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Frequently Asked Questions FAQs

Frequently Asked Questions about Prostate Cancer

How reliable is the PSA test?

It is not a perfect test, but it is the best we have at present and is considered extremely useful by most urologists, especially if it is expertly evaluated, and taken together with a DRE.  Yes, there are false PSA readings, and they can alarm needlessly, but PSA tests undoubtedly save lives and the Department of Health has recently sanctioned PSA tests in informed men aged 50–70.  The test can assist in telling the difference between cancerous and benign conditions of the prostate (the latter being inconvenient, but not life-threatening).

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If cancer is diagnosed, should I have radiotherapy, surgery, or should I ‘watch and wait’?

That depends on many factors, including your location, age, the results of biopsies, PSA levels, and your general health.  And expert opinions do differ, but get them anyway, and weigh them up very carefully before making any decision.

Radiation therapy (and there are various kinds, including brachytherapy) can be very successful for some patients, meaning the tumour cells are killed off while the prostate is kept intact (though there are sometimes unpleasant side-effects, such as rectal inflammation, while the therapy is undertaken and thereafter).  But for those whose tumours reappear later, even after some years, the possibility of successful surgery then is frankly quite low.

Bear in mind that repeated radiation is not possible in the long term, and it must be pointed out that ultimate success with radiation therapy is currently not much over 50–70% even with improved techniques.  By contrast, with a radical prostatectomy, although radical by definition, the success rate in removing tumour and preventing recurrence is commonly over 80%.  If you feel lucky or confident about your chances, then radiation therapy may well be for you, but think about it and weigh up the options carefully.

If you decide to watch and wait, make sure you have regular check-ups to see if the situation is changing, and if so, to what extent.  If cancer is present, it can stay dormant, grow slowly or accelerate rapidly, for reasons that are not yet fully understood.

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Why are certain patients ineligible for brachytherapy?

Brachytherapy is most suitable for patients with smaller, lower risk cancers and for men who have small or medium-sized prostates.  If TURP has been performed previously, the radioactive seeds cannot be sited correctly in the gland.  Pre-treatment with prostate-shrinking drugs such as LHRH analogues can sometimes make brachytherapy suitable for men with large glands.

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What are the commonest side-effects of radiotherapy?

During treatment you may often feel tired, urinate frequently and have rectal irritation.  In a small proportion of patients, the rectal symptoms persist and are associated with rectal bleeding.

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Consultants ordinarily recommend a biopsy, or even more than one, to see what degree of cancer may be present if the PSA level is raised above the norm (greater than 4 ng/ml).  I am told this can be very painful and unpleasant.  Is this true, and why is it necessary?

Biopsies are not exactly thrilling or agreeable to experience; they can be very uncomfortable or, at worst, rather painful. They can also cause rectal bleeding and blood in the ejaculate, but this has been likened to having a nosebleed, and it will stop.  Nowadays, doctors taking biopsies from the prostate, via the rectum, will often use a local anaesthetic, especially if you ask for one.

The results of the biopsy will indicate whether tumours are present, although the tests are not infallible, and they can give negative readings if they happen to miss a tumour altogether.  And pathologists who examine prostates that have been removed by surgeons commonly find much more cancer present than the biopsies had indicated, given that some evidence of tumour had originally been revealed.

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And again, consultants sometimes want you to have a bone scan, CT scan or MRI scan before they will deliberate on the best course of treatment.  Why is this?

Because this may reveal whether any cancer has spread to other parts of the body, having ‘escaped’ from the prostate gland.  If this has happened, urologists will avoid surgery, and may well recommend radiation and/or hormone therapy in such a circumstance.  Remember, though, that these tests do not give a perfect answer to the question ‘Has the cancer spread?’

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So, if I go for surgery, is the operation painful?

Not really, because any pain is expertly controlled.  This can be achieved, for example, through the use of epidural anaesthetics and of drugs given to you post operatively.

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Is there much loss of blood?

No, not normally.  Only a small proportion (about 10%) of patients undergoing radical prostatectomy nowadays require a blood transfusion, possibly about two pints — not a particularly significant quantity.

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Do I need to have some of my own blood taken beforehand?

No, unless it will buy you peace of mind, but if there are no exceptional circumstances there is no need.  Use of your own (autologous) blood is more common in the USA, where there is possibly a higher risk of infection from regular blood transfusion.  It is not advised in the UK.

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While on the subject of blood, I have heard that you see traces of blood in the urine after the operation.  Is this true and why is it?

It is true, but normally it is only a trace, and just while the catheter is draining urine immediately after the operation, or perhaps for a while longer while the re-routed ‘plumbing’ inside is healing.  It normally clears after a week or two at most.  Drinking extra fluids is helpful, as is taking laxatives, whole wheat cereal, prune juice and fruit to keep the bowels regular.

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Is there any risk that I will die during or shortly after the operation?

There is always such a risk with any operation (around 1 in 1000), but we do not often hear of it happening.  Do not be afraid to ask your surgeon what his own mortality rate is.

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What about unsightly scars as a result of the operation?

This need be the least of your concerns.  To gain access to the prostate, many surgeons perform an 8—10 cm lateral or vertical incision above the pubic bone, with a small drain hole beside it.  Clips are more commonly used than stitches these days, and the healing process is quick.  Indeed after a few months the scar is almost, but not quite, invisible.  Recently, Lapiroscopic radical prostatectomy has been performed, which results in smaller scars, but a longer operation time.  This procedure is still in development.

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How long will I be in hospital?

Between 4 and 7 days, often including a 12—24-hour period in a progressive care ward where you will be monitored for bleeding, signs of respiratory infection, or any heart rate instability.  About a fortnight after the operation, your catheter will be removed and you will be watched closely for 24 hours to make sure the new ‘plumbing’ is in order (for example, your fluid intake will be checked against your urine output).

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When will I know if the surgeon has successfully excised the cancer?

He will tell you what he thinks within 24 hours, but he has to wait for a few days for the laboratory report on the removed prostate to be sure what has been achieved.  If the report is such that some cells are thought to have escaped from the prostate into the surrounding tissue, then the surgeon may recommend some ‘mop-up’ radiation, which is usually very successful.  The radiation therapy does not have that much to do compared with clearing the whole prostate of cancer (as is necessary if surgery is not performed).  Side-effects are not usually too troublesome, although some rectal irritation and minor bleeding may occur.

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Will the PSA have dropped out of sight after the operation?

Yes, it should have dropped to about 0.6 ng/ml or thereabouts immediately after the operation, and then gradually reduce further to an ideal of below 0.1 ng/ml where, in successful cases, it will remain for the rest of your life.  But remember to have it checked every 3 months for at least a year, and at the same laboratory too, otherwise you may get a variation in results that could alarm you.  In other words, one laboratory may have machines that only read as low as 0.5. whereas another might read down to 0.1, or even 0.01.  In essence the result, as far as you are concerned, is the same.

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How many years do I have to have these tests?

The recommended time frame is 5 years or longer for any cancer to be declared truly gone, but after 3 years with no PSA rise, you can assume your chances of a normal life expectancy are excellent.  However, it is still worth having your PSA checked annually as late recurrences can occur.

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Are there any special things I need to remember when I am in hospital?

Yes.  Don’t encourage too many visitors; don’t worry about breaking wind (nurses love wind because it shows things are beginning to sort themselves out in the bowel, which will have been a bit disturbed during the operation): don’t eat too heavy a diet because you don’t want to get constipated through lack of exercise and too many heavy meals: drink as much as you can — at least 8 pints of water or soft drinks, like cranberry juice, every day for a couple of weeks if you can stand that (it helps to flush the system through after your internal plumbing has been re-routed); and, most importantly, just look forward to the new future that the surgeon will have given you.

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Is it true that my penis will be shorter after the operation?

Well, yes, some men have noticed a detectable change in length, but not circumference, when the penis is at rest once everything has settled down.  But it’s somewhat relative.  It rather depends upon how well endowed (as the expression goes) you were to begin with.  If there is a noticeable difference, it is very slight.  It is because the newly organized and re-routed urethra has been necessarily shortened and therefore had the effect of ‘pulling back’ the penis into the body just a little.  After a few months, the urethra will stretch to accommodate most of the change.  On erection, the difference is usually of little or no consequence.

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I have heard that after the operation my scrotum and possibly my penis will be very badly swollen and look severely bruised.  What will they have done to them and why is this?

This is seldom mentioned before the operation because it is of no long-term significance, but yes, there can be some rather alarming-looking swelling — more often associated with the scrotum, which can occasionally swell to the size of a small orange — but it subsides quite quickly, doesn’t hurt, and is neither damaging nor even particularly inconvenient or uncomfortable.  The penis can appear a bit bruised also, and this has to do with inevitable disturbance (during the operation) of the blood vessels and nerve endings serving the scrotum.  But it really is a very short-term problem and is soon history.

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Do I need any special nursing care when I first go home?

Not normally, though you may need some help getting up from deep armchairs, or getting into and out of bed during the first few days at home.  And it is advisable to wear loose clothes like tracksuit bottoms because your lower tummy will be a bit swollen, and getting zips done up can be a problem for a while.  Also you need a spare urine collection leg bag, which the hospital can give you, or you can buy them easily from chemists.  You need to keep yourself scrupulously clean to reduce the risks of any infection while the catheter is still in place.

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Is it painful to have the catheter removed?

Not normally, because catheters are much slimmer these days.  Usually it only takes a moment and it’s gone, but they can occasionally get a little stuck because of a tight fit — which in fact is a good thing in some respects.  If this does happen, a doctor will help with the removal, and frankly that can be somewhat eye-watering in effect unless they give you a sedative at the time.  But a modern catheter getting severely stuck is unusual, and you would have to be unlucky to experience it.

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Will I feel tired and washed out after the operation?

Yes, you will, and this is a normal protective mechanism to allow healing.  Some men feel a tremendous loss of energy, and have days when they think they will never regain their original verve, but gradually the energy level returns and the post-operative tiredness and lassitude are soon forgotten.

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How long should I be off work?

Between 6 and 8 weeks is recommended, although reading, telephone calls, and stress-free activity are all fine.  Every single patient with whom we have spoken who has returned to work a bit early has really regretted it, and his recovery has taken longer.  Remember, nobody is indispensable, and it will probably do your colleagues the world of good to shoulder some of your responsibilities while you are away!  Even if you are retired, take it easy, and handle one day at a time.  You can’t really drive comfortably for a month, anyway, so get somebody to drive you!

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Can I exercise after the operation?

Yes, but listen to your body: it will tell you how much is sensible and when to rest.  But avoid heavy lifting, such as weight training.

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Will I lose my continence control?

Not unless you are very unlucky.  Most patients now recover control almost as soon as the catheter is taken away, but it is true that for some it can take a few hours, a few days, a few weeks, and even a few months, and you might need to wear some padding for a while if leakage is a bit of a problem.  As explained earlier, many surgeons ask you to stay in hospital overnight after the removal of the catheter, measuring fluid intake and outflow to see that the plumbing is working as it should and that there are no internal leaks.  To some extent, regaining continence control depends upon individual muscle tone (and you will be taught exercises to strengthen the pelvic muscles), the skill of the surgeon who will have done all he can to spare the nerves that affect continence, and a certain amount of incalculable individual luck.  The good news is that things almost always dry up sooner rather than later, and you should have a urine stream like when you were a teenager.  If the urinary stream does deteriorate, alert your urologist.  You may be developing a bladder neck contracture, which requires gentle stretching under light anaesthetic.

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Is sexual dysfunction a problem?

Yes, for nearly everyone, whatever they claim.  However, some ability and sensation, albeit with a dry orgasm (because the seminal vesicles have been removed as part of the operation) can return after a few months, or sooner for a few lucky ones.  Normal penetrative sex is a problem because however careful the surgeon was to avoid damaging the nerves during the operation, achieving a sustainable firm erection is more difficult for most patients, although some men say they can manage reasonably satisfactorily.  Having a successful radical prostatectomy is unquestionably a trade-off because if the alternative is to die of prostate cancer, then it has to be remembered that so far as we know there is not a great deal of sex in the graveyard. (Although a local vicar, who incidentally has undergone a radical prostatectomy, told us that there is rather too much in his!) Sexual dysfunction is also quite common after radiotherapy.

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Are there things I can do to help me get back my erections?

Yes, there are silicone implants (for those who wish to afford them privately), and these work rather like a bendy toy, in the sense that you bend it up when you want that, and down when you don’t.  It has to be said, however, that some men have complained that when swimming or playing sports, they can occasionally appear to have a half erection in place, which can be understandably embarrassing.  Inflatable penile prostheses produce a more life-like result, but are considerably more expensive and also prone to malfunction.

There are penile injections of prostaglandin which are uncomfortable but not too painful, and provide an almost immediate erection which lasts well, but some men instinctively find it difficult to give themselves such injections.

Vacuum pumps can also help.  After an erection has been achieved, it is held in place by a rubber ring slipped over the base of the penis.  Although effective, some find such a device scarcely conducive to spontaneity.

Penile suppositories of prostaglandin (known as MUSE) are available, but are quite expensive.  They do work, though, and are favoured by some patients.

And now, of course, there are Viagra (sildenafil).  Some surgeons are suggesting this be tried about 3—4 months after the operation.  But it does not seem to work so well until some 6—9 months or so have passed.  And then for those with no contraindicated medical history, such as angina or a recent heart attack, sildenafil can be very effective, especially at the higher doses.  If the drug is used with common sense, many patients have reported results little short of amazing, with very few side-effects of consequence.  Perhaps a little face flushing or a headache, but after about an hour, sex is possible with a good erection, providing there is physical stimulus.  It does not work as the other methods do.  It needs sexual stimulus, and then it can often provide repeated satisfaction over a period of some 12 hours.  The tablets should not be taken more than once in a 24-hour period, and you should never mix Viagra with nitrates (used to treat angina).  Amyl nitrite, also known as ‘poppers’, is popular with the gay community, but this should never be used along with Viagra.  Such a practice could prove highly dangerous. Viagra works by relaxing the blood vessels in the penis so allowing the blood to flow there more freely.  It is a drug that can now be prescribed on the NHS for prostate cancer sufferers or diabetic men. Do not buy Viagra through the internet.

Other drugs such as Uprima (apomorphine) can be helpful.  Successors to Viagra, known as Cialis (tadalafil) and vardenafil, are in the pipeline and may act more quickly and stay effective for longer.

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How will my partner be affected?

Nobody can ‘catch’ prostate cancer from you, but your partner will certainly be affected if impotence is the result.  Frank discussion is vital before and after the operation, particularly if you go for a radical prostatectomy, and the partner must understand the implications along with you.

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Should I tell my family and friends I have, or have had, a cancer?

It’s up to you of course, but why should there be a need for secrecy and shame, and why not become an advocate for regular check-ups and possibly save a life in the process?  This is particularly true if you have sons or brothers who have yet to reach their 40s and 50s when a check-up would be wise, unless by then medical science has beaten this disease completely.

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Will the cancer come back?

Well, yes, this has been known, with any of the treatments, but is less likely after skilled surgery, followed by mop-up radiation in some cases, and current success rates are reassuringly high.  If the PSA does start to rise, treatment with the anti-androgen Casodex (bicalutamide) has been shown to halve the risk of progression.

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Was there anything I could have done to prevent the cancer in the first place?

Not really, because nobody knows for certain why anyone is affected by it.  There are plenty of theories.  Some say it is all to do with diet (ranging from eating too much red meat, to eating a lot of ice cream); others believe it is a genetic disease (and there is much research going on in that direction); yet others say it is connected with a multifarious and largely unidentifiable mix of factors, including having had a vasectomy.  Nobody has a monopoly of wisdom on the subject.  The latest research has found that men who carry a damaged version of a mutant gene are four to five times more likely to suffer from prostate cancer than those who do not have this faulty gene.  It’s a case of ‘watch this space’.

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And what about the future in terms of treatments?

There is much research going on that may one day find a solution for prostate cancer, through a vaccine, gene therapy or a more certain cure without losing the gland, but we are presently years away from this happy circumstance.  And, inevitably, more research money is needed.

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