What is the prostate? How does the prostate change as you get older? What prostate changes should you be aware of?

Prostate Changes That Are Not Cancer

What is prostatitis and how is it treated? What is enlarged prostate or BPH? How is BPH treated?

Prostate Cancer

Things to know Symptoms Risk factors Can prostate cancer be prevented?

Talking With Your Doctor

Types of Tests

Health history and current symptoms Digital rectal exam (DRE) Prostate-specific antigen test (PSA test) What do PSA results mean? Free PSA text Prostate biopsy If a biopsy is positive

For More Information

Introduction to the Prostate

You may be reading this booklet because you are having prostate problems. The booklet can help answer your questions about prostate changes, such as:

• What are common prostate changes?
• How are these changes treated?
• What do I need to know about testing for prostate changes, including cancer?

This booklet can give you basic information about common prostate changes. If you are making decisions about prostate cancer treatment, there are other resources available. See the For More Information section.

What is the prostate?

The prostate is a small gland in men. It is part of the male reproductive system.

The prostate is about the size and shape of a walnut. It sits low in the pelvis, below the bladder and just in front of the rectum. The prostate helps make semen, the milky fluid that carries sperm from the testicles through the penis when a man ejaculates.

The prostate surrounds part of the urethra, a tube that carries urine out of the bladder and through the penis.

How does the prostate change as you get older?

Because the prostate gland tends to grow larger with age, it may squeeze the urethra and cause problems in passing urine. Sometimes men in their 30s and 40s may begin to have these urinary symptoms and need medical attention. For others, symptoms aren't noticed until much later in life. An infection or a tumor can also make the prostate larger. Be sure to tell your doctor if you have any of the urinary symptoms listed below.

What prostate changes should you be aware of?

Growing older raises your risk of prostate problems. The three most common prostate problems are:

• Inflammation (prostatitis)
• Enlarged prostate (BPH, or benign prostatic hyperplasia)
• Prostate cancer

One change does not lead to another. For example, having prostatitis or an enlarged prostate does not increase your risk of prostate cancer. It is also possible for you to have more than one condition at the same time.

Back to Top Prostate Changes That Are Not Cancer

What is prostatitis and how is it treated?

Several tests, such as DRE and a urine test, can be done to see if you have prostatitis. Correct diagnosis of your exact type of prostatitis is key to getting the best treatment. Even if you have no symptoms you should follow your doctor's advice to complete treatment.

There are four types of prostatitis:

• Acute bacterial prostatitis

  This type is caused by a bacterial infection and comes on suddenly (acute). Symptoms include severe chills and fever. There is often blood in the urine. Your PSA level (see "PSA test" on page 24) may be higher than normal. You must go to the doctor's office or emergency room for treatment. It's the least common of the four types, yet it's the easiest to diagnose and treat.

  Treatment:

  Most cases can be cured with a high dose of antibiotics, taken for 7 to 14 days, and then lower doses for several weeks. You may also need drugs to help with pain or discomfort. If your PSA level was high, it will likely return to normal once the infection is cleared up.

• Chronic bacterial prostatitis

  Also caused by bacteria, this type of prostatitis doesn't come on suddenly, but it can be bothersome. The only symptom you may have is bladder infections that keep coming back. The cause may be a defect in the prostate that lets bacteria collect in the urinary tract.

  Treatment:

  Antibiotic treatment over a longer period of time is best for this type. Treatment lasts from 4 to 12 weeks. This type of treatment clears up about 60 percent of cases. Long-term, low-dose antibiotics may help relieve symptoms in cases that won't clear up.

• Chronic prostatitis or chronic pelvic pain syndrome

  This disorder is the most common but least understood type of prostatitis. Found in men of any age from late teens to the elderly, its symptoms can come and go without warning. There can be pain or discomfort in the groin or bladder area. Infection-fighting cells are often present, even though no bacteria can be found.

  Treatment:

  There are several different treatments for this problem, based on your symptoms. These include anti-inflammatory medications and other pain control treatments, such as warm baths. Other medicines, such as alpha-blockers, may also be given. Alpha-blockers relax muscle tissue in the prostate to make passing urine easier. Some men are treated with antibiotics in case the symptoms are caused by an undetected infection.

• Asymptomatic inflammatory prostatitis

  You don't have symptoms with this condition. It is often found when you are undergoing tests for other conditions, such as to determine the cause of infertility or to look for prostate cancer. If you have this form of prostatitis, your PSA test (see "PSA test" on page 24) may show a higher number than normal.

  Treatment:

  Men with this condition are usually not treated, but a repeat PSA test will usually be done if the PSA number is high.

"Changes happen so slowly that you don't even realize they're happening."

What is enlarged prostate or BPH?

BPH stands for benign prostatic hyperplasia.

Benign means "not cancer," and hyperplasia means abnormal cell growth. The result is that the prostate becomes enlarged. BPH is not linked to cancer and does not increase your risk of getting prostate cancer—yet the symptoms for BPH and prostate cancer

BPH affects most men as they get older. It can lead to urinary problems like those with prostatitis. BPH rarely causes symptoms before age 40, but more than half of men in their 60s and most men in their 70s and 80s will have signs of BPH.

The prostate gland is about the size of a walnut when a man is in his 20s. By the time he is 40, it may have grown slightly larger, to the size of an apricot. By age 60, it may be the size of a lemon.

The enlarged prostate can press against the bladder and the urethra. This can slow down or block urine flow. Some men might find it hard to start a urine stream, even though they feel the need to go. Once the urine stream has started, it may be hard to stop. Other men may feel like they need to pass urine all the time, or they are awakened during sleep with the sudden need to pass urine.

Early BPH symptoms take many years to turn into bothersome problems. These early symptoms are a cue to see your doctor.

Urine flow in a normal (left) and enlarged (right) prostate. In diagram on the left, urine flows freely. On the right, urine flow is affected because the enlarged prostate is pressing on the bladder and urethra.

How is BPH treated?

Some men with BPH eventually find their symptoms to be bothersome enough to need treatment. BPH cannot be cured, but drugs or surgery can often relieve its symptoms.

There are three ways to manage BPH:

• Watchful waiting (regular follow-up with your doctor)
• Drug therapy
• Surgery

Talk with your doctor about the best choice for you. Your symptoms may change over time, so be sure to tell your doctor about any new changes.

Watchful waiting

Men with mild symptoms of BPH who do not find them bothersome often choose this approach.

Watchful waiting means getting annual checkups. The checkups can include DREs and other tests (see "Types of Tests"). Treatment is started only if symptoms become too much of a problem.

If you choose watchful waiting, these simple steps may help lessen your symptoms:

• Limit drinking in the evening, especially drinks with alcohol or caffeine.
• Empty your bladder all the way when you pass urine.
• Use the restroom often. Don't wait for long periods without passing urine.

"My doctor and I decide visit by visit about how long I should stay on watchful waiting for my BPH.

Some medications can make BPH symptoms worse, so talk with your doctor or pharmacist about any medicines you are taking such as:

• Over-the-counter cold and cough medicines (especially antihistamines)
• Tranquilizers
• Antidepressants
• Blood pressure medicine

Drug therapy

Many American men with mild to moderate BPH symptoms have chosen prescription drugs over surgery since the early 1990s. Two main types of drugs are used. One type relaxes muscles near the prostate, and the other type shrinks the prostate gland. Some evidence shows that taking both drugs together may work best to keep BPH symptoms from getting worse.

Alpha-blockers

These drugs (see the table on page 14) help relax muscles near the prostate to relieve pressure and let urine flow more freely, but they don't shrink the size of the prostate. For many men, these drugs can improve urine flow and reduce the symptoms of BPH within days. Possible side effects include dizziness, headache, and fatigue.

5 alpha-reductase inhibitor

These drugs (see the table on page 14) help shrink the prostate. They relieve symptoms by blocking the activity of an enzyme known as 5-alpha reductase. This enzyme changes the male hormone testosterone into dihydrotestosterone (DHT), which stimulates prostate growth. When the action of 5-alpha reductase is blocked, DHT production is lowered and prostate growth slows.

This helps shrink the prostate, reduce blockage, and limit the need for surgery. Taking these drugs can help increase urine flow and reduce your symptoms. You must continue to take these drugs to prevent symptoms from coming back. 5-alpha reductase inhibitors can cause the following side effects in a small percentage of men:

• Decreased interest in sex
• Trouble getting or keeping an erection
• Smaller amount of semen with ejaculation

It's important to note that taking these drugs may lower your PSA test number. There is also evidence that these drugs lower the risk of getting prostate cancer, but whether they can help lower the risk of dying from prostate cancer is still unclear.

Surgery

The number of prostate surgeries has gone down over the years. But operations for BPH are still among the most common surgeries for American men. Surgery is used when symptoms are severe or drug therapy has not worked well.

Types of surgery for BPH include:

• TURP (transurethral resection of the prostate). The most common surgery for BPH, TURP accounts for 90 percent of all BPH surgeries. The doctor passes an instrument through the urethra and trims away extra prostate tissue. A spinal block (anesthesia) is used to numb the area. Tissue is sent to the laboratory to check for prostate cancer.
  
  TURP generally avoids the two main dangers linked to another type of surgery called open prostatectomy (complete removal of the prostate gland through a cut in the lower abdomen):
  • Incontinence (not being able to hold in urine)
  • Impotence (not being able to have an erection)

  However, TURP can have serious side effects, such as bleeding. In addition, men may have to stay in the hospital and need a catheter for a few days after surgery.

• TUIP (transurethral incision of the prostate). This surgery, which is similar to TURP, is used on slightly enlarged prostate glands. The surgeon places one or two small cuts in the prostate. This relieves pressure without trimming away tissue. It has a low risk of side effects. Like TURP, this treatment helps with urine flow by widening the urethra.
• TUNA (transurethral needle ablation). Radio waves are used to burn away excess prostate tissue. TUNA helps with urine flow, relieves symptoms, and may have fewer side effects than TURP. Most men need a catheter to drain urine for a period of time after the procedure.
• TUMT (transurethral microwave thermotherapy). Microwaves sent through a catheter are used to destroy excess prostate tissue. This can be an option for men who should not have major surgery because they have other medical problems.
• TUVP (transurethral electroevaporation of the prostate). An electrical current is used to vaporize prostate tissue.
• Laser surgery. The doctor passes a laser fiber through the urethra into the prostate, using a cystoscope, and then delivers several bursts of laser energy. The laser energy destroys prostate tissue and helps improve urine flow. Like TURP, laser surgery requires anesthesia. One advantage of laser surgery over TURP is that laser surgery causes little blood loss. The recovery period for laser surgery may be shorter too. However, laser surgery may not be effective on larger prostates.
• Open prostatectomy. This may be the only option in rare cases, such as when the obstruction is severe, the prostate is very large, or other procedures can't be done. General anesthesia or a spinal block is used, and a catheter remains for 3 to 7 days after the surgery. This surgery carries the highest risk of complications. Tissue is sent to the laboratory to check for prostate cancer.

Be sure to discuss options with your doctor and ask about the potential short- and long-term benefits and risks with each procedure. For a list of questions to ask, see Checklist of Questions for Your Doctor.

Back to Top Prostate Cancer

Things to know

Prostate cancer means that cancer cells form in the tissues of the prostate. It is the most common cancer in American men after skin cancer.

Prostate cancer tends to grow slowly compared with most other cancers. Cell changes may begin 10, 20, or even 30 years before a tumor gets big enough to cause symptoms. Eventually, cancer cells may spread (metastasize) throughout the body. By the time symptoms appear, the cancer may already be advanced.

By age 50, very few men have symptoms of prostate cancer, yet some precancerous or cancer cells may be present. More than half of all American men have some cancer in their prostate glands by the age of 80. Most of these cancers never pose a problem. They may never cause symptoms or become a serious threat to health.

Most men with prostate cancer do not die from this disease.

"When I first learned I might have a prostate problem, I was afraid it was cancer."

Symptoms

The symptoms of prostate cancer can be similar to the symptoms of BPH.

Prostate cancer can spread to the lymph nodes of the pelvis. Or it may spread throughout the body. It tends to spread to the bones. So bone pain, especially in the back, can be a symptom of advanced prostate cancer.

Risk factors

Some risk factors have been linked to prostate cancer. A risk factor is something that can raise your chance of developing a disease. Having one or more risk factors doesn't mean that you will get prostate cancer. It just means that your risk of the disease is greater.

• Age. Men who are 50 or older have a higher risk of prostate cancer.
• Race. African-American men have the highest risk of prostate cancer—the disease tends to start at younger ages and grows faster than in men of other races. After African-American men, prostate cancer is most common among white men, followed by Hispanic and Native American men. Asian-American men have the lowest rates of prostate cancer.
• Family history. Men whose fathers or brothers have had prostate cancer have a 2 to 3 times higher risk of prostate cancer than men who do not have a family history of the disease. A man who has 3 immediate family members with prostate cancer has about 10 times the risk of a man who does not have a family history of prostate cancer. The younger a man's relatives are when they have prostate cancer, the greater his risk for developing the disease. Prostate cancer risk also appears to be slightly higher for men from families with a history of breast cancer.
• Diet. The risk of prostate cancer may be higher for men who eat high-fat diets.

Can prostate cancer be prevented?

To find out more, see the For More Information section.

Back to Top Talking With Your Doctor

Different kinds of doctors and other health care professionals manage prostate health. They can help you find the best care, answer your questions, and address your concerns. These health care professionals include:

• Family doctors and internists
• Physician assistants (PAs) and nurse practitioners (NPs)
• Urologists, who are experts in diseases of the urinary tract system and the male reproductive system
• Urologic oncologists, who are experts in treating cancers of the urinary system and the male reproductive system
• Radiation oncologists, who use radiation therapy to treat cancer
• Medical oncologists, who treat cancer with medications such as hormone treatments and chemotherapy
• Pathologists, who identify diseases by studying cells and tissues under a microscope

View these professionals as your partners—expert advisors and helpers in your health care. Talking openly with your doctors can help you learn more about your prostate changes and the tests to expect.

Back to Top Types of Tests

These types of tests are most often used to check the prostate:

Health history and current symptoms

This first step lets your doctor hear and understand the "story" of your prostate concerns. You'll be asked whether you have symptoms, how long you've had them, and how much they affect your lifestyle. Your personal medical history also includes any risk factors, pain, fever, or trouble passing urine. You may be asked to give a urine sample for testing.

Digital rectal exam (DRE)

DRE is a standard way to check the prostate. With a gloved and lubricated finger, your doctor feels the prostate from the rectum. The test lasts about 10-15 seconds.

This exam checks for:

• The size, firmness, and texture of the prostate
• Any hard areas, lumps, or growth spreading beyond the prostate
• Any pain caused by touching or pressing the prostate

The DRE allows the doctor to feel only one side of the prostate. A PSA test is another way to help your doctor check the health of your prostate.

PSA (Prostate-specific antigen) test

The U.S. Food and Drug Administration (FDA) has approved the use of the PSA test along with a DRE to help detect prostate cancer in men age 50 and older.

PSA is a protein made by prostate cells. It is normally secreted into ducts in the prostate, where it helps make semen, but sometimes it leaks into the blood. When PSA is in the blood, it can be measured with a blood test called the PSA test.

In prostate cancer, more PSA gets into the blood than is normal. However, a high PSA blood level is not proof of cancer, and many other things can cause a false-positive test result. For example, blood PSA levels are often increased in men with prostatitis or BPH. Even things that disturb the prostate gland--such as riding a bicycle or motorcycle, or having a DRE, an orgasm within the past 24 hours, a prostate biopsy, or prostate surgery--may increase PSA levels.

Also, some prostate glands naturally produce more PSA than others. PSA levels go up with age. African-American men tend to have higher PSA levels in general than men of other races. And some drugs, such as finasteride and dutasteride, can cause a man's PSA level to go down.

PSA tests are often used to follow men after prostate cancer treatment to check for signs of cancer recurrence.

It is not yet known for certain whether PSA testing to screen for prostate cancer can reduce a man's risk of dying from the disease.

Researchers are working to learn more about:

• The PSA test's ability to help doctors tell the difference between prostate cancer and benign prostate problems
• The best thing to do if a man has a high PSA level

For now, men and their doctors use PSA readings over time as a guide to see if more follow-up is needed.

What do PSA results mean?

PSA levels are measured in terms of the amount of PSA per volume of fluid tested. Doctors often use a value of 4 nanograms (ng) or higher per milliliter of blood as a sign that further tests, such as a prostate biopsy, are needed.

Your doctor may monitor your PSA velocity, which means the rate of change in your PSA level over time. Rapid increases in PSA readings may suggest cancer. If you have a mildly elevated PSA level, you and your doctor may choose to do PSA tests on a scheduled basis and watch for any change in the PSA velocity.

Free PSA test

This test is used for men who have higher PSA levels. The standard PSA test measures total PSA, which includes both PSA that is attached, or bound, to other proteins and PSA that is free, or not bound. The free PSA test measures free PSA only. Free PSA is linked to benign prostate conditions, such as BPH, whereas bound PSA is linked to cancer. The percentage of free PSA can help tell what kind of prostate problem you have.

• If both total PSA and free PSA are higher than normal (high percentage of free PSA), this suggests BPH rather than cancer.
• If total PSA is high but free PSA is not (low percentage of free PSA), cancer is more likely. More testing, such as a biopsy, should be done.

You and your doctor should talk about your personal risk and free PSA results. Then you can decide together whether to have follow-up biopsies and, if so, how often.

Prostate biopsy

If your symptoms or test results suggest prostate cancer, your doctor will refer you to a specialist (a urologist) for a prostate biopsy. A biopsy is usually done in the doctor's office.

For a biopsy, small tissue samples are taken directly from the prostate. Your doctor will take samples from several areas of the prostate gland. This can help lower the chance of missing any areas of the gland that may have cancer cells. Like other cancers, prostate cancer can be diagnosed only by looking at tissue under a microscope.

Most men who have biopsies after prostate cancer screening exams do not have cancer.

"While it's important to make your own decision about cancer screening, everybody should consider getting a second opinion before getting something like a biopsy."

If a biopsy is positive

A positive test result after a biopsy means prostate cancer is present. A pathologist will check your biopsy sample for cancer cells and will give it a Gleason score. The Gleason score ranges from 2 to 10 and describes how likely it is that a tumor will spread. The lower the number, the less aggressive the tumor is and the less likely it will spread.

Treatment options depend on the stage (or extent) of the cancer (stages range from 1 to 4), Gleason score, PSA level, and your age and general health. This information will be available from your doctor and is listed on your pathology report.

Reaching a decision about treatment of your prostate cancer is a complex process. Many men find it helpful to talk with their doctors, family, friends, and other men who have faced similar decisions.

Back to Top For More Information

National Cancer Institute

National Cancer Institute Services

NCI has comprehensive research-based information on cancer prevention, screening, diagnosis, treatment, genetics, and supportive care. We also have a clinical trials database and can offer tailored searches.

Order publications at www.cancer.gov/publications or by calling 1-800-4-CANCER.

Get help with quitting smoking at 1-877-44U-QUIT (1-877-448-7848).

Free resources to ask for include:

• NCI Fact Sheet: Prostate-Specific Antigen (PSA) Test
• What You Need To Know About Prostate Cancer
• Treatment Choices for Men With Early-Stage Prostate Cancer

We invite you to call or go online to talk with our trained information specialists, who speak English or Spanish, to:

• Get answers to any cancer-related questions you may have
• Get free NCI publications
• Learn more about specific resources and organizations in your area
• Find information on the NCI Web site, www.cancer.gov

Other Federal Resources

Centers for Disease Control and Prevention (CDC)

Free booklets that are available include:

• Prostate Cancer Screening: A Decision Guide
• Prostate Cancer Screening: A Decision Guide for African Americans
• La Detección del Cáncer de Próstata: Una Guía para Hispanos en los Estados Unidos

Medicare

For information about Medicare benefits, contact:

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

NIDDK conducts and supports basic and clinical research on many of the most serious diseases affecting public health.

National Kidney and Urologic Diseases Information Clearinghouse is a service of NIDDK. They have free booklets on prostate problems, conditions, and research.

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