For Men Only; how does my prostate grow?

Of our many organs, the prostate gland seems to offer the most annoyance to men as we age. The prostate produces most of the fluid that carries semen and so is critical to reproduction. It is located near the bladder outlet and in young men is about the size of a walnut. As men age, the prostate grows. Unlike heart disease, there is nothing one can do with diet or healthy habits that impacts the prostate.

The two major problems that impact men’s health are prostate cancer and blockage of urine flow from a growing gland.

Growth of the prostate, called benign prostatic hypertrophy (BPH), is a normal part of aging, and occurs in essentially all men. Because of the location of the gland, it can impede flow of urine out of the bladder. It is a good rule that a 60-year-old man, however healthy, should not expect the urine flow of a 20-year-old.

What one does about BPH is entirely based on symptoms. The hallmark of BPH is incomplete emptying of the bladder. You may finish urinating and then feel you need to go again. Most older men will get up at night to void. It may cause urgency – the feeling that if you do not get to the bathroom you are going to lose control.

If these symptoms are mild, no treatment is needed. If they are more severe, medication can help. One class is alpha-blockers, that make it easier to void, that were originally developed to treat high blood pressure. They are generally easy to take, though may be a problem if you tend to have low blood pressure.

The more definitive treatment is to take a testosterone-blocker. Finasteride in low dose is used to treat male-pattern baldness (Propecia) and in high dose to shrink the prostate. It has been shown to reduce the need for surgery and the likelihood of complete urinary blockage. The downside is reduced sexual drive and erectile dysfunction (ED).

ED drugs like tadalafil help urinary flow and may be a good option to improve flow while also treating erectile dysfunction. Your insurance may not pay for this, as most still ration these drugs.

If medicines fail, surgery will usually work.

Prostate cancer occurs in the same organ, but otherwise is unrelated. Cancer occurs in small glands and huge ones equally. As men age, prostate cancer occurs more often and at the same time becomes less aggressive. If a 50-year-old has prostate cancer, unless it is surgically cured, he will probably die of this cancer. If an 80-year-old has prostate cancer, he will almost certainly die of something else, with his cancer but not due to his cancer.

I must also note that African-American men have almost twice the risk of white men.

While prostate cancer can be detected on a rectal exam, by this time it is usually advanced. Early detection is done with a blood test, the PSA (prostate-specific antigen). To say that PSA testing is controversial is an understatement; arguments for and against have raged in the medical literature for years.

I can best sum up the thousands of pages written by saying that screening men with regular PSA testing modestly reduces death from prostate cancer but has minimal effects on overall death rates. There is also consensus that PSA testing should stop at advanced age, though exactly when is debated. I would suggest 75.

If the PSA is elevated, in 2025 the best next step is an MRI of the prostate to detect and quantify any cancer. In low-risk patients, “watchful waiting” is a very viable option. In high-risk men, complete removal of the prostate offers the best chance for cure, with radiation therapy an acceptable alternative. Both treatments have significant side-effects, including bowel and/or urinary incontinence and loss of erection, hence the idea that not all cancers should be treated.

Prostate disorders are clearly conditions in which dialogue between the patient and doctor are key and second opinions critical. Do not accept the first option offered.


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It's a matter of balance

Falls can have very serious consequences as we age. Every year more than 25 percent of adults 65 or older have a fall, and 3 million are treated in emergency departments for fall injuries, according to the CDC.

Several things increase your risk of falling. Blood pressure that falls when you get up is a common culprit, and this in turn can be due to medication you take. If you feel light-headed when getting up, have your BP checked sitting and standing and if there is a fall of more than 10 points, discuss this with your doctor.

Poor vision, particularly when combined with poor light, can lead to a fall. Be sure that you have adequate light in your bedroom if you get up to go to the bathroom.

Be wary of electric cords that are everywhere and can easily trip you. Tape them down or to the wall.

Inadequate leg strength and poor sensation in the feet can lead to falls, as can vertigo from inner ear problems.

What can you do to reduce your risk of falling in addition to the above suggestions?

Doing specific exercises regularly will help. Start with three simple ones:

1. Stand with your feet shoulder-width apart for 10 seconds, increasing this to 30 seconds

2. Next, stand with feet together for 10 increasing to 30 seconds

3. Stand on one leg then the other

If these are too easy, do them with your eyes closed. (Be sure there is a sturdy surface you can touch such as a kitchen counter available.)

Walk heel-to-toe near a wall that can offer support.

Sit on a sturdy chair; get up without using your hands if possible. Sit down. Repeat, aiming for 10 times.

Do these exercises twice a day.

When you are going up or down stairs, hold on to the railing!

Finally, three points of contact are much more secure than two. If you are concerned about falling, a walking stick can be a great safety device.


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Is there calcium in my coronary arteries?

For many decades, doctors have used the traditional coronary disease “risk factors” to predict an individual’s risk of developing heart attacks or other major coronary events. These include smoking, diabetes, high blood pressure and elevated cholesterol.

These factors can be plugged into various formulas to predict the likelihood of a coronary event occurring in the next 10 years, and are used to decide if a person should be started on lipid-lowering therapy.

If the calculated risk is very low or very high, no other information is needed. Many people, however, fall into an intermediate risk range. In some instances, even those with high risk of coronary disease may not want to start a statin drug because of feared side effects (which are uncommon).

Such situations suggest the use of a coronary artery calcium (CAC) score.

As plaque (cholesterol deposits) builds up in coronary arteries, calcium is also deposited. A low-dose CT scan can measure the amount of calcium. Ideally, you would have a score of 0, and the higher the score, the higher the risk of developing symptomatic coronary disease.

Who might benefit from this testing?

If your doctor has recommended you start a statin but you are hesitant, a zero score would allow you to postpone the drug while a score over 100 would strongly suggest you take it.

If your calculated risk is intermediate, a zero score would suggest you do not need to begin cholesterol-lowering therapy while a non-zero score would push you to do so.

If your cholesterol is not bad but you have other risk factors for coronary disease, a CAC score will give useful information. If several family members had early heart attacks, a non-zero CAC score suggests that even if your cholesterol is not high, a statin might be a good idea.

If you have not tolerated a prescribed statin and stopped it, a CAC score may help you to decide whether to try a different statin or one of the newer injectable cholesterol-lowering drugs.

Who should not get a CAC score done?

If you are under 40, a zero score is expected and will not impact decision-making; use the traditional risk factors to guide your thinking. If you are over 80, and not on a statin, the results are unlikely to change recommendations to begin.

If your risk for coronary disease based on the traditional risk factors is high, a CAC is a waste of money: take a statin. If you are on a statin and doing well, be happy and do not get a CAC test.

Finally, if your score is zero, repeating the test can wait at least 3 and probably 5 years.


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