To PSA or not to PSA…that is the questio-Everything you wanted to know about PSA and not afraid to ask?

John Doe is 55 years old. He has no urinary symptoms. He goes for his annual physical exam. His prostate exam is normal, but his prostate specific antigen (PSA) blood test is 4.5, which is slightly elevated. His last PSA test was 2 years ago, and at that time it was 2.7. He is referred to a urologist and a discussion takes place regarding whether he should proceed to a prostate gland biopsy based upon this elevated PSA. What is he to do? This chapter will review the background of the PSA test. What is it’s purpose, and how it is used to make decisions regarding the diagnosis, evaluation and management of men with prostate issues and prostate cancer.

PSA is the most useful and accurate cancer marker of all the cancer “markers” used in medicine today. This statement is of almost universal agreement among physicians and researchers working in cancer treatment and research. Some of you may find that statement a bit startling in light of all the negative press that has appeared regarding the PSA test in recent history. Lets define then what is meant by a “marker.” This is different than cancer screening” which has actually been where the controversy surrounding PSA has arisen. A marker for a tumor is “A substance that can be detected in higher than normal amounts in the blood, urine, or body tissues of some patients with certain types of cancer.” (medterms.com) Other examples of tumor markers include CEA in the case of some gastrointestinal tumors, CA-125 as a marker in ovarian cancer, Beta-HCG and alpha-fetoprotein in some testicular tumors, and even abnormal cells found in a Pap smear used to detect cervical cancer in women.

But as markers go, the PSA test, in a patient diagnosed WITH prostate cancer (PCa), no marker is superior in monitoring the progress and even prognosis of a PCa patient as is the PSA test.

HISTORY OF PSA

It may seem as if we have always used the PSA test in screening for, and in evaluation and follow-up of men with prostate cancer, but its usefulness in this arena is actually of fairly recent onset. There is no question that the discovery of this tiny molecule has dramatically, and forever changed the playing field in the world of PCa.

Before the discovery of PSA the world of screening for, and of attempting to make an early and timely diagnosis of prostate cancer was entirely different. In the pre-PSA era, and this includes all the years prior to the late 1980’s and early 1990’s when PSA became clinically useful, it was very difficult for clinicians to diagnose PCa in a stage where it could be cured by the therapies of that time. Prior to the use of PSA as a screening tool, all we clinicians had at our disposal was our digital exam, our level of suspicion based upon a family history, and to some extent, a blood test called Prostatic Acid Phosphatase, or PAP. Unfortunately, in a large number of men eventually diagnosed by one of these methods, the cancer had often spread beyond the prostate, and hence, was incurable by the technologies of the time.

As strange as it may sound, the actual discovery of PSA is clouded in controversy, and it seems several scientists have been called the discoverers. PSA seems to have been first identified in he U.S., by Dr. Richard Ablin and his associates as early as 1970. A subsequent article by Dr. Ming Wang was published in 1979, and this has often has been cited, apparently incorrectly, as the first scientific article cited as the “discovery” of PSA. This 1979 publication however, was the first to advance the idea that the PSA test could purified and could be useful in detection of prostate cancer. At this point, research was then directed towards developing a commercially usable, reliable, reproducible, and reasonably priced blood test that could be made available to the public.

Some of the very early developmental research for PSA was on it’s presence in semen and to assess it’s properties and usefulness as a forensic marker for rape victims. Soon however, the usefulness of PSA as a screening tool for prostate cancer became quite evident, and as they say, “the rest is history.”

As early as 1981 research was demonstrating significant differences in the blood PSA levels in patients with benign, non-cancerous prostate enlargement (BPH) as opposed to men with prostate cancer. In addition, research in the early 1980’s was demonstrating that men with more advanced prostate cancers had higher blood levels of PSA than men with less advanced cancer.

So, as literally millions of data points were studied, what then is accepted as a “normal” PSA. The very simple answer is up to 4 nannograms per milliliter, or 4ng/ml. It’s never really that simple however. There are many nuances the physician must consider when evaluating a man and his PSA. For example a PSA of 3 in a man of 50 might be worrisome, where a PSA of 5 in a 75 year old man might not be. Change over time can be important. A man whose PSA went from 1 to 3 in one year, both “normal” numbers, might be more worrisome for cancer than a man who has had PSA’s between 5 and 7 over the past 10 years. More on this later, but for most lab reports you will see “normal” for PSA as between zero and 4.

During this same timeframe it was becoming apparent that men who had undergone curative treatment for prostate cancer had PSA levels close to zero, and that if the cancer reappeared, the PSA levels began to climb, making the test very useful in following, or monitoring patients to detect failure or success of treatment. In addition, it became clear that a rise in PSA could be seen usually long before the location of the recurrence could be detected by other means.

Despite all this favorable research data accumulating in the early 1980’s, PSA was originally approved by the FDA in 1986 to monitor the progression of prostate cancer in men who were diagnosed with the cancer. It may surprise you that it was not until 1994 that the FDA approved the PSA blood test , along with a digital rectal exam (DRE), to screen men without symptoms, for prostate cancer. Clearly, over this two decade period, screening for cancer with PSA and DRE has become commonplace in medicine.

Things have now gone backwards in the eyes of many clinicians, in that NOW, another governmental agency, the U.S. Preventive Task Force (USPSTF) recommends AGAINST prostate cancer screening. More on this controversial move, to follow.

Since PSA has dramatically changed our approach to screening for, diagnosing, and monitoring prostate cancer, what has changed in the two decades since this approach has been in full swing? The incidence rates for PCa took a significant upturn at the same time PSA test was approved by the FDA, and even before it was FDA-approved for screening of asymptomatic men. Clearly, clinicians recognized its utility for screening before it was “officially” approved for this particular use. The incidence rates of prostate cancer remain much higher than it was in the pre-PSA era. This is a reflection of our ability to diagnose the disease much earlier now, and not due to an actual increase in the true incidence of the disease in our society. One of the arguments of proponents of “non-screening” with PSA is that many more men are being diagnosed with cancer that might never have impacted their lives had it never been detected. More on this later.

Along with improved early detection brought on by the advent of PSA, the death rates have also begun to fall. This would certainly be anticipated. If we can diagnose cancer, or for that matter, almost any medical condition, before it is far advanced, our chances of cure or survival are enhanced. Death rates, calculated as rates per 100,000 males was rising slowly from about 1940 until about 1985 when the death rate took a spike through about 1995, and has fallen steadily over the past 20 years or so.

The number of men dying in the U.S. yearly from PCa is a little over 30,000. Many clinicians involved in studying this disease feel that if these men who die of the disease had been seeing a physician yearly, and had been undergoing appropriate screening we might be able to drop this number of deaths perhaps as much as 90%. Even with appropriate screening, and let’s say even if 100% of men over the age of 50, could be screened yearly for PCa, there would still be some deaths from the disease. Some men, albeit a small percentage, will develop a form of prostate cancer that is so aggressive and virulent, that even with the best treatments available to us today, we still cannot cure them.

Since it is intuitively clear to all of us, that early diagnosis of disease is good, and we all now know the wonderful utility of the PSA test in early detection of PCa, why has the test gotten so much negative publicity? In fact, if you have been watching, there has been almost no positive publicity in the past few years, but there has been an onslaught of negative. We physicians are asked daily now by our patients as to why there is this negativity, and then whether they should be doing the test. More about how to make the decision to test, or screen, for prostate cancer. Some guidelines to help you in this decision will follow in soon in this chapter.

We will look into the science, and some would call it “junk science” behind the recommendations of the U.S. Preventive Services Task Force recommendations against screening for prostate cancer, but let’s first take a look at some of the “politics” if you will, of cancer screening in general, as this puts a lot of it into a perspective we can all understand. A lot of this seems to be driven by finances on both a private, federal, and state level. Since a large portion of the costs of cancer screening is borne by governmental agencies, and most of the rest, by private insurance, the costs have to be taken into consideration. Now, for the thousands, or millions of Americans whose lives have been saved by early detection, and cure of their own bout with cancer, these cost issues seem quite secondary to them, and to their loved ones. They know cancer screening saves lives. They are living proof.

To actuaries looking from under their green eye shades at the numbers, screening for cancer, regardless of the lives saved, does not make good policy or financial sense. And, they would say arguably, the costs are not sustainable. We all know Medicare is going broke, despite the fact that any of us who have a job, and are receiving a paycheck, are paying not only for the private insurance we are using now, but also Medicare premiums are being taken out of every paycheck. So where does screening for cancer fit in this financial mileu?

Several cancers have taken a hit lately. Screening mammograms for early detection of breast cancer in women came under fire recently. Women rose up, and the government and insurance companies backed off. Screening for cervical cancer has come under fire, and the recommendation for screening for colon cancer, largely under the radar, has changed too. Will lives be lost? Will failure to detect early cost us in suffering and early demise of untold Americans? Of course. But in a dollars and cents world, screening for cancer is just too expensive. Let’s take a somewhat imaginary look at the numbers before we look at the USPSTF recommendations in detail.

Let us imagine a million men being screened annually for prostate cancer. Since the numbers used here are estimates, they are going to be off a little from what might be absolutely correct, but since the actual numbers are not obtainable, the numbers we use here at least give us a reasonably accurate framework. And this is done, only to try and put the costs of cancer screening into perspective.

So, back to our one million men being screening annually for PCa. Let’s suppose that this could be done for about $75.00 to include a doctor visit, the exam, and the blood test. Right away we have consumed 75 million dollars. Let’s say that of those million men, everything is normal for 800,000 of them-probably a reasonable estimate. We are through with them for this year. Now of the remaining men something in the exam, the blood test, or the medical history is concerning. The doctor has a concern that these men might have cancer. For those being screened by their primary provider, a consult with a urologist will be needed. Some of these men will be seeing a urologist for their yearly screening, but the others will have to be referred. Let’s say conservatively that of these 200,000 men, 50,000 will need a new and initial consultation with a urologist, and the cost could be around $100.00 for this initial consultation. $5,000,000 there. Some will go to immediate biopsy, but let’s say the doctors decide not to do a biopsy on half of the men, but simply to recheck them, and obtain another blood test in couple months. These would be the men for whom the urologist is not highly suspicious for cancer, but they still will need to be followed appropriately. Another couple million for the second visit and testing of blood for PSA. Now let’s suppose that out of the one million men being screened, only 1% are ultimately thought to need a biopsy. That would be 10,000 men times a conservative cost for biopsy of $1,000.00. Another $ 10,000,000 dollars for the biopsies. Now if 1 in 4 had a positive biopsy, probably 3 in 4 with cancer would need treatment. Millions and millions have been spent before treatment has even started.

So, using these numbers, which are reasonable, the screening costs for 1 million men is easily in the neighborhood of $100,000,000. Now, what if we are trying to screen 5 million men, or 10 million men, or more, yearly? You can see how this adds up to astronomical numbers. And this is only for one cancer. We have not even looked at screening for breast, colon and lung cancers which make up the rest of the “big four.”

With this financial meltdown facing health insurance providers one can see why screening for cancer has become such an issue, and perhaps these numbers factor into some of the decision making processes.

Let us now take a look at the Draft Recommendation Statement from the USPSTF. First, at this time, it is a draft. More will come. If you care to review it in detail, it is available at http://www.uspreventiveservicestaskforce.org/prostate/prostateart.htm.

However, the salient points will be reviewed for you here. Quoting, “The USPSTF makes recommendations about the effectiveness of specific clinical preventive services without related signs or symptoms.” Keeping in mind here, by the time a man has symptoms or signs of PCa, the cancer has spread beyond the prostate and is no longer curable.

Quoting: “Summary of Recommendation and Evidence. The U.S. Preventive Services Task force (USPSTF) recommends against prostate-specific-antigen(PSA)-based screening for prostate cancer. This is a grade D recommendation.”

What is a grade D recommendation? If you ever got a grade of D in school, you know it is not good! Specifically, the definition is: The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that harms outweigh the benefits. Their “Suggestions for Practice” here regarding screening for prostate cancer with the D rating, “Discourage the use of this service.”

Quoting further from the draft document:

“Prostate cancer is the most commonly diagnosed nonskin cancer in men in the the United States, with a lifetime risk of diagnosis currently estimated at 15.9%. Most cases of prostate cancer have a good prognosis, but some are aggressive; the lifetime risk of dying from prostate cancer is 2.8%. Prostate cancer is rare before age 50 years and very few men die of prostate cancer before age 60 years. The majority of deaths due to prostate cancer occur after age 75 years.”

Let’s take a quick look at this 2.8% risk of dying from prostate cancer. About 238,590 new cases will be diagnosed in the U.S. in 2013, and about 29,720 men die of this cancer in 2013 according to the National Cancer Institute estimates. It would appear from these numbers that the risk of dying from prostate cancer easily exceeds 10%.

The draft document goes on further to elaborate on harms of detection and early intervention to include risks associated with biopsy itself, the adverse effects of treatments be they surgery or radiation or hormone deprivation. Another risk is “overdiagnosis.” This, the panel seems to believe, results in many men being treated for cancer that never would impact their lives. Now since urologists and oncologists treating prostate cancer make every effort not to overtreat the insignificant cancers, we have to wonder what exactly is meant by this? As they were quoted above, “some of these cancers are aggressive,” is there a way to know which type (aggressive vs. non-aggressive) without a diagnosis? Do we as physicians owe it to our patients to help them make decisions for treatment based upon the best evidence we can provide? In most cases, one would answer yes to that question.

There is no doubt this panel put a monumental amount of time and effort into this document, and the conclusions they came to were based upon the evidence they felt was significant. They reviewed at least three large trials regarding prostate cancer, one called the PLCO, another, from Europe. The ERSPC trial, and the preliminary results from the PIVOT trial.

The USPSTF estimates that for every 1,000 men ages 55 to 69 who are screened every one to four years for a ten year period that only a maximum of one death from prostate cancer would be avoided. Using our estimated numbers above, this means it would cost about $1,000,000.00 to save one life. If this is true. There are other ways to run these numbers, and you mathematicians can have a field day with them, but you can see again, screening for cancer is very costly. Now we as physicians don’t see 1,000 men at a time, we see individual men just like you, and together you and I have to try and make our best decisions for your individual health. More on that decision making process later on.

On May 21, 2012, the USPSTF released it’s Final Recommendations of PSA Screening, and the final document confirmed what was said in the draft.

Urologists are at the forefront of being tasked with diagnosing, and in most cases, treating men with prostate cancer. We work closely with our oncology colleagues in men with very advanced cancer. The American Urological Association (AUA) has spoken out against the USPSTF recommendations.

The AUA’s position is one of outrage regarding the USPSTF position and takes the position that the Task Force “is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease. We hold true to our current position s supported by the AUA’s Prostate Specific Antigen Best Practices Statement that, when interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer patients.”

(Further 2013 position to be presented in May-will be elaborated here)

So, how are we, as men, to make decisions regarding PSA screening as it fits into our own individual lifestyle, expectations, and plans for our own medical futures?

In simplest terms, if you and your physician feel that if you are screened for PCa it would help you make decisions about the direction you would want to take if you were in fact diagnosed with prostate cancer, then screening is probably a wise step to take.

Let’s keep in mind a few facts. It is clear that PSA screening does reduce mortality from prostate cancer compared to men who are not screened. It is also true that screening has led to a diagnosis of PCa in men in whom the disease might never had caused problems. Many of these men were nonetheless, treated, hence “overtreatment.” It is also true that we as clinicians have gotten much better at helping to cull out those insignificant cancers and counseling our patients accordingly. It is also true that biopsy does carry some risk, albeit small, of serious infection. A small number of men, in our experience, less than 1% will require extended antibiotic therapy after a biopsy, and a few may even end up spending a few days in the hospital for post-biopsy fever and infection. It is also true that some men who are treated for prostate cancer will suffer adverse effects including incontinence, erectile dysfunction and bladder dysfunction. It is also true, that nearly all men who may have these effects can be adequately treated for these adverse consequences.

So, who should be screened? A life expectancy of 10 years is often used as a guideline. Clearly we don’t know how long we will live at any given time, but a very healthy 75 year old man might benefit from screening far more than a 60 year old man who has had a heart attack, bypass surgery, diabetes, high blood pressure and obesity. Now that 60 year old might live to a ripe old age, and that “healthy” 75 year old might have that fatal heart attack tomorrow. Hence, the dilemma we all face-patients and physicians alike. But we try to be as practical here as we can. But if you as a male patient feel that you would want to be in a position to make decisions regarding prostate cancer treatment if you were to be diagnosed, then the decision to screen is likely in your best interest. Our advice is to have this discussion with your physician before screening for prostate cancer.

HOW CAN WE IMPROVE SCREENING FOR PROSTATE CANCER?

With regards to PSA screening, what is on the horizon, and what do we have now to further refine and tighten our accuracy of screening for PCa?

Now that so much progress has been made with DNA and in clarifying the human genome, it seems likely that in the not to distant future, genetic identification of those either at high risk, or that in fact WILL develop prostate cancer seems plausible. We are not there yet.

From the National Cancer Institute, here are some ways that scientists and researchers are looking to improve PSA screening.

Free versus total PSA: The lower the free PSA is a percentage of total PSA the more likelihood of finding cancer, and a very low free PSA may be associated with more aggressive cancer. We like to see a free PSA greater than 25% of total. For example, a man with a total PSA of 5, and a free PSA of 2.5 has a 50% ratio. His likelihood of PCa is low (not zero though) Whereas the man with a total PSA of 5, and a free of 0.4 has a ratio of 8%, and his risk for having PCa right now is high. This is useful test, but not perfect.

PSA density of the transitional zone: To gather this information requires ultrasound measurements of the prostate, and though perhaps more accurate than PSA alone, this approach has not been fully validated.

Age-specific PSA reference ranges: Unless a man is taking medication to shrink the prostate, dutasteride or finasteride, the prostate grows a little each year. Hence there are more prostate cells to produce PSA. As a result, a “normal” PSA in a man of 70 may be different that “normal” at age 50. This approach lacks general acceptance in the urological community however, since its use may delay a diagnosis of PCa.

PSA velocity and PSA doubling time: You will recall earlier in this chapter we discussed the man whose PSA went from 1 to 3, as being perhaps more worrisome than a man with a PSA between 5 and 7 while being followed for a decade. Quoting from the National Cancer Institute, “Some evidence suggests that the rate of increase in a man’s PSA level may be helpful in predicting whether he has prostate cancer.”

Pro-PSA: There is quite a lot of work being done looking at these different inactive precursors of PSA, and there is some evidence that pro-PSA may be a better predictor, and hence a better screening methodology than PSA as we are using it today. This is not yet ready for “primetime” yet.

PCa3: This test is readily available for clinical use today, and has a place in our screening toolbox. PCa3 is a chemical produced in the prostate gland. In order to do the test, the physician must put a little pressure on the prostate while doing the digital rectal exam. This pushes a little prostate fluid into the urethra. The patient is then asked to urinate, and the first ounce or so of urine will contain that prostate fluid. This sample is then sent to a specialized lab capable of doing the test. If PCa3 is present in this urine sample, depending upon the degree, the risk of prostate cancer can be further elucidated. The nee for a biopsy can be refined depending upon the result of the PCa3.

One other approach that is receiving increased incidence we will mention only briefly here since this chapter is about PSA, but is being looked at as a screening tool for prostate cancer. This is not a blood test, but an imaging study. Prostate MRI with a powerful 3 tesla MRI machine has shown usefulness in imaging cancer with considerable accuracy within the prostate gland itself.

DEFINITIVELY DIAGNOSING PROSTATE CANCER:

As the science of prostate cancer diagnosis stands today, biopsy remains the only definitive way to make the diagnosis. There are a couple caveats here-a man with a PSA over 100 probably does not need a biopsy. A man who has on X-Ray definitive evidence of cancer in his bones, and a high PSA many not need a biopsy. However, this chapter is about screening, and especially screening in the man with no symptoms. In that man, biopsy of the prostate remains the final diagnostic test. The use of PSA and the other modalities mentioned above serve mostly to help the physician and the patient decide as to whether proceeding on to biopsy is indicated. We are trying to refine screening so that we will be able to avoid biopsy in many men because, as a result of screening tests, we can reasonably believe our patient does NOT have prostate cancer.

As is clear to all of you now, having read these pages, PSA remains an extremely valuable tool in our cancer screening toolbox. How it can be useful in the case of each individual patient remains just that, individual. With the information we hope you have gained in this chapter, you will hopefully be in a better position to understand the usefulness as well as the limitations of PSA screening. Hopefully the decision making process will be clearer to you as you have discussions with your physician regarding PSA screening for prostate cancer. For many of you, it will be quite simple. If for example, you are a healthy man between 50 and 70 years of age, and you already know that whether you have PCa matters to you so that you can make proper decisions, doing the test is a slam-dunk. This would include a wide swath of men. For some, it will not be so simple, and many factors will have to be considered prior to screening. We hope this chapter has helped.

Let’s go back to our patient described at the beginning of the blog: He is 55 years old, having no urinary symptoms and is in for his physical. His prostate exam is normal, but his PSA is slightly elevated at 4.5. Last year he did not have an exam, but two years ago it was 2.7. He is referred to a urologist and a discussion takes place regarding whether he should proceed to prostate gland biopsy. What should he do? What would you want to do it this was your data? Hopefully, you now have some parameters to help you make the decision in your own individual situation.

When It Hurts Down There In the Prostate Gland-New Treatment for Chronic Pelvic Pain

Chronic pelvic pain is a disabling condition with multiple treatment options. However, in men with chronic prostatitis, which is not due to bacterial infection, have difficulty finding relief.
The symptoms of chronic pelvic pain are pain with urination, pain under the scrotum, and urinary frequency and urgency. Now there is a new treatment using trigger point therapy that has been helpful in some men with chronic pelvic pain.
In a study published in The Journal of Urology (Volume 185, page 1294), researchers evaluated the protocol, known as myofascial trigger point therapy and paradoxical relaxation training (PRT), in 116 men who had pelvic pain for several years.
Trigger point therapy, which involves applying pressure on a trigger point in a tight muscle until it “releases,” was performed by a physical therapist for 30 to 60 minutes daily for five consecutive days. A psychologist provided daily instruction in PRT for three to five hours. The goal of PRT is to reduce nervous system arousal in the presence of perceived pain and catastrophic thinking. The men were instructed to use the techniques at home.
At six months, their quality of life had improved significantly, and 82 percent of the men reported improvement in pain and urinary dysfunction. The improvement was described as major or moderate by 59 percent and as slight by 23 percent.
Bottom Line: If you have chronic pelvic pain with pelvic muscle tenderness that has not improved with standard medical therapies, consider asking your doctor for a referral to physical and behavioral therapists with experience treating this condition.

Protect Your Prostate With a Good Diet

What can I eat to reduce my risk of developing prostate cancer? This is one of the most common questions urologists hear from men concerned about prostate health. Undoubtedly, many hope that their doctor will rattle off a list of foods guaranteed to shield them from disease. Although some foods have been linked with reduced risk of prostate cancer, proof that they really work is lacking, at least for now.
Aim for a healthy eating pattern
Instead of focusing on specific foods, dietitians, physicians, and researchers tout an overall pattern of healthy eating — and healthy eating is easier than you might think. In a nutshell, here’s what experts recommend:
Eat at least five servings of fruits and vegetables every day. Go for those with deep, bright color.
Choose whole-grain bread instead of white bread, and choose whole-grain pasta and cereals.
Limit your consumption of red meat, including beef, pork, lamb, and goat, and processed meats, such as bologna and hot dogs. Fish, skinless poultry, beans, and eggs are healthier sources of protein.
Choose healthful fats, such as olive oil, nuts (almonds, walnuts, pecans), and avocados. Limit saturated fats from dairy and other animal products. Avoid partially hydrogenated fats (trans fats), which are in many fast foods and packaged foods.
Avoid sugar-sweetened drinks, such as sodas and many fruit juices. Eat sweets as an occasional treat.
Cut down on salt. Choose foods low in sodium by reading and comparing food labels. Limit the use of canned, processed, and frozen foods.
Watch portion sizes. Eat slowly, and stop eating when you are full.
Stay active
In addition to eating a healthy diet, you should stay active. Regular exercise pares down your risk of developing some deadly problems, including heart disease, stroke, and certain types of cancer. And although relatively few studies have directly assessed the impact of exercise on prostate health, those that have been done have concluded, for the most part, that exercise is beneficial. For example:
Based on questionnaires completed by more than 30,000 men in the Health Professionals Follow-up Study, researchers found an inverse relationship between physical activity and BPH symptoms. Simply put, men who were more physically active were less likely to suffer from BPH. Even low- to moderate-intensity physical activity, such as walking regularly at a moderate pace, yielded benefits.
Using data from the Health Professionals Follow-up Study, researchers also examined the relationship between erectile dysfunction (ED) and exercise. They found that men who ran for an hour and a half or did three hours of rigorous outdoor work per week were 20% less likely to develop ED than those who didn’t exercise at all. More physical activity conferred a greater benefit. Interestingly, regardless of the level of exercise, men who were overweight or obese had a greater risk of ED than men with an ideal body mass index, or BMI.
Italian researchers randomly assigned 231 sedentary men with chronic prostatitis to one of two exercise programs for 18 weeks: aerobic exercise, which included brisk walking, or nonaerobic exercise, which included leg lifts, sit-ups, and stretching. Each group exercised three times a week. At the end of the trial, men in both groups felt better, but those in the aerobic exercise group experienced significantly greater improvements in prostatitis pain, anxiety and depression, and quality of life.

This article was excerpted from https://mail.google.com/mail/?shva=1#inbox/132cfb68cd03a854

Your Prostate Infection May Be Caused By Your Peptic Ulcers

Treatment for chronic bacterial prostatitis is fairly straightforward: antibiotics for four to 16 weeks.  But what if you have symptoms of both chronic prostatitis and peptic ulcers?  One reader asks:  “I’ve had problems with both chronic prostatitis and peptic ulcers. My doctor said that the two could be related. How can that be?”

The underlying cause of chronic prostatitis remains unknown about 90 percent of the time. Microorganisms suspected of causing chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)  include Escherichia coli, Enterobacter and Pseudomonas aeruginosa.

A relatively new suspect is Helicobacter pylori (H. pylori), which is the most common microorganism in human bacterial infections around the world. This bacterium lives in the lining of the stomach and can cause inflammation and immune responses.

People with certain health problems are more likely to have detectable signs of H. pylori in their blood. These health problems include heart disease, rosacea, chronic bronchitis and asthma.

A recent study in the Scandinavian Journal of Urology and Nephrology linked H. pylori to CP/CPPS. For the study, researchers took blood from 64 men with CP/CPPS and 55 without. They found that 76 percent of men in the CP/CPPS  group tested positive for antibodies against H. pylori, versus 62 percent of the men in the control group.

This was the first study to link CP/CPPS with H. pylori, so the relationship between the two is far from proven. But if further studies show a link, it suggests that treatment for H. pylori-induced peptic ulcers may be beneficial for H. pylori-induced CP/CPPS as well.

Reported in the John Hopkins Medical Newsletter

Getting Up At Night To Pee Doesn’t Have To Be

NEW YORK(Reuters Health) – A new study finds that one in five U.S. men have to get up at least twice a night to empty their bladders — which for some could signal an underlying medical problem or even contribute to poorer health.

Known as nocturia, those frequent overnight trips to the bathroom can be a sign of a health condition, ranging from a urinary tract infection to diabetes to chronic heart failure. In men, a benign enlargement of the prostate can also be a cause.

For some people, the constant sleep disruptions can themselves cause problems — contributing to depression symptoms or, particularly in older adults, falls.

On the other hand, getting up during the night to urinate can also be normal. If you drink a lot of fluids close to bedtime, for example, don’t be surprised if your bladder wakes you up at night.

Nocturia also becomes more common with age. Part of that is related to older adults’ higher rate of medical conditions. But it could also result from a decrease in bladder capacity that comes with age.

The researchers found that  men age 20 and up, 21 percent said they had gotten up at least twice per night to urinate.

Nocturia was more common among African-American men (30 percent) than those of other races and ethnicities (20 percent). Not surprisingly, it also increased with age: Just 8 percent of men ages 20 to 34 reported it, compared with 56 percent of men age 75 or older.

Other factors linked to an increased risk of nocturia included prostate enlargement, a history of prostate cancer, high blood pressure and depression.

Nocturia can also be a side effect of some medications, such as diuretics used to treat high blood pressure. This study did not have information on men’s medication use.

Avoiding caffeine and a large fluid intake at night may help as may other lifestyle tactics, like adjusting your sleep habits.

One recent study of 56 older adults with nocturia found that lifestyle changes — including fluid restriction, limiting any excess hours in bed, moderate daily exercise, and keeping warm while sleeping — helped more than half of the patients significantly cut down their overnight trips to the bathroom.

There are also medications available specifically for overactive bladder and nocturia. Those include a synthetic version of a hormone, anti-diuretic hormone,  that keeps the body from making urine at night, a drug that blocks the ability of the bladder muscles to contract, and antidepressants that make it harder to urinate by increasing tension at the bladder neck.

The bottom line for men is that bothersome nocturia is something they should bring up to their doctor.

SOURCE: bit.ly/fGZKNN Journal of Urology, online January 19, 2011

Flossing Your Teeth and Prostate Disease-There Just Might Be A Connection

Who would have thunk that flossing would be prostate gland protecting?  It has been well-documented that inflammation in the mouth, i.e., gum disease is linked to heart disease, diabetes, rheumatoid arthritis, and now even Alzheimer’s disease.  Now good research from Case Western Univeristy in Cleveland, Ohio has made a connection between gum disease and prostate health. The researchers from the dental school and the department of urology and the Institute of Pathology at the hospital found those with the most severe form of the prostatitis also showed signs for periodontitis, or severe gum disease.  It is theorized that reducing inflammation in the mouth-by daily flossing may also reduce prostate gland inflammation.  As my wonderful Jewish mother would say, “It may not help but it vouden’t hoit!”  So if you are looking for one more reason to start flossing, you now have one.

Excerpted from Journal of Periodontology, the official journal of the American Academy of Periodontology

“Just Say No” to Sex…Before Your Next PSA Test

For men over age 50 who are going to have a PSA test for prostate cancer, ejaculation within the past two days may artificially raise PSA levels. Men should be aware of the time of their last ejaculation and tell their doctors the last time they had an ejaculation in case results are high. Finally, while the digital rectal exam or other aspects of a prostate exam shouldn’t interfere with PSA levels, I suggest that blood be drawn before the rectal exam as a precaution.

Nutrition for Your Prostate Gland

Prostate cancer is the most common cancer in American men causing nearly 250,000 new cases each year. It is the second most common cause of death in American men, killing nearly 40,000 men annually. However, with regular examination consisting of a digital rectal exam and a PSA blood test, prostate cancer can be detected early and treated. There are other healthy life-style changes that can be easily done that may even help prevent prostate cancer.

1. Start taking vitamin D, E and selenium supplements. Although further research is needed to confirm their effectiveness, studies have demonstrated that all three, vitamin D, E and selenium, show promise with regard to prostate cancer prevention when taken regularly.
2. Eat more soybeans (or soybean products) and other legumes. Elevated levels of testosterone may increase your risk for developing prostate cancer. The phytoestrogens-nonsteroidal plant compounds that act like estrogen in the body and thus can help to regulate imbalanced hormone levels-contained in these foods may help to prevent prostate cancer; genistein, an isoflavone also found in soy foods, helps to normalize hormone levels and thus may reduce prostate cancer.
3. Drink green tea. Antioxidant compounds in green tea may help prevent prostate cancer; some have even been found to kill prostate cancer cells in test tubes, while others have blocked enzymes that promote prostate cancer.
4. Get plenty of fiber. Fiber can eliminate excess testosterone in the body; thus, a high-fiber diet can aid in the regulation of your body’s hormone levels and may help reduce the risk for prostate cancer.
5. Reduce your intake of meat and saturated fats. Follow a low-fat diet: diets high in saturated fat ­animal fat in particular-and red met have been found to increase the risk for prostate cancer. Eating a low-tat diet also helps to prevent obesity, a condition that may also increase prostate cancer risk.
6. Eat more broccoli, cauliflower, cabbage, brussel sprouts and greens. A recent study found that men who ate cruciferous vegetables more than once a week were 40% less likely to be diagnosed with prostate cancer than men who rarely ate them.
7. Eat cooked tomatoes. Lycopene, the carotenoid pigment that makes tomatoes bright red, possesses powerful antioxidant properties and has been linked in some studies to a decreased risk for prostate cancer.
8. Limit your dairy consumption. Diets high in dairy products and calcium may be associated with small increases in prostate cancer risk. Moderate your dairy consumption, and don’t overdo calcium­ supplements or foods fortified with extra calcium.
9. Get regular aerobic exercise. Regular aerobic exercise has been associated with reduced risk levels for prostate cancer: exercise also helps prevent obesity and other health-related complications that obesity causes.
10. See your physician for prostate cancer screenings regularly. While regular screenings can’t reduce your risk for prostate cancer, changes in diet and exercise can. They help ensure early diagnosis so that prostate cancer can be treated as effectively as possible. My best advice is to get screened annually if you are over the age of 50, if you have a family member who has prostate cancer, or if you are an African-American man.

Bottom Line: Prostate cancer may have a relationship with diet.  I cannot tell you for certain if you follow these instructions you will not develop prostate cancer.  But as my wonderful Jewish mother would say, “It may not help, but it voidn’t hoit!”

11 Suggestions For Decreasing Prostate Symptoms

The prostate gland is walnut sized organ at the base of the bladder.  In order men the gland increases in size and causes symptoms such as going to the bathroom frequently, dribbling after urination, and getting up at night to urinate.  Here are a 11 suggestions that you might consider to relieve those symptoms.

1.  Don’t drink anything several hours before you go to sleep.

2.  Avoid caffeinated beverages such as coffee and tea as the caffeine acts as a diuretic

3.  Limit your alcohol consumption especially at the dinner meal.

4.  Avoid spicy foods.

5.  Take medications such as your diuretics or water pills early in the day when going to the bathroom to urinate is not such an inconvenience.

6.  Avoid antihistamines and decongestants

7.  Don’t hold off going to the restroom

8.  Use the clock to help with urination. Make an effort to urinate every 3-4 hours.  Putting your bladder on a schedule is very helpful and a good habit to have.

9. Go and then go again. Stand at the toilet and empty your bladder, walk away from the toilet for a minute or two and then return and try emptying the bladder again.

10. Avoid cold seats such as at football games in the winter.

11. If you bike ride, especially for long distances, stand on the pedals every 10 or 15 minutes to take the pressure off of your prostate gland.

Bottom Line: These steps won’t cure the enlarged prostate but they will lessen the symptoms.  If your symptoms persist, consider a visit to your urologist

Urinary Tract Infections in Men

Urinary tract infections (UTI) indicate inflammation anywhere within the urinary system.  In men it can occur in the kidneys, bladder, prostate or urethra.  UTIs are more common in women, but they also affect men, especially in men more than 50 years of age.  If UTIs are left untreated, they can result in spread of the infection and cause permanent kidney damage.

Prostate infections are the most common infections in men.  Acute prostatitis occurs when bacteria lodge in the prostate and produce symptoms such as fever, chills, difficulty with urination, back pain, or blood in the urine.  The treatment is antibiotics for 7-10 days.

Chronic bacterial prostatitis is similar to the acute infection but without the fever or chills.  These men also may have painful ejaculation and low back pain.  The treatment is also antibiotics but often the medication has to be taken several weeks or even months.  Men with chronic prostatitis also may be advised to avoid caffeine, alcohol, spicy foods and chocolate.

In many men, prostatitis occurs without identifying any bacterial culprit.  This is called abacterial prostatitis or prostadynia.  The symptoms are the same a chronic bacterial prostatitis.  The pain and vague urinary problems are a result of spasm or congestion of the pelvic floor muscles or congestion within the prostate gland itself.  In most instances, antibiotics are not helpful in treating this condition.  The treatment consists of anti-inflammatory medication, muscle relaxants or alpha blockers.

UTIs can also occur after instruments are inserted into the urinary tract such as catheters or tubes as they may transport bacteria from outside of the body to the bladder and prostate gland.

Previous infections such as some of the sexually transmitted diseases may leave scars in the urethra and cause it narrow or stricture.  This disrupts the normal flow of urine and may result in infections of the urinary tract.

The diagnosis of a UTI is made with a history, physical examination and a urinalysis and a urine culture.  The latter is a test that identifies the offending bacterial and the best antibiotic to treat the infection.  Occasionally, additional tests such as a CAT scan and cystoscopy are required.

General measures for treating UTIs in men include increasing the consumption of water. Alkaline substances, such as citrates, taken in water might improve symptoms. By making the urine more alkaline, they make the environment more hostile to bacterial growth and improve the results of antibiotic therapy.

Antibiotics are the mainstay of treatment. Trimethoprim (Trimpex) is currently the first choice for lower UTI , because it is cost-effective, well tolerated and works in 80 per cent of infections. Cephalosporins and quinolones are reserved as second line drugs in patients with lower UTI, but are first choices in patients with signs of kidney infection.

You can prevent UTIs by drinking lots of fluids every day, empty your bladder often and completely, practice safe sex, always use latex or polyurethane condoms, urinate after sex to flush out bacteria, if you are uncircumcised, and wash under the foreskin each time you take a bath or shower.

Although UTIs are aggravating and affect the quality of life of those with the condition, they do not cause prostate cancer, benign enlargement of the prostate, or perhaps more importantly, impotence.

Bottom Line: With an accurate diagnosis and the correct treatment, most cases of UTIs in men can be cured, treated or certainly controlled.