Prostate

Prostate diseases fall into three groups: inflammation of the prostate (prostatitis), benign enlargement of the prostate (benign prostatic hyperplasia, also known as adenoma) and prostate cancer. All three can cause similar urinary symptoms, but they are treated in completely different ways.

Prostatitis is usually treated conservatively, with medication; if a pus-forming process (abscess) develops, surgery may be needed. For BPH, medication is usually the first step; if it does not help, endoscopic procedures (such as HoLEP) or open surgery are used.

The prostate lies deep in the pelvis; prostate cancer can be operated on using open, laparoscopic or robotic techniques. Which approach is chosen depends on the stage of the disease, the patient’s general health and the technical resources available — this decision is made after an individual assessment. Like any surgery, these operations carry risks; medication can also have side effects and should only be taken as prescribed by a doctor.

After age 50, many men begin to notice these symptoms: a weaker urine stream, an interrupted flow, waking up several times at night, difficulty starting to urinate, dribbling at the end and a feeling that the bladder has not fully emptied.

Prostate size alone does not determine how severe the symptoms are. That is why treatment decisions are based not on size alone but on the severity of the symptoms, urine flow measurements and the amount of residual urine.

Prostatitis is inflammation of the prostate gland. It can occur in men of any age and may be acute or chronic. The inflammation makes the prostate swell and become painful; the swelling narrows the part of the urethra that runs through the prostate, making it difficult to urinate. Acute prostatitis can cause fever and weakness; in severe cases the infection can spread into the bloodstream and lead to sepsis.

Treatment usually combines several measures: pain relievers and anti-inflammatory drugs, alpha-blockers that relax the prostate and bladder neck, appropriate antibiotics and, if needed, intravenous infusions. If passing urine becomes seriously difficult, a catheter may need to be placed into the bladder through the lower abdomen.

In most patients the symptoms improve within a few weeks to a few months; in some, it can take longer. If treatment is delayed or not carried out properly, a collection of pus — an abscess — can form inside the prostate; in that case surgery may be needed.

Antibiotics and other medications should only be taken as prescribed by a doctor; even if your symptoms ease, do not stop the course without agreeing this with your doctor. Before prostatitis is diagnosed, BPH and prostate cancer, which can cause similar symptoms, must be considered.

Treating prostatitis is never considered a treatment for erectile dysfunction. The anatomy explains why: the nerves responsible for potency run from the lower sides of the prostate toward the penis. Prostatitis is an inflammation inside the prostate, and it does not affect these nerves. That is why other diagnostic and treatment methods are needed in such cases.

The cause of erectile dysfunction is often neurological — that is, related to the nervous system; ordinary stress and nervous tension can cause it. These nerves can be damaged, for example, in prostate cancer, or when a prostate abscess forms and the pus damages them — in those cases erectile dysfunction can occur. Ordinary chronic or acute prostatitis, however, does not cause it.

In such cases it may also be necessary to examine the blood vessels that carry blood to the penis and those that carry it away. Age matters here as well. Sometimes this condition can be treated with just two medications, but an individual approach is essential: a wrong diagnosis must not lead to the wrong treatment.

Erectile dysfunction should therefore not automatically be attributed to prostatitis; its cause (vascular, hormonal, neurological, medication-related or psychological factors) needs to be investigated separately. The exceptions are prostate cancer and an abscess, which can damage the nerves. People with chronic pelvic pain may experience impaired sexual function; in that case the cause is looked for not in the prostate itself but in accompanying factors, and a separate evaluation is recommended.

BPH is a benign enlargement of the prostate and shows up as urinary symptoms. Prostate cancer, on the other hand, often causes no symptoms at all in its early stages — which is exactly why regular checkups are crucial.

To tell them apart, a digital rectal exam, a PSA test and, if there is any suspicion, an MRI–ultrasound fusion biopsy are used. A high PSA alone does not mean cancer; inflammation, infection and even the examination itself can raise PSA.

How often to have checkups and at what age to start are decided together with your doctor based on your individual risk factors — this is a shared decision, not a mandatory “every year” rule. A biopsy is also an invasive procedure; whether it is needed and what risks it carries should be discussed with your doctor.

There is a big difference between a benign condition — often called hyperplasia or prostate adenoma — and cancer. Both can cause the same complaints: a weak stream, getting up at night to urinate, hesitancy and a feeling of residual urine. Prostate cancer, however, cannot be detected from these complaints alone; additional tests are needed.

PSA (prostate-specific antigen) is a blood test. A high PSA does not necessarily mean there is cancer — the cause may also be inflammation. The digital rectal exam is a very important examination: it reveals the consistency of the prostate — whether it is as hard as bone or soft. Sometimes the prostate is hard, yet the PSA is not elevated.

Multiparametric prostate MRI adds further information. It uses a scale — PI-RADS 1, 2, 3, 4, 5; a score above three may indicate a suspicion of prostate cancer. The test that establishes the diagnosis is the biopsy. If all three of these tests — the digital rectal exam, PSA and MRI — or even just one of them raises suspicion, a biopsy should be performed.

If the digital rectal exam, MRI and PSA raise no suspicion, a diagnosis of adenoma is made and only the adenoma is treated. A correct diagnosis at an early stage can be of great help to the patient.

Do not interpret your PSA result on your own: inflammation, infection and the examination itself can also raise PSA. The decision to have a biopsy, and its risks, are discussed together with your doctor.

Surgery is usually considered when medication is not enough or when complications develop (recurrent urinary retention, recurrent infections, bladder stones, effects on kidney function). Most often, endoscopic techniques are used, performed through the urethra without any incisions.

In transurethral resection of the prostate (TURP), the enlarged tissue is cut away piece by piece with an electric loop; it is mainly chosen for medium-sized prostates. In laser enucleation, the tissue is separated from the capsule and removed using a holmium (HoLEP) or thulium (ThuLEP) laser, and these techniques can also be used for large prostates. In some cases, other methods are possible as well.

The choice of technique depends on the size of the prostate, urine flow and residual urine measurements, whether you take blood thinners, and any other health conditions. Every technique carries risks: bleeding, infection, temporary difficulty holding urine or urinary incontinence; backward flow of semen (retrograde ejaculation) is common after these operations. The decision is made individually after an examination.

HoLEP is a technique for completely removing enlarged prostate tissue with a holmium laser, through the urethra and without any incisions. It can also be used for large prostates, and the removed tissue is sent for histological examination.

In HoLEP, the tissue is treated with laser energy rather than a scalpel or similar cutting instruments. As a result, there is less tissue damage; in clinical experience, compared with other techniques, urinary incontinence and problems with urination after surgery are usually less common, and the risk of bleeding can be lower, recurrence less likely and the hospital stay shorter.

That said, HoLEP is still surgery: complications such as bleeding, infection and temporary difficulty holding urine cannot be completely ruled out. Whether the technique is right for a particular patient is determined after an examination (urine flow, residual urine, prostate size, other health conditions).

Laser surgery usually does not have a negative effect on erections: the laser acts only to a shallow depth, its effect on the surrounding healthy tissue is limited, and the aim is to preserve the nerves responsible for erections.

Even so, no surgery is completely risk-free. Sexual function before surgery, age and other health conditions can influence the outcome; results vary from person to person, and this question should be discussed separately during your consultation.

This is the complete removal of the prostate for prostate cancer; in some patients, the regional lymph nodes are removed as well. It is performed in patients whose disease has not spread (no metastases) and whose age and general health make them suitable candidates. The same operation can also be performed with a robot.

Robotic surgery is actually one of the laparoscopic techniques. The difference is that the robot’s instruments reproduce the movements of the human hand, whereas the instruments used in conventional laparoscopy cannot perform those movements.

In prostate cancer surgery, after the prostate is removed, a connection (anastomosis) is created between the bladder and the urethra — a step that is very difficult to perform laparoscopically. In addition, the valve mechanism called the sphincter stays in place, so after surgery the patient can urinate normally and hold urine. In other cases, that valve mechanism may be damaged.

In clinical experience, robotic surgery provides a clearer view of tissues, organs and blood vessels and reduces the likelihood of damaging them; there is less pain after surgery, patients can be discharged early and recovery is shorter.

Robotic surgery has one drawback: inserting the instruments into the body and connecting the robot to them takes some time. There are also operations where the robot cannot be used — with large tumors, because robotic surgery always requires a certain amount of working space. In every case, the decision whether to use the robot rests with the surgeon.

Radical prostatectomy is major surgery: whatever the technique, bleeding, infection, difficulty holding urine and changes in sexual function are possible. The robotic approach is not available to every patient or at every clinic; the choice is made individually based on the stage of the disease, general health and technical resources.

No. The choice of treatment depends on the stage and risk group of the cancer (PSA, biopsy results, MRI and other tests), as well as on the patient’s age, general health and personal preferences.

For low-risk disease, many patients may be offered active surveillance instead of immediate treatment, with regular PSA tests, MRI and, if needed, repeat biopsies; in older patients or those with serious other illnesses, observation alone is sometimes chosen. For cancer that has not spread, radical prostatectomy (open, laparoscopic or robotic) and radiation therapy (in some cases combined with hormone therapy) are the main options; for cancer that has spread, hormone therapy and other drug treatments are used.

Every option has its own benefits and side effects — whenever possible, the decision is made after a joint assessment by a urologist, an oncologist and a radiation oncologist, in discussion with the patient.

Once treatment is complete, lifestyle and regular follow-up are equally important: regular checkups on the schedule set by your doctor, quitting smoking, maintaining a healthy weight, a diet and physical activity program based on your doctor’s advice, and a preference for natural foods.

These steps support your overall health, while follow-up checkups make it possible to detect a recurrence or any new change at an early stage. The frequency and content of follow-up (for example, PSA monitoring) are determined individually by your treating doctor.

Lifestyle changes can help reduce risk, but they do not replace follow-up checkups.

These should not be considered treatment. Talk to your doctor before using any supplements advertised in pharmacies or online.

Trying to make urinary symptoms “go away” with such supplements can delay diagnosis — especially since prostate cancer often causes no symptoms in its early stages.