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Family Doctor Books
Preview of Understanding Prostate Disorders

What is the prostate anyway? Most people have heard of it, but have little idea what it is for, and many people don’t even know where it is. Indeed doctors and scientists don’t fully understand its functions, and there is still a lot to be learnt about the prostate and about the diseases affecting it.

The prostate gland lies just underneath the bladder. Glands produce fluid, and the prostate makes part of the fluid (called semen) released at the climax of the sexual act. The prostate needs hormones from the testicles so that it can work, and if these male hormones are low the prostate shrinks. The fluid from glands is made in the epithelium (layers of special cells called epithelial cells). In all glands the epithelium is surrounded by tissue called stroma. In the prostate this stroma contains muscle fibres, which can affect the symptoms produced by prostatic disorders. Both the epithelium and the stroma increase if the prostate enlarges. In addition, although the prostate looks like a single organ, it really has two different parts which are prone to different diseases.

Although this may seem a little complicated, it is helpful to understand the problems that the prostate can cause, and how they are treated, if it is pictured as consisting of an inner and an outer part (see below), both of which are made up of glands (epithelium) surrounded by tissue (stroma) containing muscle.

Close to the prostate are two important muscles called sphincters. These control the bladder, stopping it leaking urine. They also help to expel the semen at the climax of the sexual act. The muscle below the prostate, called the external bladder sphincter, is particularly important for preventing leakage of urine from the bladder.

Position of the prostate in relation to other organs in the lower part of the body.

Why does the prostate cause trouble?

As a man gets older, his prostate usually becomes larger. Most of this enlargement takes place after the age of 50, so it affects mainly older people. The fact that the prostate grows is not important in itself and, indeed, the trouble it causes doesn’t depend on its actual size. However, the prostate surrounds the tube from the bladder called the urethra and as the prostate enlarges it squeezes the urethra and narrows the opening out of the bladder. This is called obstruction and it results in slowing down of the flow of urine.

The prostate showing its two parts.
Glands and stroma of the prostate.

Obstructive symptoms

Because obstruction occurs grad-ually, many men do not realise it is happening. They may notice that their urine stream does not travel as far as it did when they were younger and they may be aware that it is less forceful. As their condition becomes worse there may be a delay in getting started (called hesitancy) and the urine stream tails off at the end, sometimes causing troublesome dribbling. There may be a feeling that there is still urine in the bladder – referred to as incomplete emptying.

OBSTRUCTIVE SYMPTOMS - CAUSED BY THE PROSTATE DIRECTLY OBSTRUCTING THE BLADDER
  • Poor stream


  • Hesitancy

  • Terminal dribbling




  • Incomplete emptying
 The urine flows with less force, travelling only a short distance, sometimes straight down.

Having to wait for the urine to start flowing.

The flow of urine continues after the main stream has finished, sometimes in spurts or dribbles. Occasionally a second large volume of urine is passed (sometimes called pis en deux).

After finishing, there is a feeling that there is still urine in the bladder.

Muscle sphincters around the prostate stop the bladder leaking urine and expel semen at the climax of the sexual act.
Normal and enlarged prostate obstructing bladder.

Irritative symptoms

The obstructive symptoms des-cribed above may not be too troublesome. However, the bladder has to work harder to overcome the obstruction and, after a while, this can affect the way it behaves. Some men develop irritative symptoms. They need to pass urine very often (frequency) with a feeling of getting caught short (urgency) which can become so bad that wetting occurs. If these symptoms continue during the night (nocturia), loss of sleep also becomes a problem.

As Private Godfrey found, this can be a great nuisance, not only to the man himself, who may have to avoid long journeys and need to plan shopping trips around the local public lavatories, but also to his family, friends and colleagues, who, like Captain Mainwaring, may not always be sympathetic.

In fact, friends and relatives are often more aware of the problem than the sufferer himself, who slowly adjusts his activities to cope with the symptoms and accepts them as part of life.

Often a patient is sent to seek treatment by his wife, whose sleep is also interrupted by his repeated trips to the bathroom.

IRRITATIVE SYMPTOMS – DUE TO
OVERACTIVITY OF THE BLADDER
  • Frequency


  • Nocturia


  • Urgency

With irritative symptoms, a sensation of incomplete bladder emptying sometimes occurs, even though the bladder is empty.		 An abnormally short time between passing urine.

Being woken in the night by the need to pass urine.

Being unable to hold on after feeling the need to pass urine. Can lead to urine leaking (incontinence).

Acute retention of urine

Sometimes a man with an enlarged prostate will quite suddenly be unable to pass urine. The bladder fills up and becomes very painful. This is called acute retention and is what happened to Tom in Waiting for God.

Sometimes there is a reason that can be identified as the cause of retention. It is a common compli-cation of surgical operations and even just being confined to bed, for example, by a chest infection, can be sufficient. Retention can be caused by constipation.

Some men develop retention if their bladders become overfull. This might occur, for example, on a long journey. Before motorways, hospitals on holiday routes plagued with traffic jams admitted men with retention every Saturday in the holiday season. Now that we have motorways, we still have road works and traffic jams, but the introduction of toilets on long distance coaches has made a great difference.

Cold weather is another problem. Retention occurs in men attending Easter weddings, when, perhaps after a few celebratory drinks, there will be the inevitable wait in the cold outside the church while the photographer is at work. Large drinks, especially alcoholic ones, may fill the bladder up unusually quickly. This was Tom’s downfall! Drugs called diuretics, prescribed to remove excessive fluid from the body in heart or chest conditions, also sometimes cause retention.

However, retention often occurs for no apparent reason and to men who previously have not been very much bothered by their prostates – perhaps because they mainly had the less annoying obstructive symptoms. Why this should happen is not really understood. It is possible that the final stoppage results from a slight infection or something else causing swelling of the prostate.

Enlarged prostate showing how BPH squashes the outer gland into a ‘capsule’.

Chronic retention

Painless retention (chronic retention) of urine occurs over months or years as the bladder slowly fills up until it may reach four or five times its normal size. Men are not usually aware that this is happening, but sometimes the overfull bladder leaks urine, causing wetness. In a few cases, the pressure in the bladder can rise and this can damage the kidneys. This is fairly rare but, although most men with prostate disorders are very unlikely to develop kidney failure, proper treatment in the early stages will cure it completely, so it is important that tests are done to rule it out.

Other complications

If the bladder cannot empty properly, any urine left in it may become infected or might form crystals which grow into bladder stones. If the urine becomes infected, it may cause a burning sensation, called dysuria, when it is passed.

A prostate operation may be needed for repeated infections, but sometimes they are a symptom of prostatitis. Some-times a large prostate can bleed, but bleeding is more likely to be due to some other cause and must always be investigated. Very occasionally, repeated troublesome bleeding is a reason for operating on the prostate.

Prostate cancer in the outer part of the prostate.

Why does the prostate get bigger?

Benign prostatic hyperplasia

In the majority of men, the prostate enlarges as they get older. Under a microscope this benign (simple, non-cancerous) enlargement is seen as changes called benign prostatic hyperplasia or BPH. The exact reason for this enlargement is uncertain, but it needs male hormones and does not occur in men castrated at an early age. Most men over 80 years old have the condition, and about half will have some symptoms from it.

As the prostate enlarges, both the epithelium and the stroma grow. Sometimes the gland is not much bigger, and symptoms seem to be caused by the muscle in the stroma contracting, which constricts the bladder opening and urethra.

BPH starts in the inner part of the gland and, as it enlarges, it squashes the outer part of the gland into a fairly thin shell, called a capsule. BPH never spreads outside the gland. However big the prostate, it remains covered by the capsule, rather like a chestnut in its shell. When a doctor examines a gland with BPH, it has a smooth surface with an even shape and feels rubbery, rather than hard.

Unless it causes the sort of symptoms described earlier in this chapter, the patient himself will not notice anything unusual, simply because his prostate is large, and it seems to function normally.

Cancer of the prostate

The prostate is one of the organs that can develop cancerous tumours. These usually develop in the outer part of the gland and may not block the urethra at first. Many men with tumours coincidently have BPH in the inner part of the gland, and often it is symptoms from this BPH that leads to the cancer being discovered.

Surrounding this outer part of the gland is a thin layer of tissue, also rather confusingly called the capsule. At first the tumour stays inside this outer capsule but, as it enlarges, it spreads through the capsule and grows into the tissue around the prostate. It may also spread by cells breaking away from it. These are trapped by the lymph glands near the prostate and here they can grow into secondary tumours (metastases). The tumour can also spread via blood vessels, usually to the bones of the back and pelvis.

A doctor will suspect a tumour if there is a hard lump in the prostate or if the whole prostate feels hard and the shape is uneven. However, very small tumours may be impossible to feel.

Prostatitis

Inflammation of the prostate (prostatitis) from infection or other causes is not uncommon and can occur at most ages. Sometimes it causes symptoms like cystitis – such as burning pain while passing urine. In older men, it might cause a sudden increase in prostatic symptoms. Prostatitis may cause rather vague symptoms and can be difficult to diagnose. There is more about prostatitis.

KEY POINTS
  • Prostate symptoms may be obstructive or irritative
  • The main disorders are benign prostatic hyperplasia (BPH), prostatic cancer and prostatitis