That Old Chestnut
November 12, 2009, 3:25 pm Reg Bourne menshealth
Get acquainted with your prostate before it turns on you
Editor's note: “That Old Chestnut” a first-person account of the detection and treatment of prostate cancer from our November 2008 issue, has just been awarded top prize in the print section of the Luminous Awards, which recognise excellence in the field of oncology reporting. This is especially timely as we’re right in the middle of Movember, a month dedicated to raising awareness of prostate cancer in men.
Gather round, brothers, I have some grim news. I have just been through a full-on prostate experience and I would like to share the details.
Eighteen months ago, the sum total of my knowledge about my prostate was I was vaguely aware I had one. In my experience, the demographic that talked about prostates was made up of old guys, the ones at the RSL who grunted “bloody prostate” by way of explanation when they got up for yet another slash. Their only other comments on the topic involved leering at younger blokes like me and making us wince with stories about the rubber-gloved examination we could look forward to.
That was back in what I call the “happy time”. Now I know better. So, because there is not much material out there that speaks about prostates in my language, I am telling it how it is.
While in-depth knowledge of the little sucker is often lacking, the word “prostate” itself has become a regular part of our language.
Billy Connolly has an eye-watering routine about getting his checked. Dame Edna donated her late husband’s to an auction. Sam Newman made the news with his recent prostate cancer diagnosis, something he shares with Robert de Niro and Colin Powell.
This is the cancer that killed Frank Zappa, Law and Order’s Jerry Orbach and Tiger Woods’ father, Earl, along with 3000 Australian men a year. One in nine Australian men will develop the disease.
Despite these numbers, most Aussie blokes couldn’t pick out their prostate in a police line-up, describe its known associates or report on its recent activities.
So here’s the rough guide: if you picture your lower abdomen, your bladder stores urine and the urine exits your body through a tube called the urethra. Your prostate is a gland that lives snuggled up under your bladder and through which your urethra runs. The prostate’s main job is to secrete chemicals to assist the free flow of sperm passing by as you try to further your family tree. So when you ejaculate, there is a mixture of sperm from your testicles and prostate fluid.
During what might be called your breeding years, your prostate has the important job of promoting fertility and spreading your seed. Later, during what might be called your begging years, it settles down into irrelevance and sometimes – no-one is exactly sure why – it appears to get bored and look for some attention, or it starts to get crotchety and becomes like that crazy old uncle who every once in a while does something to antagonise the family.
Most men will be annoyed by their prostate at some point in their lives, usually late in life.
Many of those grumbling old blokes who say they can’t urinate probably have BPH – benign prostatic hyperplasia, or hypertrophy. This is where your prostate starts to grow, or at least swell, squeezing the urethra it surrounds and limiting or aggravating urine flow.
If the prostate gets larger, the tube transporting your urine can get smaller, so an enlarged prostate can give you the dribbles or a few false starts, or block it completely. BPH is not prostate cancer and is not life-threatening, but it can certainly put a crimp in your lifestyle.
The larger worry is that prostates can and do become cancerous, in alarming numbers.
A living prostate cell should be happy, well formed and bouncing along, but occasionally cells start to get bent out of shape and begin to pass this attitude around. Some cancers are real bastards and attack like Godzilla with a migraine, but many others are slow and dopey – their cell structure appears to break down because they just can’t be bothered holding it together anymore. In that sense these cells are a lot like the grumpy old men they are usually found inside.
Prostate cancer is extremely rare under the age of 40. Only one per cent of diagnoses are in men under 50. Most prostate cancer cases will involve men in their sixties and seventies, but by the time we males hit 80, over 80 per cent of us will have cancerous cells in our prostates. If you follow this graph, it seems all you need to do is live long enough for nearly every male to get an invitation to the prostate cancer party.
The good news is most cancerous prostate cells are slow-growing. One of the most common pearls in prostate circles is: “Most older men will die with prostate cancer, not of prostate cancer.” In other words, something else will usually get you first.
This can mean that prostate cancers in really old blokes might not even be treated, because something else will knock them off the perch before the cancer will.
That being said, it is still a killer of far too many of our brothers each year.
Which brings me to my case.
There I was, a happy 43-year-old in the prime of life, when I went to my doctor with what I hoped might be a bladder infection. Not really wanting an answer, I summoned the courage to ask my doctor if he and I had reached that magical time in our relationship when he should start checking if this was, blush, my prostate giving me trouble. I had heard that men should get their prostates tested after they turned 40, but no doctor had ever mentioned it to me.
I had dreaded the day those “digital rectal exams” would start. My father had warned me about this stage in life when you stop reading the degrees on the doctor’s wall and start concentrating on what size wedding ring he takes. I had heard that a rectal exam by a doctor with sausage fingers really can make a grown man cry. And I just knew that no amount of “aren’t you going to buy me a drink first?” joking was going to make my butt cheeks relax enough for him to swipe his credit card, let alone insert Mr Pointer.
And exactly why, you may wonder (I did), do doctors feel the need to rush up an old bloke’s back door when prostate troubles mostly affect the plumbing at the front? If your car’s engine is misfiring, why stick a broom up the exhaust pipe?
Here’s why: although your prostate works with your wedding tackle, the easiest way to check on it without a scalpel is an index finger up the anus. The prostate can be felt through the lining of your back passage. It’s supposed to be the size and uniform texture of a soft chestnut. The digital exam checks for enlargement of the prostate and how hard it feels. Soft like a squash ball is good; hard like a golf ball is bad.
I can’t be sure, but my young GP seemed to gulp and turn an even lighter shade of pale than me, which caught me by surprise because I thought they were all mad for it. He said he could do a digital rectal exam, if I really wanted (perhaps holding my breath for so long put this emphasis in my ears) or, he said, he could simply tack on a PSA reading to my blood test.
You mean no one-finger klacker salute! You can have as much blood as you want, buddy. I was getting a blood test anyway, so I agreed and went whistling on my way.
PSA stands for prostate specific antigen, which, as the name suggests, is a chemical specific to your prostate. You will have some of it in your blood, but if you have a lot then your prostate could be leaking, or at least it suggests something is up.
Leaks may be caused by cancerous cells eating the epithelial (outer layer) of your prostate. This is not a death sentence by any means, but increases the risk that some of those cells might travel somewhere else in your system and spread the love.
You’re reading this now because it turned out I had a slightly raised PSA level for my age.
With this, I bid farewell to my GP and shook the hand – looking very carefully at the fingers – of my local urologist, where one of the first orders of business was that digital rectal examination.
Some urologists like you on a table on your knees bowing to the pharaoh, some will have you bending over holding a bar on the wall. Mine asked me to lie on my side and face the wall with my knees up under my chin.
The exam takes under a minute and while certainly foreign to my experience, it ultimately wasn’t anything to get too excited about. Those who are sexually adventurous may have already had a prostate massage from a significant other, but in the cold light of a clinic there was the thwack of latex gloves and I was still on the “Where should I put my knees?”, “Is this high enough?”, “Is he in there yet?”, “Oh, yep, he’s in there!” and it was all over.
That being said, while I know it’s in the interests of everyone in the examination room to carry on as if this is business as usual, it was still all I could do to not sit across the desk from the doc as wide-eyed as a screech owl while we discussed the results.
My prostate felt okay, but a second blood test confirmed a high PSA reading, so the next port of call was a biopsy.
For most patients, a biopsy involves day surgery and general anaesthetic while a series of needle probes take samples of your prostate via your anus, which are sent to the pathology lab. I had entered that zone where you do what you have to do, all the while hoping it turns out to be something the work experience kid labelled wrong in the lab.
In my case there definitely were cancerous cells in my prostate; not many, but some. In terms of the levels some older men produce, mine was an amazingly early find.
I learnt it is difficult to tell how ravenous these cells are. They are rated on the Gleason scale, the Richter scale for cancer, and my scores were low. It was hard to tell if the cells were going to be angry, colonising little-Hitler bastards, or sleepy, lazy, dope-smoking idiots.
So in my mid-forties I was faced with many hard questions. Had I just discovered very early evidence of the prostate cancer many guys and I would have in our seventies? Should I just wait to see what would happen? But what if the cancer was aggressive? Should it be removed?
There are various treatments available, including chemical, radioactive, and surgical paths. They all have their champions and I wouldn’t presume to tell you what to do if you find yourself faced with the choice. But if you do, get all the advice you can.
For me, I had cancerous cells inside me, they weren’t going away and I didn’t want to give them the chance to spread, so I chose to have them removed surgically.
Surgery involves an incision below your navel in a line down to the pelvic bone above your penis. The prostate, and possibly the tubes that transport your semen, are removed. The urethra is reattached to your bladder and the problem, you would hope, is over.
But rather than being as simple as an appendectomy, there are a few complications that make a radical prostatectomy, in my book, one of the hardest sells in medicine.
One is that by mucking about with bladders and urethras, the procedure could result in incontinence – from a dribble when you cough to full-on loss of control.
The second is the surgery goes straight through the two groupings of sensitive nerves that make erections possible, so your ability to achieve and maintain a chubby and, thus, your sexual future is in question.
Thirdly, by hiking up your urethra and reattaching it to the bladder, you risk losing some length from your penis.
Let’s just pause and listen to the crickets as we let that one sink in.
If I owned an advertising company, I think I would turn down the prostate cancer treatment campaign as unsellable.
And what do we gain? Some blokes might find they can urinate over the fence again after years of strangled flow. For the rest of us, it is just the knowledge that some potentially deadly cells have been removed.
One of the few rays of light for me was my youth.
I would not want to go through belly surgery at an advanced age. I was able to take the time to prepare myself, lose some weight and work on my pelvic floor muscles so I was better placed for recovery.
Eighteen months on, things are going okay. In most respects it is as though the surgery never happened. I have complete bladder control and co-operative erections. In this respect I count myself lucky; I saw some older guys in hospital looking at a long, slow recovery.
Many men will need to wear incontinence pads as a result of surgery, even if just for a little extra security. Some will be forced to use little blue pills every time they want an erection, whereas others may have to say goodbye to all that.
Most of you reading this will never have to go through this kind of surgery, and those of you who do won’t go through it until retirement. By then, there could be as yet undreamt of cures and treatments.
But among you gents will be some who have just a few cancerous cells in your prostate now where later you will have many, and I am really writing to you.
With early detection there is a better chance of a cure, and you are looking at a better, stronger recovery. That’s not something to give the finger to.
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A great article, well written and explained. Let's hope many read it as it may well save a lot of hardship. I lost a good mate of mine with prostate cancer and as he was going through the last months we shared many times taking him out to Auckland in the evenings. He told me "Encourage all your friends over the age of 40 to have regular prostrate checks. He wished he had". It was then, too late for him. He wasn't able to afford the medical advice he needed and shifted to live with his daughter in Australia for the support and what he thought a better health system. He passed away 17/09/2003 but regularly his instructions ring out to me - to advise all my mates to be checked for prostae issues. I do regularly talk to my friends on this issue. Some don't wnt to discuss it but others do. Each year I have the tests done. Thanks Des (Auncle Arthur) you may have saved either my life or that of my friends...