Prostate problems: Why men won't talk about them
Symptoms associated with an enlarged prostate affect many men but often not sufficiently to prompt them to seek help. Practice nurses can make the difference.
The Prostate Cancer Charity estimates that 40% of men over the age of 50 and 75% of men over the age of 70 have urinary symptoms that may be caused by an enlarged prostate.1
These symptoms include:
- Weak urine flow
- Intermittency - a flow which stops and starts
- Hesitancy - having to wait before you start to pee
- Frequency - having to urinate more often than previously
- Urgency - finding it difficult to postpone urination
- Nocturia - having to get up at night to urinate
The three most common prostate problems are an enlarged prostate (benign prostatic hyperplasia or BPH), prostatitis and prostate cancer.
BPH is the benign enlargement of the prostate gland. Based on Office of National Statistics data, Prostate Action has calculated that about 3.2 million men including at least a third of all men aged over 50 years have the symptoms of BPH.2
Prostatitis is inflammation of the prostate, which may be bacterial or non-bacterial (prostatodynia). In the latter, there may be symptoms consistent with prostatitis but little actual inflammation. It is estimated that about 15% of men suffer from symptoms of prostatitis at some point in their lives.3 Although the majority of cases will probably be non-bacterial, bacteria is behind most acute presentations. (Younger men with these symptoms may have sexually-transmitted bacterial prostatitis.)
Prostate cancer is the most common cancer in men in the UK. Every year 37,000 men are diagnosed with the disease. Cancer Research UK estimates that about 250,000 men are currently living with prostate cancer.4
There has been an increase in prostate cancer cases over the last two decades with the average age of diagnosis going down, although the condition is still very rare in men under 50. These trends may not be entirely down to better detection. Note that having a father or brother with prostate cancer more than doubles the individual's risk and also that the disease is three times more common in African Caribbean men than in white men of the same age.
It's unlikely that a man will come to see a practice nurse directly about prostate symptoms. The problem is that they may well not be seeing their GP about them either.
WHY MEN DON'T TALK
It is well known that men are reluctant users of primary care services. They visit their GP at least 20% less frequently than women.5 Moreover, these aren't 'manly' symptoms. Most men associate them with ageing so see them as an inevitable part of something that they don't much want to accept let alone talk about. Factor in the embarrassment of talking about your waterworks or your erection problems at the best of times and it's amazing that any men at all present with prostate symptoms.
Research for the European Men's Health Forum gives an idea of the scale of the problem. The EMHF runs a website, yourprostate.eu, which enables men to ask prostate questions online, anonymously if they wish. A small study of the men asking questions in this way found that only 60% of them had also seen a health professional.6 This is a group motivated enough to go online with their symptoms and informed enough to know that they may be prostate-related. It's not an exaggeration to suggest that the men GPs do see in surgery with these symptoms are probably the tip of a large iceberg.
Fortunately, men do sometimes come into the surgery for other reasons and this is where the GP and practice nurse can help, if you'll pardon the pun, to flush out the men who are not presenting.
HOW TO ENCOURAGE THEM
The same EMHF/yourprostate.eu research suggests that nocturia, frequency and urgency are the symptoms of most concern to men. So this may be the easiest way into the topic. If the more obvious questions such as 'how is work?' or, to retired men, 'are you keeping yourself busy?' don't lead anywhere (and they may well not), why not ask a patient how he's sleeping 'in this heat' or because 'it's so cold this time of year'. Talk about yourself: 'my partner keeps me awake with his snoring' or, more directly 'with his getting up to go to the toilet'.
If this does open a line of conversation, try the questions in the box. They're based on the International Prostate Symptom Score (IPSS), the use of which forms part of the NICE guidance on dealing with lower urinary tract symptoms (LUTS). At this early stage, and even if the man isn't forthcoming, make it clear that these sort of things are not an inevitable part of getting older and that they can be treated. Mention the significant improvements to quality of life that other patients or friends have experienced - 'after all if you can't sleep you can't do anything'.
Check what sort of nocturnal urination pattern is 'normal' for the individual. Most will be used to sleeping through the night but some lighter sleepers will have got up even as young men. Point out that as we get older more urine is produced overnight with the result that from middle age men often wake in the early morning to pee. That's not unusual but getting up three or four times is.
Give men an idea of what's normal when it comes to peeing. The average bladder holds about three-quarters of a pint (about 430ml). Most people pass urine about four to seven times each day depending on how much they drink. Feeling a sudden uncontrollable need to go, not feeling properly empty afterwards or leaking are all warning signs.
At this stage it is not inappropriate to ask about erectile dysfunction (ED). Few men feel comfortable initiating this as a topic of conversation but they will respond, in some cases with considerable relief, if you ask. There is a moderately strong association between LUTS and ED, which most men will be ignorant of or too embarrassed to mention. Ensure the man is aware of the link between ED and not only LUTS but also heart disease. Indeed, pointing out that ED is one of the best early-warning signs of heart disease may prompt a man to get the problem checked out with somewhat more urgency.7
WHEN TO SEE A GP
Look out for the red flags - the presence of blood in the urine or semen can be a symptom of more severe prostate problems. In this case you should suggest the man sees his GP as soon as possible.
Also suggest he make an appointment if any of his answers to your IPSS questions suggest that his LUTS are what NICE rather euphemistically refers to as 'bothersome'. NICE estimates that 'bothersome LUTS' can occur in up to 30% of men older than 65 years.8 Whatever the cause, in most cases, LUTS can be very effectively treated. (LUTS may have causes that aren't prostate-related, such as weak bladder neck, kidney stones, or urinary tract infection.)
Some men may suspect they have a prostate problem but be worried that the treatment is worse than the symptoms.
Make sure they understand what is going on. Prostate growth in middle age is normal and that growth is not necessarily cancerous. BPH and prostatitis are not linked to cancer in any way and do not lead to it. Indeed, BPH and cancer tend to involve different parts of the prostate (BPH on the inside, cancer on the outside).
You can reassure them about the treatment. You won't want to go into too much detail here as most men will run a mile at the mention of catheterisation. But you can mention how effective small changes to lifestyle (especially drinking habits) can be. Also mention exercises (pelvic floors can help) and drugs. (NICE suggests an alpha blocker for LUTS symptoms, a 5-alpha reductase inhibitor for enlargement and an anticholinergic for overactive bladder or storage symptoms which persist despite an alpha blocker.) Most prostate problems do not require surgery.
Equally, ensure that men understand what their symptoms may mean. It's not just about the urination problems, which the man may well think he can live with, but about the risk of having the most common male cancer. It probably isn't cancer but it needs to be ruled out. Point out that even in the worse case scenario, although prostate cancer is on the increase, mortality rates are not and a quarter of a million men are living with the disease.
If the man continues to be concerned about surgery, try to reassure. It will only be considered if drugs and more conservative treatments have been ineffective. Discuss frankly as men may not appreciate quite how many prostate operations there are and how they vary in nature and the degree of intervention involved. They may assume it's a radical prostatectomy or nothing.
MEN ALREADY ON PROSTATE TREATMENT
You may also come across patients who are on treatment or have had prostate operations. Ask them directly if there are any problems. It goes without saying that we don't all have the same priorities and it's important to try to understand your patient's.
Generally, both patients and health professional understand the needs after masectomy for, for example, breast reconstruction. There is anecdotal evidence that this is not always the case after prostatectomy as far as, for example, erectile capacity is concerned with men unaware of the likely impact of surgery on this and health professionals unaware of quite how 'bothersome' it can be.
It is sometimes a surprise to both patient and health professional to learn that patients who have had a prostatectomy are entitled to NHS prescriptions for PDE-5 inhibitors (drugs such as Viagra, Levitra and Cialis). These are limited by health circular 1999/115 and may be further limited by local prescribing decisions. The issue is further complicated by the fact that prescribing on a 'case by case' basis is permitted under health circular 1999/177 when patients are in 'severe distress'. The number of men severely distressed by ED may well be far higher than you - or the NHS - imagine. Swedish research suggests that 80% of men with ED are distressed and that PDE-5 inhibitors relieve this in around 70% of them.9
As well as drugs, there is lifestyle advice around weight, smoking, alcohol and drug consumption, exercise and stress that you can give to improve erectile quality.
Finally, let men know about the yourprostate.eu website. Currently the step from doing nothing to seeing a GP is, when it comes to LUTS, too big a step for many men to take. The website, like you as practice nurse, can help enormously by providing a shorter step on the way to the GP. All questions to yourprostate.eu are answered by urology nurses within 48 hours.
By directing men here you'll also be helping the EMHF's research into exactly what it is that men want to know, information which will the used to shape patient-information literature accordingly.
In the second of our articles on prostate care, Jim Pollard will continue his inside track male perspective on a male-only disease by looking at how LUTS and prostate cancer should be treated - including the NICE guidance - and how you can help men through what can be a difficult process psychologically as well as physically.
Declaration of interest: Jim Pollard also works for the European Men's Health Forum and has worked on yourprostate.eu.
REFERENCES
1. http://www.prostate-cancer.org.uk/information/the-prostate/prostate-problems/bph
2. Prostate Action - ProState of the Nation (September 2009)
http://www.prostateaction.org.uk/sites/default/files/ProState_of_the_Nation.pdf
3. Krieger JN. Classification, epidemiology and implications of chronic prostatitis in North America, Europe and Asia. Minerva Urol Nefrol. 2004 Jun;56(2):99-107. http://www.ncbi.nlm.nih.gov/pubmed/15195020?dopt=Abstract)
4. Cancer Research UK. Incidence of prostate cancer. http://info.cancerresearchuk.org/cancerstats/types/prostate/incidence/
5. ONS General Lifestyle Survey 2008
6. Banks I, Mayor S, Meryn S. Talking prostates. Journal of Men's Health. 2010 Oct; 7(3):221-226
http://www.jmhjournal.org/article/S1875-6867(10)00064-3/abstract
7. Jackson G et al. Erectile dysfunction and coronary artery disease prediction: evidence-based guidance and consensus. Int J Clin Pract. 2010 Jun;64(7):848-57
8. NICE. The management of lower urinary tract symptoms in men. NICE clinical guideline 97. http://www.nice.org.uk/nicemedia/live/12984/48575/48575.pdf
9 The effect of tadalafil on psychosocial outcomes in Swedish men with erectile distress: a multicentre, non-randomised, open-label clinical study. Int J Clin Pract. 2006 Nov;60(11):1386-93.
