Prostate health: who should get checked and what it involves
The prostate is a doughnut-shaped organ that surrounds the neck of the bladder.Enlarged prostate
As it enlarges, it can expand on the inside so the ‘hole’ of the doughnut gets smaller and this makes it more difficult to pee.
If this happens, men have to actively push to get the urine out when they pee and this can cause certain waterworks symptoms: straining, weak stream, feeling of incomplete bladder emptying, going often, having to rush when the urge comes to pee, and waking up at night.
The prostate enlarges with age so typically men over 50 with these symptoms may benefit from treatment to reduce the ‘blockage' from an enlarged prostate. This can be in the form of lifestyle changes, or medications that shrink or relax the muscle of the prostate. As with all medications, there can be side-effects, and thus men should always seek advice from their GP or urologist before starting such treatment.
In cases where the symptoms don’t respond well to medication, surgery to core out a hole through the middle of the prostate (to make the hole in the doughnut bigger) can be performed.
There are also newer operations that can make this hole larger without surgical cutting, using water, steam, and by lifting the prostate edges away from the hole. Again though, all operations carry side-effects and patients should always seek advice from urologists that are experienced in these techniques.
A big worry for older men with symptoms isn’t whether they have an enlarged prostate per se, but whether they have prostate cancer. And this is a reasonable concern.
Prostate cancer affects 1 in 8 white men in the UK during their life-times, with a doubled risk in those with a father or brother with the disease. The numbers sadly double again if the man is Black; a Black man whose father had prostate cancer has a whopping 1 in 2 lifetime risk of the disease.
While cancer typically affects the outer areas of the prostate that lie away from the hole through the middle, it is also a disease of older men usually. Prostate cancer and a benign enlarged prostate can co-exist and frequently do. Because the cancer itself is not symptomatic at its early stages (though its co-existing prostate enlargement can be), the best way to screen for it is using a blood test called the PSA (prostate-specific antigen) and a finger examination of the prostate.
If the finger test or the PSA are abnormal, an MRI prostate should be done and often this is followed by a prostate biopsy. Interpreting the prostate MRI and performing the biopsy are highly skilled tasks, and should be done by expert prostate cancer doctors. The biopsy will tell whether there is cancer and if so, what type and to what extent. Occasionally, further scans (CT, bone scans, or PET scans) are performed to check for spread of the cancer beyond the prostate. Based on these results, the man will be diagnosed with curable or incurable cancer.
The key to avoid the latter is early diagnosis; I believe that irrespective of symptoms all men, should have a PSA in middle age. Based on that, they will proceed to investigations as above or simply have PSA monitoring, the frequency based on their result and their risk factors (age, ethnicity, family history).
Curable prostate cancer is often treated by surgery to remove the prostate or radiotherapy to kill the cancer cells. While there is good evidence that success rates in removing the cancer are similar for most men, one of the problems with radiotherapy is that, if it fails, surgery becomes trickier. That’s why most fit men will have surgery first as they can always have radiotherapy afterwards if needed.
The main problem with surgery for prostate cancer are its potential side-effects: erection problems, urinary leakage issues, and recovery time. The use of the surgical robot has hugely reduced these side-effects, but they still occur. Also, not all robotic surgeons are equal in their results: those who have better training and do more operations tend to have better results for their patients, not just in terms of side-effects but also cancer-free rates. It’s similar to any skill: the better you’re trained and the more you practise, the better you get.
To conclude, let me advise all men with waterworks symptoms to get checked out.
Symptoms could be due to an enlarged prostate, which is easily treated. All men aged 50 and above (or 45 if Black or with a family history of prostate cancer) should get checked for prostate cancer, irrespective of whether they have waterworks symptoms or not. And, importantly, they should go to the most expert doctors available if they need further testing and treatment for cancer.
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Last revised: 25 January 2024
Next review: 25 January 2027