Health news blog

Sometimes there’s a clear cause-and-effect relationship at work in prostatitis— the insertion of a urinary catheter, for example, during a medical procedure. This causes more trauma in the urinary tract for some men than for others.

Other risk factors include a recent bladder or kidney infection; an enlarged prostate (BPH, in which the prostate grows to constrict the urethra and can have a harmful effect on the urinary tract); and rectal intercourse, also associated with trauma to the urinary tract.

In bacterial prostatitis, the question is, how did the bacteria get into the urinary tract? In the instances mentioned above, bacteria may be able to invade the prostate from the urethra when infected urine “backs up” into the prostate ducts. (During unprotected rectal intercourse, too, rectal bacteria can be picked up by the penis and drawn into the urethra, and then can make their way into the urinary tract.)

But for nonbacterial prostatitis, and prostatodynia, the basic answer is that nobody knows. There have been severe cases in which men have had their prostates removed—and yet the symptoms failed to go away. Which leads to the question of whether nonbacterial prostatitis and prostatodynia are really happening in the prostate at all? “Prostatitis is a catch-all term,” says the University of Maryland urologist. “Too often, any time a patient comes in with pelvic pain, rectal pain, lower back pain—the doctor says, ‘You’ve probably got a touch of prostatitis.’ But a lot of men are told they have prostatitis when they’ve really got something else.”

And, because the disease—in all its forms, particularly the nonbacterial kind—is poorly understood, “a lot of patients get shrugged off by their doctors,” the urologist continues.

There are as many different reactions to prostatitis as there are cases of it; how men cope depends, in large part, on their response to illness and discomfort in general. “Some men can’t seem to stand it,” the urologist says. “But other men, as long as they know it isn’t cancer, can live with it.”

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In a contact laser prostatectomy, the laser probe actually touches—and immediately vaporizes—the BPH tissue, producing temperatures between 500 and 700 degrees. So—poof! The obstructing tissue is gone immediately. Tissue touched by the laser probe instantly turns to steam. Energy from a kind of laser known as Neodynium (Nd):YAG, which penetrates deeply into tissue, is conducted through a flexible fiber (a fiberoptic pipe that conducts the light energy) and is used through a standard cystoscope. This energy can produce temperatures well over 60 degrees, which can either “cook” (and thus kill) tissue or vaporize it altogether. Yet, as powerful and as hot as the contact laser is, it barely penetrates tissue even one millimeter beyond the point of vaporization. There is no delayed sloughing; only the tissue touched with the probe is affected. Essentially, “What you see is what you get.” In other words, only the tissue removed the day of surgery is going to be gone from the prostate—no other tissue will die and be sloughed off days or weeks later. This is a key difference between the contact and non-contact laser techniques.

The contact method is more time-consuming than the non-contact technique; in this it is much more like a standard TUR than other laser prostatectomies. The potential advantages over TUR include less bleeding (and therefore a lower risk of a transfusion), no risk of TUR syndrome, less risk of incontinence and urethral stricture, and the possibility of shorter hospitalization and catheterization (a catheter is required for about three days after surgery). Also, symptoms appear to improve earlier than after non-contact laser surgery. One point to consider is the size of a man’s prostate: The probes currently being used are small and work best on smaller prostates (with a volume of less than 50 grams or slightly under two ounces). Because there is less bleeding, this form of treatment is ideal for men who are taking anticoagulants.

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Because by itself an enlarged prostate causes no problems, all of the symptoms of BPH are secondary, resulting from obstruction of the urethra and bladder and, occasionally, of the ureters and kidneys as well. Most likely, your doctor will begin by taking your medical history, and it’s critical that you give an accurate description of your symptoms. Now is not the time to be embarrassed or reticent about your urinary problems. Remember, BPH happens to most men; you are not alone.

To help you recognize how often a day you urinate, and the nature of your symptoms, you may want to keep a symptom diary for a few days before your appointment, noting when you urinate, how long it lasts, whether it’s characterized by a weak stream, hesitancy, and so on.

There are two important goals for this visit to the doctor: First is to get help for these bothersome symptoms. Second, and equally important, is for your doctor to rule out any other problems—such as a bladder infection, or a blockage (also called a stricture) in the urethra—that may be causing the trouble.

For example: As men grow older, many have trouble making it through the night without one or more trips to the bathroom. But this symptom has many possible causes; so by itself, this might not mean BPH. Among other things, it can be caused by the body’s need to eliminate excess urine that accumulates during the day. Many older people—for a variety of reasons—develop swelling in their legs. At night, when the legs are elevated, the fluid that caused the swelling is reabsorbed and excreted by the kidneys. Also, it’s recently been recognized that many of the symptoms associated with BPH simply happen because the bladder is aging. (In fact, many symptoms that previously were thought to be suffered only by men, and thus were attributed to BPH, are also present in women as they age.)

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Finally, the study showed a variety of reasons why the patients themselves didn’t ask for adequate pain medication. Some men aren’t very good at expressing their symptoms, or conveying the depth of their pain, the researchers found. Some men feel it isn’t “macho” to admit that their pain is intolerable. (If you have a problem with this, it may help to take along a family member who feels no such hesitation when you go to see the doctor.) Other men are afraid of becoming addicted—and some of these men aren’t helped any when zealous family members urge them to “just say no” to drugs!

Some men believe that the pain is just an inevitable part of having the cancer and that nothing car be done to help them. Others worry about the pain yet to come, and want to save the “big guns,” the strongest medications, until the pain becomes intolerable. (Actually, with heavy-duty painkillers like morphine, relief always comes when doctors boost the dosage, so there is nothing to be gained by seeing how much pain you can stand.) Some men don’t want to be labeled as “bad” patients because they complain about their pain. And finally, the study said, some men—ever the breadwinners—worry that costly pain medication will use up all their families’ resources. For these men, methadone may be a good option—at around $30 a month, it’s the cheapest narcotic.

The bottom line is that you—or a loved one with prostate cancer—do not need to suffer terrible pain. There is help available. Take it.

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Another concern is that, unlike most treatments for prostate cancer—or for any disease, for that matter—cryoablation is not backed up by years of solid, careful laboratory research. In this country, by the time almost any procedure is tried on humans, it’s been thoroughly tested, sometimes for decades, in laboratory studies and in animals to see if it even works, and to make sure it’s safe. There was little laboratory testing of this technique before doctors began using it in men. It has not been proven that cryoablation can completely destroy the prostate in a dog, much less a man.

There are no long-term studies on how well cryoablation works. But we do know that at two years after treatment, 20 percent of men have positive biopsies, and a large percentage of patients have elevated levels of PSA.

Currently, cryoablation is used to treat men with localized prostate cancer as well as men who have undergone unsuccessful radiation treatment. Again, we come back to the critical question: Does it work? As more men opt for this therapy, this question is becoming increasingly important. To answer it, we need thoughtful studies that not only determine the risks of late complications, but that demonstrate cryoablation’s long-term success in controlling cancer.

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