Johns Hopkins Health Alerts - Enlarged Prostate

Overactive Bladder Concerns

Tue, 02 Mar 2010 06:00:00 CST

In this Grand Rounds column from a recent Prostate Bulletin, a reader writes: Early this year I had the TURP surgery (transurethral prostatectomy) for BPH (benign prostatic hyperplasia). Before the surgery, I would take one 5 mg tablet of Ditropan XL or oxybutynin each evening and I did not have to get up to urinate during the night. Now, after the TURP procedure, I am back to getting up to go to the bathroom. I tried taking Ditropan XL and oxybutynin, but they no longer worked. I tried taking one pill in the morning and another at night, and that didn't work either. In addition, I am careful not to drink anything after 6 P.M. ...

At my urologist's suggestion, I tried a new prescription drug, VesiCare, and when that didn't work, I tried Detrol LA. I still have to get up four, sometimes five times a night to urinate. I've now noticed that during the daytime I have to urinate more often before, sometimes in a panic.

Do you have any idea why this is happening? Any recommendations about what I can do to get a better night's sleep? It seems like my bladder is just not functioning properly anymore. Novato, CA

Dr. Jacek L. Mostwin answers: A few things that can be considered as possible causes of your symptoms could be easily treated. Is there a urinary tract infection? A urinalysis and a urine culture would answer that question. Is there a bladder stone? An ultrasound or a cystoscopic examination would answer that question. Is there a scar or a bladder neck contracture in the area where the prostatic surgery was performed? Cystoscopic examination or a flow rate would help to answer that question.

If the suggestions described above don't lead to a diagnosis, your overactive bladder symptoms may be due to changes in spinal reflexes that took place over the many years during which the prostate was blocking your bladder. These reflexes improve partially after prostatectomy, but in some cases they do not improve completely. We generally expect about 15% of patients to continue to have significant overactive bladder symptoms, and some of them may get worse.

Again, if none of the suggestions made in the previous paragraph provide an answer, and there is no other explanation for your severe overactive bladder symptoms, you may require more decisive intervention. It all depends on how bothersome your symptoms are.

A device called the Interstim is approved for the treatment of your problem. It is more commonly described as a spinal cord stimulator, although the electrodes used to stimulate the bladder nerves do not actually enter the spinal cord at all. It is a safe device and has been used in many thousands of patients with good results. This would be one possible solution to consider if your symptoms are very disruptive and they have not responded to any other medications or conservative fluid management.

Complaining About Prostatitis

Tue, 23 Feb 2010 10:00:00 CST

Prostatitis is a condition found in adult men, with no respect to age, race, or nationality. It's estimated that as many as 14% of adult American men will at some point go to their doctor complaining of one or more of the symptoms that doctors now believe constitute a diagnosis of prostatitis. How do you know if you have prostatitis? Dr. Richard B. Alexander explains what prostatitis feels like.

Q. What are the main complaints of men with chronic prostatitis?

A. Pain in the pelvic region that lasts more than three months is the primary symptom. Men may say they feel like they are sitting on something like a peach pit. Many patients also experience pain during or after ejaculation. Symptoms such as urinary frequency or discomfort during urination may also be present.

For some men, the pain of chronic prostatitis is so debilitating that they are simply unable to function normally. More than two thirds of men with chronic prostatitis have reported episodes of major or minor depression because of the disease.

Q. Is the pain associated with chronic prostatitis relatively constant, or is it provoked or intensified by certain activities?

A. The pain of chronic prostatitis is highly variable, depending on the patient and his specific circumstances. It may range in intensity from just mild discomfort (a 1 on the NIH-CSPI scale) to the worst pain you can imagine (a 10 on the pain scale). The most common sites of pain are the perineum (the region between the genital area and the anus), the testicles, the whole penis, the shaft or tip of the penis, the suprapubic area (the mid-lower abdomen), and the lower back. The pain can occur at several of these sites or at one predominant site.

To fulfill the diagnosis of chronic prostatitis, the pelvic pain has to last more than three months. Although this may seem like an arbitrary time frame, that's how we currently define it. The pain of chronic prostatitis tends to wax and wane -- some days it is worse than others. There's not really a good explanation as to why that is. Pain after ejaculation is common and is the most specific symptom that distinguishes men with chronic prostatitis or chronic pelvic pain syndrome from men with other prostatic conditions.

Should You Try Botox for Nocturia?

Tue, 19 Jan 2010 06:00:00 CST

In this excerpt from a recent Prostate Bulletin, a reader asks: “What are your thoughts on the use of Botox injections of the prostate and bladder base as a treatment for chronic frequent nocturia? I have tried a variety drugs for this urination problem but they cause insomnia and daytime sleepiness. I was hoping that Botox might work for me. “ Dr. Jacek L. Mostwin answers …

Dr. Mostwin: Botox has been used for the treatment of bladder overactivity due to spasms of the bladder in neurological disease and in some cases of bladder overactivity for which there are no defined causes. The FDA does not approve it for this purpose, so treatment must take place in a controlled study. Botox has not been studied for treatment of nocturia alone, regardless of cause.

Nocturia is a special form of urinary urgency that awakens the patient at night with the desire to void. Sometimes it is an early sign of benign prostatic hyperplasia (BPH) irritation and obstruction, but it can also be a sign of early congestive heart failure or other troubles associated with the heart, so an evaluation is required.

Botox is made from Botulinum toxin, a poisonous material extracted from spores of the bacterium Clostridium botulinum. It prevents release of acetylcholine, the chemical transmitter released by nerve terminals to activate contraction. Botulinum toxin A, sold commercially as Botox, has been injected directly into the bladder muscle of patients with overactive bladders in an effort to relax the overactive muscles, thereby decreasing urgency and urge incontinence. Botox is not approved by the FDA for injections into the bladder, but must be used under special conditions in approved studies.

Before considering Botox, it would be much better to start with combined medical therapy for prostatic disease. The standard treatment would consist of alpha-blockers (Flomax, Cardura, Hytrin, Uroxatral) along with medication to reduce prostatic volume (Proscar, Avodart). Anti-muscarinic medications (Detrol, Ditropan, Oxytrol, Enablex, Vesicare, and similar drugs) can also be used to reduce bladder overactivity.

The number of patients with residual, severe symptoms needing Botox injections is likely quite small, so the chances are that you can be helped with something much simpler. I would probably never advise a patient to consider Botox for nocturia treatment alone, as fluid restriction and careful use of desmopressin (DDAVP, a tablet hormonal medication that reduces urine production during the night) usually do the trick.

Options for Treating Chronic Prostatitis

Tue, 09 Feb 2010 10:00:00 CST

The formal term for chronic prostatitis is chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). The condition is generally defined as chronic pelvic pain lasting more than three months, with no signs of bacterial infection.

Like other forms of chronic pain, chronic prostatitis/chronic pelvic pain syndrome is a complex condition with no simple solutions. Successful management depends on treating the original source of the pain as well as the neurological and psychosocial problems that often accompany it. As a result, your doctor may prescribe several different types of medication.

Antibiotics. Even in men who have no evidence of a bacterial infection, one round of antibiotic therapy -- for example ciprofloxacin (Cipro) or levofloxacin (Levaquin) -- may be tried early in the course of chronic prostatitis/chronic pelvic pain syndrome. About 75% of these men who have not previously been treated with an antibiotic will improve.

Alpha-blockers. As with antibiotics, alpha-blockers like tamsulosin (Flomax) or alfuzosin (Uroxatral) may be given early in the course of chronic prostatitis/chronic pelvic pain syndrome to men who have not been heavily treated with alpha-blockers previously. Researchers theorize that these drugs might be effective because they relax smooth muscle in the prostate and may reduce nerve inflammation in the lower urinary tract.

Finasteride. Only a few studies of the 5-alpha-reductase inhibitor finasteride (Proscar) for chronic prostatitis/chronic pelvic pain syndrome have been done, and results show it's not significantly better than placebo. Nevertheless, some men report improvement in symptoms, especially if they also have BPH.

Herbal therapy. Some herbal therapies may have an anti-inflammatory effect. While several small studies suggest that quercetin, saw palmetto, or Cernilton N (a pollen extract) may improve symptoms of chronic prostatitis/chronic pelvic pain syndrome, there is no strong evidence demonstrating effectiveness.

Anticonvulsants. Although gabapentin (Neurontin) and pregabalin (Lyrica) were originally approved by the U.S. Food and Drug Administration (FDA) to treat epilepsy, both show promise in treating nerve-related pain, including that from diabetes and shingles. Use of Lyrica to treat chronic prostatitis/chronic pelvic pain syndrome is being studied in a randomized, controlled trial.

Antidepressants. These drugs, in particular tricyclic antidepressants, are sometimes prescribed to help with chronic prostatitis/chronic pelvic pain syndrome-associated depression.

Other treatments. A host of additional therapies also are under study. These include botulinum toxin type A (Botox), acupuncture, physical therapy, sildenafil (Viagra), and pentosan polysulfate sodium (Elmiron).

When the Chronic Pelvic Pain of Prostatitis Takes a Toll on a Man's Sex Life

Tue, 08 Dec 2009 06:00:00 CST

If you have chronic prostatitis, the pain in your pelvic area can be excruciating. In the most severe cases, it's the kind of agonizing pain that can affect every aspect of your life, including your ability to urinate, sleep, even sit -- not to mention the toll it can take on your sex life. Now a study published in the Journal of Sexual Medicine (Volume 5, page 657) takes a closer look at the impact of chronic prostatitis on sexual function.

Men who suffer from chronic prostatitis/chronic pelvic pain syndrome experience difficulty or dissatisfaction in many areas of their sex lives.

To examine this problem, researchers asked 72 men with chronic prostatitis/chronic pelvic pain syndrome and 98 men who had no pain condition (control group) to fill out questionnaires on sexual function and satisfaction. The men with chronic prostatitis/chronic pelvic pain syndrome completed additional questionnaires about their pain and psychological adaptation to their condition.

Regarding sexual function and pain, 64% of men with chronic prostatitis/chronic pelvic pain syndrome had experienced pain during or after intercourse compared with 5% of the control group. As a result of their pain, 70% of men with chronic prostatitis/chronic pelvic pain syndrome said they had experienced decreased sexual desire and 40% had problems with sexual function. Thirty-six percent said they had never had pain with ejaculation, 51% reported having it occasionally, and 13% said they had it most of the time or always. Compared with men who didn't have chronic prostatitis/chronic pelvic pain syndrome, those with it had less frequent sexual desires or thoughts, engaged in sexual activity less often, and reported less arousal/erectile function.

If you find that pain from chronic prostatitis/chronic pelvic pain syndrome is affecting your sex life, talk to your doctor about management strategies that can address your pain and any emotional or psychological issues.

Primer on Prostatitis

Tue, 06 Oct 2009 06:00:00 CDT

Chronic prostatitis usually affects men in their early 40s, and it is one of the leading reasons why men visit a urologist. According to one study, men with prostatitis have a diminished quality of life that is on par with those who have recently suffered a heart attack.

Prostatitis is a common condition in which the prostate becomes infected or inflamed, causing severe pain in the perineum -- the area between the rectum and scrotum. Prostatitis is often difficult to treat, and part of the problem is that the disease comes in several forms. Some prostatitis patients experience acute flare-ups, with sudden and continuous pain that lasts for several days. More common, however, is chronic prostatitis, which may last for several weeks, only to disappear and then start up again.

Prostatitis is further differentiated by bacterial and nonbacterial causes. Nearly 95% of patients are thought to develop prostatitis from nonbacterial causes, which have yet to be identified. In addition, some men have signs of inflammation, such as white blood cells in their semen, but none of the painful symptoms of prostatitis. A related condition, called prostatodynia, causes the same symptoms as prostatitis, but with no signs of infection or inflammation on laboratory tests.

While the causes of bacterial prostatitis are obvious and easy to detect, researchers are unsure why men develop the more prevalent, nonbacterial form. Some men find that stress, emotional problems, or even coffee may trigger flare-ups. Other possible culprits include zinc deficiency, tight urinary sphincter muscles, infrequent ejaculation, and dehydration.

Some experts suggest that nonbacterial prostatatis is not really a prostate problem at all. Rather, flare-ups could be the result of a pelvic muscle spasm or some other cause that mimics symptoms originating in the prostate.

Another theory under investigation is that prostatitis is caused by an autoimmune disorder, in which the immune system mistakenly attacks healthy prostate tissue and promotes inflammation -- not unlike the way rheumatoid arthritis targets the joints. Indeed, researchers recently found that men with chronic prostatitis had increased levels of the same pro-inflammatory molecules that are elevated in the joint tissue of people with rheumatoid arthritis.

What to do. Treatment is fairly straightforward for bacterial prostatitis. A patient is given antibiotics for a period of 4 to 16 weeks. Appropriate antibiotics include carbenicillin (Geocillin), trimethoprim/sulfamethoxazole (Bactrim ), doxycycline (Doryx), fluoroquinolones like ciprofloxacin (Cipro), and others.

Treatment of nonbacterial prostatitis is more difficult, and no one treatment has been proven to improve symptoms for most men. It may take some trial and error to find a combination of therapies and self-care techniques to obtain symptom relief.

While antibiotics typically are reserved only for bacterial diseases, many patients with nonbacterial prostatitis receive antibiotics and a prostate massage, followed by high doses of alpha-blocker drugs (typically used for BPH). Emerging evidence suggests that exercise may improve symptoms.

Alternative Treatment for Chronic Prostatitis May Help

Tue, 17 Nov 2009 10:00:00 CST

Should you try acupuncture to relieve the pain of chronic prostatitis? Results from a recent study provide the answer.

Like other forms of chronic pain, chronic prostatitis is a complex condition with no simple solutions. Successful management depends on treating the original source of the pain as well as the neurological and psychosocial problems that often accompany it.

As a result, your doctor may prescribe several different types of medication. Some men also benefit from cognitive behavioral therapy, which can help improve coping strategies and psychological well-being.

But what if you’ve tried medications and they haven’t helped? Should you give acupuncture a try?

Results from a small study in The American Journal of Medicine suggest that acupuncture may provide relief to men with chronic prostatitis. The study compared the potential benefits of acupuncture versus sham (inactive) treatments in 89 men who had symptoms of chronic prostatitis for three or more of the past six months and who had a score of 15 or higher on the National Institutes of Health Chronic Prostatitis Symptom Index.

The men were randomly assigned to receive two acupuncture treatments or two sham treatments a week for 10 weeks. The sham treatments were nearly identical to genuine acupuncture needle insertions except for the location and depth of placement.

True acupuncture was nearly twice as effective as the sham procedure in relieving chronic prostatitis symptoms. Moreover, patients treated with acupuncture were more than twice as likely as the men given the inactive treatment to experience long-term prostatitis relief. Few of the men experienced complete resolution of their symptoms.

This study supports findings from other trials showing a benefit from acupuncture for chronic prostatitis. More study is needed before the treatment can definitively be recommended, but if nothing else has worked for you, a trial of acupuncture might be worth considering.

What Causes BPH?

Tue, 27 Oct 2009 06:00:00 CDT

If you experience a frequent urge to urinate, urinary incontinence, or intermittent urine flow, you may have an enlarged prostate or BPH – a common, non-cancerous condition affecting one in four men by age 55. What is BPH? Here is an explanation, in brief.

Although the cause of enlarged prostate hyperplasia (BPH) is not well understood, normal levels of testosterone and aging are essential for the development of the condition. Studies in dogs suggest that the female sex hormone estrogen may also play a role in BPH.

The word hyperplasia refers to any abnormal accumulation of cells that causes enlargement of a body part or organ. BPH occurs when an increase in the number of prostate cells produces discrete nodules in the prostate. The increase in nodules is due to a slowing of the normal rate of death of these cells, rather than to a heightened production.

Whether or not the resulting enlargement puts pressure on the urethra and increases resistance to urine flow depends on the location of the nodules. Although the transition zone accounts for only about 5 percent of the prostate mass, the nodules in men with BPH occur primarily in this region.

Because the transition zone directly envelops the urethra, excess tissue tends to obstruct urine flow. Contractions of the smooth muscle cells surrounding the nodules can also obstruct the urethra.

Consequently, some men with a very enlarged prostate may have no urethral obstruction, while others with mild enlargement may have marked symptoms because a nodule is located where it compresses the urethra, or because smooth muscles tighten. To compensate for urethral narrowing, the muscular wall of the bladder contracts more strongly to expel urine. These stronger contractions lead to a thickened bladder wall, which decreases the bladder's capacity to store urine.

Over time, the bladder holds smaller and smaller amounts of urine, resulting in a need to urinate more frequently. As the urethral obstruction worsens, the contractions can no longer empty the bladder completely. Urine retained in the bladder may then become infected or lead to the formation of bladder stones. Less often, the kidneys become damaged, either as a result of increased pressure on them from the overworked bladder or because an infection has spread from the bladder to the kidneys.

Should You Try Combination Treatment for Your BPH?

Tue, 25 Aug 2009 06:00:00 CDT

If your benign prostatic hyperplasia (BPH) symptoms have not been relieved by treatment with a single medication, combination therapy is worth a try, according to data reported in The Journal or Urology (Volume 179, page 616).

Two types of drugs are used to treat (BPH): 5-alpha-reductase inhibitors and alpha-1-adrenergic blockers. Research suggests that these drugs improve BPH symptoms in 30 to 60% of men. However, it is not yet possible to predict who will respond to medication or which drug will work best for a particular person.

For men with moderate to severe lower urinary tract symptoms and BPH who are at high risk for BPH progression, using two different types of drugs may be the most effective approach.

In an ongoing study known as CombAT (Combination of Avodart and Tamsulosin), researchers compared the effectiveness of the 5-alpha reductase inhibitor dutasteride (Avodart) and the alpha-blocker tamsulosin (Flomax) with the use of either drug alone in reducing symptoms and prostate size.

Study participants were age 50 or older, had moderate to severe BPH symptoms, and were at risk for disease progression as indicated by a prostate volume of at least 30 mL and/or a prostate-specific antigen (PSA) level of 1.5 ng/mL or greater. The nearly 5,000 men were assigned to receive either 0.5 mg of dutasteride, 0.4 mg of tamsulosin, or a combination of the two drugs for four years.

At two years, men taking combination therapy had significantly greater BPH symptom improvements than men taking either Avodart or Flomax alone. Combination therapy was also better than Flomax, but not Avodart, in reducing prostate volume.

The Importance of a BPH-Friendly Diet

Tue, 04 Aug 2009 06:00:00 CDT

What can you do to prevent benign prostatic hyperplasia or BPH? A recent study published in the American Journal of Epidemiology (Volume 167, page 925) suggests that diet, not dietary supplements, has the greatest impact on the development of BPH.

BPH is the noncancerous enlargement of the prostate gland due to an increase in the number of prostate cells. What triggers BPH is not well understood, but aging and testosterone are believed to be the primary influences on its development. Animal studies suggest that the female sex hormone estrogen (produced in small amounts in men) also may play a role, perhaps when a man’s testosterone production declines and the balance of the two hormones is altered.

Taking dietary supplements has less impact on a man’s risk of developing BPH than does his overall eating pattern, according to an analysis of a subset of men who participated in the Prostate Cancer Prevention Trial (PCPT).

The researchers studied 4,770 men who were in the placebo group in the PCPT and were free of BPH at the study’s outset. The men were monitored for the development of BPH over the seven years of the study and filled out a 15-page diet and supplement questionnaire a year into the trial. The questionnaire addressed the men’s typical consumption of various types of food and beverages, including alcohol. It also documented their use of antioxidant supplements (like vitamin E or selenium) and other supplements such as vitamin D and fish oil.

There was no association between the use of antioxidant supplements and the development of BPH and only limited evidence for a beneficial effect of lycopene, zinc, or vitamin D. However, the risk of developing BPH was lower among men who followed diets high in protein and vegetables and low in total fat and red meat and who regularly consumed alcohol (two or more drinks per day).

The bottom line: If you want to reduce your risk of BPH, eating a healthy diet is more likely to help than taking dietary supplements.

A Lexicon of BPH Surgical Techniques

Tue, 14 Jul 2009 10:00:00 CDT

Known as simple prostatectomy, surgery for benign prostatic hyperplasia (BPH) typically involves removing only the prostate tissue that is surrounding and pressing on the urethra. The procedure is performed either transurethrally (through the urethra) or by making an incision in the lower abdomen. Here are the most commonly-performed surgeries, in brief.

The most common surgical procedure for BPH, transurethral prostatectomy (TURP), is considered the "gold standard" treatment for the condition. Some newer treatments that use heat to relieve symptoms are less invasive, do not require a hospital stay, and are associated with fewer complications. However, many men who receive these minimally invasive treatments need to undergo TURP years afterwards because their symptoms eventually recur.

TURP (transurethral prostatectomy). In this procedure, a long, thin instrument called a resectoscope is inserted through the urethra. A wire loop at the end of the instrument cuts away excess prostate tissue that obstructs the urethra. The loose bits of tissue collect in the bladder and are flushed out of the body through the resectoscope at the end of the procedure.

In minimally invasive procedures, other types of devices are inserted through the urethra to obliterate tissue by means other than cutting it away.

TUMT (transurethral microwave therapy) uses a small antenna to emit microwave energy that heats the prostate to a temperature above 110° F. A cooling system in the catheter protects the urethra from heat damage.

TUEVP (transurethral electrovaporization of the prostate) uses a resectoscope fitted with a small grooved roller at the end to deliver electric current that vaporizes prostate tissue.

TUNA (transurethral needle ablation), TUIP (transurethral incision of the prostate), and PVP (photoselective laser vaporization of the prostate) all involve inserting an instrument through the resectoscope that delivers either low-level radiofrequency energy (TUNA) or laser energy (PVP or TUIP) to vaporize excess tissue. Some versions of TUIP use a miniature electric knife rather than a laser to cut the tissue. Shields in the instrument protect the urethra from heat damage.

When Should You Treat Your BPH?

Tue, 23 Jun 2009 06:00:00 CDT

How do you know if your BPH is serious enough to require treatment? The International Prostate Symptoms Score was developed to help men evaluate the severity of their BPH symptoms. Johns Hopkins encourages you to take this self-administered test and then read this Health Alert before talking with your urologist about your BPH treatment options.

The progression of benign prostatic hyperplasia (BPH) cannot be predicted for any individual. Symptoms and objective measurements of urethral obstruction can remain stable for many years and may even improve over time in as many as a third of men. In the Medical Therapy of Prostatic Symptoms (MTOPS) study, only 14% of untreated men in the placebo group experienced worsening symptoms during an average follow-up time of 4.5 years.

Men who eventually need treatment for BPH typically experience a progressive decrease in the size and force of their urinary stream or a sensation of incomplete emptying of their bladder. Although frequent nighttime urination is one of the most annoying symptoms of BPH, it does not predict the need for future treatment.

If urethral obstruction worsens and is left untreated, complications can occur. Potential complications include a thickened bladder with a reduced capacity to store urine, infected residual urine, bladder stones, and a backup of pressure that damages the kidneys.

Decisions regarding BPH treatment are based on the severity of symptoms (as assessed by the International Prostate Symptom Score questionnaire, see Do You Have BPH?), the extent of urinary tract damage, and the man's age and overall health. In general, no treatment is needed for men who have only a few BPH symptoms and are not bothered by them.

Treatment -- usually surgery -- is required in the following situations:

kidney damage due to inadequate bladder emptying

a complete inability to urinate after treatment of acute urinary retention

incontinence due to over filling or increased bladder sensitivity

bladder stones

infected residual urine

recurrent blood in the urine despite treatment with medication

symptoms that have not responded to medication and are troublesome enough to diminish quality of life

Talking About Prostatitis With Dr. Alexander

Tue, 12 May 2009 06:00:00 CDT

How do you treat prostatitis and will it recur? In a recent issue of The Johns Hopkins Prostate Bulletin, Dr. Richard B. Alexander, an internationally recognized expert on chronic prostatitis, answered these common questions about prostatitis.

Q. Is an approach that combines more than one form of treatment for the various aspects of prostatitis, such as infection, inflammation, and neuromuscular spasm, now usually recommended for chronic prostatitis?

Dr. Alexander: Yes. However, I typically start with one therapy at a time. If the patient appears to get absolutely no benefit from one therapy, such as an alpha blocker, then I might drop it and try something else, such as Prosta-Q. I tend to add medications over time to see if a combination of therapies can help the patient get better.

Frankly, as hard as it is to believe, what really helps is to tell people the truth about their condition. A big part of my time with prostatitis patients is spent dispelling myths that men have taken to be truths. The most common myths include:

Prostatitis is caused by a sexually transmitted disease.

A man with chronic prostatitis is harboring bacterial organisms in his prostate that cannot be eradicated, even with several courses of antibiotics.

A patient can transmit this infection to his wife or sexual partner.

Normal men do not have bacteria in their prostate.

I explain to my patients that infection is not currently thought be the cause of their prostatitis. I also explain that sexually transmitted diseases are not likely to be involved either, and that they should not be concerned about transmitting any infection to their partner.

Most men, including those without prostatitis, have bacteria in their prostate, but these organisms are not causing any disease. When patients finally hear the facts based on objective data, many of them are able to take solace from this information and move on with their lives. They can get on with trying to understand the factors in their own lives that can influence the prostatitis and that they can do something about. Such factors include physical activity, diet, stress reduction, and other lifestyle factors

Q. How likely is it that chronic prostatitis will recur in men who have a very good response to one of the current treatments?

Dr. Alexander: By its very nature, prostatitis is a chronic disease, and it's likely to recur. Even so, we don't have good data on how many of the two million men diagnosed with chronic prostatitis each year actually get cured and never need medical treatment again. I tell patients that we have therapies that are not likely to cure them but that rather will help get them better. That's what we're shooting for at this point. There are patients who do get better, but they still tell me, "Doc, I feel better but it's still there. I know it."

Should You Avoid Alcohol If You Have BPH?

Tue, 21 Apr 2009 06:00:00 CDT

Many men believe that they should not drink alcohol because they have an enlarged prostate (BPH). In this article from our Prostate Bulletin, medical editor Dr. Jacek L. Mostwin reviews the evidence and his conclusions may surprise you.

Even in this evidence-based world of ours, many medical myths and old wives' tales still survive. "A lot of men read in men's magazines or their local newspapers that once you have a prostate problem, you're not to drink a drop of alcohol, because it will make your BPH symptoms worse," said Mark A. Moyad, M.D., M.P.H. "This is why Dr. Roehrborn's finding is a critical finding, and I'm glad this research came out."

What exactly what did Dr. Claus Roehrborn uncover in his examination of more than 19,000 men? Dr. Roehrborn, the director of Urology at the University of Texas Southwest Medical Center at Dallas, reported that the more alcohol men drank, the better their BPH symptoms were, dismissing the persistent myth that drinking alcohol worsens voiding symptoms.

"Those who drink alcohol had a lower total International Prostate Symptom Score compared to those who do not drink," said Dr. Roehrborn. "There was a striking difference in scores between alcohol consumers and those who never consume. People who drink are less bothered by their irritative prostate symptoms and have less trouble."

"People who do not drink have worse overall symptoms, poorer flow rates, and are less likely to be sexually active," noted Dr. Roehrborn. "Why this would be is hard to explain. One of the ideas is that alcohol influences circulating levels of androgens, testosterone and dihydrotestosterone, which are clearly important in the biology of the prostate. However, across all groups in our study, the levels of hormones were all the same, so it doesn't serve well as an explanation. And differences in prostate size and body weight can't sufficiently explain this finding. All we can say is that people who drink complain of fewer or milder BPH symptoms.

"I am advocating that doctors with patients complaining of voiding symptoms stop telling them, 'Don't drink alcohol, it will worsen your BPH symptoms.' This advice is not founded on evidence. We had a large number of men, 19,000 across five continents, and a large spectrum of ages, and this advice was not found to be true."

Dr. Roehrborn's study adds to the growing body of research pointing out the benefits of moderate alcohol consumption on health. If you are a teetotaler, you should certainly not start drinking in hopes of reducing your BPH symptoms. Heavy drinking can damage the heart, liver, and other organs, and can lead to accidents, which is why many medical groups do not recommend drinking alcohol. However, if you already drink, do so moderately -- a drink or two per day. One drink is generally defined as 12 oz. of beer, 5oz. of wine, or 1.5 oz. of 80-proof spirits.

Can You Prevent BPH With NSAIDs?

Tue, 31 Mar 2009 06:00:00 CST

If you take a daily aspirin for your heart, you may be doing your prostate a favor as well. Emerging research suggests that daily use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, or naproxen, reduces the risk of developing benign prostatic hyperplasia (BPH). But the benefits of NSAIDs to the prostate may not be worth the risk. Read what Johns Hopkins recommends …

In a long-term study of NSAIDs and BPH, researchers monitored the prostate health of nearly 2,500 men, ages 40–79, for more than 10 years. At the onset of the study, all of the men answered a questionnaire about their BPH symptoms, and about 20% also underwent clinical evaluations for BPH, including a digital rectal exam, an ultrasound of their prostate, and blood tests to determine their prostate-specific antigen (PSA) level.

The same process was repeated every two years to detect and track BPH symptoms. None of the men had BPH symptoms at the study's outset, and about one third reported taking an NSAID every day. Among the daily NSAID users, 80% took aspirin; the rest took other common anti-inflammatory medications, such as ibuprofen (Motrin and others) or naproxen (Aleve and others).

Compared with men who did not take the medications, daily NSAID users were 27% less likely to report that their urinary symptoms (such as difficulty urinating or the need to urinate more urgently or more often) were moderate to severe, 47% less likely to have prostate enlargement, 48% less likely to have an elevated PSA level, and 49% less likely to report a weak urinary stream.

These findings suggest that taking a daily NSAID reduces the risk of developing BPH symptoms, and results from several previous studies seem to indicate that regular use of aspirin or other NSAIDs may also lower the possibility of developing prostate cancer.

What Should You Do Now? At this point, doctors do not recommend taking a daily NSAID strictly to improve prostate health. More research is needed to confirm the apparent beneficial effects of NSAIDs on the prostate. Plus, long-term use of these medications can lead to dangerous side effects, such as gastrointestinal bleeding and kidney problems, in some people. And a growing body of evidence suggests that, with the exception of aspirin, NSAIDs can increase your chances of having a heart attack or stroke if you have or are at risk for heart disease.

For now, if your doctor has prescribed a daily aspirin to help prevent heart disease—or you are taking prescribed NSAIDs for arthritis—you may be reaping prostate benefits as well. And, while there's no specific BPH prevention diet, it won't hurt to eat more veggies and pass up that extra slice of bread. If you lose weight in the process, all of your organs will thank you.

Weight Gain Triggers BPH

Tue, 10 Mar 2009 06:00:00 CST

Benign prostatic hyperplasia (BPH) is the most common benign (noncancerous) growth process in men. About one in four men experiences BPH-related symptoms by age 55; by age 75, half of men have BPH symptoms.

What triggers BPH is not well understood, but aging and testosterone (the predominant male sex hormone) are believed to be the primary influences on its development. Animal studies suggest that the female sex hormone estrogen (produced in small amounts in men) also may play a role, perhaps when a man's testosterone production declines and the balance of the two hormones is altered.

Now there are new insights as to the causes of BPH. A study reported in The Journal of Urology (Volume 177, page 1395) found that men who are overweight -- especially those with excess fat around the middle -- are more likely to develop BPH than men of normal weight.

Researchers examined the risk of BPH among 5,667 men age 55 or older who were in the placebo group of the Prostate Cancer Prevention Trial. They considered potential risk factors such as race, ethnicity, body mass index, and waist circumference. The researchers assessed the men for the development of BPH annually for seven years.

The study results revealed that the risk of developing BPH increased 4% for each additional year of age and that black and Hispanic men had a 41% higher risk of BPH than did white men. BPH risk was higher for all men with a body mass index greater than 25 (the cutoff point defining "overweight"), with the increased risk ranging from 13-29%. Men with abdominal obesity -- defined as a waist-to-hip ratio (waist measurement divided by hip measurement) of 0.95 or greater -- were also at higher risk. For men with a ratio of 1.05 or higher, the risk of developing severe BPH was increased by 45%.

Although the study was not designed to address the impact of weight loss on BPH, these findings suggest that if you're overweight, you might be able to reduce your risk by dropping excess pounds.

Get Moving to Protect Your Prostate

Tue, 27 Jan 2009 06:00:00 CST

It's well known that regular exercise is good for your heart. But increasing evidence indicates that being physically active also protects your prostate. A study in The Journal of Urology suggests that regular aerobic exercise can improve symptoms of chronic prostatitis. Here's what the researchers found …

Logging in about three to five hours of vigorous exercise per week helps keep prostate enlargement in check and may reduce the risk of developing advanced prostate cancer. Regular exercise also eases symptoms of prostatitis and helps manage some of the side effects of prostate cancer treatment

Chronic prostatitis/chronic pelvic pain syndrome is an often debilitating condition with no truly effective treatment. But a new study reported in The Journal of Urology (Volume 177, page 159) suggests that regular aerobic exercise can relieve pain and improve quality of life for men with prostatitis.

Researchers assigned 231 sedentary men with chronic prostatitis/chronic pelvic pain syndrome to perform regular aerobic exercise or only stretching or movement exercises (placebo group) for 18 weeks. At the study's outset, the men were given screening tests, blood tests, and a physical exam, and they filled out questionnaires and rating scales about their symptoms, pain level, and mood. The men were reassessed at one, six, and 18 weeks.

The aerobic exercise group performed warm-up and cool-down and strengthening exercises and walked on a track at a fast pace for 40 minutes three times per week. Men in the control group performed flexibility and movement exercises (typical exercises working different parts of the body) for the same duration and number of times per week.

At the end of the study, symptoms in both groups had improved. But the aerobics group had significantly greater improvements in pain and quality of life.

If you haven't experienced relief after treatment for chronic prostatitis/chronic pelvic pain and have a sedentary lifestyle, aerobic exercise may be just the prescription you need.

More Good News About Vegetables

Tue, 16 Dec 2008 10:00:00 CST

Now there's another good reason to eat your vegetables. A recent study suggests that a high intake of vegetables such as spinach, peas, and Brussels sprouts can reduce your risk of prostate enlargement (BPH).

Eating more vegetables each day may help stave off benign prostatic hyperplasia (BPH). That’s the conclusion of a new analysis of data from the long-running Health Professionals Follow-Up Study, reported in the American Journal of Clinical Nutrition (Volume 85, page 523).

The study, which began in 1986, enrolled more than 50,000 men between the ages of 40 and 75. The men provided information on their medical histories, lifestyle, and dietary habits. This information was updated every four years. Beginning in 1992, every other year the men reported whether they had undergone surgery for an enlarged prostate. They also filled out the American Urological Association’s BPH symptom index on three occasions.

A man was considered to have BPH if he had undergone surgery for an enlarged prostate or had a BPH symptom score of 15–35. In the current analysis, men who ate the most vegetables had a lower risk of developing BPH than men who ate the least. Total fruit consumption was not related to BPH risk. But men who frequently ate fruits and vegetables rich in beta-carotene, lutein, or vitamin C, including spinach, peas, Brussels sprouts, and peaches, did have a reduced risk of developing BPH.

This study provides further evidence of the value of eating a well-balanced diet that includes a variety of fruits and vegetables.

Dialogue With Dr. A: Will Prostatitis Affect My Quality of Life?

Tue, 25 Nov 2008 10:00:00 CST

Chronic prostatitis can be a devastating ailment that seriously impairs a man's quality of life. In this excerpt from an in-depth report on chronic prostatitis from the Johns Hopkins Prostate Bulletin, Dr. Richard Alexander provides insights.

Prostatitis is a condition found in adult men, with no respect to age, race, or nationality. It’s estimated that as many as 14% of adult American men will at some point go to their doctor complaining of one or more of the symptoms that doctors now believe constitute a diagnosis of prostatitis. In the United States, more than two million doctor visits are made each year because of prostatitis complaints.

Q. What’s the usual impact of prostatitis? Is it more of a nuisance, or does it tend to severely disrupt a man’s quality of life?

Dr. Alexander: Quality of life surveys indicate that the impact of chronic prostatitis on a man’s life is often equivalent to that of a heart attack or diabetes. The discomfort may be so severe that many men have to leave their jobs and go on extended disability leave.

On the other hand, the ailment is not life threatening -- it doesn’t kill anybody. Unfortunately, since there are no known cures for prostatitis, the disorder tends to be ignored or minimized by doctors, who may give a man with chronic prostatitis a prescription for an antibiotic just to get him out of the office. Sad to say, that’s how this disease is “managed” by many doctors in this country.

Q. Does chronic prostatitis have a negative effect on a man’s sex life?

Dr. Alexander: I conducted an Internet survey several years ago of men with chronic prostatitis, and it revealed that most men with the disorder were monogamous, sexually active, and potent, but their frequency of sexual encounters seemed to decrease after they developed chronic prostatitis. Pain during or after ejaculation is the one symptom that’s most consistently associated with a negative effect on their sexual activity.

Dialogue With Doctor M: Are my Urinary Problems Caused by LUTS, BPH, or LOO?

Tue, 23 Sep 2008 11:00:00 CDT

How can you tell if your urinary frequency problems are caused by a condition in the bladder or the prostate – and what should you do about it? In this excerpt from a recent Johns Hopkins Prostate Bulletin, Dr. Jacek Mostwin explains how to differentiate LUTS, BPH, and LOO.

Q. I am confused. I’m 52, and for the past three years I have had urinary frequency and urgency problems. I finally decided to go to a urologist. After taking my history, the doctor gave me a DRE (I had a “large” prostate, he said) and then took blood for a PSA test.

A week later, the doctor called to say that he wanted me to have a prostate biopsy. My PSA test had come back at 6 ng/ml. Long story, short: My prostate biopsy was negative. I was given Proscar and Flomax for my urinary problems and the doctor said to come back to see him in about six months.

I assume that he gave me this vague time frame because it may take that long for the drugs to work. I can accept that. However, what if the urinary problems are not caused by my prostate, but by my bladder? I don’t want to embarrass my doctor by second-guessing him, but can any urologist really ascertain whether urination complaints arise from the bladder or prostate, or is the diagnosis made by exclusion? Bronxville, NY

Dr. Mostwin: You are right to be concerned about the source of your lower tract urinary symptoms (LUTS) being either the prostate or bladder. LUTS can be caused by benign prostatic hyperplasia (BPH), bladder outlet obstruction (BOO), and other conditions. LUTS are only rarely caused by prostate cancer in early stages.

Urinary cytology and cystoscopy are often sufficient to exclude these conditions, but sometimes a transurethral (as opposed to a transrectal) biopsy may be needed. The most common situation is the man with LUTS and BPH. Formerly, all LUTS in men were attributed to prostatic enlargement, and prostatectomy was frequently the recommended treatment.

More recently, it has become clear that both men and women suffer from a similar age-related increase in LUTS, and that LUTS may be complicated by BPH, but may not always be caused by it. LUTS, BPH and BOO may all co-exist, but may not be directly related, so that LUTS may be improved by medications affecting the bladder or the sensory nerves to the bladder, or it may be affected by reducing prostatic volume, or both.

Sound complicated? Welcome to the world of urology! If prostate cancer is excluded and there is no blood in the urine at the time of initial evaluation, it is reasonable to offer combined medical therapy for LUTS in the setting of BPH. There should be some sign of improvement within the first few weeks from the Flomax alone; the improvement from Proscar takes a good six months to kick in. If there is no improvement in the first month, it is reasonable to re-assess the situation and decide whether the patient should wait a full six months for further improvement, or if invasive testing is required.

Prostatitis--Nailing Down the Diagnosis

Tue, 04 Nov 2008 10:00:00 CST

According to one study, men with prostatitis have a quality of life so diminished that it is comparable to that of men who have recently suffered a heart attack. If you experience symptoms of prostatitis, the first step is getting a correct diagnosis. Johns Hopkins provides advice.

Prostatitis is a broad term for an infection or inflammation of the prostate. Over the past decade, urologists have identified four types of prostatitis:

Acute bacterial prostatitis is a sudden-onset infection that lasts for several days.

Chronic bacterial prostatitis is a recurrent infection that can last for weeks, subside, and then flare-up again.

Chronic non-bacterial prostatitis/chronic pelvic pain syndrome (CPPS) is diagnosed when no infectious organism can be identified.

Asymptomatic inflammatory prostatitis is diagnosed when white blood cells are found in the prostatic secretions or prostate tissue of a man who has no symptoms of prostatitis.

A thorough diagnostic work-up for prostatitis is critical for several reasons. Some symptoms of prostatitis overlap with those of urethritis (inflammation of the urethra), cystitis (inflammation of the bladder), benign prostatic hyperplasia, and prostate cancer, and these conditions must be ruled out. It’s also essential to distinguish between the various types of prostatitis because treatment that is effective for one type may have no effect on another.

Recognizing and accurately reporting your prostatitis symptoms is the first step in obtaining a correct diagnosis. After taking a detailed history of your symptoms, your urologist will conduct a number of diagnostic tests to rule out other conditions and to identify the type of prostatitis you have. Common tests include:

Digital rectal exam (DRE). A digital rectal exam will tell your physician whether the prostate is swollen, tender, warm, and firm (suggesting an acute bacterial infection) or enlarged and either soft or firm (suggesting a chronic bacterial infection).

Urine analysis. Your urine will be analyzed for the presence of bacteria. If chronic prostatitis is suspected, another urine sample may be collected after prostate massage.

Prostate secretion analysis. A sample of prostate fluid obtained with prostate massage will be examined for signs of infection or inflammation.

Prostate-specific antigen (PSA) test. An elevated PSA level can indicate an inflamed prostate or prostate cancer.

Do You Have BPH?

Tue, 14 Oct 2008 10:00:00 CDT

Approximately 50% of all men experience symptoms of enlarged prostate, BPH, by age 75. If you're one of them, you'll want to take this easy, self-scoring questionnaire to calculate the severity of your symptoms.

The International Prostate Symptom Score questionnaire, also called the American Urological Association Symptom Index, was developed by the American Urological Association to help men evaluate the severity of their symptoms from benign prostatic hyperplasia (BPH) -- enlarged prostate. This self-administered BPH test can help determine which type of prostate treatment is needed, if any.

However, the BPH questionnaire alone cannot be used for diagnosis for two main reasons. First, other diseases can cause lower urinary tract symptoms similar to those of BPH. Second, as men age, the bladder naturally becomes less efficient at storing urine, and symptoms of urinary frequency and urgency become more common.

Therefore, a careful medical history, physical examination, and laboratory tests are required to exclude conditions such as urethral stricture (narrowing of the urethra) and bladder disease. In fact, some reports indicate that as many as 30% of men who undergo surgery for BPH are found not to have urethral obstruction (meaning their symptoms were caused by something other than BPH).

Prostate Symptoms Questionnaire:

Use this key to answer each question, then tabulate your score to assess your BPH severity: mild BPH (1 to 7), moderate BPH (8 to 19), or severe BPH (20 to 35).

Generally, no treatment is needed if BPH symptoms are mild; moderate BPH symptoms usually call for some form of BPH treatment; and severe symptoms indicate that surgery for BPH is most likely to be effective.

Not at all = 0
Less than 1 time in 5 = 1
Less than half the time = 2
About half the time = 3
More than half the time = 4
Almost always = 5

1. Over the past month, how often have you had the sensation of not emptying your bladder completely after you finished urinating?
2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

3. Over the past month, how often have you found you stopped and started again several times when you urinated?

4. Over the past month, how often have you found it difficult to postpone urination?

5. Over the past month, how often have you had a weak urinary stream?

6. Over the past month, how often have you had to push or strain to begin urination?

7. Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

What Causes Prostatitis?

Thu, 20 Nov 2008 10:00:00 CST

If you have prostatitis, you're not alone. Prostatitis usually affects men in their early 40s, and it is one of the leading reasons why men visit a urologist. In this Health Alert, Johns Hopkins explains why chronic prostatitis is so difficult to treat.

There are two kinds of prostatitis -- bacterial and nonbacterial. Nearly 95% of patients are thought to develop prostatitis from nonbacterial causes, which have yet to be identified.

While the causes of bacterial prostatitis are obvious and easy to detect, researchers are unsure why men develop the more prevalent, nonbacterial form. Some men find that stress, emotional problems, or even coffee may trigger flare-ups. Other possible culprits include zinc deficiency, tight urinary sphincter muscles, infrequent ejaculation, and dehydration.

Some experts suggest that nonbacterial prostatitis is not really a prostate problem at all. Rather, flare-ups could be the result of a pelvic muscle spasm or some other cause that mimics symptoms originating in the prostate. Another theory under investigation is that prostatitis is caused by an autoimmune disorder, in which the immune system mistakenly attacks healthy prostate tissue and promotes inflammation -- not unlike the way rheumatoid arthritis targets the joints. Indeed, researchers recently found that men with chronic prostatitis had increased levels of the same pro-inflammatory molecules that are elevated in the joint tissue of people with rheumatoid arthritis.

If you have bacterial prostatitis, your treatment options are fairly straightforward : a course of antibiotics for a period of 4 to 16 weeks. Indeed, b acterial prostatitis is the most curable form of the disease, although some patients may not respond to treatment, or symptoms may reappear once the antibiotics are stopped.

Treatment of nonbacterial prostatitis is more difficult, and no one treatment has been proven to improve symptoms for most men. It may take some trial and error to find a combination of therapies and self-care techniques to obtain symptom relief. While antibiotics typically are reserved only for bacterial diseases, many patients with nonbacterial prostatitis receive antibiotics and a prostate massage, followed by high doses of alpha-blocker drugs.

Should You Consider Watchful Waiting?

Tue, 06 Jan 2009 10:00:00 CST

Benign prostatic hyperplasia (BPH) is the most common benign (noncancerous) growth process in men. About one in four men experiences BPH-related symptoms by age 55; by age 75 half of men have BPH symptoms. If you are diagnosed with BPH, you and your doctor will decide together if watchful waiting is an option for you.

Doctors can’t predict how quickly an enlarged prostate will require treatment. Symptoms and objective measurements of obstruction in the urethra associated with BPH can remain stable for many years and may even improve over time in as many as a third of men. In one study from the Mayo Clinic, urinary symptoms did not worsen over a 3 1/2-year period in 73% of men with mild BPH.

Because the progression of and complications from BPH are unpredictable, watchful waiting -- meaning that you are closely monitored but no immediate treatment is attempted -- is best for men with minimal BPH symptoms that are not especially bothersome. With this treatment option for BPH, you only need to see your doctor about once a year to review the progress of symptoms and undergo a physical examination a few simple laboratory tests.

During watchful waiting for BPH, you should adopt certain lifestyle measures to help relieve symptoms of BPH and prevent them from worsening. For example, you should not take over-the-counter antihistamines and decongestants and should avoid delaying urination. If you have BPH you also need to be careful about your fluid intake by avoiding beverages that contain caffeine, limiting alcohol intake and the amount of fluid consumed at any one time, and avoiding beverages after 7 p.m.

Other helpful measures for these men with BPH include limiting spicy or salty foods, keeping warm, engaging in regular physical activity, and doing Kegel exercises (which involve squeezing and relaxing the pelvic floor muscles that support the bladder and surround the urethra).