Frequently Asked Questions

Prostate cancer doesn’t cause symptoms until it is advanced and often incurable, but men often present with urinary symptoms (frequency, urgency and/or a poor stream) due to benign (non-cancerous) prostatic enlargement that co-exists with the cancer and initiates the investigations that reveal it.

No. Lower grades (a marker of aggressiveness) of prostate cancer are treated by active surveillance in the first instance. This involves close monitoring and treatment only if there is evidence of tumour progression. Higher grades and stages (the extent of the tumour) are potentially lethal and mandate active treatment.

The ‘tigers’ are the aggressive cancers and the ‘pussy cats’ the slower growing ones. The Gleason grading system allows this to be expressed as a number: grade 6 (out of a maximum of 10) tumours are generally slow growing and have little potential to spread. Gleason 7 tumours can grow rapidly and spread but this is relatively uncommon, whereas Gleason 8, 9 & 10 tumours behave aggressively.

Established treatment options are active surveillance for low grade tumours and radiotherapy or surgery for tumours that need active treatment. Damaging the tumour with heat (high intensity focused ultrasound or HIFU) or cold (cryotherapy) may be appropriate in patients who are not suitable for surgery or radiotherapy and are not considered mainstream treatments as the evidence to date does not show them to be equivalent in terms of cancer control. Focal treatment (treating part, usually half, of the prostate) may be offered in the unusual patient who has cancer on only one side of the prostate but this is also at the trial stage at present.

There is no one right treatment for all and the choice depends on many factors including tumour grade and stage, age and priorities.

Although the best candidates for surgery are those with tumours confined to the prostate there is convincing evidence that men with locally advanced prostate cancer and those with limited metastases (spread to the bones and/or lymph nodes) may also benefit significantly from surgical de-bulking of the cancer prior to the use of adjuvant hormonal therapy and/or radiotherapy.

There is no single number that encompasses all the important outcomes following surgery, the main three being cancer control, continence (urinary control) and potency (sexual performance). Success rates are surgeon dependent, usually correlate closely with experience and may vary widely.

The prostate gland is an organ composed of smooth muscle and secretory glands that lies at the base of the bladder. It is pierced by two tubes which meet just below the prostate: from back to front by the ejaculatory duct, through which semen is expelled during climax; and vertically by the urethra, which drains urine from the bladder to the outside world.

Urinary symptoms become commoner with age and approximately 65% of men aged 60 have some urinary symptoms. If they are bothersome you should have them investigated. ‘Obstructive’ bladder symptoms include having to wait to get started, a poor flow, and needing to strain to pass urine. In some patients, the back-pressure caused by the obstruction separates the nerve endings from the bladder muscle fibres they are travelling towards, causing the bladder to behave in a reflex or unstable manner rather like a baby’s bladder does. The ‘irritative’ symptoms caused by an unstable bladder include frequency (going often), urgency (going in a hurry) and urge incontinence (leaking if you can’t get to a toilet in time).

Prostate-specific antigen (PSA) is a chemical which is only produced by prostate cells (hence ‘prostate-specific’) and which is detectable in the blood. A number of factors cause its increased production: increasing age, increasing prostate size, ejaculation, urinary infection, prostatitis, prostate injury (such as a biopsy) and prostate cancer. Additionally, there are many men who have an elevated PSA who appear to have none of these conditions. Although PSA is not completely specific or sensitive for detecting prostate disease, including cancer, it remains an extremely useful indicator of the risk of prostate disease and the need for further investigation.

PSA has come in for a lot of criticism for not being specific for prostate cancer but urologists have always known this and never diagnose or exclude prostate cancer based on the PSA alone. However, the PSA level is useful in knowing which men should be looked at more carefully.

Balanced against the risk of over-detecting prostate cancer is the risk of under-detection. Prostate cancer kills 10,000 men a year in the UK or one man every hour. The European Randomised Study of Screening for Prostate Cancer has shown a 44% reduction in prostate cancer related deaths at 14 years’ follow-up in men who were screened compared to those who were not.

Depending on test results, the first line treatment is nearly always with tablets.

Surgery is reserved for men who either do not respond to tablets or who have more severe levels of prostatic obstruction.

Transurethral resection of the prostate (TURP) involves coring out the central part of the prostate (rather like one might core out the centre of an apple) to physically enlarge the channel one passes urine through. It was the first ‘keyhole’ operation and remains the standard to which other procedures for BPH are compared. It is performed under general or spinal anaesthetic, usually lasts 30 minutes and involves no incisions on the outside. It is performed using a hot wire loop, which is used to remove the prostate in slivers, inserted into the urethra via a telescope. These are washed out at the end of the operation and a catheter is inserted for 1-2 days, through which irrigation fluid flows into the bladder to rinse any blood in it.

Retrograde ejaculation as the path of least resistance after TURP is back into the bladder. Semen is then eliminated in the urine. This doesn’t interfere with the enjoyment of climax but it does usually preclude fathering more children. There is also a 5% risk of erectile dysfunction after TURP – this usually only affects men older than 70 years.