Health News and Information

For many men, the symptoms of prostatitis appear suddenly and then go away with treatment. For these men, prostatitis is an awful episode to endure and then put behind them; it does not require a lifetime adjustment. But for Alan, a 52-year-old Baltimore attorney with perhaps a “worst-case” scenario of nonbacterial prostatitis, the situation is distinctly different.

His trouble began three years ago. He’d had some minor prostate “episodes” before that, he says, but nothing like this. Then, after seeking treatment for a headache, he was prescribed a migraine medication, in a class of drugs called tricyclic antidepressants. “What it [the drug] did, was slow down my urine flow terrifically.” Within a couple of days, Alan began noticing some new symptoms: “I found I was spending a lot of time going to the bathroom, and I developed some stinging, and a lot of nonspecific symptoms like headaches— just not feeling well. The first time I had sex after that [developing these symptoms], it was painful, and I was sore for a day or two afterward,” with pain in the lower abdomen, scrotum and perineum.

Eventually, Alan was diagnosed as having nonbacterial prostatitis. “The symptoms ebb and flow, but they haven’t disappeared,” he says. These include reduced urine stream; occasional difficulty starting and stopping urination; generalized pain in the perineal region, usually beginning about twelve to fifteen hours after sexual intercourse and lasting two to three days; and “just feeling lousy.” He’s also been awakened by muscle spasms in his perineal region, but he can’t pinpoint an exact location. He tried abstaining from sexual intercourse, but that didn’t help.

At first, Alan had what he describes as “menopausal-type” feelings, accompanied by a lot of anxiety: “When this first came on, because of that fear of losing something very special to me, I think there was a heightened sense of sexual drive or desire, which was of course immediately frustrated by the inability to do anything about the symptoms.” And he thought, “Is this going to be a permanent impairment, will this limit sexual activity and the free expression of physical love in my marriage? Is this going to be the end of a chapter in my life?”

Alan’s suggestions for men with his condition: “First, just try to have a positive oudook on being able to live with this situation. With time, there comes a better ability to adjust and accept what is really a very annoying and irritating condition.”

He was treated early on by an internist, who described Alan’s problem as “prostatosis,” a vague, unhelpful term that means simply “a condition of the prostate.” Another word of advice: “Don’t let anybody tell you it’s all in your head.” Alan even consulted a psychiatrist, who confirmed that prostatitis is “a real, live condition that could not be explained solely by psychological causes.”

“Sometimes the symptoms are worse than others,” Alan says; “I can’t determine what makes them different. There just isn’t any clear-cut pattern. I guess part of this experience has been simply accepting the condition.”

*312\201\8*

One advantage of laser prostatectomy is smaller instruments, which should produce fewer strictures, scars resulting from injury to the bladder neck or urethra. And, if the bladder neck is not treated, there should be no retrograde ejaculation and no sexual dysfunction. These techniques cause less bleeding, and unlike the TUR they can be performed on an outpatient basis under local anesthesia. Also, there’s no fluid absorption (so no risk of TUR syndrome).

To date, the biggest problems with these still relatively new techniques have been prolonged urinary obstruction after the operation in some patients, and the need for a catheter (either in the urethra or a suprapubic tube, attached directly to the bladder) for several days after surgery. Also, it takes longer for laser prostatectomy to improve urinary flow than for TUR. So, laser surgery may not be best for an impatient patient. The ideal candidate for laser prostatectomy should have a prostate that weighs less than sixty grams or two ounces; should not have urinary retention; and should have mainly obstructive, not irritative, symptoms.

Another problem is that no tissue samples are available for pathologic study. And if the energy beam creates holes in the prostate, there can be distressing irritative symptoms that persist until the tissue has dissolved and been flushed from the body.

Moreover, lasers may not be as widely available as other forms of treatment because of their cost: Laser fibers are very expensive, and most of them can’t be reused. For each laser procedure, the laser fiber alone costs about $800. (The laser machines themselves cost hospitals about $100,000, but they can be used for other procedures.)

*274\201\8*

Urinary retention—difficulty in emptying the bladder completely, or in urinating at all—also can be triggered by many things, including consuming alcohol; having prostatitis; and taking such medications as antihistamines, antidepressants, tranquilizers, or decongestants. It could even mean prostate cancer, although in most cases, prostate cancer is regrettably “silent,” producing no symptoms until it becomes considerably advanced. Two other symptoms, however—trouble starting urination, and a slow or weak stream— almost always signal obstruction.

The lower urinary tract can also be affected by neurological disorders such as diabetes mellitus; multiple sclerosis; Parkinson’s disease; and spinal stenosis, pressure on the spinal cord that impairs the brain’s ability to communicate with the bladder. These and other diseases can give rise to obstructive and irritative symptoms like those in BPH. (Parkinson’s disease makes it particularly tricky to treat the symptoms of BPH. For more on this, see Chapter 10.) The term “neurogenic bladder” refers to a bladder affected by such conditions.

So, because other conditions can mimic the obstruction produced by BPH, a good medical history is vital even if you have what seems like a classic case. An injury to the urethra (from an episode of gonorrhea many years ago, perhaps, or from having a catheter inserted into the bladder during a surgical procedure, such as a coronary artery bypass) can produce a urethral stricture—a scar that narrows the urethra—that has nothing to do with the prostate, yet produces urinary problems just as BPH does. Blood in the urine, or pain in the bladder or penis could point to a bladder tumor; it could also indicate that a stone has developed in the bladder, prostate, or kidney. And having a history of other urologic problems—recurrent tract infections or prostatitis, for example— could mean one of these old adversaries has returned, in a different guise.

You will also be asked to score your symptoms on a questionnaire (such as the one in table 9.1). Be honest; your answers will help your doctor determine whether your symptoms are mild, moderate or severe, and the impact they’re having on your life.

*235\201\8*

DRUGS FOR PAIN

It makes sense to treat each level and kind of pain differently. At the lowest level is mild pain that responds to aspirin, acetaminophen (Tylenol), or ibuprofen (Advil or Motrin). Next come low-powered opiates, drugs such as codeine. As opiates go, these drugs are considered weak. In terms of pain relief, they can’t hold a candle to high-powered opiates such as morphine—the highest rung on the pain ladder. (However, these milder opiates generally are sufficient to ease moderate pain.) The biggest advantage to strong opiates is “their lack of ceiling effect,” as one study puts it. “Increasing the dose always increases the pain relief,” although it can also increase the side effects.

In addition, other drugs not generally classified as painkillers—particularly corticosteroids—have proved helpful in reducing inflammation and bringing relief from some spinal pain. Ask your doctor if one of these drugs might be right for you.

If you are elderly, have other health problems, or are taking other medications, certain painkillers may have a stronger effect in you than in other men. Be sure to discuss these factors, the side effects of various drugs, and the form in which you should take these drugs—a pill, or liquid, rectal suppository, skin patch, or shot—with your doctor. If you need additional information, your pharmacist may also be able to provide you with the package insert sheets for various drugs. These generally are impenetrable, written in tiny print, and confusing—they contain more information than most people want to know. They also tend to list every possible side effect, even the unlikely ones. However, some people find this information helpful.

*196\201\8*

External-beam radiation therapy is an excellent treatment option for many men with prostate cancer. First and foremost, it requires no surgery—this is a key advantage for older men, as well as for men with other health problems that might preclude major surgery. Also, it can be used in men with prostate tumors that are too far advanced to be cured by surgery.

There are two standard approaches to radiation treatment for prostate cancer—sending radiation into the tumor from the outside, with external-beam radiation therapy, and implanting radioactive seeds directly into the tumor; this is called interstitial brachytherapy.

Currently, the “gold standard” for radiation is external-beam radiation therapy. Sophisticated refinements have transformed it from the imprecise, mostly palliative treatment it was just decades ago into a powerful treatment that can cure localized cancer—not just relieve the symptoms of advanced disease.

*158\201\8*