Be aware of key risk factors for prostate cancer: West African ancestry, family history (father, brother, uncle with prostate cancer, especially at a young age), and smoking (linked to more aggressive cancer at a younger age).
Do not use finasteride or dutasteride for hair loss due to the risk of post-finasteride syndrome (decreased sex drive, impotence, anejaculation, depression, potentially permanent) and the significant impact on PSA interpretation, which can mask aggressive prostate cancer. Explore alternatives like hair transplants.
Patients should take ownership of their PSA monitoring, understanding their numbers and trends, and discussing them proactively with their physicians, as early detection using advanced metrics (PSA velocity, density) can be life-saving.
Every man at age 45 should have a baseline PSA test to understand their individual baseline and track changes over time. If PSA is below 1, recheck every 2-4 years.
If taking finasteride or dutasteride, be aware that PSA levels will decline by about half. It is critical to adjust PSA interpretation accordingly (e.g., multiply by 2) and monitor for any rise, as a rising PSA on these drugs is a strong warning sign of aggressive prostate cancer.
Educate yourself that increased fluid intake leads to increased urinary output. Regulate what you drink and when you drink it, avoiding large volumes before bed and diuretics like caffeine.
Be aware that constipation and changes in bowel function can contribute to pelvic pain and urinary discomfort due to the anatomical proximity and shared innervation of the rectum and prostate. Maintaining regular bowel habits can help.
For individuals experiencing nighttime urinary frequency (nocturia) and peripheral edema, strongly consider wearing knee-high TED stockings to reduce fluid shifting from extracellular to intravascular space when lying down.
If experiencing nocturnal urinary frequency, get screened for sleep apnea, as it is a driver of this symptom and treating it can resolve the issue.
For men experiencing nocturia without a clear explanation or enlarged prostate, a very low dose of desmopressin (typically 0.2 milligrams before bed) can have profound effects by acting as a synthetic anti-diuretic hormone.
If behavioral modifications are insufficient or symptoms are unusual, keep a voiding diary to track fluid intake (timing and volume) and urinary output (timing and volume). This helps identify excessive intake or unusual patterns.
If behavioral modifications fail for lower urinary tract symptoms, consider an alpha blocker (e.g., alfuzosin, silodosin). These medications relax smooth muscles in the prostate, theoretically enhancing the diameter of the urethral channel and improving stream strength and emptying.
If alpha blockers improve obstructive symptoms but storage symptoms (frequency, urgency) persist, consider an M3 agonist. These relax bladder muscles, significantly impacting urgency and frequency, with fewer neurocognitive side effects than older anti-muscarinics.
If still bothered by urinary symptoms despite medical management, discuss outpatient surgical procedures with a urologist, as these can offer a long-term fix without continuous medication.
For men with very large prostates (e.g., over 70-80 grams, up to 600 grams) causing urinary symptoms, consider Holmium Laser Enucleation of the Prostate (HOLEP) by an experienced surgeon. This procedure removes the entire inner pulp of the prostate, offering durable relief with minimal bleeding and often no catheter post-procedure.
Be cautious of minimally invasive procedures like Urolift that offer only temporary relief and may cause pain or interfere with future diagnostics (e.g., MRI). These are generally not recommended if more effective, durable options are available.
If medications are ineffective or symptoms are severe, consider surgical options like TURP (Transurethral Resection of the Prostate) or HOLEP. Modern TURP uses saline irrigation to reduce complications, and HOLEP is highly effective for large prostates.
If profound urinary symptoms persist with a small prostate and unresponsiveness to medical management, investigate other causes such as prostate infection (bacterial/viral), prostatitis, or pelvic floor dysfunction.
If profound urinary symptoms persist with a small prostate and unresponsiveness to medical management, ensure a workup for urothelial carcinoma (cancer in the bladder/urethral lining) is performed, including urinary cytology.
If concerned about a prostatic infection, undergo a four-step Stamey test (capture initial void urine, midstream urine, expressed prostatic secretion, and post-massage urine). Culture these samples, looking for bacteria at a lower threshold (10^2 or 10^3) than standard UTI diagnostics.
In very unusual cases of persistent pelvic pain, consider a bacterial infection in the seminal vesicles. This can be diagnosed by bacterial testing of semen.
If a rectal exam reveals tightness or ‘guitar string’ bands in the pelvic floor muscles, consider transrectal myofascial release therapy, as this can significantly alleviate pelvic pain syndrome.
If experiencing pelvic discomfort or pain without clear cause, keep a thorough diary of food intake to identify potential dietary triggers, similar to interstitial cystitis in women.
If experiencing chronic pelvic pain syndrome that improves with antibiotics but without confirmed bacterial infection, transition away from long-term antibiotic use. Instead, use NSAIDs (e.g., naproxen, ibuprofen, meloxicam) and potentially anxiolytics, as antibiotics often act as anti-inflammatories.
For chronic pelvic pain syndrome with unknown etiology, explore mast cell dysfunction. Clinical trials are investigating mast cell inhibitors for this condition (e.g., at Northwestern Feinberg School of Medicine).
For elderly patients, especially those with dementia, maintain good hygiene and monitor voiding history to minimize the risk of urosepsis. If catheterization is necessary, intermittent catheterization is preferred over indwelling catheters due to lower infection risk, provided sterile technique is used.
For elderly individuals, especially those with comorbidities or dementia, ensure adequate hydration. Dehydration concentrates urine, increasing the risk of infection and urosepsis, as older people often lose their sensation of thirst.
If an initial PSA test is elevated, always recheck it due to potential transient rises. Additionally, consider advanced PSA-based testing (e.g., percent-free PSA, prostate health index, 4K score) to increase specificity and discriminate between benign enlargement and cancer.
Understand PSA density (PSA value / prostate volume). A PSA density of 0.1 or less is generally safe for young men. For average age, if PSA density is more than 0.15, consider additional testing, as higher PSA density correlates with higher risk and aggressiveness of cancer.
Monitor PSA velocity (rate of PSA rise). A rapidly rising PSA is a canary in the coal mine, indicating a warning sign that requires additional evaluation.
If you have an elevated PSA and are considering a prostate biopsy, always get a pre-biopsy multiparametric MRI (3T, T2, diffusion-weighted imaging, dynamic contrast enhancement if needed). This helps identify suspicious lesions (PI-RADS 3, 4, 5) and reduces unnecessary biopsies while enhancing detection of clinically significant disease.
If an MRI shows a suspicious lesion (PI-RADS 3, 4, or 5), consider a biopsy that samples both the specific lesion (target biopsy) and systematically samples the surrounding peripheral zone.
When undergoing a prostate biopsy, consider the transperineal approach over the transrectal approach, as it significantly reduces the risk of infection by avoiding the introduction of rectal bacteria into the prostate. This can often be done without antibiotics.
If undergoing a transperineal prostate biopsy, ask for buffered lidocaine for pudendal nerve blocks. Buffering the lidocaine (pH ~5) with bicarbonate reduces the burning sensation during injection, making the procedure more tolerable.
If diagnosed with high-grade prostate cancer (Gleason 8+ or 4+3=7 with significant pattern 4), undergo a PSMA PET scan to determine the extent of the disease (staging). This is the most sensitive and specific way to identify metastases, as prostate tumors are not FDG-avid.
If diagnosed with low-volume Gleason 3+3=6 prostate cancer (least aggressive, 1-4 cores), active surveillance is generally recommended. This involves close monitoring (PSA every 6 months, confirmatory biopsy at 1 year, repeat MRI if PSA changes or initially missed) rather than immediate aggressive treatment, as the risk of progression to incurable disease is very low (0.1%).
For small-volume Gleason 7 (3+4) prostate cancer, especially with minimal pattern 4 (e.g., 1-2 millimeters), consider genomic testing (e.g., Decipher) to assess aggressiveness. Many such tumors behave like Gleason 6 and may be candidates for active surveillance.
For Gleason 8 or higher prostate cancer (including 4+3=7 with significant pattern 4), aggressive treatment is typically required. These tumors have a higher probability of deep roots and spreading to lymph nodes, necessitating active intervention.
For high-grade prostate cancer (Gleason 8+ or 4+3=7 with significant pattern 4), especially with lymph node involvement, consider multimodal therapy (e.g., surgery followed by radiation, or radiation with androgen deprivation therapy) for aggressive treatment.
When choosing a surgeon for prostatectomy, ask about their practice scope (e.g., prostatectomy-only vs. general urology), their surgical margin rates, and their rates of functional recovery (urinary continence, erectile function). Seek a surgeon with dedicated experience and transparent outcomes.
When considering radical prostatectomy, inquire about pelvic fascial sparing techniques. This advanced surgical approach preserves surrounding fascia and structures, significantly improving urinary continence recovery and potentially erectile function without compromising cancer control.
Understand that erectile function recovery post-prostatectomy is a long process (up to 24-30 months) and depends on age, pre-surgical function, and tumor aggressiveness. Be prepared for a 65-75% chance of recovery with Cialis for a healthy 65-year-old with contained cancer.
Post-prostatectomy, consider using injectable prostaglandins (e.g., into the cavernosal body) as a temporary measure to trigger erections during the nerve recovery period. This helps reoxygenate the penis, maintain penile length, and support sexual activity.
If radiation therapy is chosen, inquire about MRI-guided prostate radiation. This advanced technique offers tremendous precision, real-time adjustments for patient movement, and the ability to boost specific lesions, significantly reducing rectal side effects and potentially improving cancer control.
For radiation therapy, consider the use of a hydrogel spacer (SpaceOAR). This gel is percutaneously deposited between the prostate and rectum, separating them by 5-10mm, which substantially reduces radiation toxicity to the rectum.
If undergoing radiation for high-grade or locally aggressive prostate cancer, androgen deprivation therapy (ADT) is often used as a radiation sensitizer. It induces double-strand DNA breaks, making cancer cells even more susceptible to the radiation.
For short-course ADT (e.g., 6-24 months) used with radiation, consider oral LHRH antagonists. These offer rapid onset and offset, increasing the likelihood of testosterone recovery compared to traditional LHRH agonists.
For metastatic prostate cancer, systemic therapy is essential. This includes androgen deprivation therapy (ADT) with LHRH agonists/antagonists, often combined with novel hormonal therapies like CYP17 inhibitors (e.g., abiraterone) or androgen receptor competitive binders (e.g., enzalutamide, apalutamide, darolutamide) to significantly extend lifespan.
For patients with low testosterone and prostate cancer, especially luminal-type tumors, testosterone supplementation can be considered. Luminal tumors are exquisitely sensitive to testosterone suppression, and understanding tumor biology (e.g., via genomics) can guide this decision.