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The prostate gland is an essential part of the male reproductive system. It is located inside the body between the bladder and the penis and sits just in front of the rectum. (It’s this proximity to the rectum that makes it possible to insert a finger into the anus and feel the gland). While the prostate gland is commonly described as “walnut-sized,” this is only true in men younger than 40 years old. Typically the prostate increases in size over time.
The prostate gland surrounds part of the urethra. The urethra is a tube through which urine travels from the bladder to the tip of the penis. That’s why an increase in the prostate’s size can cause issues with urination. We’ll discuss this in detail a little later on, too. The word “prostate” comes from the Greek word prostates, meaning “the standing in front” or “guardian” and refers to the prostate’s position in front of the bladder.
The function of the prostate gland
The prostate gland’s job is to produce and secrete prostatic fluid, one of the components of semen. This fluid both nourishes and transports sperm and typically accounts for 25-30% of semen volume. (65-70% of semen comes from the seminal vesicles while just 2-5% is sperm, which is produced in the testicles.)
During ejaculation, smooth muscle cells inside the prostate contract and forcefully press the fluid that has been stored in the prostate out into the urethra. Here, the prostatic fluid combines with sperm and with fluid from other glands to form semen, immediately before being ejaculated.
Prostate gland anatomy zones
The prostate tissue is made up of many branching ducts surrounded by connective tissue and muscles known as the stroma. These ducts contain the cells that make the prostatic fluid. The prostate has a left lobe, right lobe, a “base” that sits at the lower part of the bladder, and an apex where the gland narrows at the urethra. It is divided up into four anatomy zones:
- Anterior fibromuscular zone: a thick muscle and fibrous tissue covering of the apex; there are no ducts in this part of the prostate
- Peripheral zone: This is the largest area of the prostate and the one closest to the rectum. Most of the fluid producing ducts are located here, and it is most easily felt in a digital rectal exam (DRE). This is where a majority of prostate cancers arise.
- Central zone: This is the area around the ejaculatory ducts, which run from the seminal vesicles to the portion of the urethra surrounded by the prostate (prostatic urethra).
- Transition zone: This is the area around the prostatic urethra and the part of the prostate that enlarges with age, also known as benign prostatic hyperplasia.
Understanding changes in prostate function
Many men report needing to get up to urinate more often than they did when they were younger.
A lot of the time, an increase in the size of the prostate is the cause of their nocturnal urination or “nocturia.” As mentioned above, typically the prostate grows after age 40 and can cause an array of lower urinary tract symptoms or LUTS. Some of these will be manageable, while others can affect quality of life quite considerably. Regardless of how normal or expected lower urinary tract symptoms are, all should be discussed with your healthcare provider. Here are some of the most common LUTS which may or may not be related to changes in the prostate.
- Having an urgent need to pass urine (increased urgency)
- Feeling the need to urinate more often during the day or night (increased frequency)
- Producing less urine than usual during urination
- Feeling pain or burning sensations when passing urine (dysuria)
- Difficulty starting to urinate or straining to complete urination
- Having difficulty emptying your bladder (urinary retention) completely
- Pain with ejaculation
- Discharge from the urethra
- Discomfort in the genitals, groin, lower abdomen or lower back
As men age, the risk of prostate problems increases. The most common issues are prostatitis, benign prostatic hyperplasia or benign prostatic hypertrophy (BPH), and prostate cancer.
Prostate problems: prostatitis
The suffix “itis” means inflammation. Prostatitis, then, means inflammation of the prostate gland. In this condition, the prostate is often swollen and tender. Prostatitis affects at least half of men at some point in their lives though it does not increase the risk of prostate cancer. Prostatitis can be due to bacteria or inflammation (Krieger, 1999). There are four main categories of prostatitis:
- Acute bacterial prostatitis: While this is the least common of the type of prostatitis, it’s the easiest to treat. As the name suggests, this type is caused by bacteria and develops rapidly. Common symptoms include fevers/chills and blood in the urine. A urinary tract infection is often also present, and you may have urinary frequency, urgency, and pain with urination. Treatment is a course of antibiotics lasting for 2-4 weeks. Most cases respond well to treatment
- Chronic bacterial prostatitis: This type is also caused by bacteria but develops slowly. Symptoms include bladder infections that keep coming back. Taking antibiotics for several weeks can significantly improve symptoms in 60-80% of patients (Nickel, 2011).
- Chronic nonbacterial prostatitis or chronic pelvic pain syndrome: By far the most common type of prostatitis, it’s also the least understood. The symptoms come and go and can vary from person to person; symptoms include pelvic pain, pain with ejaculation, and urination problems. It can be inflammatory or non-inflammatory, and often, no specific cause is found. Treatments vary based on your symptoms and include anti-inflammatory medications, alpha-blockers, antibiotics (Pirola, 2019).
- Asymptomatic inflammatory prostatitis: As you may have already guessed, this type of prostate inflammation does not have any symptoms; often, it is discovered while testing for other conditions. Because it’s asymptomatic, treatment is generally not necessary.
Prostate problems: prostate enlargement/Benign Prostatic Hyperplasia (BPH)
Benign prostatic hyperplasia or hypertrophy (BPH) is a non-cancerous (benign) enlargement (hyperplasia) of the prostate gland. It usually affects older men. About 50% of men over the age of 50 years have BPH; the rate increases with increasing age. Up to 90% in men over 80 years of age are affected by BPH (Kim, 2016). Other than age, risk factors for developing BPH, include obesity, family history, atherosclerosis, and type 2 diabetes (NIDDK, 2014).
The exact cause of BPH is unknown, but testosterone (T) and dihydrotestosterone (DHT) are implicated in both normal prostate growth and abnormal growth that occurs in prostate cancer.
There are several theories regarding why these two male hormones are involved in both normal and abnormal growth. One theory is that as men age the amount of testosterone in their blood decreases, leaving more estrogen behind. It is this higher estrogen to testosterone ratio that may encourage prostate cell growth (Ho, 2011). Another is that decreasing testosterone levels lead to an increase in DHT, which may also promote prostate cell growth (Rastreilli, 2019). Lastly, chronic inflammation is thought to play an increasing role in this condition. It’s more likely that a combination of these things leads to prostate growth (Vignozzi, 2014).
The growth in BPH is mainly at the transitional zone of the prostate (the part of the prostate around the prostatic urethra). As it gets bigger, it can put pressure on the prostatic urethra and the base of the bladder. This pressure leads to LUTS, which include straining, weak stream, urinary retention, frequency, and urgency.
BPH is diagnosed primarily by a medical history of LUTS, enlargement on digital rectal exam, and frequently a urinalysis. Sometimes a blood test called “serum PSA” may be ordered. It’s important to note that PSA testing does not distinguish between BPH and prostate cancer. To interpret the results of a PSA test, you’ll need to talk with your healthcare provider.
The goal of treating BPH is to improve the quality of life of patients suffering from LUTS. The American Urological Association (AUA) recommends watchful waiting for patients with mild symptoms or mild-moderate symptoms with minimal decrease in their quality of life (McVary, 2011). Watchful waiting involves yearly physical exams, including DREs, education, and modification of lifestyle risk factors. Some lifestyle modifications include:
- Limiting the consumption of caffeine and alcohol
- Reducing liquid consumption for 2 hours before bedtime
- Urinating before bedtime
- Emptying the bladder as completely as possible with each urination
- Doing pelvic floor (kegel)muscle exercises
- Preventing constipation, which can worsen symptoms of BPH
- Avoiding medications like antihistamines and decongestants as these can make BPH symptoms worse.
- Maintaining a healthy weight and exercising regularly.
In patients with quality of life issues due to LUTS/BPH, medical management is usually an option. There are three main classes of medications used for BPH: alpha-blockers, 5-alpha-reductase inhibitors, and phosphodiesterase 5 (PDE5) inhibitors; they can be used individually or in combination.
- Alpha-blockers: they relax the muscles of the prostate and bladder to improve the flow of urine and reduce symptoms
- 5-alpha-reductase inhibitors: they block the production of DHT, which may be one of the triggers for prostate growth, and work by shrinking the prostate over several months
- PDE5 inhibitors: these medications are also used to treat erectile dysfunction and can be used to decrease urinary symptoms
If drugs are not effective, minimally invasive procedures and surgical treatments may help if you and your healthcare provider think the benefits outweigh the potential risks.
Prostate problems: prostate cancer
After skin cancer, prostate cancer is the most common cancer in men in the United States. The American Cancer Society estimates that 174,650 men in the US will receive a prostate cancer diagnosis in 2019, and 31,620 men will die from the disease (ACS, 2019).
Prostate cancer usually starts in the cells of the peripheral zone of the gland. The most significant risk factor is age: 50% of men at age 50 have cancer cells in their prostate as do 80% of men at age 80 (Grozescu, 2017). Other than age, additional risk factors include African-American heritage, family history, and a diet that is high in saturated fat. Fortunately, for most people, prostate cancer tends to grow very slowly, and many of these cancers may never cause a problem.
Prostate cancer is diagnosed from symptom history (if any), a digital rectal exam (DRE) and a PSA test. In developed countries, the majority of prostate cancers are detected through PSA screening. If the physician suspects prostate cancer, he may order a transrectal ultrasound (TRUS) to get a better “look” at the prostate gland. However, to make a definitive diagnosis of cancer, the prostate cells need to be looked at under the microscope to see if there is abnormal growth.
The urologist will get a sample of cells during a prostate biopsy. A positive biopsy means that cancer cells are present, and the pathologist uses the appearance of those cells to determine their Gleason score. This score describes how aggressive or how likely a cancer is to spread to other parts of the body. Treatment would then depend on the Gleason score and cancer stage (how much the cancer has spread).
n a medical setting, prostatic massage is a procedure by which a physician can obtain expressed prostatic secretions (EPS) by applying manual pressure on the prostate. It is performed similarly to the DRE, but rather than just touching the prostate to assess the size and texture of the prostate, the prostate is stroked several times until the EPS exits the urethra.
Some people believe that prostatic massage clears out the prostate ducts and can help with the symptoms of prostatitis. However, there is limited medical research supporting this and mainly comes in the form of small case studies and anecdotal evidence. Some studies have shown that combining prostatic massage and antibiotic therapy can be helpful in patients with chronic prostatitis (Shoskes, 1999). However, it should never be performed in cases of acute bacterial prostatitis as this can increase the risk of bacteria getting into the bloodstream.
Prostatic massage may be useful in the management of patients with suspected prostate cancer. After the massage, some of the prostatic fluid contents get into the urine stream and can make blood tests for specific cancer markers more effective.
The prostate gland is a vital part of the male reproductive system. Prostate conditions are very common, especially as men get older. It is important to pay attention to any urinary or sexual symptoms and discuss any changes with your healthcare provider who will help you understand any conditions that may be affecting you. If any testing needs to be performed, he or she will discuss the risks and benefits. Your health requires a team approach, and decisions should be made together.
- The prostate is a small gland located at the base of the bladder.
- In men below age 40, it’s about the size of a walnut though it grows as men age.
- The job of the prostate is to produce and secrete prostatic fluid, which nourishes and transports sperm.
- Prostate conditions are very common, especially as men get older.
- These common conditions include prostatitis, benign prostatic hyperplasia (BPH), and prostate cancer.