As men grow older, they run the risk of developing prostate problems. In this interview by Sade Oguntola, a consultant urologist at the University College Hospital (UCH), Ibadan, Dr Augustus Takure speaks on why men should be proactive about their prostate health to maintain their sexuality and fertility level throughout life.
Currently, a lot of men are afraid of prostate issues. It is believed that almost every elderly man on the street has one prostate issue or another. And it’s killing them. Is that observation right?
Yeah, the observation is right, but it is killing them because of their carelessness or their carefree attitude. The typical African man’s behaviour is that if you have a car that develops a fault, you will not visit a mechanic until there are many faults in the car. The same thing happens in our lives. As Africans, we do not take our health very seriously. We have signs that we should be proactive. But we ignore those warning signs until the disease of the prostate catches up with us. Whether we like it or not, the prostate will get big. Whether we like it or not, the prostate will eventually become cancer. But we can reduce the chances of infection of the prostate, which is within our power to change. But we cannot prevent the cancer, but we can pick it up early by screening regularly.
Men should not be afraid. Rather, they should go see their medical practitioners or urologists for a yearly PSA, and occasionally, they should have an examination of the rectum. They don’t need to go for a biopsy. If they do that, they will catch the disease early and treat it appropriately.
Is it that they need not fear dying or being incapacitated by the prostate problem?
The person who will not die has not been born. The moment a man is born, he is walking towards his grave. What do you do then? It is about men being proactive about the health of their prostates. It is about the individual.
What is the prostate, and what is its function?
A prostate is a walnut organ that is found strictly in men or male animals. It’s found above the bladder base, and it appears like a cone that is turned upside down so that the apex of that cone faces the lower part of the abdomen while the base is above the bladder. So it surrounds the upper part that drains urine from the bladder to the outside of the body. The prostate essentially produces what we call the prostate-specific antigen that is necessary to make the male ejaculum liquid so that the sperm can move freely. That’s the essential function of the prostate. It’s important in the process of fertilisation.
At what age should a man or a boy start thinking about his prostate health, and why?
Well, we should start thinking about prostate health at the age of 40, especially in blacks, because it’s a very common disease. It’s more common among blacks than among Caucasians. So at the age of 40, we should start getting worried or concerned about the organ called the prostate.
Why should men start to get concerned about their prostate health at age 40?
This is because we have reported men age 40 and below who have an enlarged prostate that is causing some symptoms in them. The majority of the time, it occurs after the age of 50. But we have seen 36-year-old men with enlarged prostates that are causing some problems. But more often than not, you should get worried by the age of 40 or get more concerned about what could be going on in the prostate by the age of 40, particularly blacks. But for whites, maybe from the age of 50, but for blacks, from 40 years.
What are the common symptoms of these prostate problems?
Well, there are three common problems in the prostate, and they depend on age. For men below the age of 45, the commonest prostate issue is inflammation of the prostate. As men grow older, simple enlargement, or an increase in the size of the prostate, comes in. That is medically termed benign prostate enlargement. As a man grows much older, we will be thinking about prostate cancer. So with an increase in age, the various conditions of the prostate will manifest. The first is the prostate infection. The second is the simple enlargement of the prostate. The third is prostate cancer. Those are the three common diseases of the prostate.
Now the prostate surrounds the urether, the pipe that brings urine out of the bladder. So if the prostate is diseased, the ability of the bladder to empty itself of urine will be affected. So there will be symptoms showing abnormalities in the function of the bladder. This will include an inability to hold urine, causing the frequency and urgency of passing urine. He is going to pass urine almost every one to 2 hours, so there is also an increased frequency of waking up in the morning to pass urine.
The second set of symptoms is the inability of the bladder to empty itself. Urine ordinarily should flow freely from the bladder outward through the urethra. But when the prostate is enlarged, the stream of urine will be reduced. We call that a weak stream. Also, the individual will strain to pass urine. As he applies pressure in order to empty the bladder, the urine flow will break and continue instead of flowing smoothly. And at the end, there will be a feeling of incomplete emptying of the bladder. So this second set of symptoms—weak urine, straining, intermittent or passing urine, and incomplete emptying of the bladder—are called voiding lower urinary tract symptoms. When urine just remains in the bladder and is painless, it is dangerous because it gradually affects the functions of the kidney.
Now the extreme of symptoms, or usually how they can present, is that there can be a sudden, painful inability to pass urine. We call that acute retention of urine. It is a sudden, painful inability to pass urine. This is what brings people to the hospital when they have prostate issues.
When there is painless storage of urine in the bladder, it is more dangerous because it gradually affects the functions of the kidney. The third, or most extreme, of the symptoms is that the patient may start passing blood mixed with urine. The fourth is that they can have recurrent infections of the urinary tract. So these are the symptoms that you can have that will make you suspect that the man may have prostate disease.
Q: What is the difference between benign prostate enlargement (BPH) and prostate cancer?
A: It’s very obvious. Benign means something that is not harmful or likely to spread but increases and disturbs normal function. Enlargement means an increase in the size of that organ. So benign prostate enlargement is simply an enlargement of the prostate that is unlikely to spread from that location of the prostate, but it can disturb the normal function of the prostate. However, cancer means there is a rapid increase in the size of the organ, and those cells are multiplying at an increased rate, so they can spread into the blood. They can spread to the surrounding organs and cause more havoc in those who have them.
With reference to the prostate, prostate cancer is the rapid growth or multiplication of prostate cells that have a tendency to spread. It can spread to the backbone, and so the individual will be unable to walk. It can spread to the junction of the blood that comes from the leg. So the legs will be swollen. It can spread to the chest. As such, there will be pain in the ribs. It can even spread to the bones of the head. So you have lumps or swellings of the scalp.
What does a prostate examination entail? And is it necessary for everyone to take it?
Is it necessary for everyone to take it? Yes. It is advisable that you do the examination or the test. Now what are the tests? The reason you should do those tests is to detect prostate cancer early. So you can cure it. If you don’t do the test regularly, you will miss it. And the cancer will come late.
Now what are the tests? The prostate is below the bladder and in front of the rectum. The rectum is the part that brings out feces. So if you want to examine the prostate, we will stick our finger in the rectum. And we will be able to feel it. So when we stick our finger into the rectum, we will be touching the prostate. A prostate that is smooth, not tender, and big is a benign prostate enlargement. When you stick your finger and the prostate is very tender, you must stop that examination. That tenderness suggests an infection of the prostate.
When you stick your finger and the prostate feels bumpy, it feels hard, like stones; if it has multiple hard areas, it suggests prostate cancer. So from that examination, you can suspect the likely type of prostate problem the individual has.
Now the second test is that the prostate produces prostate-specific antigen (PSA). It comes specifically from the prostate cells, and it is released into the urethra. But when there is a disease of the prostate, the level of PSA starts to rise in the blood. This is what we use to screen patients. So men should, on a yearly basis, check for any increase in the PSA level so that they can take the appropriate action. The moment the PSA rises beyond the level for the age of that individual, you suspect cancer. So you need to take part of the prostate with a special needle to the laboratory to examine it. We give you injections that will not make you feel the pain. We call it a prostate biopsy. That is what establishes a diagnosis of cancer or a simple prostate problem. We do a biopsy when we suspect cancer.
If the individual is unfit for the biopsy, then you can do a pelvic magnetic resonance imaging study. It is a special X-ray that takes a cross-section of the prostate, and it can show suspicious areas of the prostate that are consistent with prostate cancer.
When should they start to do these tests that you have highlighted?
PSA should be done at the age of 40 in a black man, particularly if there is a family history of prostate cancer. If there is no family history of prostate cancer, you can still wait until the age of 50 and start doing your yearly PSA check. But once there is a history of prostate cancer in the father, in the uncle, or in the grandparents, then you must start checking your PSA at the age of 40. The sticking of the finger into the rectum is not a pleasant test, but we can make it pleasant when we give you some local anaesthetic agents.
What lifestyle measures contribute to poor prostate health?
That’s a difficult one. What we will say is that in order to minimise the effects of prostate disease, you need to watch your sexual activities so that you do not acquire infections along the urinary tract. An infection along the urinary tract can spread to the prostate.
Number two, the moment you notice that you are waking up in the night to pass urine and that is not a usual habit, or you cannot hold urine, or you have a weak stream of urine, it is possible that urine is staying within the bladder. Once urine stays within the bladder, it is a problem. So you must watch out for those symptoms that suggest that there is a problem with the bladder, so that you can start paying attention to the prostate.
Number three: depending on the prostate disease, if you grow older, you are likely to have benign prostate enlargement. If you grow much older, the chances of also having prostate cancer are much higher. So it comes with age, and there is no way we can stop it. The reason why it comes with age is that there is a substance that is produced by the testes called testosterone. It has been implicated in people with benign prostate enlargements and prostate cancer. So testosterone is a risk factor for prostate cancer. So, if you want to have a healthy prostate that will not trouble you, then you have to look out for these symptoms and treat them promptly.
Are there dietary changes or supplements to take to support prostate health?
I will not talk about supplements because I’m a medical doctor and we are not experts in supplements. However, diets rich in antioxidants have a protective effect on the prostate. The antioxidants tend to destroy cancer, so we talk about increased intake of vegetables and fruits like tomatoes. These diets have a protective effect on the prostate. Of course, there are diets that can help reduce the effects of these symptoms, like saw palmetto. Saw palmetto is a fruit in Africa called African pumpkin. African pumpkin has some effects on reducing the symptoms of the prostate. But we do not prescribe such things. But we can advise that if you take them, you will do well.
How does prostate health affect urinary function? And what can be done to manage your urinary symptoms?
Prostate health disturbs the flow of urine. If we want the urine to flow well, then we put the individual on some medications that can block the effects of testosterone on the prostate. Such medications are very common on the market. They are given either tablets or capsules to be taken once a day. Once on this medication, it relaxes the prostate so that the urine can flow freely. That is for benign prostate enlightenment. For those who have a prostate infection, we give antibiotics that need to be taken for a minimum of 4 weeks to clear the infection.
How about those with prostate cancer? What do you do for them?
What we do for them depends on the stage at which they have come. If they come very early, when they have no symptoms, their PSA is normal for their age, and because there is a family history of prostate cancer, we do a biopsy. The biopsy will show if there are traces of prostate cancer in them. Then, they can be cured by surgery, radiation treatment, or by freezing the prostate (cryotherapy). And currently, we are talking about gene therapy. In addition, they are trying to see if sending radioisotopes directed into the prostate cells can be used to destroy the cancer. This is still in the experimental stage.
Now, if the individual comes with a cancer that is advanced, we cannot cure it. Rather, all that is done is to control it. To control the cancer, we can place them on tablets that they take every day or on injections that they will take once a month or once every three months forever. Of course, their financial status must be good. They are all imported drugs that are quite expensive. However, when prostate cancer is advanced, a combination of treatments is adopted to control the disease. For instance, injection can be combined with radiation.
For those who cannot afford the injectable drug that is taken monthly or three-monthly, some procedures are done on the testis, the source of the hormone. But you don’t give a single treatment because it won’t lead to a good recovery. So, it will be combined with external beam radiation or the monthly tablets.
Can prostate problems impact fertility or a man’s sexual function?
Let’s look at it this way. The pipe that brings sperm passes through the prostate. If there is severe cancer of the prostate, it can affect that pipe. That can reduce the ability to release sperm into the posterior urethra, and it can indirectly reduce fertility.
Now, can it affect sexual function? Yes, it can. At the side of the prostate gland are the nerves that supply the penis. If someone has prostate cancer that has spread to the nerves, the nerves at the side of the prostate, then it can hold on to the nerve and reduce the conduction through the nerve. That will reduce sexual function. So for advanced cancer of the prostate, yes, sexual function can be affected. But we will not be talking about the fertility of a 90-year-old man.
We will only talk about fertility in a young man. We have had some patients who are young, about 50, married, and have no children, and in the course of testing them for infertility, we accidentally discovered prostate cancer. So, the dilemma is: what do you do? If you give drugs to control cancer, it will affect fertility; if you go and operate on the testis, there will be no sperm cells. Whatever you do will affect the fertility and erection of this young man. But he has to be alive, so what do you do? The decision is for the family to make: either we treat you and you have other means of having children through adoption or assisted reproductive technology, or we leave you alone and you keep on trying to have your own child through the natural route, and then the cancer will take you. So it is a very difficult situation.
How about the other two problems of the prostate: infection and enlargement? Can they affect sexual function and fertility?
When the prostate enlarges, it affects the neck of the bladder. Normally, during sexual intercourse, the sperm cells are released into the posterior urethra. That area where the prostate surrounds, that is where they are released into. The neck of the bladder is closed at that point of release of the ejaculum into the posterior urethra. But when there is a disease of the prostate, whatever is released will go into the bladder. So, the sperm cells, instead of coming out, go into the bladder. So, the individual will not release anything to the wife. So, if you are not releasing sperm into your wife, then it is unlikely that the wife can get pregnant the natural way.
But, having said that, with the next passage of urine, the sperm comes with it, and you are not going to pass urine and sperm into your wife. So, the urine that contains sperm can be collected, and then we will filter the sperm cells away, wash them, and then use it for in vitro fertilisation (IVF).
Now, concerning erection, can it affect erection? A large prostate will stretch the nerves at the side because, as I told you, the nerves that supply the male organ and are responsible for erection pass by the side of the prostate. So, if the prostate becomes very big, like a python, it is going to stretch that nerve, and as it stretches the nerve, it is going to reduce the function of the nerve. So, erections may be reduced. But, for infection, if someone has a serious infection of the prostate and has a deep sting in the lower part of the abdomen, how would he be thinking of sex? When he is bleeding or having pain, his ability to go ahead with sexual activity will definitely be reduced. And he is not going to talk about erections when he is in pain. So those activities will be postponed until he recovers from the treatment of his disease.
So, what are the potential complications of untreated prostate problems, including prostate cancer?
For those who have a simple enlargement of the prostate, which we call benign prostate enlargement, if they are not treated, it will affect their quality of life. They cannot sleep well; they will keep waking up several times in the night to go and pass urine. When they are in the offices, they cannot continue to conduct meetings because every five minutes or 10 minutes, they will get up to go and pass urine. So, the quality of life will be severely affected. As a result, they may be depressed because they will be unhappy with themselves.
Now, for those who ignore the symptoms of prostate and keep the urine indefinite or do not pass urine frequently, the lower part of the abdomen becomes bigger because the urine is not coming out. As such, over time, they will come down with recurrent urinary tract infections. They may present with a sudden, painful inability to pass urine, which may necessitate the insertion of a catheter. They may also experience tiredness or fatigue because the kidneys are shutting down. So, they will present with progressive kidney failure. They can also come down with the passage of urine mixed with blood. Those are the symptoms of benign prostate enlargement. They can form stones in the bladder, and these stones will further worsen the infection and worsen blood loss from the urine.
Now, for prostate cancer, prostate cancer is a different kettle of fish. If it is not identified on time, whether by checking the PSA or going for a regular medical check-up, then it will spread. When it is spread, it can affect an individual’s quality of life. They may not be able to walk around. There will be weakness in the legs, numbness, and a needle-prick sensation in the legs. The bones can break suddenly. The bones of the leg can break, even from a trivial fall, or maybe fall from trying to sit down. The bones that are weak and have cancer cells will just break. That includes the bones of the leg. They can have such severe back pain that they will be in tears.
So, if you see an elderly man who suddenly cannot walk, your first suspicion should be prostate cancer. If you see an elderly man who is having a discussion with the family or in a meeting and falls down and the bones are broken or the bones of the legs are broken, you should suspect advanced prostate cancer. So, these are complications of prostate cancer.
What will be your parting word for men so that they can be proactive about their prostate health?
The first thing is to know your family history. Is there a family history of prostate cancer? If yes, then you stand at risk of developing prostate cancer. Second, know the symptoms that are suggestive of prostate disease. The moment you start waking up in the night to pass urine frequently, you should run to the hospital. That is a warning sign. The moment you start noticing that you cannot hold urine, you are having a meeting, and you have the urge to pass urine, you have to move immediately. You should kindly go to the hospital for a proper evaluation because those symptoms suggest that the prostate needs your attention. Of course, we know from some studies that when you are tall, you have a slightly higher risk of having prostate cancer. If you are tall, it is a blessing from God. But you should check your PSA regularly. Also, obesity, overweight, and a body mass index greater than 30 are all risk factors for prostate cancer. So, if you are obese or fat, do regular exercise to burn out the excess fat. Regular exercise will cut down on your weight and reduce your risk of having prostate cancer. So, you should not go to sleep; any slight change in your passing urine should attract your attention.
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