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The male urethra is a strong barrier against infection but the prostate is vulnerable to infections, cancers, and benign enlargements.

In contrast to female urinary infections, male urinary infections are uncommon because the male urethra presents a stronger barrier against ascending bacteria.  However, when bacteria succeed in swimming up to the bladder, they hide inside the prostate and from its sinuses may invade and reinvade the urinary bladder and kidneys.

Like women, when men get urinary bladder infections, they have similar symptoms such as frequency, urgency, and burning.  But, unlike women, men’s bladder infections are always secondary to prostate infections and therefore require longer treatments (7-10 days instead of 2-4 days). 

Since prostate and bladder infections don’t cause much fever, when men have fever and chills, it indicates that they actually have three infections that have occurred in sequence: prostatitis (prostate infection), which caused the cystitis (bladder infection), which in turn caused the pyelonephritis (kidney infection).  In such cases of ascending urinary infections, antibiotic treatments will not normalize the fever before three days and antibiotics should be given for at least two weeks.  Because kidneys seldom get infected in normal men, when they do, further investigations become necessary to rule out secondary causes such as kidney stones, scars, anatomical abnormalities, and tumors.

Once a prostate gets infected with bacteria, it becomes resistant to antibiotic cure because bacteria can hide deep in the prostate where antibiotics cannot reach.  Because of that peculiarity, it is imperative that patients who have had one episode of infection be informed that they are likely to have relapses.  Consequently, it is wiser to teach these patients to treat their own infections at the first sign of urinary symptoms such as burning, frequency, urgency, or fever.  This strategy would avoid unnecessary delays in therapy and would diminish serious complications.

It is also possible for men to have prostate infections (prostatitis) without seeding (infecting) their urinary bladders or kidneys.  The symptoms of isolated prostatitis are pain, poor urine flow, low-grade fever, and chills.  Occasionally, the prostate might swell to such a degree that it might totally obstruct urine flow, which may necessitate catheterization in order to relieve the obstruction.

A prostate may also swell with age, not from infection, but from progressive enlargement (Benign Prostate Hyperplasia) and might obstruct the flow of urine.  In such cases, there are medicines that can shrink the prostate and improve the urine flow.  If, however, this urinary obstruction proves too severe and too resistant to medicines, surgical interventions might become necessary.

As men age, their prostates tend to develop cancers, but many of these cancers are local, innocent (not aggressive), and do not shorten life.  This presents a major medical problem that has not been adequately solved.  There are screening tests that can detect prostate cancers such as the Prostate Physical Examination (DRE) or the blood Prostate Specific Antigen (PSA) but these tests don’t always tell us if the cancer is aggressive and requires treatment or if it is of the innocent type.

Given that the median age of death from prostate cancer is 80 years, the US Preventive Service Task Force has recently concluded that available evidence is insufficient to assess the balance between potential benefits and harms of using the Prostate Specific Antigen (PSA) to screen men <75 years old for prostate cancer and has recommended against screening men >75 years old.  Not all professional organizations agree with these conclusions and heated debates continue even though, in a 12-year study, treating localized prostate cancers in men >65 years old showed no benefit over watchful waiting.

In autopsy studies, prostate cancer has been reported to occur in 15-60% of men >60 years old.  In one autopsy study of men (median age 64 years) who had died of other causes with no evidence of prostate cancer, careful tissue sections detected cancer in 29%.  Such a high frequency of undetected prostate cancers in older men suggests that most of these cancers tend to be of the innocent type.

 Although Prostate Specific Antigen (PSA) screening has been associated with a decrease in prostate cancer death rates, detection of clinically unimportant cancers continues to be a problem.  Given that over diagnosis leads to over treatment, men need to know that Prostate Specific Antigen screening, which might lead to unnecessary anxiety and unnecessary procedures, might also be life saving.  Because of these dichotomies, individualizing screening and treatment is the wiser way¹.

1- The Medical Letter, Volume 50, Issue 1298, November 3, 2008.

2009 - ISSUE 79