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The prostate is a walnut-sized gland in men that produces fluid that is a component of semen. The gland has two or more lobes — or sections — enclosed by an outer layer of tissue. Located in front of the rectum and just below the bladder, where urine is stored, the prostate surrounds the urethra, which is the canal through which urine passes out of the body.
The most common prostate problem in men under 50 is inflammation or infection, which is called prostatitis. Prostate enlargement is another common problem. Because the prostate normally continues to grow as a man matures, prostate enlargement, also called benign prostatic hyperplasia or BPH, is the most common prostate problem for men older than age 50. Older men are at risk for prostate cancer as well, but it is much less common than BPH.
Sometimes, different prostate problems have similar symptoms. For example, one man with prostatitis and another with BPH may both have a frequent, urgent need to urinate. Other men with BPH may have different symptoms. For example, one man may have trouble beginning a stream of urine, while another may have to get up to go to the bathroom frequently at night. A man in the early stages of prostate cancer may have no symptoms at all. This confusing array of symptoms makes a thorough medical examination and testing very important. Diagnosing the problem may require a series of tests.
Talking With Your Doctor or Nurse
Letting your doctor or nurse know you have a problem is the first step. Try to give as many details about the problem as you can, including when it began and how often it occurs. Tell the doctor or nurse whether you have had recurrent urinary tract infections or symptoms such as pain after ejaculation or during urination, sudden strong urges to urinate, or hesitancy and a weak urine stream. You should talk about the medicines you take, both prescription medicines and those you can buy over the counter, because they might be part of the problem. You also should talk about how much fluid you typically drink each day, whether you use caffeine or alcohol, and whether your urine has an unusual color or odor. In turn, the doctor or nurse will ask you about your general medical history, including any major illnesses or surgeries.
Other typical questions are as follows:
· Over the past month, from the time you went to bed at night until the time you got up in the morning, how many times a night did you typically get up to urinate?
· Over the past month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
· Over the past month or so, how often have you had a weak urinary stream?
· Over the past month or so, how often have you had to push or strain to begin urinating?
Your answers to these questions may help your doctor or nurse identify the problem or determine what tests are needed. You also may receive a symptom score evaluation that can be used as a baseline to see how effective later treatments are at relieving those symptoms.
Preparing for the Exam
The common tests your doctor or nurse will perform first require no special preparation. Digital rectal exams (DRE) and blood tests for prostate-specific antigen (PSA) are often included in routine physical examinations for men older than age 50. For African American men and men with a family history of prostate cancer, it is recommended that tests be given starting at age 40. Some organizations even recommend that these tests be given to all men starting at age 40.
If you have urination problems or if the DRE or PSA test indicates that you might have a problem, you will probably be given additional tests that may require some preparation. Ask your doctor or nurse whether you should change your diet or fluid intake or stop taking any medications. If the tests involve inserting instruments into the urethra or rectum, you may be given antibiotics before and after the test to prevent infection.
Procedures
DRE
This exam is usually done first. Many doctors perform a DRE as
part of a routine physical exam for any man older than age 50, some even at 40,
whether the man has urinary problems or not. You may be asked to bend over a
table or to lie on your side holding your knees close to your chest. The doctor
slides a gloved, lubricated finger into the rectum and feels the part of the
prostate that lies next to it. You may find the DRE slightly uncomfortable, but
it is very brief. This exam tells the doctor whether the gland has any bumps,
irregularities, soft spots or hard spots that require additional tests. If a
prostate infection is suspected, the doctor might massage the prostate during
the DRE to obtain fluid for examination with a microscope.
PSA Blood Test
To rule out cancer, your doctor may recommend a PSA
blood test. The amount of PSA, a protein produced by prostate cells, is often
higher in the blood of men who have prostate cancer. However, an elevated level
of PSA does not necessarily mean you have cancer. The U.S. Food and Drug
Administration has approved a PSA test for use in conjunction with a DRE to help
detect prostate cancer in men age 50 or older and for monitoring men with
prostate cancer after treatment. However, much remains unknown about how to
interpret the PSA test, its ability to discriminate between cancer and benign
prostate conditions, and the best course of action if the PSA is high.
Because so many questions are unanswered, the relative magnitude of the test’s potential risks and benefits is unknown. When added to DRE screening, PSA enhances detection, but PSA tests are known to have relatively high false-positive rates, and they also may identify a greater number of medically insignificant tumors.
The PSA test first became available in the 1980s, and its use led to an increase in the detection of prostate cancer between 1986 and 1991. In the mid-1990s, deaths from prostate cancer began to decrease, and some observers credit PSA testing for this trend. Others, however, point out that statistical trends do not necessarily prove a cause-and-effect relationship. The benefits of prostate cancer screening are still being studied. The National Cancer Institute, a part of the National Institutes of Health, is conducting the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, or PLCO Trial, to determine whether certain screening tests reduce the number of deaths from these cancers. DRE and PSA exams are being studied to see whether yearly screening will decrease the risk of dying from prostate cancer.
Until a definitive answer is found, doctors and patients should weigh the benefits of PSA testing against the risks of follow-up diagnostic tests and cancer treatments. The procedures used to diagnose prostate cancer may cause significant side effects, including bleeding and infection. Treatment for prostate cancer often causes erectile dysfunction, or impotence, and may cause urinary incontinence.
Urinalysis
Your doctor or nurse may ask for a urine sample to test
with a dipstick or to examine with a microscope. A chemically treated dipstick
will change color if the urine contains nitrite, a byproduct of bacterial
infection. Traces of blood in the urine may indicate that a kidney stone or
infection is present, or the sample might reveal bacteria or infection-fighting
white blood cells. You might be asked to urinate into two or three containers to
help locate the infection site. If signs of infection appear in the first
container but not in the others, the infection is likely to be in the urethra.
Your doctor or nurse might ask you to urinate into the first container and then
stop the stream for a prostate massage before completing the test. If urine
taken after prostate massage or the prostate fluid itself contains significantly
more bacteria, it is a strong sign that you have bacterial prostatitis.
Transrectal Ultrasound and Prostate Biopsy
If prostate cancer is
suspected, your doctor may recommend a transrectal ultrasound. In this
procedure, the doctor or technician inserts a probe slightly larger than a pen
into the rectum. The probe directs high-frequency sound waves at the prostate,
and the echo patterns form an image of the gland on a television monitor. The
image shows how big the prostate is, and whether there are any irregularities,
but it cannot unequivocally identify tumors.
To determine whether an abnormal-looking area is indeed a tumor, the doctor can use the probe and the ultrasound images to guide a biopsy needle to the suspected tumor. The needle collects a few pieces of prostate tissue for examination with a microscope.
Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT) Scans
MRI and CT scans both use computers to create three-dimensional or cross-sectional images of internal organs. These tests can help identify abnormal structures, but they cannot distinguish between cancerous tumors and noncancerous prostate enlargement. Once a biopsy has confirmed cancer, a doctor might use these imaging techniques to determine how far the cancer has spread. Experts caution, however, that MRI and CT scans are very expensive and rarely add useful information. They recommend using these techniques only when the PSA score is very high or the DRE suggests an extensive cancer, or both.
Urodynamic Tests
If your problem appears to be related to blockage,
your doctor or nurse may recommend tests that measure bladder pressure and urine
flow rate. You may be asked to urinate into a special device that measures how
quickly the urine is flowing and records how many seconds it takes for the peak
flow rate to be reached. Another test measures postvoid residual, the amount of
urine left in your bladder when you have finished urinating. A weak stream and
difficulty emptying the bladder completely may be signs of urine blockage caused
by an enlarged prostate that is squeezing the urethra.
Abdominal Ultrasound
For an abdominal ultrasound exam, a technician
will apply gel to your lower abdomen and sweep a handheld transducer across the
area to receive a picture of your entire urinary tract. An abdominal ultrasound
can show damage in the upper urinary tract that results from urine blockage at
the prostate.
Cystoscopy
After a solution numbs the inside of the penis, the doctor
inserts a small tube through the urethral opening at the tip of the penis. The
tube, called a cystoscope, contains a lens and a light system, which allow the
doctor to see the inside of the urethra and the bladder. The doctor can then
determine the location and degree of the obstruction.
After the Test
You may have mild discomfort for a few hours after urodynamics and cystoscopy. Drinking an 8-ounce glass of water each half-hour for two hours should help. Ask your doctor whether you can take a warm bath. If not, you may be able to hold a warm, damp washcloth over the urethral opening to relieve the discomfort. A prostate biopsy also may produce pain in the area of the rectum and the perineum, which is between the rectum and the scrotum.
Your doctor may give you an antibiotic to take for one to two days to prevent an infection, but not always. If you have signs of infection — including pain, chills or fever — call your doctor at once.
Getting the Results
Some test results can be discussed with your doctor or nurse immediately after the test. Other tests may take a few days. You will have the chance to ask questions about the results and possible treatments for your problem.