This month, the Deseret News/Intermountain Hotline introduces an online component. Besides calling in to ask questions about prostate cancer of Dr. Jay Bishoff and Dr. Scott Chidester, urologists at the Intermountain Urological Institute at Intermountain Medical Center in Murray, readers also submitted questions by e-mail. Here, Chidester tackles the most common questions asked.
Most of the e-mails centered around two complications related to prostate cancer treatment, erectile dysfunction and urinary incontinence. Some of the questions are presented here, edited to remove personal, potentially identifiable information.
The hotline, now in its 13th year, tackles a different health topic the second Saturday of each month. Readers can phone in questions directly to the specialists during hotline hours.
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Question:
Does "leaking" of urine during the night indicate any possibility of an enlarged prostate and/or prostate cancer?
Answer:
Leaking urine at night is not generally a symptom of prostate cancer, unless it indicates that the person is not emptying his bladder. Most of the time, prostate cancer causes no symptoms until it has spread. It is important for anyone who is having symptoms to see a doctor and get checked with a prostate-specific antigen (PSA) blood test and a rectal exam.
Questions about Lupron use:
With a PSA of 6.5 two years ago and diagnosis of "stage 3-4 cancer" I had my prostate removed surgically and the resultant test three months later was 0.03. My doctor prescribed a Lupron shot when PSA went to 0.07 a month later. After undergoing the effects of the shot, my PSA was at 0.3 one year after the shot. The current feeling of my physician is that I should undergo treatment with Avodart to hold the number down. My doctor does not want to refer me to an oncologist at this stage of my treatment and has stated the chances of a cure with radiation are 50 percent and chemotherapy should be saved as a last resort.
At what point would my PSA number indicate I should go to another form of therapy or doctor?
I am 78 and healthy. Nine years ago I had a prostatectomy. My PSA went very low and then within three months started to gradually rise. I then had Lupron and 38 sessions of radiation. My PSA went down to 0.
I quit taking Lupron shots and my PSA stayed at 0.0 for four years. Then it gradually started to rise again. Over a period of four years it rose to 11.6. It was very gradual at first, it started rising more rapidly near the end of the four years and would go up like 4.8 in 3 1/2 months. That is when I got a 3-month Lupron shot. My PSA went down to 1.4 and then after a second Lupron shot three months later to 0.013. I had a third Lupron shot and I assume that it will be down to 0.00 after my next PSA test.
If my PSA is 0.00 after my next test, should I keep taking Lupron shots to try and suppress the cancer and keep it from coming back, or should I stop taking Lupron shots and just wait until my PSA rises again like I did after my original treatment? If my PSA reappears at some time in the future and starts to rise, should I just ignore it because of my age or start treating it with Lupron or some other drug again? Or try something else?
Answer:
Regarding the PSA rising more rapidly as it gets higher: That is because as cancer grows it doubles in number of cells, volume and, of course, PSA so it takes as long for the PSA to go from 2 to 4 as from 8 to 16.
One way to give the hormonal-ablative treatment Lupron is to give it intermittently, usually giving two or three shots until the PSA is undetectable, then stopping and waiting for the PSA to rise again. This allows the patient to have a break from the side effects (hot flashes, fatigue, muscle mass loss, ....). Then when the PSA rises, another shot or series of shots can be given.
This is not a curative treatment so at some point the cancer may continue to grow despite the absence of testosterone. At that point, sometimes chemotherapy may help, but it is unlikely to be curative.
Among questions about incontinence and erectile dysfunction:
Can incontinence improve after 12 months?
Last year, I had radical retropubic prostatectomy. I am in my 50s. During surgery there was a complication of reconnecting the urethra to the bladder neck (mobilizing bladder to reach the urethra). Subsequently, vest sutures were placed!
Before surgery, I had total urinary control. Three weeks after surgery the catheter was removed, and I was totally incontinent. I have a constant drip 100 percent of the time (sleeping, sitting, standing, walking). When I am sleeping I can get up and urinate, but I am wet from the continuous drip. The Urodynamic test determined my bladder is normal and not hyperactive. I am scheduled to have a Cystoscopy Test. My doctor believes incontinence will only improve within 12 months, but not after 12 months! I am being told after 12 months I will need to have an Artificial Urinary Sphincter.
Note: I began doing Kegel exercises after the catheter was removed!
I would rather be normal again and do not want to jump the gun and have an Artificial Urinary Sphincter installed prematurely, although I hate living with no urinary control and do not want to suffer hopelessly for additional months unless there is a chance correction will take place.
My prostrate was removed four years ago with robotic surgery out of state. The surgery and healing was nearly painless and went well except for the above stated problems.
The exercise to strengthen the muscle never helped and two and a half years after the operation I saw a local urologist and it was decided to have an implant of a AMF-800 artificial urinary sphincter.
This resulted in very little improvement in incontinence. Another surgery was done to check the sphincter and add more fluid to the pump. There is still minimum improvement and after several visits with the urologist it was concluded he could give me no further help.
The only thing my doctors have suggested for the erectile dysfunction was to use Viagra. I tried this several times with no result.
Answer:
Unfortunately, erectile dysfunction and loss of bladder control are the major complications of radical prostatectomy. Usually, the incontinence will gradually improve over time. While most of the improvement will occur during the first year, it may continue to improve after that, but probably not a lot.
There are a lot of things that can be done to decrease incontinence, certainly surgical technique and trying to keep blood loss to a minimum.
After surgery, the patient can do Kegel exercises to improve the function of the sphincter. Often, medication can help, like over-the-counter Sudafed. If surgery is required, sometimes a bulking agent can be injected into the urethra, or a sling-type procedure can be used. As a last resort, an artificial urinary sphincter can be placed. Even with the sphincter, people often will have a small amount of leakage. If it is severe, a second cuff can be placed, which often helps.
Comment:
I am 62 years old. My BPH is about typical for my age, according to my urologist. Over the past few years, my PSA has fluctuated wildly from as low as 1.5 to as high as 13.5. Twice when it was high, I underwent biopsies, which thankfully were negative. Currently my PSA is about 2.0 and I am in good health and exercise daily.
If a benign tumor in the body had a one in six chance of future malignancy, I think most people would want it removed because of those high odds. Why not remove a healthy prostate in a person of my age, rather than to wait and see if I get cancer? This would give me one less thing to worry about in life, and would also eliminate the need for incessant PSAs, rectal exams and biopsies. Not a bad trade-off.
The ED and incontinence risks are not as big as in the past, and besides, they don't scare me like cancer does. As it is, I have some incontinence from the BPH anyway, and am being treated with Avodart.
I know that some women with high cancer risk based on family history elect to have preventive healthy-breast mastectomies, which are much more radical and deforming than a prostatectomy would be. How about adding preventive healthy-prostate removal as a treatment option?