Making decisions about your prostate

The outpatient clinic visit gives you the opportunity to tell a surgeon what is bothering you. The surgeon will listen to you, ask questions and give you a medical examination. He/she may request some special tests to decide how severe the condition is. They usually include the following:

• You will be asked to give a fresh urine sample to check for infection.

• You will have a blood test to check for kidney or prostate disease.

• You will be given a rectal examination so that the surgeon can feel if the prostate (which is in front of the rectum) is enlarged and to check for anything unusual.

• You are likely to have a urine flow test. Here you will drink enough water to fill your bladder. When you feel the need to urinate you use a special container which measures the flow rate. You may be asked to repeat this test.

• Some men need further tests called ‘urodynamics’ which measure pressure when urinating. For this test a tiny tube is passed into the bladder; this only causes brief discomfort.

Other tests:
• ‘ultrasound’ tests involve passing a device over the lower body which gives a TV scan image of the prostate, bladder and kidneys. This is safe and painless.

• An ‘IVU’ test is sometimes necessary. Here a special liquid is injected into the bloodstream, followed by some X-rays which show your entire urinary system including the bladder and prostate.

Should I have an operation?
Surgery on the prostate is an effective way of reducing symptoms. In our survey, two thirds of those who chose an operation were satisfied with the improvement in their condition by the third month after surgery. The rest found that things did get better but not everything improved. Some others suffered a side-effect of the surgery itself. Nine per cent reported that their symptoms got worse after surgery.

Those who choose not to have surgery can instead opt for regular check-ups by their GP or surgeon. A minority of men with mild symptoms, who choose to watch and wait rather than have surgery, do tend to get better over time. However, in some cases it may still be advisable to operate, even where there are no symptoms. For example, tests may have shown that the kidneys are at risk or the bladder is not emptying well.

When deciding whether to have an operation, you need to weigh up the pros and cons. Your surgeon will help you make your decision.

What possible side-effects of an operation must I consider?

The effect on your sexual life
Many patients are not concerned about sexual side-effects. However, if your sexual life is important, you must bear in mind the following if an operation is not essential for you.

The removal of prostate tissue usually has no effect on a man’s ability to have sex. However, a small minority do report a loss of sexual desire following the operation.
Retrograde ejaculation
One lasting change from this operation is the ‘dry orgasm’. When you ejaculate the semen will be directed backwards into the bladder instead of coming forward through the penis. This causes no harm at all and you pass this semen in your urine (which may be cloudy as a result).

Fertility
As a result of the ‘dry orgasm’, you are unlikely to father children after this operation. It is important to let your GP and surgeon know if you were planning to have children. On the other hand, it is not 100 per cent certain that you will be sterile either. So you cannot rely on this as effective contraception.

Sensation of orgasm
In our study, about half the patients found a change in the sensation of orgasm. Some regretted this or even found it distressing.

Impaired erection
Between 10-30 per cent of men reported that it was more difficult to get an erection after their prostate surgery. This is sometimes a result of any kind of surgery, so it may not always be due to the physical change following this operation.

Leaking of urine
The prostate operation usually improves leakage. The sphincter which acts as a valve to stop the flow of urine is sometimes affected during the operation, although this is rare. Our study found that 6 in 100 patients reported starting to leak urine after surgery through this is usually a temporary side-effect which will improve with time. 

Bleeding
Although this is very rare, excessive bleeding can occur immediately after the operation, and a further operation may be required to stop it. This is more likely to happen when patients are taking drugs which interfere with blood clotting. Inform your surgeon at the outpatient clinic if you are taking aspirin, persantin or anticoagulants such as warfarin, when you are booked for your admission to hospital. Also let the ward staff know if you have been taking any of these medications.

Need for a re-operation
About one in ten men who have a prostate operation will require another. This is necessary if prostate tissue regrows and squeezes the urethra again. It can take several years for this problem to recur.

Spraying
Occasionally, the urine stream comes out in a spray after the operation. This may require a small operation to correct it.

Death
There is a risk of death after any operation. After a prostate operation, death occurs in less than 1 in 300, nearly always in very elderly men with other serious medical conditions.

Complications
As with any major operation, the usual complications of surgery may occur. These can include: chest infections, heart attacks or vein thrombosis.

Reasons to delay, or alternatives to, surgery

Ask your surgeon about the following if you feel your symptoms are manageable or if your conditions allow for one of these alternatives.

• Mild symptoms which do not bother you may or may not get worse over time. You could ask your surgeon to review your condition after 6 months or so.

• Your general health may make the risk of surgery too great.

• Sudden retention of urine may have been relieved by a catheter. If you find you can then pass urine normally, you may not need an operation.

• Devices which clear the obstruction when inserted into the prostate – such as springs, coils or ‘stents’ – can be an alternative to surgery for those with other serious health problems. However, these are not the best option for younger, fitter men.

• In cases with mild symptoms, no treatment at all may be needed. There are certain drugs which can improve symptoms slightly. Some dampen down the irritative symptoms (called ‘anti-cholinergics’). Others work by relaxing the muscle of the prostate and bladder neck (called ‘alpha’- (or ‘a’) blockers’). Some are claimed to shrink the prostate (called ‘5-a reductase inhibitors’). Drugs will be an option only if your general health permits their use.