Understanding What Prostate Cancer Is and Who's at Risk

Prostate cancer is a malignant tumor that starts in your prostate. Some prostate cancers are very slow- growing. Causing you no trouble unless you live a very long time. On the other hand. quick- growing prostate cancers - and I think most of the ones picked up by doctors are this kind - can kill you if the cancer spreads beyond the prostate. if the cancer isn’t diagnosed in time. or if you take no action after your diagnosis. However. you can often be cured of prostate cancer if the cancer is localized (or confined) to the prostate. I had surgery for my own localized prostate cancer in 1999. The surgery cured me. causing no side effects.

But even if a cure isn't possible. you can always be treated to at least temporarily shut down the cancer.

Sure. you may experience side effects from treatment. just like you may end up with a scar from a wound your doctor sews up. But you're alive. and you likely have good prospects for many years ahead. So read this book. talk to your doctor. decide what to do about your cancer. and then do it.

In this chapter. I discuss what prostate cancer is. who's most at risk for developing the disease. what you

can do about the disease. and how to handle the emotions you and your family may feel after a diagnosis of prostate cancer.

Understanding What Prostate Cancer Is and Who's at Risk

Any man can develop prostate cancer. but some men are at a greater risk for the disease. For example. If you haven't been diagnosed with prostate cancer. but your father. brother. or another male relative has (or has had) the disease. your risk for developing cancer increases. and you should have an annual screening for prostate cancer. Black men also have a higher risk for developing prostate cancer. although no one nows for sure why this is the case. Not to say that if you're not black. you don't have to worry about prostate cancer: All men are at risk for developing the disease. You can read more about the risks for developing prostate cancer in Chapter 3.

Prostate cancer isn't your fault. Experts really don't know what causes prostate cancer. so no one

can blame you for making yourself sick. (And you shouldn't blame yourself. either.) At the same

time. when you know that you have prostate cancer. you need to discover all you can about the

disease and the treatment options. And then. with your doctor’s help. you can select the best

treatment for you.

ldentifying Prostate Cancer lmpostors

You may be experiencing some symptoms that may indicate prostate cancer. such as urinary frequency and urgency. or a poor urinary stream. Because men often don’t experience any symptoms with prostate cancer. these same symptoms may indicate another illness altogether. The most common cancer impostors are

• Benign prostatic hyperplasia (BPH): The key word in BPH is benign. Benign is the opposite
• of cancer. and that has to be a good thing. However. BPH can be agonizingly painful for some men. BPH is a tissue overgrowth that can cause major pain and considerable trouble with urination. If you have symptoms of BPH. such as constantly having to urinate or having trouble urinating. you should see your doctor for treatment - which is often medication or sometimes surgery. Without treatment. BPH usually only gets worse. so don’t try to ignore it.
• Prostatitis: This condition is characterized by inflammation and pain in the prostate. (When you
• find -itis at the end of a medical word. it usually refers to inflammation.) Prostatitis is sometimes
• caused by a bacterial infection that's treatable with antibiotics or other drugs. If you ignore the
• infection. it can spread to your bladder. kidneys. or other organs. See your doctor if you're having pain and trouble urinating.
• Bladder infections: As men age. they develop a greater risk for bladder infections. (This

• condition is also known as cystitis. another -iIi.s' word.) The symptoms of a bladder infection

• difficulty with urination. for example - are similar to the symptoms that are characteristic of othergenitourinanv diseases (having to do with the kidney. bladder. prostate gland. penis. and testicles). including prostate cancer. BPH. and prostatitis.

If you have a bladder infection. you doctor usually prescribes antibiotics. Make sure that you take

all the antibiotics your doctor orders. If you take your antibiotics for only two days when your doctor ordered medication for seven days. you only wipe out the weak germs. The stronger germs. which are still there. will continue to multiply. Bladder infections that are not treated properly can be dangerous. because the bacteria can spread to your kidneys.

Check out Chapter 4 for more detailed information on these medical problems. as well as on several others that may be confused with prostate cancer.

Working with physicians

Working with physicians you trust is absolutely essential when you haVe prostate cancer. I say physicians  plural because you usually deal with at least two different types: Your primary care physician. who usually perl‘onns your annual physical examinations. an important ritual that can help Flag the early indicators of prostate cancer. and the speeialist(s) who eonfimis and treats the cancer. You inyariably need to see a urologist (an expert in treating diseases ofthc prostate. kidneys. bladder. and testes). but you may also need to work with urologie. radiation. or medical oncologists (physicians who specialize in treating cancer some urologists subspecializc in treating cancers of the genitourinary system). See C haptcr 6 for more about finding and working with specialists.

A self-test: Could you have prostate cancer?

Only a doctor can determine for sure whether you have prostate cancer. A self-test, such as the one I provide here, can give you possible indicators, at best. Keep in mind that in most cases, early prostate cancer has no symptoms whatsoever, which is why an annual physical examination and prostate specific antigen (PSA) blood test are so very important.

 Get some scrap paper and jot down your answers to the following yes or no statements. Then read my analysis at the end of the list.

1. My father and/or brother has been diagnosed with prostate cancer.
2.  I’m having trouble with urination. (You have trouble going or you have to go a lot. Or- Ouchl - you have both problems.)
3. I notice some blood in my urine.
4. l have constant, severe back pain.
5. I'm tired all the time.
6. I lose weight, even when I'm not trying to take off the pounds.

Now here’s an analysis of your answers. If you answered yes to even one of these statements,

you need to see your doctor.

Question 1: If you answered yes to this question, you have an increased risk for

developing prostate cancer. You should be diligent about having an annual physical exam,

which includes a rectal exam (I know, I know, nobody likes this test, but it can save your life)

and a PSA blood test, as well as a discussion with your doctor about your general health.

Question 2: Trouble with urination may just be a sign of an infection or another

correctable problem. See your doctor so that he can zero in on the culprit. If you have prostate

cancer, you need treatment. If you have a bladder infection, you also need treatment, because

it may get worse.

Question 3: If you see blood in your urine (doctors call it hematun'a), don't panic, but do

see your doctor right away. Having blood in your urine is not normal, and the cause needs to be

investigated. It may be a sign of an infection, prostate cancer, or cancer of the urinary system.

Your doctor can determine the source of the problem.

Question 4: Back pain has numerous causes, ranging from infection to a pulled muscle

to a disc problem (and on and on). Prostate cancer is another possible cause of back pain.

Penile implants — What to expect and how to prepare

Penile implants can restore erectile function. Explore your choices and find out what to expect from this procedure.
Penile implants are artificial devices implanted inside the penis that allow men with erectile dysfunction (ED) to achieve an erection. They're also sometimes used to treat Peyronie's disease, a disorder that causes bent or painful erections. There are two basic designs:

Inflatable. Also called hydraulic, inflatable implants can be pumped up to create an erection and then deflated. 

Semirigid. These implants are always somewhat firm.
First introduced in the 1970s, penile implants were the most reliable treatment for erectile dysfunction until the 1980s when medications injected into the penis became available. In the 1990s, oral agents such as sildenafil (Viagra) were introduced. These medications have since become the most popular erectile dysfunction treatment, but they don't work for all men with erectile problems. About two-thirds of men with ED will respond to oral medications — but some men can't take them, or the medications don't produce satisfactory results. For these men, penile implants are an additional option.

Penile implants require complex and permanent surgery, and there is a risk of infection and a risk that the device will malfunction. But, since these devices were first introduced, new materials, designs and surgical procedures have greatly improved outcomes for penile implants. Most men who have the procedure and their partners say they're satisfied with the results.

Penile implant surgery can be costly but may be covered by Medicare and other types of insurance.

Who is it for?

Erectile dysfunction can be caused by a number of health problems and injuries, and can be a complication of certain surgeries. Depending on the cause of erection problems, implants may be the best treatment choice. Penile implants are a good option for men with erectile dysfunction who can't take medications or for whom medications don't work. Some men make the personal choice to receive an implant rather than using alternative means to restore sexual function.

Implants are also used to treat some cases of Peyronie's disease — a condition that causes internal scarring that can lead to a bending of the erect penis, painful erections and other problems with sexual function.

Most men with erectile dysfunction opt for a penile implant only after other less invasive methods prove ineffective — these include oral medications, medications injected into the penis with a needle or via the urethra (the tube that carries urine and semen through the penis), and use of a vacuum pump device.

A penile implant procedure may have a higher risk of failure if you have immune system problems, a chronic health condition such as diabetes or are at high risk of infections.

How do you prepare?
Penile implant surgery is usually done at a surgery center or hospital by a urologist.

Most candidates for penile implant surgery are evaluated by their surgeon to determine the cause of their erectile dysfunction and to assess their risk of a surgical procedure.
Once you and your doctor have determined that a penile implant may be a good choice for you, your doctor will help you understand the procedure, the risks and potential complications, and the type of implant that suits you best. Include your partner in the consultation with your doctor, if appropriate.
Follow your doctor's instructions about taking medications before and after your surgery. Often, during the two weeks before and after penile implant surgery, your doctor will tell you not to take medications that can alter the function of the platelets in your blood and can increase the risk of bleeding. Your surgeon should review your medications and suggest alternatives if you're taking medications that might make the surgery riskier.
Your surgeon might suggest that you bathe with antibiotic soap for three nights before your surgery to reduce the risk of infection. Do not shave the surgery site yourself.
You may be dismissed the day of surgery or may stay overnight, depending on the circumstances. Arrange for someone to drive you home from the surgery center or hospital.

How is it done?

Normally, spongy tissue inside the penis fills with blood to create an erection. To insert the penile implant, your doctor will stretch these tissue-filled chambers inside your penis (corpora cavernosa). After measurements are made and appropriately sized prostheses are selected, the cylinders (either inflatable or semirigid) are then inserted into the two chambers. With an inflatable implant, your doctor will also place a pump inside your scrotum, and possibly a fluid-filled reservoir in your lower abdomen, depending on the type of implant you receive.

There are two basic types of penile implants:

Inflatable implants

There are two- and three-piece inflatable implants.

Three-piece implants use a fluid-filled reservoir implanted under the abdominal wall, a pump-and-release valve placed inside the scrotum, and two inflatable cylinders inside the penis. Before you have sex, you pump the fluid from the reservoir into the cylinders to cause an erection. After sex, you release the valve inside the scrotum to drain the fluid back into the reservoir.
The two-piece model currently available in the United States works in a similar way to a three-piece design, but the fluid reservoir is part of the pump mechanism implanted in the scrotum.
Semirigid rods
This type of implant is always firm. The penis may be bent away from the body to have sex and toward the body to conceal the device.

In the United States, inflatable devices are the most common type of penile implant.

Three-piece inflatable devices are used in about 70 percent of penile implants.
Two-piece inflatable devices are used about 20 percent of the time.
Semirigid devices are the least used, accounting for about 10 percent of implants.
Although less commonly used, semirigid devices are less complicated, easier to place and have less risk of mechanical failure. Inflatable devices are more costly than semirigid types are, but they're more natural because they can be inflated to create an erection — and deflated at other times. Inflatable implants also reduce the possibility of damage to the inside of the penis due to constant pressure — which can be a problem for some men with semirigid implants.

Although semirigid implants are mechanically simpler — and early inflatable designs often had problems — improved design, materials and construction have made modern inflatable designs much more reliable.

The decision about which type of implant you should have is based on both your preference and your medical situation. Your doctor may advise one type of design over another based on factors including your age, risk of infection, and health conditions, injuries or medical treatments you have had in the past.

Type of implant Advantages Drawbacks

Three-piece inflatable Creates a more natural erection than does a semirigid implant
Creates a firmer erection than does a two-piece implant
Can take pressure off the inside of the penis by deflating the implant when not in use, reducing the chance for injury
Most costly of all implant types
Has more parts that could malfunction than does any other design
Requires the most extensive surgery of any implant design

Two-piece inflatable Creates a more natural erection than does a semirigid implant
Mechanically simpler than a three-piece inflatable implant
Less costly than a three-piece inflatable implant
No need to implant a separate reservoir in the abdominal wall, as with a three-piece design
Can take pressure off the inside of the penis by deflating the implant when not in use, reducing the chance for injury
Requires more extensive surgery than does a semirigid implant
Mechanically more complicated than a semirigid implant
Results in a bulkier scrotum than with a three-piece device

Semirigid Requires the least extensive surgery of all penile implant types
Less parts than any other design, so less of a chance of malfunction
Least costly of all implant types
Penis always semirigid — not entirely hard or entirely flaccid
Less easy to conceal under clothing than other devices
Constant pressure on the inside of the penis, causing injury in some men


What can you expect during the procedure?
Immediately before surgery

Penile implant surgery is usually done under either spinal or general anesthesia administered by an anesthesiologist.
Within a couple of hours before the surgery, you may be given antibiotics to reduce your risk of infection.
A tube called a catheter may be placed into the bladder through your urethra to drain urine. In most cases, the urinary catheter is removed the in the first 24 hours after surgery.
During surgery

Your surgeon will make an incision below the head of the penis, at the base of the penis, or in the lower abdomen.
Next, your surgeon stretches the spongy tissues in the penis that would normally fill with blood during an erection. This tissue is inside the two hollow chambers called the corpora cavernosa.
After flushing the area with antibiotic fluid to prevent infection, your surgeon will choose the correct size implant and seat the cylinders inside the penis.
If your doctor is implanting a two-piece inflatable device, the pump and valve mechanism are placed inside the scrotum. For a three-piece device, your surgeon will also implant a fluid reservoir under the abdominal wall through an internal incision.
Once the device is in place, your surgeon will sew the incisions closed.
Recovery

Most men go home within 24 hours of surgery.
You will need to take antibiotics as directed by your surgeon to prevent infection.
Following surgery, wear loosefitting underwear and clothing. Men with an inflatable device will need to make sure the scrotal pump stays in place during healing.
Most men can resume strenuous physical activity about a month after surgery. You can resume sexual activity four to six weeks after surgery depending on the type of implant you have and the instructions of your surgeon.
Results
New designs and surgical procedures have improved the function and safety of penile implants. Although implants are the most invasive and least often chosen treatment for erectile dysfunction, they have a very high satisfaction rate. About three-fourths of the men who have the procedure, and their partners, say they're satisfied with the results. Many use the devices to have sex several times a week. Men with Peyronie's disease who have the procedure report slightly lower satisfaction rates.

While most men are satisfied with their penile implant, there are some things men should know before choosing to have the procedure:

Implants cause an erection, but they don't increase sexual desire or sensation.
A penile implant will be shorter than the erection you had naturally.
Some partners feel that sexual pleasure is diminished by their lack of involvement in creating an erection.
This surgery is permanent. If your implant is removed, you will not be able to get an erection.
Infection is a possibility, especially if you have diabetes or certain other health problems. An infected prosthesis has to be removed and replaced.
You may have reduced sensation in the head of your penis. In some men, this improves when they also take phosphodiesterase type 5 inhibitors, such as sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra).

Risks
Infection

Penile implants sometimes become infected. Surgery to replace the prosthesis is almost always necessary to treat an infection.

For men who are not already at higher risk of infection because of an underlying health condition, infection rates are low — about 1 percent to 3 percent.
Men with diabetes are at higher risk, with an infection rate of about 8 percent.
Men with a spinal cord injury have about 9 percent risk of infection.
Men having revision surgery — surgery to adjust or replace an implant — have about a 10 percent risk of infection. Men with diabetes who have revision surgery are at higher risk.
If an infection occurs, it's usually not until weeks or more after surgery. In some cases, an infection occurs years later. Symptoms can include long-term pain, a component of the prosthesis sticking to the skin, or rarely, a component that breaks through the skin of the penis. With inflatable models, the entire prosthesis can also become infected.

More serious infections — which in most cases start within weeks of surgery — can cause swelling of the scrotum, drainage of pus and fever.

Malfunction
Although new penile implant designs are very reliable and may last a lifetime, they can malfunction. For example, in some semirigid devices, internal parts can break down over time, leading to a prosthesis malfunction. In inflatable devices, fluid can leak or the valve or pump device can fail. Surgery is necessary to repair or replace a broken implant.

Looking ahead
New implants coated with antibiotics have reduced the incidence of infection, but more studies are needed to determine how effective they are.
Manufacturers recently released a three-piece inflatable implant with a lock-out device to prevent the device from accidentally inflating on its own. More research is needed to see how well this device works, but initial results are promising.
Because some men who have their prostate removed to treat prostate cancer have erection problems, experts are studying whether implanting a penile prosthesis at the same time the prostate is removed is appropriate.
The best solution to erectile dysfunction would be to repair the damaged tissue that caused the problem in the first place. Research is currently ongoing to devise injections of materials that would repair damaged penile tissue to allow natural erections to occur.