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by Stanley Ducharme, Ph.D.

With aging, most men will at some time develop disorders related to the prostate gland. Typically, these problems are first seen after age 50 or during the 60s.Unfortunately, having a spinal cord injury does not eliminate the probability of developing a prostate problem. Although most of us think of cancer when we think of prostate trouble, other disorders related to the prostate are far more common. These may include prostate enlargement or “ BPH” as well as acute or chronic infections known as prostatitis. Fortunately, prostate problems don’t need to mean complicated operations, embarrassment with urination or the end of sexual functioning. Today, early diagnosis, new techniques and effective medications have greatly improved the treatment of prostate disorders.

What is the prostate and what does it do?
The prostate is a small gland located just below the bladder. The gland is only found in men. It is shaped like a doughnut and surrounds the urethra, the tube through which urine flows. The prostate reaches its adult size by the age of 20 and weighs a little less than one ounce. It is stimulated to grow during the teenage years by the male sex hormones which become active during puberty. For reasons that are not well known, the prostate again begins to grow at about age 45 or 50 and continues growing throughout the life span of the man.

The main purpose of the prostate gland is to produce a fluid that combines with sperm and other fluids to form semen. For men with spinal cord injury, this semen may be expelled from the body during ejaculation or mixed with urine in the bladder (retrograde ejaculation.) This ability to ejaculate is unique for each man depending on the level and completeness of the spinal cord injury. In all men, the prostate gland responds to the level of sexual arousal in the individual. As the man becomes aroused, the prostate gland produces more fluid in preparation for ejaculation. During ejaculation and intercourse, this semen is the fluid that carries the sperm into the vagina.

If there is no ejaculation when the man becomes aroused, the fluid produced by the prostate will be excreted into the bladder and expelled during urination. By allowing this fluid to empty into the bladder, the prostate gland avoids a condition known as prostate congestion. Although not dangerous, prostatic congestion can be unpleasant and uncomfortable if the man has intact or some sparing of sensation.

As the prostate gland becomes enlarged during the ages beyond 50, it also squeezes the urethra causing both urinary difficulties and a decrease in ejaculatory fluids. For men with spinal cord injuries, urinary changes may not be noticeable depending on the urinary collection techniques and if bladder surgery was performed. For example, intermittent catherizations provide a direct route into the bladder so that enlargement of the prostate will not impair urination as it might in a man without a disability. In addition, if the man has had previous surgery on the bladder neck, changes in urine flow, urgency for urination and difficulty starting or stopping urination will not be a concern. Since urinary changes are often the first signs of prostate problems, it may be difficult for the man with spinal cord injury to recognize early prostate disease without regular PSA (prostatic specific antigen) blood tests.

Although not a lot is known about the prostate gland in men with spinal cord injury, recent evidence has suggested that PSA levels may be somewhat more elevated than for men without injuries. In addition, studies at the University of Miami have begun to study the seminal fluid produced by the prostate in men with these injuries. Newer studies are suggesting that alterations in the semen from the prostate in men with spinal cord injuries may be responsible for male infertility in this population. Scientists have discovered biochemical changes in the seminal plasma of the prostate that seem to have a direct impact on sperm motility in men with spinal cord injuries.

Enlargement of the prostate or BPH
The most frequent cause of prostate trouble is a condition called BPH. This stands for benign prostatic hyperplasia, which means noncancerous enlargement of the prostate. BPH is quite common and by the time men reach their 60s there is a good chance that most men will experience some prostate enlargement. BPH is rarely a life threatening disease. It progresses slowly and potential serious complications can be anticipated and avoided.

Typically, doctors suspect BPH by understanding urination patterns, urine flow and frequency. The symptoms of BPH include some or all of the following: a need to urinate more often than usual at night, difficulty in starting your urine stream, slowness and weakness of your stream, a need to urinate frequently and with great urgency, dribbling of urine after urination and passing small amounts of blood in your urine or ejaculate. Because of neurogenic bladders after spinal cord injury, many of these symptoms may not be present in the man with a spinal cord injury.

Without proper diagnosis and treatment, BPH can lead to acute urinary retention, urinary tract infections, loss of normal bladder functioning and eventual kidney damage. From a sexual perspective, BPH can significantly affect ejaculation and make it difficult for the ejaculatory fluid to be expelled from the body. In rare cases it may cause erection problems but this tends to be unlikely. Interest in sex can be affected if the man experiences problems with ejaculation and erection or if he is uncomfortable due to urinary tract infections.

Over the last decade, medications have replaced surgery as the primary treatments for BPH. Some of these medications include: Hytrin, Flomax and Proscar. These tend to either relax the smooth muscles of the prostate and bladder neck or reduce the size of the prostate itself. Some medications such as Proscar can affect sexual abilities and have been shown to reduce ejaculatory force, impair erections and decrease sex drive. Usually, these side effects will disappear when the medication has been finished. As a side note, women who have the potential for pregnancy should not handle crushed Proscar since it can be absorbed through the skin and has been shown to cause certain types of birth defects.

Some men with spinal cord injuries have had surgical procedures known as transurethral resections (TUR). This procedure is also used for the surgical treatment of BPH. In this procedure, a surgical instrument is inserted in the urinary passageway and some of the enlarged prostate is cut to widen the passage in which you urinate. It is the simplest operation and leaves no scar. Unfortunately however, this procedure can seriously affect the man’s ability to get an erection. Many doctors will attempt to preserve sexual abilities after TUR but sexual difficulties are very prevalent even in these cases.

Prostate infections can be acute or chronic and are called prostatitis. In men with sensation, prostatitis can cause back pain, pain in the rectal area and burning with urination. Treatment of this problem is usually done with antibiotics but warm baths and muscle relaxants have also been found to be beneficial. Although prostatitis doesn’t typically affect sexual functioning, some men report painful ejaculations due to painful spasms of the prostate muscle at the time of ejaculation.

Another form of this disorder is called congestive prostatitis. Although the exact cause is generally unknown, some doctors feel that constant vibration or irritation can be a factor. Truck drivers and motorcycle riders, for example, often develop this uncomfortable condition.

Prostate cancer
Cancer of the prostate is the most common malignancy of men in the United States. There are three major goals for treating men with prostate cancer. Obviously, the most important is to eliminate all malignant cells. The second goal is to maintain as much urinary control as possible. The third is to try to preserve erectile ability. Because one of the potential side effects of treatment for prostate cancer is erectile problems, an increasing number of men and their partners are affected by sexual changes.

The two standard treatments to address prostate cancer are removal of the prostate gland (radical prostatectomy) and radiation therapy done either by an external machine or from implanting radioactive seeds. Both surgery and radiation treatment carry the risk of erection problems. Prior to 1982, loss of erections was inevitable in all men who had their prostate removed. In that year however, a new procedure was developed at Johns Hopkins University in Baltimore. This procedure, called a nerve sparing radical prostatectomy, attempts to preserve the nerves that are connected to the erection tissue. Even with this surgery however, erection problems are very common.

The best predictor of whether erection problems will occur after surgery is the quality of the erections before surgery. Cigarette smoking, alcohol use, cholesterol levels, medications, diabetes and the spinal cord injury itself will all determine how much sexual functioning is preserved after treatment for prostate cancer. Typically, it can take at least several months to determine whether sexual functioning will return after surgery or radiation. During this time, maintaining ongoing contact with your urologist is a good idea in order to explore treatment options and their effectiveness.

Many of the treatments for erection problems after spinal cord injury are also commonly used in men who have had radiation treatment or prostate removal. These include the use of penile injections, vacuum devices and oral medications such as viagra. Most of these treatments tend to be well received although currently there is little available data on the effectiveness of viagra after prostate cancer. Even if viagra was helpful after spinal cord injury, the same dosage may not be as effective after prostate treatment. However, if you have partial erections after surgery, viagra alone may restore your abilities without further treatment.

Typically, when sexual functioning is regarded as important, men will begin to address erection issues within one to three months after surgery. Often the use of erection treatment within a few months after surgery will ultimately help a better return of sexual functioning in the months or years that follow. This is probably due to the increase in oxygen to the penis that occurs during frequent erections.

In conclusion, prostate problems are very likely in many men after age 50. Regular check-ups, blood tests and prostate examinations need to be conducted on an ongoing basis. Today however, prostate problems have received considerable attention by the medical establishment and many new procedures and medications have emerged in the last several years. Although many prostate problems can affect sexual abilities, there are effective treatments which can restore potency. Today, prostate problems no longer need to signify a loss of sexual functioning.

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