Prostex, another over-the-counter medication, is made up of three pure amino acids (glycine, alanine and glutamic acid), according to its manufacturers, who claim the drug works by relieving swelling caused by edema (fluid retention) in the prostate and pelvic tissues. The problem here is that, because this swelling is not a cause of BPH, there is no evidence to suggest that treating edema will improve BPH symptoms.

To the best of our knowledge, there currently is no over-the-counter medication that’s effective in treating BPH. However, it is humbling to realize that one of the most effective medications for the heart, digitalis, is derived from a plant leaf, and one of the newest and most promising anti-cancer drugs, taxol, comes from the bark of the Western yew tree. So, because we don’t know the cause of

BPH, we can’t dismiss these medications out of hand. The makers of these over-the-counter medications have been strongly encouraged to carry out adequately controlled, randomized trials, so their value can be truly assessed.

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To reach the prostate, a urologist makes an incision in the skin and muscles of the lower abdomen to expose the lower part of the bladder, which is opened next. The surgeon’s index finger reaches into this incision in the bladder and through the bladder neck to remove the tissue at the prostate’s innermost core, the part compressing the urethra. The surgical description for what happens here is that the tissue “enucleates.” For the most part, what this means is that the tissue separates from the surrounding tissue like a walnut from its shell. (At some places, however, a few cuts must be made so some stubborn bits of tissue can be removed along with the rest.)

Because it allows access to the bladder, this procedure is ideal if any problem there, such as a bladder stone or a large bladder diverticulum, needs attention. With the patient’s permission (given before surgery), some surgeons perform a vasectomy during this operation to prevent the development of inflammation in the epididymis. (Epididymitis can result from damage to the ejaculatory ducts, which allows infected urine to “back up” into the vas deferens.) A vasectomy involves cutting the vas deferens, so sperm can no longer exit the urethra during ejaculation but are reabsorbed into the body.

The prostate tissue the surgeon has removed is sent to a pathologist, who will examine it for the presence of hidden cancer. The average hospital stay for this surgery is five to seven days.

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There are four components to normal sexual function in men—libido (sex drive), erection, emission of fluid (ejaculation), and orgasm. All of these elements are regulated separately; there is no centralized “sex control center.” One major cause for a diminished libido in men undergoing treatment for prostate diseases is a drop in testosterone. However, other factors—environmental as well as psychological—can have an impact on sex drive.

Orgasm happens primarily in the brain. For orgasm to take place, there must be sensation and stimulation. In men who are impotent after radical prostatectomy, TUR or radiation therapy, sensation is not interrupted; therefore, orgasm should always be possible and it should be no different from the way it was before treatment. (Except for men receiving hormonal therapy. For them, orgasm is not an issue—even though a few can still have erections—because the hormone treatment causes a loss of libido, a lack of interest in sexual activity.)

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Estrogens

Many men, for many reasons, don’t want to undergo surgical castration, so they opt for chemical castration—taking drugs that accomplish the same result without the cosmetic change.

DES, the main oral estrogen, targets a different checkpoint—the hypothalamus and pituitary connection, instead of the testicles. It works by blocking the release of LHRH, which in turn blocks the release of LH and FSH, virtually shutting down the Leydig cells, the testicles’ testosterone-making factories. So testosterone drops to the castrate range.

The effect is not as speedy as with surgical castration; it generally takes ten to fourteen days for testosterone to fall to the castrate range. And, it’s not permanent—in most cases, the testicles start making testosterone again soon after a man stops taking DES.

We talk about DES here because it’s the most widely used oral estrogen, and it’s the gold standard of estrogen therapy for prostate cancer. Other drugs, such as Premarin and ethinyl estradiol (both medications used by women during menopause) are considered as effective as DES; neither is better. Another drug, called cholotriansene (TACE), is a synthetic estrogen that lowers testosterone but doesn’t completely shut down its production; it also permits the body to make a litde bit of LH. (It has proven to be ineffective, and is no longer used in attempts to lower testosterone levels to the castrate range.) A drug called polyestradiol phosphate (Esradurin), injected once a month, may be easier to tolerate for men with gastrointestinal problems; And for men with advanced prostate cancer who haven’t responded to other estrogen drugs, diethylstilbestrol diphosphate (Stilphostrol) may bring relief of symptoms. It is administered intravenously, at 500 to 2,000 milligrams a day.

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The purpose of radiation treatment is to disable the prostate, to stop cancer there from continuing to grow. Because the prostate is the source of PSA, it’s pretty obvious that something is wrong if PSA is still being made, and there are two possibilities here: Either the cancer has returned locally, to the prostate or surrounding tissue, or a distant metastasis—a tiny bit of cancer that probably escaped the prostate before treatment began—has started causing trouble.

Some doctors advocate “salvage” procedures—additional treatments, such as radical prostatectomy or cryotherapy. Radical prostatectomy is generally not a good idea; the risk of complications after the prostate has been irradiated is so high that many surgeons have a hard time justifying the procedure. Also, by the time most men who initially had radiation treatment seek surgery, it may be too late for surgery to cure the cancer; it has already spread outside the prostate. (This includes men who originally had clinical stage T3 or C disease. Remember, men with cancer that has spread beyond the prostate aren’t considered good candidates for surgery in the first place; having had radiation therapy is just another strike against the odds of cure. Also, surgery is not advisable for patients who have advanced, palpable cancer after radiation therapy, for men with PSA levels greater than 10 or 20, or with poorly differentiated cancer—a Gleason score of 8 or higher.)

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