The Prostate and Its Problems

Troubles with the prostate gland--the cause of President Reagan’s recent hospitalization--are something that most men over 50 experience in varying degrees.

The small gland is often misunderstood and shrouded in a kind of mythology that discourages many men from having it examined regularly, thus needlessly costing thousands of lives each year, doctors say.

Dr. Patrick C. Walsh, a noted urologist at Johns Hopkins Hospital in Baltimore, said often men don’t even know they have this walnut-sized gland, which surrounds the neck of the bladder and the urethra like a doughnut around a tube.

A man can’t see or feel his prostate. A secondary sex organ found only in males, its function is to produce fluid for semen, said Dr. Jean de Kernion, chairman of urology at the UCLA school of medicine. “That’s it, other than cause problems,” he observed.

Minor Size, Major Discomfort

Despite its tiny size and minor duties, the prostate will cause 75% of men over age 50 to experience some discomforting symptoms in their lives, such as difficult, frequent or urgent urination, and 25% of men who reach age 80 will require some form of surgery, according to Walsh. A prostate problem can be mildly annoying, or it can kill, or do many things in between.

There are three basic problems that occur in the prostate:

- Prostatitis, an infection of the gland. This is the most common prostate problem in younger men, sometimes caused by bacteria and treated with antibiotics. Some infections do not respond to antibiotics, and for these people the disease can be a long-term nuisance. Symptoms include fever, chills, painful or difficult urination and pain in the lower back and between the legs.

- Benign prostatic hypertrophy, an enlargement of the prostate, usually in men over 40. This is the most common prostate problem, and the one that President Reagan had surgery for in 1967 and again last Jan. 5. More than 330,000 such operations were performed last year, 260,000 of those on men over 64.

- Prostate cancer. Detected early in a yearly, routine rectal examination by a doctor, prostate cancer can be cured, usually without impairing sexual function. The disease progresses slowly, but later-stage prostate cancer spreads to other tissues and bones, and the prospects of survival and preserving potency become more problematic. While the incidence of prostate cancer is No. 2 among cancers in men, it is the No. 3 cancer-killer, having claimed 26,000 lives in 1986, slightly fewer than rectal and colon cancer, which are usually computed together. (Lung cancer is the No. 1 man-killing cancer, taking 89,000 lives--which constitutes more than one third of all male cancer deaths.)

While much campaigning has succeeded in persuading many women to have regular cervical pap smears and breast exams to detect cancer, there has been no comparable public push for yearly rectal exams for men over 40, even though such examinations are the key to catching prostate cancer in its early, curable stages.

There is “no question” that many thousands of men die of prostate cancer simply because it is not detected early enough, said De Kernion.

Walsh is upset that “ignorance and fear,” particularly fear of impotence that may result from treatment, “plus the fact that rectal exams are not comfortable, have been deterrents for men to have early diagnosis,” he said. “As a consequence many men present (themselves to a doctor) only when their cancer is far advanced and can no longer be cured.

“Today men should realize that cancer of the prostate can be cured without adversely affecting the quality of life in most patients, but it must be diagnosed early and treated effectively, with surgery or radiation.”

Three years ago, Walsh and Dr. Pieter Donker of the Netherlands unveiled a new method of performing the incisions in a cancer operation, sparing the critical nerves that enable a man to achieve sexual function. But the old fears that any sort of prostate problem, if discovered, will lead to surgery and impotency have discouraged men from having this simple, yearly examination, doctors say.

Not As Many Checkups for Men

“Men don’t go to doctors as often as women, but we can’t blame that on men being less interested,” said Walsh. “We (medicine and the media) haven’t made the point (of having yearly check-ups) to men as we have to women.

“Part of the problem is that we have men taking care of men. If a doctor knew that he might be sending a patient into a situation that would make him impotent, the natural response is, ‘Why make a diagnosis?’

“As more physicians become educated that the gland can be removed without adversely affecting the quality of life, they will start encouraging men to be examined for this.”

Doctors stress the importance of catching the tumor early in a yearly exam.

“Just in my own practice,” said Walsh, “I find that if a man comes in with cancer, and I say, ‘Do you have yearly exams?’ And he says, ‘Yes,’ you can be certain he’s in a curable stage. If the patient says he hasn’t been checked in five years, that patient will be very lucky if the cancer has been detected when it’s curable.”

Men who do not go for checkups for years and then are found to have prostate cancer usually have tumors that are so advanced that the new surgical technique preserving potency cannot be used on them.

“In youngish patients in their 50s with small tumors, who are potent before the surgery, the chance of preserving their potency is 80% or a bit better,” said De Kernion. “In an older patient with a larger tumor, the chance is maybe only 40%.

“But people don’t understand what impotency means. They get all messed up with that. It (the surgery that severs the nerves) only means you can’t get an erection. It is not the end of sex, pleasure and orgasm. So all they need is something to make the penis more rigid, and there are numerous ways to do that, through implants and protheses.”

Early Cancers Detectable

A urologist who performs several of these rectal exams each day can detect evidence of an early cancer that has yet caused the patients no symptoms, said De Kernion. Early cancer forms on the periphery of the gland, and therefore does not squeeze the urethra, which is what causes pain and discomfort. As cancer tumors become larger, then they begin to squeeze the urethra, causing burning, difficult or frequent urination.

If a man is checked every year and develops these symptoms, he probably has the much more common and less serious problem of enlargement of the prostate. Surgery is required only if the discomfort has become intolerable. The enlargement is not any kind of danger or illness in and of itself.

Although about 10% of men who undergo surgery for enlargement of the prostate will be found to have cancer, it is really more of a coincidence than anything else. Enlargement of the prostate “is not a precursor” of cancer, said Walsh.

As men grow older, the gland enlarges, causing discomfort that is often troublesome enough to require the surgery President Reagan underwent, a transurethral resection. During this operation, the patient is awake and has a spinal anesthetic while a tube is inserted in the canal of the urethra into the prostate. Using an electrified wire instrument, doctors cut away prostate material, allowing the urethra to open back up to its normal size. Following a recuperation period, all normal bodily functions resume.

At the time of the President’s surgery, a news report sent ripples of concern through the urology community in quoting Dr. John E. Wennberg, a professor of epidemiology at Dartmouth University, as saying that the chances of dying from the surgery Reagan had were greater than the “less than 1%” that was being commonly quoted by most experts. The article, quoting a federal government study, claimed that 2.7% of the patients who were 75 or older died within six weeks as a result of the procedure. Reagan is almost 76. Wennberg added, “It’s quite obvious that the number of people dying is a lot higher than is commonly supposed.”

Both Walsh and De Kernion thought the article was misleading.

“That’s a matter of playing with statistics,” said De Kernion. “If you treat healthy patients who are in good shape in every respect, the rate’s going to be less than 1%.” De Kernion said he would include Reagan in that “healthy” category, even though the President underwent surgery for cancer of the colon in 1985.

“I thought the article was very misleading,” said Walsh. “There are two types of patients. One is the otherwise healthy man, and my belief is that the mortality rate is less than 1% for him. The second set is a patient already in the hospital with another illness, a stroke, cancer, or heart attack, and he requires this, too. There, the incidence (of death) might be 3%.”

Doctors do not know if benign enlargement of the prostate is just a natural process of aging, like getting gray hair, or if other factors are involved, said Walsh, “factors, which if identified, could be reversed.”

The cause of prostate problems continues to be a matter of study, debate and even a little foolishness. There has long been the tale that either too little or too much sexual activity gives rise to these problems, but Walsh and De Kernion say that never has been proven.

Another theory is that a sedentary life style causes problems; yet another points a finger at stress. And there’s more. “It’s been postulated that enlargement of the prostate is perhaps due to excess fat in the diet, but there is no real proof of that, either,” said De Kernion.

Proponents of this fat theory note that Mormons, who for religious reasons do not smoke, drink alcohol or use caffeine, have fat consumption habits similar to other men and are struck as a group more often by prostate cancer than any other form of cancer.

In fact, according to Dr. Dee W. West, director of Utah’s cancer registry, the incidence of prostate cancer in that state, where many Mormons live, is 29% higher than in the rest of the country. A study done by Dr. A. Wayne Meikle at the University of Utah suggested that brothers of men diagnosed as having prostate cancer before age 63 have a four-fold higher risk of developing the malignancy than the general male population in Utah. Although only 52 men were studied, the Utah researchers felt this established a “substantial familial link” with levels of sex hormones and incidence of prostate cancer, as the brothers tended to have plasma hormone levels that were more alike than those of unrelated men. Walsh noted that “the two common denominators of enlargement of the prostate and prostate cancer are that they both occur in men as they get older, and only in men that have testes. So hormones may be either causative or permissive with prostate problems.”

Some doctors are suspicious that workplace exposures to rubber production or to cadmium during welding, electroplating and the production of alkaline batteries may increase a man’s risk of getting prostate cancer, but this, like all the other theories, has not been proven conclusively.

Therefore, when asked what men could do to avoid prostate problems, the doctors had no advice, other than to have regular checkups.

No Known Prevention

“I know of no effective means to prevent these diseases,” said Walsh.

Scientists are also experimenting with drugs that might shrink an enlarged prostate without undesirable side effects, and new drug therapies for prostate cancer are also being studied.

In Tel Aviv, a team of doctors is trying to shrink enlarged prostates by inserting a warm probe in the rectum for a number of hours.

One of the more curious aspects of prostate cancer is that it does not strike every man equally. Black Americans lead the world in prostate cancer incidence. A study conducted on Atlanta men found the prostate cancer rate of blacks to be 133 per 100,000, almost twice that of whites, whose rate was 74. Black Africans do not show the same high rates.

Prostate cancer death rates vary greatly around the world, and nobody quite understands that, either. In Sweden, approximately 32 of 100,000 men die in a year of prostate cancer, while in Hong Kong, the figure is 3, 10 times less than Sweden. The United States is about in the middle, with 22 deaths per 100,000 men. Japan also has a very low rate, about 3.6, but Japanese men lead the world in deaths from stomach cancer.