Archive for March 30th, 2009

posted by admin on Mar 30

You suspected it for a long time, and now you know for sure: You’ve got BPH. What should you do? Do you need to be treated, and if so, how? With surgery, medication, or another form of treatment? Or, should you just wait a while, and see whether your symptoms get worse?

If your symptoms are mild and you can live with them, you should consider watchful waiting. This doesn’t mean “do nothing.” It means “wait and see.”

A lot of men with BPH, consciously or not, plan their day around trips to the bathroom. What about you? Has BPH started to intrude on your life? Can you still do everything you want to do? If not, do you want treatment badly enough to run the risk of side effects or complications? If you’re somewhere in between these two extremes of BPH mentioned above, there are many options for you to consider. Read about them, weigh the risks and benefits of each, and discuss them with your doctor.

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posted by admin on Mar 30

Incontinence affects from 2 percent to 4 percent of men who have a TUR. It can have several causes: One is damage during surgery to the external sphincter—the valve that opens and shuts at the junction between the prostate and urethra (see figure 5.1). Another is a bladder that’s been damaged and rendered hypersensitive by months or years of urinary obstruction from BPH; it might be that surgery has come too late to undo the years of damage. A third possibility is that there’s some residual prostatic tissue blocking the urethra, which either is holding the external sphincter open or is obstructing the urethra, producing overflow incontinence.

Most men experience temporary urgency and stress incontinence after the catheter is removed; it takes the urethra hours to days to recover from being stretched or irritated by having the catheter inside. There’s also something you can do to help control stress incontinence—Kegel exercises, which strengthen the external sphincter. The best way to do them is when standing to urinate: Try to start and stop your urinary stream by contracting the muscles in your buttocks. There are other methods of performing Kegel exercises, but by doing them this way you can be sure you’re exercising the right muscles.

If incontinence doesn’t get better over time, your doctor may do cystometry to determine the state of the bladder, or check with a cystoscope to make sure there’s no residual prostatic tissue blocking the urethra. Some drugs may also help: If you have urgency incontinence, for example, anticholinergic drugs can help stop involuntary bladder contractions. For stress incontinence, drugs that cause smooth muscle tissue to contract—such as nasal decongestants, or even an antidepressant that often makes it more difficult to urinate (a drug called imiprimine)—can help. If incontinence persists for more than a year, or is severe, your doctor may suggest further treatment—possibly placement of an artificial sphincter. In this procedure, a rubbery cuff is positioned around the urethra and connected by tubing to a reservoir for fluid that’s installed in the abdomen, and to a small pump, placed in the scrotum. The pump transfers fluid from the reservoir to inflate the cuff (and block the urethra), and a valve next to the pump can be released to deflate the cuff and allow urine to pass through the urethra. The artificial sphincter is an elaborate device; but there are several simpler solutions that involve injecting material (collagen) into the tissue around the urethra or bladder neck. It’s possible that with further refinements, these techniques will be sufficient for managing incontinence in almost all men who develop it.

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posted by admin on Mar 30

Penile implants, or prostheses, are available in several varieties; the simplest are bendable, and the more complicated ones are inflatable or mechanical. The implants are not a new idea, but they have improved considerably since they were first introduced about twenty years ago. The bendable prostheses, for example, were exactly the same size all the time—whether or not the penis was in the erect position—which, as you can imagine, often proved awkward in social settings. Earlier models of the inflatable prostheses that did allow for a “non-erect” size sometimes failed to work and needed to be replaced.

If these relatively clumsy but functional early designs were the prosthetic equivalent of the typewriter, then the latest models are more like a Macintosh computer—sleek, sophisticated and user-friendly They are more reliable, easier for surgeons to implant, and are designed to look more natural in the “non-erect” phase—even the bendable prostheses, which are more malleable than before. And they can restore sexual function entirely to normal.

Some of the more complicated devices involve a pump and a reservoir for fluid, housed in the abdomen or scrotum, and inflatable chambers, which are placed in the corpora cavernosa. (Fluid is pumped into the penis to create an erection and is then held there by a valve. Afterward, the valve is released, and the fluid returns to the reservoir.)

Penile prostheses used to be offered routinely to most impotent men. Now, with other good treatments available, many urologists have come to regard penile prostheses as a last resort because they do involve surgery—and thus, they carry the risk of complications. These can include infection, scarring, damage within the corpora cavernosa, or a problem with any part of the prosthesis. However, these side effects are relatively rare. Most men who have penile prostheses are satisfied with the result and have a normal sex life.

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posted by admin on Mar 30

The big advantage of the combined therapy is that it seems to stretch out the time that hormones work—the time to progression of cancer is lengthened by several months. However, overall survival is not significantly better for the men on the combined treatment. In a huge analysis of about five thousand prostate cancer patients in Europe and America, doctors studied overall survival and found, at five years after treatment, a 3 percent difference between the men on total androgen blockade and the men who underwent castration or took LHRH agonists alone. This is not a stunning display of the success of total androgen blockade.

And, after a certain point, some patients actually benefit from stopping flutamide. For example, when a man taking flutamide in combined therapy begins to relapse—when his prostate cancer begins growing again, and his PSA level goes up—one step his doctors should take right away is to stop the flutamide. In from 40 to 75 percent of these men, PSA levels drop when flutamide is stopped. Paradoxically, flu amide can make some patients—who initially were helped by it—worse. Exactly why this happens is not clear. In certain prostate cancers, over time, the androgen receptors (the part of the cell responsive to hormones) undergo a mutation—and all of a sudden, flutamide stimulates the cancer. Remember, flu amide normally acts like a dummy key in the “lock” (the receptor), whose purpose is to block testosterone and DHT from activating the receptor. With this mutation, however, the flutamide key actually works—it turns in the lock and activates the receptor.

There is one crucial concept here that you need to understand: Ultimately, total androgen blockade is going to stop working, just as every other kind of hormone therapy does. Anyone who leads you to believe otherwise is not doing you a favor. And when hormone treatment stops working, it’s not because of the tiny amounts of testosterone and DHT being made by the adrenal androgens—in other words, it’s not the fault of some renegade hormones that are sneaking through the hormonal blockade. It’s because of the hormonally independent portion of the cancer—the cells that couldn’t care less what hormones its host is taking, because hormones have no effect on this portion of the tumor. Using hormones to fight these cells is like trying to kill a cockroach with hair spray instead of insecticide. The problem is, we haven’t found the right “Raid” yet.

As one Johns Hopkins molecular biologist explains, “Cancer cells are very efficient. And as they keep dividing, they jettison some dead weight. One of the first pieces of unnecessary baggage to go may be the system of controls—the part of the cell that takes orders from hormones. Over time, the deadliest cancer cells survive because they become pure, stripped-down growing machines.”

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posted by admin on Mar 30

The ideal patient for radioactive seeds is a man who is also ideally suited for external-beam radiation therapy and radical prostatectomy—and both of these treatments can cure prostate cancer in men with localized disease. So the question is, is interstitial brachytherapy equally good or better? And the answer for now is, probably not, although the treatment is continually improving. Before the development of sophisticated guidance systems, major problems arose from seeds being either too far apart or too close together, resulting in an uneven distribution of radiation throughout the prostate—some cancer cells were killed, but some weren’t. In many cases, the cancer returned, or never completely went away in the first place. Better placement may change this picture.

Radiation seeds are not recommended for men who have had a previous TUR procedure; for one thing, because they’ve had significant amounts of tissue around the urethra removed to alleviate their BPH symptoms, there’s not a lot left to hold the seeds in place.

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