Benign prostatic growth (BPH)
The prostate gland lies just below the base of the bladder and the water pipe (urethra) runs through it to get out of the body (see diagram X). When most men get older, their prostate gland enlarges: this enlargement is not due to cancer, but occurs because of gradual growth of additional benign prostate tissue (benign prostatic hyperplasia, or BPH). In many men, the effect of this enlargement is that the urethra is gradually constricted as it passes through the prostate gland. This means that gradual obstruction to emptying of the bladder develops, making it harder to pass urine (poor stream), and raising the pressure that the bladder needs to develop for urine to pass.
This process, BPH, may lead to other urinary symptoms, such as frequency, urgency, nocturia, hesitancy and others (see urinary symptoms). BPH may also occur in some men without causing any bothersome symptoms. There may be other causes of urinary symptoms (see urinary symptoms).
If bothersome symptoms do occur, they are assessed to decide whether there is a significant cause, and to assess whether they are affecting draining of the bladder or function of the kidneys. Urinary symptoms are often managed by simple adjustments in lifestyle (which may include advice on fluid intake, or on how to hold urine for longer), or by using medication, either to try to help the prostate to allow urine to drain better, or to try to help the bladder to hold urine better. In some men, if these measures do not help sufficiently, it may be helpful to discuss the option of telescopic surgery (TURP or laser prostate surgery) to relieve the obstruction caused by BPH.
Most tumours in the bladder grow from the surface lining of the bladder (called the urothelium). All of these are technically forms of cancer, although most do not behave in an aggressive way, tending to spread and threaten life, as cancers such as lung or breast cancer tend to do.
Most bladder tumours grow on the urothelium without growing into the wall of the bladder. Some do grow into the wall of the bladder though, reaching either the main muscle coat, or the connective tissue layer between the urothelium and the muscle layer (see diagram of structure of the bladder, and diagram of staging of bladder cancer). Bladder tumours are removed, either completely or partly, by telescopic surgery (transurethral resection, or TURBT), and the pieces of the tumour are then examined in the laboratory, to determine what the nature of tumour is.
Patients who have tumours that do not involve the muscle coat of the bladder have regular telescopic checks of the bladder (cystoscopy) to look for any recurrence of the tumour. Recurrences can usually be removed by further telescopic surgery. Instillation of either a chemotherapy drug (Mitomycin C), or a vaccine (BCG) may be used to reduce the chances of further trouble from the tumour.
Patients who have tumours that involve the muscle coat of the bladder are assessed to see if they will benefit from chemotherapy. This is often given as the next treatment after TURBT, and then followed by surgery to remove the bladder (cystectomy), or sometimes by radiation treatment (radiotherapy).
Epididymal cyst This describes a localised collection of fluid (a cyst) arising from the epididymis (part of the tubing system that carries sperm away from the testicle). An epididymal cyst may be one simple collection of fluid or made up of a number of “compartments”, so that its shape may be smooth and round, or irregular.
Problems with getting and maintaining erections is collectively known as erectile dysfunction or ED. ED results because of a failure of arousal to lead to the development of an erection. ED can have many causes and can affect men of all ages. In some men the problem may be related to a more widespread problem with blood circulation or problems with the nervous system. Conditions such as peripheral vascular disease, heart disease or diabetes can all contribute to the development of ED. ED can itself be an early manifestation of these conditions. There are many effective treatments for ED including drugs such as oral like Viagra and agents that can be introduced directly into the penis. In severe cases artificial prosthesis can be placed in the penis to induce an erection.
Hydrocoele This describes fluid collecting in the space in the scrotum around the testicle itself. This space usually only contains a very small amount of fluid. A hydrocoele can vary in size from a few cc to a very large swelling containing over a litre of fluid, and greatly expanding the scrotum. Most hydrocoeles make the side of the scrotum in which they are found become about the size of a tennis ball. They usually do not have an obvious cause, but can be caused by infection or inflammation within the scrotum, or occasionally by testicular cancer.
This is a condition that affects the bladder. It results in symptoms of urinary frequency, urgency (needing to rush to the toilet) and bladder pain. This diagnosis is made in the absence of any obvious cause so it is very important that if you have these symptoms, that you seek medical advice to exclude more worrying causes, such as infection, urinary tract stones or cancer. Tests would include examining the lining of the bladder and sometimes taking a bladder biopsy. Treatments would include medication taken by mouth or instilled into the bladder or surgery which include distending the bladder or infrequently, major surgery involving removal of the bladder and diverting the urine into a bag (ileal conduit) or into a new bladder made of bowel (substitution cystoplasty).
Patients who have an overactive bladder will have symptoms of going to pass water frequently, urgently or leaking urine before getting to the toilet in time. This can be very debilitating and can seriously impair quality of life. To investigate symptoms, you may require a flexible cystoscopy or urodynamics studies. Treatment options include botulinum toxin into the bladder, sacral nerve stimulation or major surgery. The latter may involve enlarging the bladder using a segment of bowel (clam enterocystoplasty) or diverting the urine into a bag (ileal conduit) or into a new bladder made of bowel (substitution cystoplasty).
Peyronie’s disease (Penile bending)
Peyronie’s disease is the name given to a condition in which there is a progressive curvature of the penis. The cause of this condition is unknown but it is thought to develop because of increasing fibrosis or scarring of the linings of the wall of the penis. Men may notice that the penis develops a bend which may also be associated with pain and discomfort in the shaft of the penis. In most cases the bend will be mild and not interfere with penile function or sexual performance. In severe cases however the bend may be severe enough to need surgical correction and can cause erectile dysfunction.
Prostate cancer Prostate cancer is the most commonly diagnosed cancer in men in the UK. However while many men are diagnosed with the disease only a minority will actually die of it. Many men will therefore live with the disease rather than die of it.
Investigations for suspected prostate cancer: The test for prostate cancer is the serum PSA which is a blood test that can be done by the GP. If the levels are higher than normal for a man’s age, a referral may be made for a prostate biopsy. The PSA however can be elevated for a number of reasons and does not mean that there is prostate cancer. Another important part of the initial assessment is an examination of the prostate by a finger into the rectum. This is called the digital rectal examination or DRE. The PSA test or DRE might prompt a referral by your GP for further investigations by a urologist including an MRI scan and a targeted prostate biopsy.
Staging and categorizing prostate cancer: Men can be diagnosed at different stages of the disease. Increasingly men are diagnosed with early disease as awareness grows amongst GPs and the public. Some men however will still be diagnosed with advanced disease at the time of presentation. At diagnosis and after biopsy further scans of the prostate (an MRI scan) or of the whole body (a bone scan) may be requested. This information will be used to assign a grade (called the Gleason grade) and stage to the cancer. This will be the basis for planning any necessary treatment.
Localised prostate cancer: This is the term used to describe cancer that is confined to the prostate. Depending on the patient and the grade of disease treatments can include active monitoring, radiotherapy, brachytherapy, radiotherapy or surgery.
(i) Active monitoring – this is where the prostate cancer is closely monitored with regular PSA measurements, MRI scans and repeat biopsies. If the PSA is seen to rise then this is used as a trigger for a change in treatment.
(ii) Brachytherapy – this is a treatment where radioactive seeds are inserted into the prostate directly. The procedure requires a general anaesthetic but only a short stay in hospital.
(iii) Radiotherapy –Radiotherapy is delivered to the prostate from an external source and is usually divided into daily treatments given over a 6 week period.
(iv) Surgery (Radical prostatectomy) – In this procedure the entire prostate is removed surgically.
Locally advanced prostate cancer: In locally advanced disease the cancer has just gone outside the confines of the prostate. The treatment options are primarily radiotherapy and surgery. If surgery is performed then further treatment with radiotherapy may be required. If radiotherapy is used as a treatment it is combined with a period of hormone therapy to get maximal effect in therapy.
Metastatic prostate cancer: In some instances the prostate cancer may already have spread at the time of presentation. In this case the disease has escaped the prostate and spread around the body. The most effective treatment for this form of prostate cancer is hormone treatment. In this treatment tablets and an injection are prescribed which are designed to block production and action of the male hormone testosterone. This form of treatment can be extremely effective and results in marked shrinkage of the cancer.
Hormone refractory prostate cancer: Despite good control by hormone therapy, in some cases the disease will progress. This is called hormone refractory or castration refractory prostate cancer. Hormone refractory prostate cancer can be treated by chemotherapy and there are also many new drugs becoming available for this stage of the disease.
Prostatitis describes a range of problems that are believed to result usually from either infection or inflammation in the prostate gland, or associated structures. It can be an acute illness (acute prostatitis) or a longer-term problem (more properly called chronic pelvic pain syndrome).
Acute prostatitis is a bacterial infection of the prostate gland that may be associated with urine infection. It generally results in an acute illness, with a fever, and with pain within the pelvis. It will virtually always require treatment with antibiotics, and may require admission to hospital.
Chronic pelvic pain syndrome describes a longer-term problem, with symptoms that typically include pain in the area behind scrotum (the perineum), possibly with pain elsewhere at any point below the waist and above the mid-thighs, including the scrotum or the groin. This may occur in men who had had previous urine infection, and it may be associated with evidence, on testing, of either inflammation or infection in the prostate. The treatment is usually with a combination of anti-inflammatory medication and with antibiotics.An obstruction can form that results in impaired passage of urine from the kidney to the waterpipe that carries urine to the bladder (the ureter). This can cause symptoms of pain in the loin area (typically after increased fluid intake), a mass in the loin area, urine infection or blood in the urine. Tests for the condition would include ultrasound tests and kidney function tests. Treatment may involve temporary placement of a stent, or an operation to overcome the blockage (pyeloplasty) by open or keyhole surgery.
Scar tissue within the waterpipe that leads from the bladder (urethra) can result in narrowing and difficulty in emptying the bladder. Considerably more common in men, it can result from infection, chronic inflammation and from trauma. Diagnostic tests involve examining the waterpipe with a flexible cystoscopy and specialised Xray tests. Treatment is surgical and may include an optical urethrotomy or urethral reconstruction.
Urine infection is often a one-off episode but it can become something that occurs repeatedly (recurrent urine infection). This commonly occurs in women between the ages of 20 and 60, but can occur at most ages and can occur in men.
When recurrent urine infection occurs, it is important to check that no serious cause exists for it, although a serious cause is not commonly found. The cause is usually infection with a bacteria from the patient’s own bowel. All of us have millions of bacteria in the bowel, but recurrent urine infection tends to be caused by a bacteria that is different from the usual bowel bacteria, and better able to survive in the bladder and cause symptoms.
Treatment is usually with a long course of a small dose of antibiotic medication that helps to allow our own body defences to eradicate the infection.
Cancers in the kidney primarily arise from the urine producing part of the kidney (the kidney cortex) or the urine collecting part of the kidney (the renal pelvis). Most kidney cancers are found by chance when having an ultrasound scan or CT scan when investigating symptoms for non-renal causes. Kidney cancers can also present with blood in the urine, pain in the loin and a mass in the abdomen. Investigations usually involves blood tests and CT scanning with possible biopsy of the lesion. Treatment options depend on a number of factors but may include surveillance (regular imaging of the kidney), freezing parts of the kidney via needles placed through the skin (cryotherapy), removal of part or the whole of the kidney by keyhole or open surgery (nephrectomy) or chemotherapy.
Testicular cancer is an uncommon cancer with only about 2000 cases reported every year. It is most common in men between the ages of 15-45 though can affect men of all ages. It presents most often as a painless lump in the scrotum found during self examination. The diagnosis is confirmed by an ultrasound of the testis. Rarely testicular cancer may present at an advanced stage when it has already spread to other parts of the body. In the majority of cases testicular cancer can be cured through a combination of inguinal orchidectomy and chemotherapy.
Testicular lumps and swellings
Testicular lumps or swellings are very common in men. In the scrotum the testis has three main parts, the testis itself, the epidydmis which collects the sperm and the spermatic cord which carries the sperm and also contains the blood vessels. These can be due to a number of conditions. The most important feature is whether a lump feels like it is a part of the testes or whether it can be felt separately from the testes. Soft lumps or swelling may be due to a fluid collection around the testes (called a hydrocoele), a cyst on the head of the testis (epidydimal cyst) or dilated veins in the testicular blood vessels (varcicoele or varicose veins of the testis). Painful or tender lumps may be due to an infection of the testis (orchitis), epidydmis or indeed both (epidydimo-orchitis). A hard painless lump may indicate the presence of a testicular cancer and needs an urgent check by a urologist. Occasionally a lump in the scrotum may actually have arisen in the abdomen as a hernia and tracked into the scrotum (inguino-scrotal hernia).
In this condition the foreskin is too tight and causes difficulty during erection or in passing urine. In some cases the foreskin or frenulum (on the underside of the foreskin) tears during intercourse. Often the foreskin is affected by the development of scarring or a condition called balanitis xerotica obliterans (BXO) which makes the skin tight. The treatment for this is a circumcision or less commonly a lateral preputioplasty where the foreskin is cut superficially to release a tight band but it is not completely removed.
This is the involuntary loss or urine. It is an embarrassing condition that considerably reduces your quality of life. It is important to determine the cause of incontinence. This may occur because the bladder contracts too frequently (urge incontinence), the supporting pelvic muscles are weak and incontinence occurs during movement or coughing (stress incontinence) or because the bladder is chronically full and does not empty properly (overflow incontinence). Tests may include a cystoscopy, ultrasound examination and/or urodynamics studies. Treatment options include lifestyle changes, medications and surgery.
Urinary tract stones
Stones (calculi) can form anywhere in the urinary tract but are most often found in the kidney or the waterpipe that carries urine to the bladder (the ureter). They can cause symptoms of severe pain (especially when they block the passage of urine from the kidney), blood in the urine and urinary infection. They may also be found incidentally when having radiological imaging such as Xrays or ultrasound for other symptoms. Treatment of the stone(s) depends on the size of the stone, it’s position in the urinary system and whether it causes symptoms. Available treatment options include placement of a ureteric stent, ESWL, PCNL or ureteroscopic stone fragmentation.
This describes the presence of varicose veins in the upper part of the scrotum, usually on the left side. This is a common condition, usually without an obvious cause. There has been concern about a link with infertility, although this is not generally believed to be the case. There is ongoing debate about whether a varicocele can account for pain in the scrotum.