#273 ‒ Prostate health: common problems, cancer prevention, screening, treatment, and more | Ted Schaeffer, M.D., Ph.D.
Oct 2, 2023
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Ted Schaeffer, internationally recognized urologist specializing in prostate cancer, delves into prostate health, including aging-related urinary symptoms, the drug finasteride and post-finasteride syndrome. He explores the pathogenesis of prostate cancer, screening tools like PSA and MRI, and treatment options. Topics include surgical interventions, androgen deprivation therapy, and more. This episode covers various aspects of prostate health, from common problems to prevention and treatment.
The management of lower urinary tract symptoms caused by various conditions related to the prostate includes the use of alpha blockers and M3 agonists as pharmacologic tools.
Minimally invasive surgical procedures like TURP and whole lab are effective techniques to treat larger prostates causing urinary symptoms.
The proximity of the prostate to the rectum may contribute to prostatitis and the spread of inflammation, and other potential causes of pelvic pain should be considered for diagnosis and management.
The prostate acts as a natural barrier against bladder infections, while aging and prostate enlargement can increase the risk of bladder infection in men.
Specific tests are required to diagnose and treat infections in the prostate and seminal vesicles, and directed antibiotics are used for treatment.
Chronic pelvic pain in both men and women can have various causes, and treatment options depend on the source of the pain.
Deep dives
Management of Lower Urinary Tract Symptoms
The podcast episode discusses the management of lower urinary tract symptoms caused by various conditions related to the prostate. One of the main treatment options mentioned is the use of alpha blockers to relax the smooth muscles in the prostate, improving urinary symptoms. Additionally, the use of M3 agonists is discussed as a way to address storage symptoms, such as frequency and urgency. Minimally invasive surgical procedures like TURP (transurethral resection of the prostate) and whole lab (homeom laser enucleation of the prostate) are mentioned as effective techniques to treat larger prostates causing urinary symptoms. The importance of considering other causes of urinary symptoms, such as urethelial carcinoma or pelvic floor dysfunction, is emphasized. The podcast indicates that skilled surgeons like Dr. Amy Krambeck can handle surgical procedures on all sizes of prostates, bringing relief to patients' urinary symptoms.
Prostatitis and Pelvic Pain
The podcast briefly touches on prostatitis, a condition characterized by inflammation of the prostate. Prostatitis can cause discomfort and pain during urination. Different forms of prostatitis, such as acute bacterial infection or non-bacterial inflammation, are mentioned. The proximity of the prostate to the rectum is highlighted as a potential factor contributing to prostatitis and the spread of inflammation. The discussion also includes the importance of identifying other potential causes of pelvic pain, such as pelvic floor dysfunction or urethelial carcinoma, when diagnosing and managing prostatitis.
Pathology of Urinary Symptoms and Enlarged Prostate
The podcast addresses the pathology behind lower urinary tract symptoms and enlarged prostates. It explains that the prostate is an extra-conglant organ in men, located just below the bladder. It produces fluid components of semen and can grow with age due to hormonal changes, particularly in the transition zone of the prostate. The discussion highlights the impact of hormonal imbalances, such as decreasing testosterone and increasing estrogens, on prostate growth. Surprisingly, it suggests that larger prostates may be associated with a lower risk of aggressive prostate cancer. The connection between the prostate and the rectum is mentioned, as well as the potential translocation of bacteria between the two. The podcast indicates that bladder and urinary symptoms may also be influenced by pelvic floor dysfunction.
Prostate as a Natural Barrier for Infection
The prostate is hypothesized to act as a natural barrier against bladder infections. In pre-modern medicine, bladder infections in men were life-threatening. The prostate's acidic environment may prevent the spread of bacteria to the bladder. Women are more susceptible to UTIs due to their shorter urethra and efficient bladder emptying, reducing the risk of kidney infections. In men, increased urinary stasis due to aging and prostate enlargement can lead to bladder infection and potential complications.
Prosthetic and Seminal Vesicle Infections
Infections in the prostate and seminal vesicles can be difficult to diagnose and treat. Specific tests such as the stamey for glass test or semen bacterial testing may be required. Infections in the prostate can be more challenging to clear than in other parts of the urinary tract. In rare cases, infections in the seminal vesicles can cause pelvic pain and persistent infection. Directed antibiotics are used to treat prostate and seminal vesicle infections.
Chronic Pelvic Pain and Treatment
Chronic pelvic pain in both men and women can have various causes, including bacterial or viral infections, inflammation, or muscle tension in the pelvic floor. Treatment options depend on the source of the pain. For prostatic pain, alpha blockers and medications like Cialis can be used. For pelvic floor muscle tension, myofascial release is effective in providing relief. A thorough examination and dietary diary may help identify triggers for discomfort. Pelvic pain in men may be linked to inflammation or mast cell dysfunction, and ongoing research is being conducted to identify targeted treatments.
Monitoring low-grade prostate cancer in active surveillance
For low-grade prostate cancer (Gleason score 6) that is of low volume, active surveillance is a recommended approach. This involves regular monitoring through PSA testing every six months and repeat biopsies at specific intervals. The risk of a significant change in tumor aggressiveness or bulkiness within the first five years of surveillance is around 12.5%. Beyond that, the annual risk of change in tumor grade is around 2-3%. Overall, the chances of Gleason 6 prostate cancer becoming metastatic or progressing to an uncurable stage are very low. Patients in active surveillance have the advantage of avoiding immediate treatment and its associated side effects.
Determining treatment for Gleason 7 prostate cancer
For Gleason 7 prostate cancer, the percentage of pattern 4 cancer present is a key factor in determining treatment options. If the percentage of pattern 4 is minimal (less than 5%), active surveillance may be considered. Monitoring the tumor closely and evaluating factors such as age and life expectancy are important when making a decision. However, if there is a substantial amount of pattern 4 cancer present, treatment options such as surgery may be recommended.
Considerations for Gleason 8 prostate cancer
Gleason 8 prostate cancer is considered a higher-grade cancer. Treatment options such as surgery or radiation therapy are typically recommended for Gleason 8 tumors due to their increased aggressiveness. The extent and aggressiveness of the tumor, as determined by the percentage of pattern 4 present, will play a key role in deciding the best course of action. Patients with Gleason 8 tumors will undergo further evaluation and monitoring to determine the appropriate treatment approach.
Advancements in Surgical Techniques for Prostatectomy
One of the main advancements in surgical practice for prostatectomy is the shift towards pelvic fascia sparing surgery. This technique focuses on preserving the fascia and ligaments surrounding the prostate, leading to better urinary control and faster recovery. The surgeon operates in a smaller space, maximizing preservation of structures such as nerves for erectile function. The procedure takes longer but offers improved outcomes in terms of continence and sexual function.
Integration of Precision Medicine
The integration of precision medicine is an exciting development in the field of prostate cancer. Understanding the molecular subtypes and phenotypes of individual tumors can revolutionize treatment recommendations. Precision medicine allows for tailoring treatment plans based on each patient's unique tumor characteristics, such as determining radiation sensitivity or androgen resistance. This approach is expected to have a significant impact on patient management and outcomes in the next five years.
Ted Schaeffer is an internationally recognized urologist who specializes in prostate cancer. In this episode, Ted delves deep into the realm of prostate health, starting with strategies for vigilance and effective management of the issues that can arise with aging, including urinary symptoms, prostatitis, pelvic pain, and prostate inflammation. Ted sheds light on the popular drug finasteride, renowned for its dual purpose in prostate shrinkage and hair loss prevention, as well as the contentious topic of post-finasteride syndrome. Ted then shifts to the topic of cancer, explaining how androgens, genetics, and non-genetic factors contribute to the pathogenesis of prostate cancer. He provides valuable insights into cancer screening, examining blood-based screening tools like PSA and the use of MRI in facilitating biopsies and their interpretation. Finally, he explores the various treatment options for prostate cancer, including surgical interventions, androgen deprivation therapy, and more.
We discuss:
Changes to the prostate with age and problems that can develop [3:45];
Behavioral modifications to help manage nocturnal urinary frequency and other lower urinary tract symptoms [8:30];
Pharmacologic tools for treating nocturnal urinary frequency and lower urinary tract symptoms [16:30];
Surgical tools for treating symptoms of the lower urinary tract [26:15];
HoLEP surgery for reducing prostate size [32:30];
Prostate size: correlation with cancer and considerations for small prostates with persistent symptoms [40:30];
Prostatitis due to infection: symptoms, pathogenesis, and treatment [46:45];
Prostatitis caused by factors besides infection [58:45];
How to minimize risk of urosepsis in patients with Alzheimer’s disease [1:05:00];
Prostate cancer: 5-alpha reductase inhibitors, how androgens factor into pathogenesis, and more [1:10:00];
Post-finasteride syndrome [1:18:15];
The relationship between testosterone and DHT and the development of prostate cancer over a man's lifetime [1:26:30];
How genetic analysis of a tumor can indicate the aggressiveness of cancer [1:35:15];
Pathogenesis and genetic risk factors of prostate cancer and the use of PSA to screen for cancer [1:37:45];
Non-genetic risk factors for prostate cancer [1:45:45];
Deep dive into PSA as a screening tool: what is PSA, definition of terms, and how to interpret results [1:56:30];
MRI as a secondary screening tool and the prostate biopsy options [2:13:15];
Ted’s ongoing randomized trial comparing different methods of prostate biopsy [2:24:00];
Determining when a biopsy is necessary, interpreting results, explaining Gleason score, and more [2:27:00];
Implications of a Gleason score of 7 or higher [2:46:45];
Metastasis of prostate cancer to different body locations, treatment options, staging, and considerations for patients' quality of life and survival [2:53:30];
How prostate cancer surgery has improved [3:09:30];;
Questions to ask your neurologist if you are considering prostatectomy for cancer [3:21:45]; and
