What every man needs to know about his Prostate

This guide to understanding the health of your prostate could save your life.

You may have been directed here by our leaflet. However, there is more information here than can be fit in the leaflet.

To make this document easy to understand, we have used common names rather than medical terms.

What is your prostate?

The prostate is a gland which men have. It is in the lower abdomen, just below the bladder. The prostate produces about 40% of your semen and combines that with the components produced by other organs, so it is necessary for fathering children. The pipe carrying pee from the bladder to the penis goes through the middle of the prostate.

Trans-women and some intersex people also have a prostate, and this leaflet is relevant to them too.

What can go wrong with the Prostate?

There are 3 main things which can go wrong:

• Enlarged prostate, which happens to many men from age 50 upwards.
• Prostatitis, which is inflammation of the prostate
• Prostate Cancer, which is the most frequently diagnosed cancer in the UK.

Enlarged Prostate

Many men’s prostates never stop growing and can start to cause problems from age 50 as they get larger due to the narrowing of the pee pipe or pressing on the bladder. This is also known as BPH - benign prostatic hyperplasia. The size at which a prostate starts causing problems varies widely - some men with only a slightly enlarged prostate might have problems, while other men with much larger prostates don't yet have any problems.

Enlarged prostate symptoms include:

• Peeing more often, particularly more than once overnight.
• It is difficult to start peeing, peeing slowly, straining to pee, taking a long time to finish peeing or being unable to pee at all. (If you cannot pee, you must go to A&E immediately - this is a medical emergency).
• A sudden need to pee, and you can’t wait.
• Peeing small amounts, and a sense that you haven’t emptied when you finished peeing.

An enlarged prostate is not prostate cancer, but you can have both conditions, which become a risk at around the same age. You should talk with your GP if you experience any of these symptoms, and it's also a good opportunity to ask for a PSA blood test (see Prostate Cancer below). Medications are available to help with the symptoms of an enlarged prostate. In severe cases, a common surgical procedure might be necessary.

Prostatitis

Prostatitis is inflammation of the prostate. This can happen at any age, from puberty. It is usually painful, but occasionally it has no symptoms. The pain may seem to come from somewhere else, such as the tip of the penis, balls (testicles), rectum, or lower back. It can also be painful if a doctor feels your prostate during ejaculation while peeing or doing a poo.

A bacterial infection can cause prostatitis, although this rarely shows in urine or semen samples, even when there is an infection.

You should see your GP if you think you may have Prostatitis. However, prostatitis is sometimes difficult to treat, and you may need to refer to a prostatitis specialist at the hospital.

Prostate Cancer

Although Prostate Cancer is the most frequently diagnosed cancer in the UK, there is no screening programme such as those for breast cancer and bowel cancer. So, it is your responsibility to understand prostate cancer and how it might impact you. Over half of prostate cancer cases are diagnosed at a late stage, by which time the disease is more difficult to treat, including over 1 in 5, which are diagnosed too late to be cured. Early diagnosis results in better treatment outcomes.

When should you be concerned about Prostate Cancer?

There are two things to consider: your risk of getting prostate cancer and any symptoms you have which could be related to prostate cancer.

Your risk of Prostate Cancer

Prostate cancer happens to many healthy people, and it can be a significant surprise. For some cancers, what you eat, if you smoke, what you drink, and if you are overweight can increase your cancer risk. Prostate Cancer is not a lifestyle cancer, or at least, we haven't yet learned what lifestyle factors might raise your risk.

• 1 in 8 men will get significant prostate cancer during their lives. This figure may be higher in men born from 1960 at 1 in 6 men.

However, we do know several factors that increase your risk of getting prostate cancer.

• The risk of prostate cancer increases with age. Men aged 50 are considered at risk, and this risk increases with age.
• Black African and Black Caribbean men have twice the risk of prostate cancer, and they often get it at a younger age and more aggressively, so they are considered at risk from age 45.
• If your father or brother had prostate cancer, you have twice the chance of getting it yourself.
• If your mother or sister had breast or ovarian cancer below age 60, your chance of getting prostate cancer is slightly increased.

Being overweight probably does not increase your risk of getting prostate cancer, but does increase the risk of it being more aggressive and being diagnosed at a later stage, with less favourable outcomes.

Symptoms of Prostate Cancer

Many prostate cancer awareness leaflets list the symptoms of an enlarged prostate related to peeing as also being symptoms of prostate cancer. However, this does not fit with what we find in support groups for men diagnosed, and most urology consultants agree that urinary symptoms are not symptoms of prostate cancer.

Many GPs still regard problems with peeing as prostate cancer symptoms, which means that you are more likely to get a PSA blood test if you have symptoms of an enlarged prostate. However, this also means some GPs refuse to do a PSA blood test if you have no symptoms. Yet most men diagnosed with prostate cancer (certainly while it's still potentially curable) had no symptoms of the prostate cancer.

The following paper goes into this in some detail:
Urinary symptoms and prostate cancer - the misconception that may be preventing earlier presentation and better survival outcomes other trialsl, such as ProtecT, also showed no link between problems of peeing and prostate cancer.

Most men diagnosed with Prostate Cancer have no symptoms of the cancer.

Occasionally, prostate cancer can cause:

• Problems getting erections or weaker erections.
• Significant reduction or loss of semen.
• Blood in pee or semen.
• Pain in the back, ribs, pelvis/groin, other bones.

These are all usually caused by something else, but you must go to see your GP if you have any of these.

So, how do I get checked?

There are two simple checks a GP can do:

• A simple blood test to check for raised PSA levels.
• Feel the surface of your prostate.

Neither of these is a direct test for prostate cancer, but they can indicate you need to be referred to the hospital for a scan. Other things can raise the PSA level. About 1 in 6 prostate cancers don’t raise the PSA level.

All men are entitled to a PSA blood test from their GP from age 50 or age 45 if they are a high risk. Never be put off having a PSA blood test just because you have no symptoms. Most men diagnosed with prostate cancer have no symptoms of the cancer. If your PSA is above the normal range, your GP might check for infection and repeat the test in 4-12 weeks. However, you should be referred to the hospital for a scan if your PSA is still raised.

You can also get a PSA blood test by post or at a charity event, and these are listed here:https://mypsatests.org.uk/.

The following might cause a temporary rise in PSA and are best avoided before a PSA blood test:

• Ejaculating in the previous 24-48 hours
• Cycling or horse riding in the previous 24-48 hours
• Some forms of strenuous exercise in the previous 24-48 hours
• Having COVID in the previous month
  Variation of Serum PSA Levels inCOVID-19 Infected Male Patients with Benign Prostatic Hyperplasia (BPH): A Prospective Cohort Studys
• Having a COVID vaccination in the previous month

PSA Thresholds

There's no one agreed set of PSA thresholds.

NICE (NHS) recommends:
Below 40 Use clinical judgement
40 to 49 More than 2.5
50 to 59 More than 3.5
60 to 69 More than 4.5
70 to 79 More than 6.5
Above 79 Use clinical judgement

ICBs, Cancer Alliances, and individual hospital urology departments can override these on a regional and local basis.

Urologists sometimes use the BAUS (British Association of Urological Surgeons) recommendations:
40-49 2.7
50-59 3.9
60-69 5.0
70-79 7.2
80-84 10
85+ 20
Borderline results should be retested in 3 months before referral.

CHAPS uses the following thresholds, which have been worked out from research into screening using PSA testing.These levels are roughly in between the NICE and BAUS recommended levels:

Under 50: 2-3 retest in 3 months and refer if >2. Refer immediately if >3.
50-59: 3-4 retest in 3 months and refer if >3 Refer immediately if >4.
60-69: 4-5 retest in 3 months and refer if >4. Refer immediately if >5.
Over 69: 5-6 retest in 3 months and refer if >5. Refer immediately if >6.

CHAPS recommends stratified retest intervals depending on the last test result and the man's risk.

The NICE and BAUS figures are specified as for men with symptoms (pretty meaningless given current research shows most men diagnosed have no symptoms). The CHAPS figures are for screening men and, hence, for men without symptoms. So we use the CHAPS figures in the leaflet, but your doctor may use one of the other recommendations.

Some sets of recommendations also suggest referral if your PSA increases by more than a certain percentage per year (such as 20%) even if you are still below the age threshold, although NICE, BAUS, and CHAPS don't cover this case.

How often should I be tested?

You should also consider asking for periodic PSA blood tests because prostate cancer can appear in the future, even if your current test result is OK. The maximum suggested test interval can be anywhere between 1 and 3 years, depending on what the level is and your other risk factors.

*Retest and investigate if the situation has not been resolved.

These retest intervals are as recommended by CHAPS, based on their experience of screening men using PSA testing.

If you are unfortunately diagnosed with prostate cancer or another prostate problem, please do give us a call for a chat by contacting us.