Prostate is a glandular organ related to the male urinary tract and the reproductive organs. It is located just at the exit of the urinary bladder, and the urinary tract, the urethra, passes through the prostate gland. The vesicles, where the semen is stored, are also connected to the prostate gland with a thin channel. In other words, the prostate gland can be thought of as a junction point that connects the urinary tract and the reproductive tract for men. It also plays a role in the formation of semen and keeping the urinary tract moist with the secretions it produces.

What are prostate diseases?

Popular statements like “I got prostate,” or “I have prostate” are caused by the lack of information. It is not possible to get prostate because it is an organ already present in our body. There are three main diseases associated with the prostate gland which is a reproductive organ in men.

These are:

  • Prostatitis (inflammatory prostate diseases),
  • Benign Prostatic Hyperplasia (BPH) (benign prostate enlargement), and
  • Prostate cancer.

What are the symptoms of prostate diseases?

The size of the prostate enlarges with age. Due to the enlargement of the prostate, the urinary canal (urethra) gets pinched and urinary complaints occur.

The complaints of prostate diseases are grouped under two headings. The first one is related to the storage function of the bladder (urinary bladder). These complaints result from the decrease in the urine storage function of the urinary bladder, and usually appear as frequent urination, burning during urination, frequent waking up at night for urination, urgent need to urinate, and urinary incontinence before reaching the toilet.

The other group of complaints seen in prostate diseases is related to the discharge function of the urinary bladder. This group includes complaints such as difficulty in urinating, feeling of insufficient emptying, bifurcation of urination, dripping of urine, intermittent urination, inability to pass urine forward, thinning of where urine comes out, or not being able to urinate at all.

The first complaints are generally urinating during the night and frequent urinating.
These complaints are common in both prostate cancer and benign prostate enlargement. It is not possible to tell whether the prostate problem is benign or malign by just looking at the complaints.

Also, in prostate cancer, it should be noted that no complaints may show themselves depending on the region where cancer develops (far from the urinary tract, spread from other regions, etc.). For this reason, it is advised that men older than a certain age should be controlled regularly for prostate diseases.

Who should have prostate control?

In our country, we recommend that healthy men over 50 with no risks for or complaints of prostate diseases should have prostate control once a year. In countries like the USA, where prostate cancer is common (especially in Afro-American men), this age limit is much lower.

The most important risk factor of prostate cancer, which is known, is the presence of prostate cancer previously detected in the first-degree blood relatives of the person (father, brother, uncle, grandfather, etc.). These people should start having controls after they are 40 and the controls need to be repeated every six months. How are prostate diseases diagnosed?

For diagnosing prostate diseases, firstly, it is necessary to listen to the patients’ complaints and create a symptom (complaint) score. For this purpose, there is the International Prostate Symptom Score (IPSS). This score provides more objective information about the patients’ complaints.

Then, the patient must be examined with fingers through the rectum (anus). This examination provides valuable information about the size and stiffness of the prostate gland. The stiffness of the prostate gland is of much importance in distinguishing prostate cancer.

In addition, the amount of Prostate-Specific Antigen (PSA) in the blood must be measured. These two methods give us crucial tips for distinguishing prostate enlargement (BPH) and prostate cancer. If any suspicious condition is seen with these two diagnostic methods, the patient is guided to prostate biopsy.

Besides, in patients with difficulty in urinating, information about how fast the urine flows is gathered by measuring the urine flow rate with uroflowmetry. If the urine flow rate is low, this makes us think that the urinary tract is narrowed due to the enlargement of the prostate.

Moreover, it is possible to have information about the dimensions of the prostate through ultrasonography. The ultrasonography also gives us information regarding the condition of the kidneys. Also, measuring the remaining urine in the bladder (urinary bladder) after urination with ultrasonography provides important information for planning the treatment.

Sometimes, cystoscopy may be required to see whether the prostate really narrows down the urinary tract and investigate whether there is another disease in the urinary bladder. Cystoscopy is the visual examination of the urinary tract with a thin camera.

What is PSA?

PSA is a protein, found in blood, that is secreted by only the prostate gland. Contrary to popular belief, high PSA mostly does not make people sick. However, high PSA shows us, the doctors, that there is an extraordinary situation in the patient’s prostate and that we need to examine it more closely. This extraordinary situation may result from infections or may be a symptom of malign diseases. The final diagnosis is only possible as a result of the pathological examination of the tissues taken from the prostate. In our daily practices, we benefit from PSA to diagnose as much prostate cancer as possible by performing as few prostate biopsies as possible.

What should a normal PSA value be?

The upper limit of normal PSA value is now accepted as “2.5 ng/ml”. Previously, this value was accepted as 4 ng/ml. However, some studies showed that if the values lower than 4 ng/ml are accepted as normal, a considerable number of prostate cancers will be overlooked. In fact, no value is totally innocent. Even with a PSA value below 1, there is a possibility of prostate cancer. However, as the percentage of these incidences is low and to make a diagnosis with these values, high numbers of normal people will need to have unnecessary biopsies, today, the limit is considered to be 2.5 ng/ml, which is a reasonable value.

With age, we raise the upper limit of PSA a little higher. For example, for a patient around 70-75 years of age, 4.0 ng/ml may not be a worrying value.

Even if the PSA is within the normal limits, extreme increases in the yearly follow-ups raise our suspicions. For this reason, we recommend yearly controls even when the results of examination and PSA values are normal.

What is important and concerns us is not the highness of the PSA, but why it gets high.

A variable course of PSA values with rising and falling usually makes us think of prostate or urinary tract infections rather than prostate cancer. However, there is still a need to be vigilant in terms of prostate cancer. The PSA’s tendency to rise continuously with high percentages worries us more in terms of prostate cancer.

What are the differences between benign and malign prostates?

Malign prostate enlargement is called prostate cancer. And now, we all know that cancer is an anarchic tissue enlargement working against the body. Prostate cancer that is not treated timely may spread throughout the body, especially to the lymph glands and bones. After a while, this may cost the patient’s life. The decision on how to treat prostate cancer should be made by considering cancer and the patient’s characteristics.

Benign prostate enlargement (BPH) occurs due to the enlargement of the glands and the connective tissues of the prostate. The enlargement causes difficulty in urinating and emptying the urinary bladder. And sometimes, the enlarged prostate presses down the urinary bladder leading to complaints of an urgent need to urinate, or urinary incontinence before reaching the toilet. Benign prostate diseases do not spread to the body. The most significant and feared effect of benign prostate enlargement is that, if it is left untreated for a long time and left to its own course, it may lead to kidney failure due to the constant urine remaining in the bladder which forces the kidneys.

What are herbal treatments for prostate diseases?

There are some herbs in the medicinal form and used in the treatment of benign prostate enlargement. Uncertainties about the effectiveness and effect mechanisms of these herbs usually limit our chances of using and recommending these medicines. Besides, herbal substances may not be harmless all the time. Saw palmetto extract is the most popular herbal treatment alternative with proven effectiveness.

It is thought that many plants such as pumpkin seeds, black sesame (nigella sativa), nettle (urtica dioica), and broccoli may have a positive effect on prostate diseases.

There are also some foods recommended for general prostate health. Consuming foods like red wine, red grapes, pomegranate juice, cooked tomatoes or tomato paste, garlic, or olive oil will be beneficial for prostate health.

Is nutrition important in preventing prostate diseases?

Some foodstuffs are thought to be associated with the development of benign prostate enlargement (BPH) and related symptoms. Increased energy intake, excess protein consumption, red meat, fat, cereals, bread, poultry, and starch increase the risk of clinical BPH development and BPH surgery. Data are showing that vegetables, fruits, polyunsaturated fatty acids, linoleic acid, and vitamin D reduce prostate enlargement and related complaints. It is also known that the amounts of vitamin E, lycopene, selenium, and carotene in body circulation are inversely proportional to the risk of BPH development.

Lycopene is a substance that is mainly found in tomatoes. Thanks to its strong antioxidant properties, it is thought to have preventing effects on many cancer types.

For prostate health, doing sports, eating mainly vegetables and fruits, avoiding fried foods, limiting red meat consumption, consuming fish at least two times a week (preferably oily cold sea fish in the form of boiled or grilled), using food supplements such as selenium, zinc, vitamin B and D are recommended. Such a diet and lifestyle also have positive impacts on sex life and heart health.

Moreover, there are data showing that consuming green tea or 1-2 glasses of red wine reduce the development of prostate cancer.

It is seen that the increase in body mass index and the fat in waist circumference go hand in hand with the increase in prostate size.

Do prostate diseases affect the sex life?

Among the prostate diseases, the only problem that can affect the sex life is chronic prostate infection (chronic prostatitis). Continuing urination complaints and a subsequent psychological impact can trigger sexual problems.

Sexual problems caused by other prostate diseases are not common. However, as patients in this group are mostly over middle age, they may have sexual problems accompanying the prostate complaints. Mostly, such complaints are not explained because of embarrassment. We must investigate the presence of such complaints without hurting the feelings of patients.

Some medications used in the treatment of prostate diseases, especially prostate cancer, may cause sexual problems.

Do prostate diseases cause infertility?

Infertility cases caused by prostate diseases are not common.

Inflammation of the prostate, called chronic prostatitis, mostly affects younger people. Sometimes, environmental changes in the semen due to chronic prostatitis (by converting the alkaline environment to acid) that disrupt the living conditions of sperm cells may result in infertility.

Benign prostate enlargement does not cause infertility. However, some medical and surgical treatments for this disease may lead to problems by causing the semen to escape back into the bladder (retrograde ejaculation). At the time of ejaculation, the semen goes to the bladder instead of looking for a way outside. In such cases, it is possible to use sperm cells taken from the bladder for artificial insemination.

In prostate cancer surgeries, since the prostate and its adjacent glands and channel structures are completely removed, there will be no ejaculation even if there is a feeling of orgasm (dry orgasm). So, it is not possible for those patients to have a baby in natural ways.

Can prostate shrink with medication?

Medications used in the treatment of BPH may provide regression up to 30% in the weight and volume of the prostate. However, this result can be achieved with the use of these treatments for six months. When the medication is discontinued, the prostate turns back to its normal size. Another issue to keep in mind is that the PSA values found in patients using this type of medication for six months or longer should be multiplied by two to find the normal PSA value of the patient. This is because these medications falsely lower the PSA values.

Hormone treatments for prostate cancer also lead to a decrease in prostate weight.

Does urinating while sitting or standing have an effect on the prostate?

Urinating while sitting or standing has no importance on prostate enlargement, prostate cancer, or the occurrence or the increase of the related complaints.

Besides, it is worth saying that some rumors are completely groundless. Conditions such as extreme or less sexual intercourse, or masturbating or not, do not have any positive or negative effect on the prostate.

What is prostatitis?

Prostatitis is a group of diseases that can be basically explained as the inflammation of the prostate. Almost 15% of adult males have complaints of prostatitis in a period of their lives. The most common complaints are burning while urinating, pain in the penis and testicles, and having difficulty urinating.

However, the definition of prostatitis covers many clinical conditions. Acute and febrile bacterial prostate infections can be seen, as well as chronic infections or non-bacterial inflammations.

Chronic prostatitis is a disease mostly seen in younger people with annoying symptoms about the urinary tract despite no apparent enlargement of the prostate.

Recently, there are serious concerns that chronic prostatitis may cause prostate cancer in later ages, therefore it is important to diagnose and treat patients in the right way.

What are the symptoms of chronic prostatitis?

Chronic prostatitis patients often seek medical advice with complaints such as burning when urinating, frequent urination, inability to relax after urination, feeling of need to urinate despite urination, inguinal pain, and pain that hits the anus from under the testicles. Generally, standard tests do not reveal any problems. If necessary, a urine test after a prostate massage could help make a diagnosis by detecting the increase of the inflammatory cells due to the mixing of prostatic secretions into the urine.

How is prostatitis treated?

Inflammations of the prostate gland are generally named as prostatitis. Although they are not caused by bacteria all the time, antibiotic treatments are often used for a long time in the treatment of prostatitis. Also, some painkillers are used to regress the inflammation in that area and some prostate drugs are used to relax the urinary canals in the treatment of prostatitis.

Surgical methods are not used in the treatment of prostatitis.

What is Benign Prostatic Hyperplasia (BPH) (benign prostate enlargement)?

Conditions explained as “getting prostate” in daily life are actually benign prostate enlargement.

The prostate gland enlarges with age due to the effects of testosterone. Prostate enlargement can affect in two ways. An obstruction may occur in the urinary tract due to prostate enlargement, causing difficulty when urinating or intermittent urination. And sometimes, the enlarged prostate presses down the urinary bladder, causing the constant stimulation of the bladder and thus leading to frequent urination or urinary incontinence.

What are the symptoms of benign prostate enlargement?

The symptoms seen in prostate enlargement are not peculiar to this condition. Many diseases such as prostatitis, prostate cancer, and the narrowing of the urinary tract may show similar symptoms. It is important to make a diagnosis by evaluating these symptoms correctly.

The most common complaint is the weakening of the urine flow. Although this weakening is more apparent, especially in the morning, it can be seen at any time of the day. Other complaints include difficulty starting urination, a feeling of not being able to empty the bladder completely, frequent urination, intermittent urination, bifurcation while urinating, and prolonged dripping after urination. Sometimes there may be an inability to urinate at all, and in this case, it may be necessary to insert a catheter to empty the urine from the bladder.

Prostate enlargement may cause kidney failure due to the presence of so much urine remaining in the bladder and the kidneys’ functioning against constant high pressure.

How is benign prostate enlargement treated?

For the treatment of prostate enlargement, medicinal or surgical treatments may be chosen depending on the intensity of complaints and the medical condition. While planning the treatment method, whether the prostate enlargement physically harms the patient (kidney failure, repeating bleeding) and the life quality of the patient must be considered.

For the treatment of patients with no physical harm caused by prostate enlargement, the primary method is to use medicinal treatment. Today, there are various medications used for this purpose. While some medications reduce the size of the prostate enlargement, some others relax the muscles at the outlet of the bladder and also the prostate gland, making it easier to urinate. The decision about which medication to use must be made according to the complaints and the general condition of the patient.

In cases where medical treatment is not sufficient, surgical treatment takes its place on the agenda. There are many surgical methods used today. Among these methods, the most appropriate one must be selected based on the general condition of the patient and the size of the prostate enlargement.

Which surgical methods are used for the treatment of benign prostate enlargement?

Today, the most popular and the gold standard method used all over the world is the transurethral resection of the prostate (TURP) also known as minimally invasive surgery of the prostate. In this surgery, the enlarged prostate tissues are cut out by entering through the urinary canal, with a minimally invasive method, and the urinary canal is widened which facilitates the urine flow. The removed tissues are examined by a pathologist. The advantage of this surgery is that the removed tissues can be examined, however, some problems may occur because the surgery lasts long, especially for large prostates, and due to the properties of the liquids used during the surgery.

Therefore, the use of this treatment method is limited for large prostates. Another surgical method, which has been developed using new technologies and cutting energies, and which has spread rapidly all over the world recently, is the surgical method called bipolar or plasma kinetic TUR-P. In this method, the prostate tissues are cut and removed by entering in a minimally invasive way and sent for pathological examination. The advantage of this method over classical TUR-P surgery is that it can be used to treat large prostates without time limitations and with lower amounts of bleeding. The patients stay catheterized for less time and are discharged from the hospital in the early period.

Some other methods that have gained popularity recently are the vaporization surgeries of the prostate using laser energy. The long-term efficacy and safety of these methods have not been fully proven yet. In the latest BPH guidelines published by the European Association of Urology and aiming to standardize the treatment approaches of urologists in Europe, prostate vaporization methods using lasers are only recommended as a primary treatment for people who use blood thinners and have bleeding problems. Also, as the prostate tissues are vaporized in these types of surgeries, no tissues can be taken out for examination by a urologist, causing the probable cancer cases to go unnoticed.

Open prostate surgery is a treatment alternative that can be used in patients with an extremely enlarged prostate and also with bladder stones. How to decide on the surgery to be applied in benign prostate enlargement?

Do sexual functions get affected by benign prostate enlargement surgeries?

After benign prostate enlargement surgeries, some problems with the ejaculation of the semen may occur. In such cases, called retrograde ejaculation, the semen cannot be ejaculated outside and goes into the urinary bladder. During the first urination, the semen will go out with urinary spillage. This situation does not affect having sexual pleasure and orgasm. The person feels himself as normally ejaculated, but the semen is not expelled.

After surgeries for benign prostate enlargement, erectile dysfunction rarely occurs. These surgeries are generally reliable and do not have an impact on sexual performance.

What are the symptoms of prostate cancer?

The point which needs attention here is that prostate cancer may occur without any symptoms. For this reason, men over 50 are advised to have yearly prostate controls even if they have no complaints.

The symptoms of prostate cancer are similar to those of benign prostate enlargement. General complaints seen in all prostate diseases include frequent urination, burning during urination, difficulty in urination, and being unable to empty the urinary bladder. It is not possible to understand whether a disease is benign or malign by just looking at the patient’s complaints. To make a distinction, some tests must be performed.

What causes prostate cancer?

While prostate cancer is more common in the US and Northern Europe, the risk of prostate cancer decreases in far eastern countries like Japan. However, the fact that the risk in Japanese who immigrated to the US is closer to that in American men suggests that some environmental factors that have not been fully defined today play an important role in the development of prostate cancer. Excessive consumption of animal fats is the main factor accused.

Prostate cancer is the uncontrolled proliferation of the cells that make up the prostate, when unnecessary. It is one of the most common cancers seen in men. Although situations that pose a risk for the development of prostate cancer are not clearly known today, some situations that increase the risk have been defined. The most important one of them is genetics. If the father or a brother of the person experienced prostate cancer previously, the risk of developing prostate cancer for this person doubles. The cases of two or more prostate cancer in the first-degree blood relatives increase the risk of developing prostate cancer for the person five to 11 times more.

How is prostate cancer diagnosed?

When we doubt that our patient may have prostate cancer, we apply the methods of multiparametric prostate MRI and prostate biopsy.

To diagnose prostate cancer, one needs to suspect about its presence first. Prostate examination and PSA (Prostate-Specific Antigen) levels in blood give us significant information about the situation. PSA is a protein produced only in the prostate cells in the body. Some amount of PSA is also found in blood and can be measured with blood tests. The PSA level in the blood increases in extraordinary situations such as cancer or infection in the prostate. Although increased PSA levels in the blood make us suspicious about the presence of prostate cancer, it is not enough to make a clear diagnosis. As well as the measurement of PSA, that the prostate is hard during examination by hand warns and causes us to suspect prostate cancer.

How is prostate biopsy performed?

Prostate biopsy is not an open surgical intervention. It is the procedure of taking tissues from the prostate with a special needle, guided by imaging the prostate gland with ultrasonography. Although there are different applications performed in the clinics, the accepted practice in the world today is to take tissues from 12 different points of the prostate. Thus, the probability of detecting even the newly developed small tumors in the prostate increases.

Today, a prostate biopsy is a frequently used diagnostic procedure. Prostate biopsy is a procedure that can be applied under local anesthesia and also under general anesthesia if asked by the patient. After the biopsy procedure, the patient is discharged from the hospital on the same day. The material obtained with the biopsy procedure is examined in a pathology laboratory.

Our patients, who are diagnosed with the prostate cancer as a result of the pathological examination, undergo a series of radiological imaging to determine how widespread the disease is in the patient, and the treatment is planned according to the results of this staging process.

What are alternative treatment methods for treating prostate cancer?

In the treatment of prostate cancer, one or a combination of surgical treatments (open or robot-assisted), radiation therapy, hormone therapy, or chemotherapy can be applied, considering how far the disease has progressed and the age of the patient.

Since prostate cancer is a type of cancer with very satisfactory results when diagnosed early, all men over 50 should undergo control by a urologist once a year, even if they have no complaints. For diagnosis, the measurement of the PSA level, which is a protein secreted by the prostate, and rectal prostate examination with fingers are of great importance.

Prof. Dr. Gürhan Günaydın

Graduated from Ankara University Faculty of Medicine in 1980, Dr. Gürhan Günaydın received the titles of Specialist Doctor in 1984, Associate Professor of Urology in 1994, and Professor of Urology in 2000 in Ege University Urology Department.