After almost a back-to-back treatise on women issues it became imperative to address something directly pertinent to men although this should concern women in Nigeria even more because they are the ones that mostly take care of the chronic medical problems of our aged parents, especially our fathers. Most of the topics I have written on were due to petitions from several people in Nigeria juxtaposed with my knowledge of the rampant mismanagement of such cases there and this is not an exception. As such, the topic might not be exhaustive based on its scope but once it is poignant and able to address then subsequently rectify a certain entrenched but misapplied behavioural practice, I will consider the job of the medical iconoclast fulfilled in that area of life. So let us discuss what is commonly referred to as ‘prostrate problem’ in Nigeria ( actual designation is prostate problem).
The prostate is a gland that surrounds the neck of the urinary bladder where it opens into the urethra, and any growth or enlargement of thos prostate can result in obstruction of urine flow. It consists of a glandular and a mucular part all surrounded by a tough capsule which is difficult to penetrate by the regular medications and antibiotics that can breach other organ barriers. The muscular part is targeted by medications that aim to relieve symptoms of prostate enlargement and it is its contraction that causes ejaculation of semen into the urethra for outward flow during sexual activity. Thus without the prpstate, there will not be the act of ejaculation although the rest of the seminal fluid will still flow passively into the urethra. The the glandular part releases prostatic fluid which is secreted through ducts that open into the prostatic urethra to become a component of the seminal fluid (semen), which we erroneously commonly call sperm in Nigeria. In case you do not not know, what is released by a man during ejaculation is called semen, not sperm, but contains about 20 million sperm to one milliliter of the semen released, giving a total of about 60 million sperm (full name spermatozoa) in one ejaculation. The confounding thing here is that only one sperm out of the 60 million is needed to fertilize a woman’s egg and produce a baby!! As such, in my didactic moments, I drive home this fact albeit facetiously by telling guys that they destroy 60 million Nigerians with one ejaculation when everything is done to avoid pregnancy but can you even imagine the population explosion that could have resulted if not for this?? Just a hahaha moment!
Lest I digress, there are several diseases afflicting the prostate which we shall touch on briefly but will concentrate on the two major types which are the poster children of prostate diseases, at least in Nigeria. These diseases include prostatitis, prostatic calculi or stones in the prostate, benign enlargement of the prostate (benign prostatic hyperplasia commonly called BPH) and prostate cancer.
Prostatitis is inflammation of the prostate and is often the result of gonorrheal urethritis, or what we just call gonorrheain Nigeria. I am buttressing this terminology because most Nigerians do not know that one could have arthritis (joint inflammation and pain) due to gonorrhea! Just imagine the incredulity of a Nigerian patient that consulted me for joint pains and after a series of tests I told him, ‘nnaa my brother, o bukwa gonorrhoea ji gi’ (translated, my brother, you have gonorrhoea). The person will just storm out of my consulting room and tell me to go back to medical school! Anyway, prostatitis could present with symptoms of urinary tract infection (UTI) like increased frequency of urination, burning with urination, lower abdominal/pelvic pain and occasionally rectal pain and discharge. If a man has symptoms of UTI not amenable to the routine antibiotics given, it may be prostatitis. Remembering that thevprostatic capsule could be a barrier to antibiotic penetration, a choice of strong antibiotic here like levofloxacin for 2 to 3 weeks may be in order. In chronic untreated prostatitis, infertility from the man could arise but this is quickly reversible once the prostatitis is treated.
Calculi of the prostate are uncommon in that they may be incidental findings in men over 60 years old and are usually asymptomatic but in debilitating cases may require surgical removal.
BPH and PROSTATE CANCER:
BPH and prostate cancer are common after 60years of age and result in urethral obstruction, impeding urination and occasionally leading to retention. Debunking a common myth, sexual actvity has no documented role in making prostate diseases either rampant or infrequent.
Prostate cancer is a malignant transformation of the prostate that requires a mixture of surgery, chemotherapy and radiotherapy to treat but in very advanced cases with distant spread, only immunotherapy is indicated. I will not dwell much on prostate cancer because most of its management is in the hospital. Some of its presentations are rectal pain, rectal bleeding, pelvic pain, low back pain, weight loss and symptoms of other sequelae like fatigue in case of anemia. A simple blood test called PSA (prostatic specific antigen) is done and when astronomically elevated, is highly suggestive. Normal level is less than 4 although 15% of men with mild to moderate elevation of PSA have no cancer or may just have BPH whilst some men with cancer have normal PSA although significantly elevated levels tend to correlate with the presence of cancer. Apart from hrlping with initial diagnosis, the PSA can also be used to monitor response to treatment of prostate cancer. Of course digital rectal exam showing hard painful prostate often enlarged and bleeding, also helps. Transrectal ultrasound of the prostate can also be done as well better scans like CT scan, MRI scan and bone scan ( in case of spread to the bones). Prostate biopsy still remains the gold standard for diagnosis of prostate cancer. Generally, early detection and management is recommended because this is one of the cancers that one can live for long with after diagnosis, so does not really carry the ominous aura of a traditional cancer, once treated. It is also the most common cancer amongst men in the USA, and possibly Nigeria, though no reliable statistics exist there.
BPH is benign enlargementof the prostate, meaning that it is not cancerous or expected to cause major harm or death but the symptoms of advanced disease can be debilitating too. Untreated severe cases can cause kidney damage due to damming back of the obstructed urine causing kidney distension and damage. It is different from prostate cancer in not being malignant and does not in any way result in prostrate cancer but it has almost the same symptoms, and even more and include:
- Poor urine stream
- Sensation of an incomplete bladder emptying
- Difficulty initiating urine voiding
- Urinary urgency
- Urinary frequency in the day
- Nocturia or waking up frequently at night to urinate
- A urinary stream that starts and stops
- Straining to void
- Persistent dribbling of urine
- Returning to urinate again soonafter finishing
Due to the blockage of the prostatic urethra by the enlarged prostate and whose severity is dependent on the size of the enlargement, sufferers present with decreased ability to urinate leading to poor urine stream. Over time, the urine will start pooling in the urinary bladder stretching its walls giving the patient the reflex need to urinate often, causing the person to go frequently. Each time he goes, only small amount comes out because of the blockage and he has to strain to urinate more because of the feeling of incomplete emptying with the full bladder. This is why it is called a ‘growing” problem and not a ‘going’ problem because although the patient ‘goes’ frequently to urinate, the main cause is a ‘growing’ prostate. This ‘going’ is worse at night when patients are known to wake up even up to 5x to go and urinate, a process called nocturia. IT IS THIS NEED TO GO FREQUENTLY TO URINATE THAT MAKES SOME MEDICAL PEOPLE IN NIGERIA TO ERRONEOUSLY DIAGNOSE AND TREAT BPH PATIENTS WITH DIABETES MELLITUS, OFTEN WITHOUT BLOOD TESTS FOR DIABETES IN SOME PLACES!! I HAVE BEEN INUNDATED PERSONALLY WITH THESE SITUATIONS FROM PATIENTS IN NIGERIA AND PREVENTION OF SUCH MALPRACTICE IS THE REASON BEHIND THESE ARTICLES!! In diabetes, people urinate frequently but mostly in the day but not really at night, and urine stream is normal with no dribbling, urgency or straining. They do not wake up at night per se to urinate
As the urinary bladder continues to pool urine and swell, a fast distention of the bladder can result in acute low abdominal swelling and pain that has to be relieved with a urinary catheter, and this is the only time a BPH can give you pain, otherwise it is painless. Contrast with prostate cancer which could be asymptomatic initially but gives severe pelvic and low back pain especially in advanced stages. Continuing, the full bladder may start leaking urine slowly and continuously into the urethra giving the person urinary incontinence and the social malaise of continuous urine smell which some combat with pampers and other soaks. It can also cause urgency, which means in those not leaking continuously, the urine comes out before they get to the bathroom in small amounts but once they reach, they cannot urinate again and have to strain to even just dribble.
Diagnosis of BPH is through measures similar to the plethora of tests for prostate cancer but the PSA could just be slightly elevated here but most times is normal. Also digital rectal exam shows boggy enlarged smooth-surfaced painless prostate.
TREATMENT OF BPH
I have heard stories of local herbs which in Nigeria are supposedly eclectic in efficiency and I am using this opportunity to tell everyone that I am not a fan of local herbs for anything. Does this detract from their efficacy or otherwise, no, but just like Joshua said in the Bible, for myself family and my friends, no local herbs!
The mainstay of treatment are the peripherally-acting alpha adrenergic blockers which relax the smooth muscles of the prostate resulting in improved urine flow. They include tamsulosin (flomax), terazosin (Hytrin), doxazosin (Cardura), prazosin, etc. These were initially manufactured as blood pressure medications but when BPH patients took them for their high blood pressure, they were inadvertently found to urinate well. They were then subsequently approved for BPH. Because of the effects they may have on normal blood pressure patients with BPH, they are recommended to be taken only at nights, just before bedtime, once in 24hours.There is abundance of free doxazosin in my village Obiene Ututu which I sent from the USA and a lot of people with BPH are getting symptomatic relief with it. They are to be taken for life.
The next group of medications are the 5-alpha-reductase inhitors that prevent conversion of testosterone, the male hormone, into its active component, hence reducing the stimulation of the prostate from this active component. They include Finasteride and Dutasteride. They are usually taken once a day for 6 months to augment the work of the alpha adrenergic blockers above and free finasteride is available also in Obiene Ututu, from me.
These two classes of medications are adequate for most of BPH. In the cases of urinary incontinence as enumerated above as well as in acute painful urinary obstruction, a urinary catheter can be inserted for a reasonable time for symptomatic relief.
Only in small percentage of cases is surgery indicated for symptom relief and is usually via a trans-urethral resection of the prostate (TURP). It is mainly via passing a probe into the penis through the urethral opening and hitting the prostate and cutting off that part blocking the urethra just within the circumference of the urethra. This provides significant relief with improved instantaneous flow but is fraught with complications like infection, bleeding and even incontinence assuming a large chunk is removed. This may condemn the patient to a chronic indwelling urinary catheter and because of these, surgery is usually a last resort. In recalcitrant cases where urine retention is causing flowing back of urine and distending the kidney with imminent kidney damage, TURP will be quickly indicated.
I hope this helps. Thank you