantage of that similarity, some researchers are testing alpha-blocker drugs for BPH symptoms. Alpha-blockers are normally prescribed to reduce high blood pressure because they make smooth-muscle tissue relax. Apparently they can reduce prostate pressure as well, since about two-thirds of patients taking them show some short-term improvement.

Why do alpha-blockers seem to work? Researchers think that enlargement of the prostate gland may not be the major aggravating factor in all cases of benign prostatic hyperplasia. They theorize that spasmodic contractions of muscle within and surrounding the enlarged prostate may cause the symptoms in some men. Alpha-blockers don't shrink the prostate; they merely take the pressure off.

Alpha-blockers, unlike other drug options, work as quickly as surgery (in those people who respond). The major side effect is a slight lowering of blood pressure, which can lead to episodes of dizziness or sluggishness. There's also an increased risk of fainting, especially when getting out of a chair quickly. Dangerous lowering of blood pressure is very rare.

The second form of drug treatment shrinks the enlarged hormone-responsive areas of the prostate. The hormone in question is testosterone, which gives a man his sex drive. Testosterone also seems to stimulate growth in both benign and cancerous enlargements of the prostate. That's why drugs that block testosterone can be effective for BPH. Unfortunately, many of these drugs are the chemical equivalent of castration. The good news: Several newer drugs seem to spare the love lives of many users.

The most available of those new drugs is flutamide, which was approved by the FDA for prostate-cancer therapy. It works by blocking the prostate's testosterone receptors. This prevents the hormone from entering prostate cells, but doesn't decrease levels of it in the rest of the body, preserving sex drive. Does it work for BPH? "About one-third to one-half of men in preliminary studies had a significant decrease of symptoms after taking flutamide," reports E. David Crawford, M.D., chairman of urology and director of the prostate center at the University of Colorado.

One major problem with flutamide and most other hormone-blocking drugs is that they're slow. "They can reduce the size of the prostate by 25 to 30 percent, but it might take three to six months to do so," says Dr. Oesterling. Side effects of flutamide include diarrhea, breast tenderness and, in rare cases, liver toxicity.

Two European drugs similar to flutamide may hold promise, if they can get their green cards. Anandron, from France, is currently under FDA review as a potential prostate-cancer therapy. Casodex, from England, isn't under consideration yet but is a likely candidate. If the FDA permits their use on an investigational basis, their side effects and efficacy can be compared with flutamide's.

A different class of hormone blocker created a lot of excitement when it was announced last year, but most urologists are adopting a wait-and-see attitude until more data become available. Finasteride lets testosterone enter prostate cells, but inhibits its conversion to the active form of the hormone. Like flutamide, finasteride doesn't cause impotence. Better yet, the drug doesn't seem to have as many serious side effects as flutamide, and comes in a once-a-day dose. The drug's manufacturer is now running more trials.

The newest drug being tested for BPH is atamestane, yet another variety of hormone blocker. Most research so far has been performed on dogs and monkeys, whose prostates shrank 25 to 30 percent while on this drug. "The only human study to date to test this type of drug didn't evaluate it against an untreated control group," says Dr. Oesterling. "So we really don't know if it's effective." It reportedly doesn't cause any major side effects, at least in animals.

"Right now, all drug options are temporary measures," says Dr. Crawford. "But they can help the right patient at the right time." Chet was one of those patients. He was given a combination of prazosin (an alpha-blocker) and flutamide for almost nine months while awaiting laser surgery. (Most patients are given one or the other--rarely both.) "I would never have made it through those months of waiting without the medication," Chet reflects. "But I was sure glad to get the surgery because I was getting tired of taking pills."

`MECHANICAL' TACTICS
Two alternative therapies use mechanical means to open up the prostate-strangled urethra. They seem to have been borrowed from cardiovascular medicine. Both balloon dilation and springlike stents (devices normally used to hold open blood vessels) have been used with mixed success to expand cholesterol-narrowed arteries. Whether or not they will have more success as prostate therapies can only be determined by comparative clinical trials.

The balloon treatment is pretty straightforward: A catheter is passed through the urethra to the prostate area. Then a balloon at its tip is inflated (to about one inch) and kept in place for 10 to 15 minutes. The catheter is removed and that's that. No cutting, usually no hospital stay and no major side effects. It can be performed under local or spinal-block anesthesia. And unlike all the other new therapies we've discussed, the balloon procedure has the FDA's approval as a BPH treatment.

Sounds too good to be true? Perhaps it is since doctors aren't exactly sure how it works. It may just compress tissue and squeeze out extra fluid. Or it may break the muscular capsule surrounding the prostate, allowing it to expand without constricting urine flow.

More important, they're not sure how long it works. Only about 1 patient in 10 seems to have long-term success with this procedure. Many patients notice a return of symptoms within a few months to two years, and so require another bout with the balloon or some other procedure. For that reason, many doctors have lost their initial enthusiasm for balloon dilation. "I'd recommend it only as a temporary `time-buying' procedure for middle-aged men with mild to moderate symptoms, or for older men who might be too sick to undergo surgery," says Dr. Oesterling.

The intraprostatic stent seems to be a much more promising option, although it hasn't yet been approved by the FDA. It works simply by holding the urethra open-- sort of like reinforcements shoring up a tunnel. Stents are made of tubular metal mesh and are self-anchoring once they've been inserted. They're relatively easy to put in place (through the urethra, of course), and the implant takes only 20 minutes or less under local or spinal-block anesthesia. The patient can go home that day, or may have to spend one night in the hospital. Because the stent works the minute it's implanted, there's no need for a catheter to drain the bladder after the procedure. If a problem should arise, the stent can be removed--even months later.

"I'm extremely pleased with how well the stent has worked for me," says Willis, age 71, a retired researcher with the United States Department of Agriculture. "Now, no more `slow starts.' And instead of two or three nightly trips to the bathroom, I'm down to one."

Other advantages: Only about 25 percent of stent users experience retrograde ejaculation (as opposed to 75 percent of TURP patients). The device doesn't cause impotence or incontinence. Doctors in Europe report no problems with reblockage or infection. "The stent isn't perfect, but it seems to be very good based on our data," Dr. Oesterling says.

Many doctors consider the stent to be a first-rate option for older patients with heart or lung disease that would make surgery too dangerous. But Willis is on the other side of the coin: "I was told about surgery and the stent, and I opted for the stent because it meant less time wasted recuperating. I'm usually very active, and I didn't want to slow down for an operation," he says.

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OUR SOURCES: Reginald C. Bruskewitz, M.D., professor of surgery, University of Wisconsin, Madison; T. Ming Chu, Ph.D., chairman of diagnostic immunology research, Roswell Park Cancer Institute, Buffalo; E. David Crawford, M.D., chairman of urology and director of the prostate center, University of Colorado; Christopher M. Dixon, M.D., assistant professor of urology, Medical College of Wisconsin, Milwaukee; Robert P. Huben, M.D., chief of urologic oncology, Roswell Park Cancer Institute, Buffalo; Charles McKiel Jr., M.D., chairman of urology, Rush Medical College, Chicago; Joseph E. Oesterling, M.D., assistant professor of urology, Mayo Medical School, and consultant in urology, Mayo Clinic, Rochester, Minn.; Richard D. Williams, M.D., chairman of urology, University of Iowa, Iowa City.

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By Steven Lally

PROTECTING AGAINST PROSTATE CANCER
Most prostate tumors are first suspected during a standard digital rectal exam in a doctor's office.But a great number of cancers can remain unnoticed through years of screening. Since prostate cancer has virtually no symptoms in its early stages, it's easy to miss.

A simple, inexpensive blood test, however, may help bridge this deadly gap. It's called the PSA test, which stands for Prostate-Specific Antigen. PSA is normally secreted by the prostate, but the amount increases when cancer begins to form in the prostate. "There are detectable increases even in the early stages of tumor growth," says T. Ming Chu, Ph.D., developer of the PSA test and chairman of diagnostic immunology research at Roswell Park Cancer Institute, in Buffalo. "That can give the patient a head start on treatment once the diagnosis is confirmed."

The PSA test is far from perfect. "In up to one-half of men with a known early prostate cancer, the PSA can be normal (false negative). And one-third of men with benign prostate disease may have an elevated PSA level (false positive) but not have prostate cancer," says Richard D. Williams, M.D., urology department chairman, University of Iowa, Iowa City. Prostate cancer is generally quite slow to grow and spread, so some of the false negatives may be caught later on. But it's a worrisome statistic nonetheless.

Still, according to many experts, the PSA test is the most useful cancer marker yet discovered. Much of the controversy surrounding the test concerns its proposed use as a population-wide screening exam for men over 50. "That would be a waste of money," says Dr. Williams. "But selective testing of men at highest risk could be worthwhile."

And that selective testing should include men with enlarged prostate and an increased risk of prostate cancer, which includes having a family history of prostate cancer, being Afro-American or being older than 65.

The primary screening method recommended by the National Cancer Institute (NCI) is the digital rectal exam. The doctor simply checks the interior few inches of the rectum (and the prostate, which can be felt through the colon wall) with a gloved, lubricated finger. The exam is used to screen for cancers of the prostate, lower colon and rectum. The NCI recommends that all men over 40 have this exam done as part of a regular yearly check-up. There's a third screening method currently used in some hospitals to confirm a potential diagnosis of prostate cancer: It's an ultrasound probe that can detect cancers that may be missed in a digital exam. While it's fairly accurate, it's also expensive compared to the PSA test or digital exam and may err by finding areas that appear cancerous but are not.

Prostate cancer is the most common serious cancer affecting men. (Statisticians ignore skin cancer, which is overwhelmingly common but rarely life-threatening.) It's also one of the most curable: An average of 71 percent of prostate-cancer patients survive for more than five years after diagnosis.

If you have been diagnosed with prostate cancer--or with any other cancer--you can get information about the most up-to-date treatment options by calling the NCI's hotline: (800) 4-CANCER.

BACTERIAL PROSTATITIS: THE YOUNG MAN'S OBSTRUCTION
Prostate enlargement and its accompanying urinary obstruction generally happen only in men over 50. So what's going on if you're 25 and have the same symptoms of difficult or frequent urination? It could be an infection of the prostate, known in the medical world as bacterial prostatitis.

Bacterial prostatitis affects men of all ages. It's usually caused by the spread of infection in the bladder or urethra (the tube that drains the bladder). In addition to urination problems, the symptoms can include lower-abdominal pain and fever. "It's relatively easy to treat," says Christopher M. Dixon, M.D., assistant professor of urology at the Medical College of Wisconsin, Milwaukee. "Quinolones, which are broad-spectrum antibiotics, are currently considered the best drugs for the job." In most cases, symptoms improve in 24 to 48 hours, but it may take two to three weeks to resolve completely.

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