**Dear GQ Doc. I'm 50 years old and in pretty good shape for my age. My questions is: do I need to get my prostate checked? William, via email **
Most people that come to see me have an issue in their mind that either ends with a question about a symptom or a request for a test. In men, particularly those coming up to, or are over 50 years of age, asking to have a prostate check is one of the most common. It is, of course, not without good reason – fear of cancer.
With prostate cancer responsible for 26 per cent of all male cancers, most men will have a family member who has cited a "prostate issue" at some point in their lives. Indeed, one in eight men is likely to acquire it in our lifetime. For something so common it would not be unreasonable to think that there is, like other cancers, such as bowel and breast, a national screening program. There is not. Controversially to many, studies demonstrate that prostate cancer screening tests do not reduce rates of mortality – a necessity for national screening.
For many men, the prostate carries almost mythical uncertainty both in location and function. If anyone has seen the movie Road Trip, in which Sean William Scott's character has the nurse insert a finger up his anus, to "milk the prostate", you'll no doubt be somewhat confused. This is not a modern-day practice, I might add. Away from the Chinese whispers of Hollywood films, your prostate is simply a walnut-sized gland that sits near your bladder. Through it passes the urethra, a tube channeling urine from your bladder and out of your penis. Apart from this engineering role, your prostate also produces a protein called prostate specific antigen (PSA) helping to make your semen more viscous.
Now, many men I meet in clinic have heard of the PSA test. We will come on to this, but first let’s take a step back and talk about symptoms. After all, no test is done without good cause. As your doctor, I would first want to know what symptoms you are having that suggest you may need your prostate checking. These are typically referred to as lower urinary tract symptoms (LUTS), and reflect the possibility that an enlarging prostate may be squeezing around your urethra and thus causing an obstruction of your urine flow from bladder to penis.
LUTS can include:
- Poor stream.
- Hesitation in starting the flow.
- Feeling of incomplete emptying of your bladder.
- Increased frequency of passing urine (polyuria), particularly at night (nocturia).
If you have any of these present, then the next sensible stage would be to have an examination of your prostate. Thanks to how we were put together, the only way to achieve this is to have your doctor’s index finger (gloved and lubricated) inserted via your anus and into your rectum to sweep around the prostate and assess its shape, size and consistency. It will come to all of us. I’m already clock watching as the years go by.
The next step is then decided by the clinical correlation of your history, risk factors (like being older, having a strong family history of prostate issues and being of black or Asian ethnicity) and examination. You may agree with your doctor to first trial lifestyle modification and monitor your symptoms. This may involve keeping a bladder diary for a month – something I do with all my patients with symptoms – to assess the severity and to see if it is just a one-off phenomenon after a weekend binge. Alcohol switches off your antidiuretic hormone and so you pass urine a lot more. Our plan may also involve tailoring off your fluid intake later in the evening to help minimise how often you have to get up in the night.
Alternatively, if your prostate is large and you have strong LUTS then it is now time to talk about the PSA blood test. Again, before this is done, personally I give out written information about the test so you can digest the clinical path that you are potentially committing to.
You see, there is an issue with the PSA test: it will not tell you if you have prostate cancer. It is simply a blood test measuring the PSA level. A higher PSA equals a bigger prostate. However, to confuse matters more, all of the following can falsely elevate your PSA result: exercising vigorously, ejaculating in the past 48 hours, having a urine infection or having a prostate (the finger) examination. Interpreting your PSA result will also depend on your age. Quite simply, as you get older, the normal range increases. This is a direct result of your prostate cells growing in size and number in response to natural testosterone exposure.
Let us say that you have the PSA test, excluded all the falsely elevating causes and yet it is raised for your age. Yes, this could signpost us to prostate cancer. However, 15 per cent of men diagnosed with prostate cancer have a normal PSA reading. Conversely, 65 per cent of men with a raised PSA do not have prostate cancer. Instead, they may have benign prostatic hypertrophy (BPH), a very common and non-cancerous condition. Indeed, 40 per cent of men in their fifties and 90 per cent of men in their nineties will have this. This makes sense as your lifetime exposure to testosterone slowly accumulates (even accounting for its own rate of decline over time) and causes your prostate to grow.
Once again, this would be time to pause for review. We now consider your history, risk factors, examination and PSA result as a whole clinical picture. If there is any risk, then we refer you to the urologist for further specialist investigations (routinely or urgently). Alternatively, we trial the aforementioned lifestyle changes, along with medications (to minimise growth of your prostate and relax your genitourinary plumbing – also helpful in BPH). Whatever the outcome, part of a good routine follow-up for you is to intermittently check symptoms with your doctor along with your PSA.
So back to your original question: do you need a prostate check? If you have concerns and you are experiencing lower urinary tract symptoms, the answer is yes. My advice to you, and anyone else, is that if you have any worries, symptoms or uncertainties regarding your prostate, then see your GP and talk through them first. This should precede any thoughts of PSA testing. For more digestible information, visit: https://patient.info/health/prostate-gland-enlargement
Dr Nick Knight is a GP registrar with a special interest in sports, exercise and lifestyle medicine. Follow him on Twitter @DrNickKnight and Instagram DoctorNickKnight
