News, Culture & Society

ASK THE GP: Which prostate operation would you have if you were me? 

For a long time I’ve suffered from an enlarged prostate, but I cope quite well so I’ve managed to avoid surgery. Nevertheless, when I heard about UroLift I thought I’d finally found the answer. Now I’ve read about yet another procedure, PAE (prostate artery embolisation). If you were in my shoes, which procedure would you choose?

Norman Wanstall, Burford, Worcs.

After four decades in medical practice I have learned to be cautious of any new drug or treatment, medical or surgical, especially before making recommendations, because experience tells me that new quite often isn’t better and can sometimes end up being worse.

An enlarged prostate, known medically as benign prostatic hyperplasia, is increasingly common in men with age.

Over the years, male hormones cause the gland — which sits around the urethra and underneath the bladder — to become slowly enlarged. This can obstruct the urethra, leading to a poor stream, hesitancy (an intermittent stream), urgency (needing to go in a hurry) and nocturia (going more than once at night).

Medications can be very effective — alpha-blockers work by relaxing the muscle of the prostate tissue, while alpha-reductase inhibitors block the effects of male hormones — but a significant number of men do still require surgery.

An enlarged prostate, known medically as benign prostatic hyperplasia, is  starting to become increasingly common in men the older they get

Since the Eighties, the most popular option has been transurethral resection of the prostate (TURP), a keyhole procedure where a wire, guided by a camera, is inserted into the urethra then heated to burn away some of the enlarged gland.

TURP remains the gold standard because it’s the only procedure that long-term studies have shown is safe and effective.

However, some men fear TURP as it involves a general anaesthetic and two or three days in hospital. Some are also anxious about the potential risks, as TURP can damage a sphincter (or valve) at the entrance of the bladder, causing retrograde ejaculation — where semen is sent backwards into the bladder. Erectile function is not harmed, but patients are no longer fertile.

The UroLift System is a new option that can be done under local anaesthetic. Two to four pairs of what are effectively treasury tags are used to pull back the enlarged tissue, improving flow.

The procedure seems to be effective, but no more so than TURP, and there are questions about how long the effects might last as we don’t yet have enough long-term studies to know.

The most common procedure is transurethral resection of the prostate (TURP), a keyhole procedure where a wire is inserted into the urethra then heated to burn away some of the enlarged gland

The most common procedure is transurethral resection of the prostate (TURP), a keyhole procedure where a wire is inserted into the urethra then heated to burn away some of the enlarged gland

Also the treasury tags are, in part, metallic, which may distort the signal in MRI imaging should that be needed in the future, for example to diagnose prostate cancer.

PAE is another new procedure (first used in the UK in 2012) that must be regarded as experimental until we see the results of large studies — and the National Institute for Health and Care Excellence approves it.

Here, the prostate is shrunk by using microscopic particles to block the blood vessels supplying it. It’s done by feeding a catheter up through the main artery in the groin under local anaesthetic.

I think you will guess the option I’d prefer if I were in your shoes.

When I was a child, I had Raynaud’s disease. It improved in my teens, but now I’m 73 it’s back with vengeance. I also have fibromyalgia.

I’ve been told by doctors the drugs for Raynaud’s are worse than the symptoms. I’ve read they can cause a flushing face and headaches.

The Raynaud’s affects my hands, feet, ears and back, and even when I’m indoors with the heating on I need to wear two vests, shirts, a long-sleeve pullover and a woolly-lined jacket. To crown it all, if I get too cold in bed the pain gets worse, but it also worsens if I get too hot.

A. Cartrill, Ipswich, Suffolk.

Raynaud’s is a disorder where some of the blood vessels have an exaggerated response to cold conditions.

The vessels in the skin help control body temperature: the arteries dilate when it’s hot for warmth to be lost, and constrict in response to cold to minimise heat loss. However, those with Raynaud’s react to even minimal cooling; muscles in their small arteries spasm, temporarily blocking blood flow.

Typically, it’s the arteries of the fingers, toes and other extremities that are affected. It can cause considerable discomfort when blood flow restarts.

The body’s temperature is controlled by the sympathetic nervous system (the fight or flight part), which explains why stress, as well as cold conditions, can cause symptoms. Raynaud’s is usually linked to an underlying disease. However, in 5 per cent of cases, there’s no obvious cause and it’s probably genetic.

Secondary Raynaud’s, as the most common form is known, typically occurs with autoimmune rheumatic disorders such as rheumatoid arthritis.

As there is no known association with fibromyalgia, I do wonder whether, given your history, this diagnosis is correct? Could it be that you have an associated rheumatic disorder, especially as your Raynaud’s symptoms appear to be quite severe?

Attacks can be reduced by dressing warmly, wearing gloves, avoiding smoking (nicotine causes arteries to constrict) and keeping clear of medicines that cause blood vessels to constrict, such as cough decongestants.

I’m not so convinced that medications for severe Raynaud’s are worse than the condition, though there is a balance to be struck.

Drug treatments include nitroglycerin ointment, high blood pressure medications (e.g. losartan), sildenafil (also known as Viagra) and antidepressants such as fluoxetine (known as Prozac). These work by dilating blood vessels.

My policy has been to treat patients who have severe recurrent symptoms with blood pressure drugs called calcium channel blockers — nifedipine or felodipine — at the lowest effective dose to avoid causing low blood pressure, which would result in feeling faint.

Other potential side-effects are headache, flushing, ankle swelling and an increase in heart rate.

Randomised trials have shown this approach appears to be modestly effective.

Never skimp on sleep 

If you needed more confirmation of the importance of a decent amount of sleep, how about the emerging evidence that our dreaming may help take the emotional sting out of memories — thus reducing the anxiety of bad experiences?

One early U.S. study found that women who had bad dreams about their divorce were less likely to be depressed a year later than those who didn’t report such dreams.

We get more of this (largely REM) ‘healing’ sleep later on in the night, between six to eight hours after nodding off. A timely thought as we struggle with the effects of the clocks going forward. It’s easy to fall into the trap of staying up because your body’s on ‘old’ time. The message is, don’t.

In my view…. Don’t be complacent about jabs 

We forget too easily the huge impact vaccines have had on our lives. I was reminded of this during the recent cold spell, when two senior ladies — one aged 89, the other 91 — came over for afternoon tea in front of a blazing log fire.

The younger of my visitors has been troubled with a severe and worsening cough for some years. She was eventually diagnosed with bronchiectasis, where the airways become enlarged and blocked with sputum.

It’s linked to lung damage from a number of causes, but in this patient’s case it was whooping cough as a child. Whooping cough is a highly contagious infection caused by the bacteria Bordetella pertussis. It can be dangerous for the very young and, until a vaccine became available, it claimed many lives — 3,000 children in the UK in 1941 alone.

This led to what now seem rather desperate measures. At the time it was noted that children living close to gasworks had a lower incidence of the disease and it was thought that the vapours might be therapeutic.

My visitor with the cough said she clearly remembered being taken for a visit to the local gasworks in the early Thirties. And my other visitor described her own visit to a gasworks in early childhood for the same reason.

Such history reminds us of the great value of childhood immunisation programmes, which commenced shortly after the NHS was created in 1948.

But we must not be complacent about this disease. Indeed, as the protection from childhood fades over time, some adults may suffer a mild version of whooping cough (characterised by coughing lasting weeks or months after a minor flu-like illness).

And it remains dangerous for babies. As the vaccines aren’t offered until children are six weeks old, their mothers are advised to have the vaccine during pregnancy so their protective antibodies can cross the placenta. Please do take up the offer.

Why I’m worried about…. 

The failure to teach doctors about nutrition.

A recent U.S. study found that almost half of all deaths from heart disease, stroke and diabetes are linked to the food we eat.

Good nutrition can be vital for patients recovering from surgery and disease. Yet the co-chairman of the British Medical Association’s students committee has said that many medical students feel ‘underprepared’ to manage patients’ nutrition.

I support his call for medical schools to give student doctors better training in nutrition though, frankly, I’m astounded we’re only just now talking about this.