“IN the aging population of men today, particularly in the Caribbean, any term associated with ‘prostate’ can be very dreadful to their mental state. An enlarged prostate is often incidentally found on routine ultrasounds for different pathologies. Men would defer medical visits for assessment of their prostate due to fear of digital rectal examinations, commonly known as the ‘finger exam’.”

These were the words of Dr Orissha Denbow, practicing physician at the University Hospital of the West Indies, Mona, Jamaica.

In an exclusive interview with the Guyana Chronicle, Dr Denbow explained that at the end of many visits, despite extensive explanations by medical personnel, men seem to be misguided and misled in their opinions of the prostate, some may even inquire if this is an abnormal structure that was just discovered on routine examination, as they are unaware of the normal male anatomy.

Physiology of the prostate
Dr Denbow sought to explain the normal physiology of the prostate gland, as well as the pathophysiology of enlargement of the prostate gland; causes, complications, and treatment (medical vs surgical) in an effort to help the male to better understand themselves and the prostate that many of them encounter.

The prostate gland, she stated, is part of the male reproductive system, which lies deep within the pelvis, below the bladder and in front of the rectum. The normal prostate size can be compared to a small lime, which is approximately 20cc. The function of the prostate is to secrete a slightly alkaline fluid, milky or white in appearance that in humans usually constitutes roughly 30 percent of the volume of the semen. She further explained that the prostate gland surrounds the urethra, which is the tube through which urine passes out of the body.

She submitted that prostate enlargement occurs in most men as they age, which is also known as Benign Prostatic Hyperplasia (BPH). The likelihood of BPH is approximately equal to the age of a man; men at 40 years of age have a 40 percent likelihood of BPH and men by age 80 have an 80 percent chance of BPH. This benign prostatic hyperplasia is essentially the enlargement of prostate, caused by the overgrowth of smooth muscle and glands which surround the urethra.

“Half of the men diagnosed with BPH will be asymptomatic [producing or showing no symptoms], while the other half will be symptomatic of lower urinary tract symptoms (LUTS). These symptoms include waiting long periods to pass urine, poor stream, having the sensation of incomplete emptying after urination, waking up many times at night to urinate, as well as going to urinate frequently during the day, feeling the urge to pass urine, leaking or wetting oneself due to inability of controlling the urge to pass urine,” Dr Denbow explained.

She said that these symptoms are mainly due to the enlarged prostate blocking normal bladder emptying and also as a result of the muscle in the bladder getting thicker to compensate for the blockage, therefore causing the bladder to become irritable. Dr Denbow further explained that lower urinary tract symptoms can be progressive and so it can adversely affect the quality of life of men. LUTS is not BPH specific and having symptoms does not necessarily equal BPH.

Complications and treatment
Dr Denbow stressed that the goal of treatment, primarily by the physician, is to alleviate the bothersome lower urinary tract symptoms that result from what is called, ‘prostatic enlargement’, at the time of presentation. “The main agents used include alpha blockers e.g. Tamsulosin, which help to relax muscles around the prostate; 5-alpha-reductase inhibitors, (eg. Finasteride) which shrink the prostate gland and provide the reduction of LUTS.

She noted that other agents include anticholinergic agents and muscarinic agonists, which help to relax bladder; Phosphodiesterase inhibitors, which are commonly known as ‘Viagra’ is also used to relax bladder and muscles around the prostate, she said.

Dr Denbow, in further discussing the issues of an enlarged prostate, warned that the complications or failure of medical therapy will warrant the need for surgical intervention in BPH. Some of these complications include persistent urinary tract infections, the presence of bladder stones, blood in urine and worsening renal function. She said that various surgical interventions may be advised by the Urologist at the time of such complications.

The Caribbean
In the Caribbean, common surgical interventions include Transurethral Resection of Prostate (TURP) and open prostatectomy, which would aim to remove the obstructing part of prostate and alleviate the bothersome lower urinary tract symptoms, Dr Denbow noted.

It is also important, Dr Denbow said, “to distinguish BPH from prostate cancer. Prostate cancer may present with similar symptoms as BPH, but it is associated with the malignant potential of the prostate and the ability to spread to the bone, causing lower back pain and fractures, renal failure due to obstruction of the kidney by an enlarged prostate and even death.”

Dr Denbow said that prostate cancer is the first most frequent cancer diagnosed in Caribbean men. She said the most common investigation used to screen for prostate cancer includes a blood test and a finger examination of the prostate to appreciate bumps or any irregularities of the prostate.

The blood test, she explained, is known as a PSA, which is the abbreviation for Prostate Specific Antigen and is produced by the glands of the prostate, which is primarily a protein which helps to liquefy semen.

Dr Denbow further added that the normal PSA levels range from 0-4ng/L. She said that when it is elevated it can indicate prostate cancer or BPH, but the only way to make a distinction between the two pathologies is by aid of a prostate biopsy. Further, it is very important to know that not all diagnosis of prostate cancer deserves treatment, she said.

“When a male is diagnosed, the various options need to be discussed with a physician or private urologist depending on how advanced the cancer is and also the age of the patient and need for intervention,” Dr Denbow stated, explaining that these options include radiation therapy, surgery and hormonal therapy.

Testing in the USA
She noted that in First World countries, such as the United States of America, there has been a falling out of routine PSA testing due to their low likelihood of having aggressive prostate cancer. However, due to prostate cancer being so prevalent in our male Caribbean population, as well as being very aggressive, a correlation cannot be drawn and routine PSA’s are recommended.

Dr Denbow said that currently, a database is being formulated to capture men in Jamaica over a 12-year period, who have been diagnosed with prostate cancer and the various therapies which have been offered to them. “This study is driven by our Head of Department of Urology at University of the West Indies Mona Campus, Dr. Belinda Morrison, a pioneer in her field,” she said.

This database will aid in the trends of prostate cancer in the Jamaican community, which can also be extrapolated to the Caribbean. The information attained can also help to guide the establishment of health policies aimed at reducing the economic effects of disability from prostate disease and also improve the quality of life of men, she told Guyana Chronicle.

It is important that the distinction is made between prostate cancer and Benign Prostatic Hyperplasia (enlarged prostate). In the Afro- Caribbean population of men, routine PSA testing is recommended from age 40.

It is also of great significance that the male population is able to make the distinction between an enlarged prostate and prostate cancer hoping that it will subsequently motivate the male population to attend routine follow up and maintain good prostate health, said Dr Denbow. (mercilinburke2017@gmail.com)