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20 November 2006
A Prostate Enlargement Primer
by Paul Aitken

Getting up in the night to pee is pretty much de rigueur for men over thirty. In my case, the urge usually hits around 5:00 in the morning, although if I've sunk a couple of beers I'll be padding off around 2:00. But over the last few years I've noticed a slow creep backwards. My nightly jaunt is now at 4:00 AM, sometimes 3. The other night, I had to get up twice. As far as I can recollect this was a first; but apparently, for a man of my age (47), I'm right on schedule.

One of the best examples of the strength of evolution is how quickly the body falls apart after one passes one's prime procreative period. I know that men are capable of siring fresh progeny well into their declining years (witness Charlie Chaplin/Paul McCartney), but sex with a younger women is a requirement, and for most of us, that ain't likely. We get a good run, but around the age of 45, the gas runs out. After that we're cut adrift from our procreative responsibilities and with them the protection afforded us by evolutionary necessity. At age 44 I could read fine print in the map book by the dashboard light. Three years later I need glasses to read the newspaper in full daylight. The list of indignities suffered by men on the leeward side of 45 is long, but perhaps nothing is more emblematic of male decline than what happens to our prostate gland.

The prostate is one of those body parts that young men never think about. Dick - check. Balls - check. Prostate - huh? Whazzzat? We're aware that something called the prostate exists. We're aware that it has something to do with why the old fart in front of us is hogging the urinal while we've got seven beers screaming to get out. I personally had no idea what the prostate did until my father was diagnosed with prostate cancer a few years back. And even then I only learned the dry theory. My increasingly frequent late night trudges to the bathroom are the first hint of what promises to be a long and intimate relationship with my own prostate.

For those of you still under-appreciating your youth, here is a glimpse of what lies in wait for you and lest you think you'll dodge this bullet be advised: By age sixty, you stand an even-chance of being one of those old farts tink-tink-tinking into the urinal. By age ninety those odds will have grown to 90 percent. But before we get into the unhappy details of how and why this happens let's have a look at just what this gland is all about.

The prostate is an exocrine gland that surrounds the urethra at the base of the bladder. Its raison d'etre is to secrete a fluid upon ejaculation which bathes the sperm and protects them in the harsh vaginal environment. All very necessary I suppose, but in design terms it's a disaster. The first flaw lies in the way it surrounds the urinary tract. Because the tract is surrounded, any growth of the prostate constricts it. As long as such growth doesn't occur, it allows for a more efficient secretion of fluid into the urethra. All up, it's a triumph of short-term term pragmatics over long-term sustainability but then, hey, so is the way we run the world.

The second "flaw" serves no purposeful function, and if God designed us, he has some ‘splaining to do. The root of the problem is the way the prostate gland adheres to the two cavernous nerves leading to the penis. The nerves direct the blood vessels inside the penis to open or close, allowing for erection. If for some reason the prostate gland has to be removed, these nerves have to be separated, an operation that has been described as akin to "peeling a wet tissue, undamaged, from a surface." That's why many prostatectomies result in complete erectile dysfunction.

Anyway, back to the wee-hours weeing. As men enter their post-procreative years, the prostrate gland begins to enlarge, a condition known as benign prostatic hyperplasia (BPH). It called benign because it's non-cancerous. Hyperplasia is a general term used to describe an increase in the number of the cells of an organ or tissue leading to enlargement. BPH therefore occurs when there is an increase in the number of glandular cells surrounding the urethra. These cells are epithelial cells and as such are constantly undergoing division. During our procreative years this cellular multiplication is balanced by a process of programmed cell death (apoptosis). But for reasons not well understood, as we age our prostatic cells develop a resistance to kicking-the-bucket, and begin to increase in number. Most of this happens in the tissue adjacent to the urethra and the resulting growth restricts urinary flow. This leads to incomplete voiding of the bladder which in turn leads to more frequent visits to the john in the middle of the night.

In the early stages, BPH is a minor annoyance. As the growth continues however, it becomes... well... a major goddamned annoyance. Your bladder never voids completely. The urge to pee becomes almost constant. Your nightly trips to the john become hourly and when you get there the flow never exceeds a trickle. And get this, the trickle continues after you finish, sometimes dripping for several minutes. If it gets bad enough you may have to resort to wearing diapers. The inability to void the bladder can lead to infection and the formation of spiky bladder stones. In the worst cases, the urinary tract becomes blocked and no urine can get out, a condition that can lead to kidney failure and death.

What's the treatment for BPH? Up until recently the surgical standard was the transurethral resection, which is a fancy way of saying they work a tiny plumbers-snake up through the hole in the tip of your dick until they get to the blockage and then they roto-root the sucker until it's large enough to allow urine to flow freely. The cut and slash method is being replaced by techniques that burn the tissue with laser or electric current. A newly developed device know as the Prostatron burns the tissue using microwaves.

Luckily, we live in the age of pharmacology and a number of drugs have been developed that may forestall the need to submit to such invasive violence. One such drug is finasteride. Finasteride, as you may recall from a previous column on balding, works by blocking the enzyme that converts testosterone to its more powerful metabolite, dihydrotestosterone (DHT). While DHT is not thought to cause BPH, it is thought to play a permissive role. By eliminating DHT, apoptosis is allowed to resume. The trouble, however, is that DHT is also a necessary ingredient in sexual interest and function, and many men taking finasteride report a sharp decline in sexual activity.

Another class of drugs called alpha blockers relax the prostatic muscles and allow the urethra to expand sufficiently to allow urine to pass. These drugs do nothing, however, to stop the increase in the number of cells which is the root of the problem.

The development of future drugs will likely depend on our understanding of the etiology of BPH. There is growing evidence that estrogens play a pivotal role in the development of BPH. As men age, their estrogen levels rise and their testosterone levels decline. Interestingly, the opposite is true in women. So, as both sexes age, they become more alike. If estrogens are ultimately responsible, it should be possible to develop a class of drugs that mitigates their influence on the prostate.

So, there is hope, even for guys like me who have already started down the slippery slope. By the time I get to age 60 there should be an assortment of drugs that deal with BPH. Until then I've got no problem getting up during the night. And if it takes me a couple of extra minutes to pee, hey, it's more reading I'll get done... if only I could remember to wear my glasses.




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