Photography by Michael Heiko (digital rendering: John Corbitt)
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A Wee Problem
By Stephen Rae, January & February 2005
The pesky prostate causes symptoms from embarrassing to excruciating. Here’s help
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The prostate gland wreaks untold havoc—untold because men don't
like to talk about what goes wrong with their private parts. Sure, erectile
dysfunction is finally out in the open, now that there are drugs for
it—and celebrity spokesmen to hawk them. But ED isn't the only thing
that can go wrong with the, uh, equipment.
Two common prostate diseases get little attention: benign prostatic
hyperplasia (BPH)—the classic "I've gotta pee but I
can't" condition—and prostatitis, an agonizing assortment of
urinary, sexual, and pelvic ills. About half of men in their 50s have BPH, and
as many as one third of men over 50 have chronic prostatitis. And yet they
sometimes don't even tell their physicians. That's a shame because
lately doctors have made real progress toward understanding the diseases.
Night Stalker
The prostate, which produces fluid in the semen, sits below the bladder,
encircling the urethra, the tube urine passes through. When BPH develops, the
gland grows and blocks the flow of urine. For 6.3 million American men, the
disease is an infuriating nuisance. Men find it difficult to start urinating,
producing only a weak stream. Over time they have to go more often and more
urgently.
"It's not just a convenience problem," says Charles Napier, a
character actor. "It wrecks your entire life." Napier, 68, first
developed symptoms in his 50s. By the time he sought help he needed a bathroom
break every hour. "I was so wrecked from lack of sleep, I couldn't
remember my lines," he says.
The first treatment is usually alpha-blocker medication, which relaxes
muscles in the bladder, improving urinary flow. Uroxatral, part of a new
generation of alpha-blockers, has fewer side effects than earlier medications.
Another standard drug is Proscar, which shrinks the prostate. Each reduces the
risk of BPH progression by about 30 to 40 percent.
In 2003, researchers published a promising discovery: Proscar and
alpha-blockers are much more effective when taken in tandem. In a New
England Journal of Medicine study of about 3,000 patients, men who took
both were 67 percent less likely to need surgery than those who took
neither.
More than half of men over 50 can't let go even when
they feel the urge. But treatments are improving.
When drugs aren't enough, the standard surgery, transurethral resection
of the prostate (TURP), expands the hole through the middle of the gland. TURP
gets the job done 80 percent of the time, but this Roto-Rooter-like treatment
usually requires a hospital stay and can cause sexual problems: 5 to 10 percent
of TURP patients have a hard time getting erections. (Viagra and similar drugs
are prescribed for this.)
In the past decade, a dozen less-invasive outpatient techniques have become
available, each less likely to cause side effects than TURP. Most of these
thread tiny catheters through the penis into the prostate, where excess tissue
is blasted away with lasers, microwaves, or radio waves. One of the latest,
Prolieve, combines microwaves with a balloon that compresses the prostate.
About 60 percent of patients get relief from their symptoms with Prolieve,
which causes ED only 1 percent of the time.
A Low-Down Shame
If BPH is uncomfortable, prostatitis can be murder. Along with urine-flow
problems, sufferers may have pain in the testicles, penis, and lower back,
climaxes that feel like electrocutions, and the feeling of being impaled on a
spear.
"It can be disabling," says Leroy Nyberg, M.D., Ph.D., who heads
up urology research at the National Institute of Diabetes and Digestive and
Kidney Diseases. And prostatitis is extremely common: half of men will suffer a
bout in their lifetime.
Some acute cases are caused by known bacteria and can be cured with
antibiotics. But chronic prostatitis, which is more common, is a puzzle. No one
even knows what it is: an infection tests can't detect? an autoimmune
disease? Until lately, doctors did not have many options for treating it.
Thanks in part to lobbying by the Prostatitis Foundation, founded in 1995,
Congress authorized the National Institutes of
Health to fund research into chronic prostatitis. First, NIH proved that
the standard treatment—antibiotics—was ineffective. Now, NIH is
choosing new treatments to test.
One promising candidate for study is quercetin, a compound found in red
wine, green tea, apples, and onions. It is available over the counter. In a
small 1999 study, 67 percent of the prostatitis sufferers taking quercetin
reported that their symptoms were reduced by at least 25 percent. Men who took
an over-the-counter quercetin preparation that contained the enzymes bromelain
and papain fared even better: 82 percent reported improvement of at least 25
percent. (Quercetin can interfere with the action of antibiotics in the
quinolone class, such as Cipro, so it shouldn't be taken with those
drugs.)
While there's no cure, drugs are doing a better job of alleviating
symptoms. Detrol and Uroxatral may help reduce urinary problems.
Anti-inflammatory drugs such as ibuprofen may help with pain. And, taking a cue
from the treatment of other chronic-pain syndromes, some doctors are even
prescribing antidepressants, muscle relaxants, or antiseizure drugs to mask the
pain, though their use is controversial.
More striking than any new treatment, though, is a shift in the way a few
doctors are thinking about the problem. Increasingly, they see it not as a
disease of the prostate but as a result of chronic tension of the muscles of
the pelvic floor that surround it. Rodney Anderson, M.D., a Stanford School of
Medicine urology professor, and David Wise, Ph.D., a former research scholar at
Stanford, suggest that chronic prostatitis is a neuromuscular dysfunction that
strikes men who hold tension in their pelvis. Relieve this tension and master
the stress behind it, they argue, and prostatitis symptoms will diminish or
even disappear. Their treatment, which includes relaxation training and
specialized physical therapy aimed at rehabilitating the tissue inside the
pelvis, is not yet proven, but men on prostatitis information websites such as
www.chronicprostatitis.com and
www.prostatitis.org swear it works.
(For more information, go to www.pelvicpainhelp.com.)
So for men suffering in silence with BPH or prostatitis, there's
hope—both for treatments and for understanding. "Just talking about
it helps," says Michel Pontari, M.D., an associate professor of urology at
Temple University School of Medicine. "It helps to know you're not the
only one."
Stephen Rae wrote about massage in the July-August
2004 issue.
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