Prostate cancer? Do you know where your prostatic urethra is tonight?

8_relationship of bladder to prostatic_urethra.tiff

Regardless of the treatment of your prostate cancer you choose…the prostatic urethra or lack thereof will impact your potential for urinary symptoms.

I commonly see patients for a second opinion about what to do with the newly diagnosed prostate cancer. In most cases they have been told the diagnosis and the options. I don’t know if it is really the case but the patient will usually state that the previous urologist seemed to push having the prostate removed. As a rule the idea of surveillance has not been adequately explained to the patient. After reviewing the psa, the Gleason’s score and the volume of disease noted in the path report, and the underlying medical history, I then begin to elucidate the negative effects of any treatment and then which ones are the most concerning to the patient. Then I inquire about voiding symptoms.

When you ask men about how they void you have to be persistent and specific in the question and discerning regarding the answer you get. Men are poor historians in general but are particularly bad sizing up their urinary patterns.

Although the male is bothered by getting up at night and that is the chief complaint, it is hard for them to comprehend that the fact that the urinary stream is slow because of an enlarged prostate is actually the problem. Getting up at night is a secondary symptom based on the bladder not emptying well as a result of the prostate. So when you ask,  “Is your stream good?” The answer is usually yes. And then you get, “What bothers me the most is getting up at night to pee.”

Why is the above important? Well…if the male is having problems voiding, regardless of the symptom, it will be worsened by radiation as a treatment. If the prostatic urethra is obstructing the flow of urine before radiation it will most probably be worse after radiation in addition to the irritation that the radiation will cause.

If the prostate is causing a poor stream, an the patient is inclined to have surgery, then this is a perfect fit because the slow stream will be corrected by the removal of the prostate.

But then this begs the question. His stream may be better after the surgery but is he willing to risk the potential of some degree of incontinence? So the patient has to begin sizing up what side effect trumps what benefit to the particular treatment.

It all goes back to the prostatic urethra and how treatment affects it if it is radiation or how the lack of a prostatic urethra  might affect continence and sexual function.

This is why in my book I began this part of the decision process as “All roads lead not to Rome but through the prostatic urethra.”

Do you know where your prostatic urethra is tonight?

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