Dear Dr. G,

The sheer mention of the prostate really scares me.

I guess this stems from my youth when I saw my father admitted to hospital being catheterised when he was unable to urinate.

He underwent an operation to unblock his urinary system and the sight of the catheter coming out of his penis and bleeding for days really traumatized me.

For years I was avoiding the topic and the sheer mention of the prostate really sent chills down my spine.

However, I am now heading into my 50s and had to do a full-body checkup for insurance purposes. The checkup found that my my prostate cancer marker (PSA) was elevated, and I must face the nevitable visit to a urologist

Before doing so, I thought it is a good idea to put Dr. G on the spot for clarification.

Can you tell me what exactly is the prostate and where is it located? What are the signs and symptoms of problematic prostate and how is the prostate examination conducted in the clinic?

On the other hand, what is the PSA? Is a PSA elevation a sign of cancer?

How do urologists determine the diagnosis of prostate cancer if the PSA is high and what are the complications of such tests?

Please help me to alleviate my Persistent Stress and Anxiety


Stressed Steven

The prostate is a walnut size organ that is situated between the base of the bladder and the penis. This organ is responsible for the production of semen, which provides the nutrients for sperm and the enzymes to digest the hostile barriers created by the cervix. Most of the quantity of ejaculate produced by men is derived from the prostate; hence men will continue to have unaltered semen despite having had a vasectomy.

As the prostate is inconveniently located between the penis and the bladder, the passage of urine must go through the prostatic urethra before leaving a man’s body. Therefore, an enlarged prostate will result in several urinary symptoms such as poor flow, difficulty initiating and residual urine causing day and nighttime frequency. Although most urinary symptoms are caused by benign prostatic enlargement, as age progresses, there is also an increasing risk of prostate cancer.

The prostate assessments for both young and older men is generally straightforward and painless. Most men are surprised when they realise that the process is less horrific than anticipated. The assessment of prostate health usually begins the assessment using the International Prostate Symptoms Scores (IPSS). The general examination is conducted with overall abdominal examination followed by a Digital Rectal Examination (DRE).

This is a quick examination using the index finger of the doctor and it is just mildly uncomfortable. The final stage of the examination is usually a urine flow test and some lab investigations including renal function and cancer markers such as PSA.

In this, the Prostate Specific Antigen (PSA) is a natural marker specifically produced by the prostate, hence completely absent in women or men after a prostatectomy. A PSA test is not a brilliant test to indicate the presence of cancer, as the level may also be high due to non-cancerous conditions such as infections and age-related benign enlargement.

A transient PSA elevation is often observed in men shortly after ejaculation or long-distance cycling. Therefore, many men with PSA elevation are troubled by the fear of needing further tests to evaluate the possibility of cancer.

The definitive way to detect cancer after PSA elevation is through a TRUS (Trans Rectal Ultrasound) guided biopsy of the prostate. The investigation will require an insertion of an ultrasound probe into the rectum, visualizing the prostate and extracting samples for analysis. The potential complications following a TRUS biopsy of the prostate include infection, urinary and rectal bleeding. The use of antibiotics followed by careful monitoring are crucial for men undergoing a prostate biopsy. In addition, the random biopsy of the prostate may also give a false assurance if the cancer is missed during the sampling.

Scientific advancement in recent years has improves the detection rate of prostate cancers. Detailed assessment of the prostate by MRI scans can delineate certain cancer characteristics, avoiding many unnecessary risks of a biopsy in men with high PSA but without cancer. The MRI also can identify the exact location of the abnormal tissue, allowing more accurate targeting. This is also important to avoid false negatives in tissue sampling. The only drawback is that MRI scans can be costly and may not be affordable for many men with elevated PSA.

The detection of prostate cancer after the biopsy will still require further evaluation. The cancer will be assessed according to the degree or aggressiveness by a scoring system named the Gleason Score. An additional assessment to determine the stage of the cancer is also crucial prior to treatment. At the early stages of detection with organ-confined disease, the chance of a cure is often high.

However, when hen lymph nodes and distant organs are metastasized, then palliative care is unavoidable.

The month of November is often linked to the Men’s Health Movement. The campaign is even more important when statistics in Malaysia reveal that more than one third of men with prostate cancer present with late- stage disease. This reflects a lack of awareness in aging men, and reluctance to face the fear and anxiety of a troubling prostate.

When Dr. G is put on the spot by men haunted by Persistent Stress and Anxiety due to the troubling PSA, his view is that perhaps it is time to confront anxiety and get the prostate checked for many more pleasurable years ahead.

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