Clarification of Answer by
12 Jul 2005 22:54 PDT
You are so right when you said this is a complicated field of
medicine, and answers are not clear cut. The fact that each patient is
different, and each doctor has her/his methods of treatment makes
prostatitis a very thorny condition.
1)?what do these tests imply??
?Recent 6 month old PSA 4.0/0.88/0.22
2 series of testosterone injections, after which PSA was 7.6/1.67/0.22
Your first PSA of 4.0/.88/0.22 was borderline for having a biopsy, in
the US. The fact that it became elevated to almost double after the
testosterone may be worrisome, which is why I suggested you start with
a new PSA since you have discontinued the testosterone injections. If
your PSA is still 4 or above, a biopsy is indicated, along with a
?feel? exam, known as a DRE (digital rectal exam). As far as the drop
in testosterone, it is expected to fall since you are no longer taking
?Testosterone 14.9 to 11.4nmol/L, free 36.3 to 26.4pmol in latest 9 week period.?
10-35 nmol/L is the normal range for testosterone (Normal ranges vary
from lab to lab, so this is a ballpark range) Free testosterone
generally makes up about 2% of total testosterone. I would expect your
testosterone level to rise after injections, and drop upon
According to many reputable medical sites, ?4? is the magic number
for PSA. If your PSA is 4 or over, you have a greater chance of having
prostate cancer. At this stage a DRE (Digital rectal exam), a ?feel?
exam is in order. Your doctor will determine at that point if a biopsy
is indicated. (I?ll bet she or he may order one-at least if you were
in the US!) The testosterone injections may have falsely raised your
PSA to 7.6.
Keep in mind these causes of false positives and false negative PSA results:
PSA can rise when there isn't any cancer. A variety of non cancerous
causes are listed below;
BPH - PSA from the benign adenoma can raise levels
Prostatitis - inflammation raises PSA significantly
UTI - bladder infections also cause inflammation
Urinary retention - is often caused by a small prostatic infarct, releasing PSA
Sex / Ejaculation - PSA is elevated for 48 hours after sex
Trauma - bike riding, catheterisation etc
Cancer may be present but the PSA is normal
Finasteride (Proscar / Propecia) - blocks the activation of
testosterone within the prostate. It lowers the PSA by 50%
Poorly differentiated cancers - rarely cancers are so poorly
differentiated that they cannot make PSA
Read this additional information:
?Joel M. Kaufman, MD: Well BPH means benign prostatic hypertrophy or
an enlarged prostate. It?s a common condition in men as they get
older, and it cases urinary difficulties; slow urinary stream,
frequent urination. We know that the prostate is stimulated by
testosterone, and the concern is that if you treat men who have
prostate problems with testosterone that you might worsen their
Hugo Verhoeven, MD: Why is testosterone inducing BPH? Or inducing
prostatic cancer, is there any aetiology known?
Joel M. Kaufman, MD: There is no aetiology that testosterone induces
prostate cancer, but what we know is that the prostate cells are
sensitive to testosterone. Men who do not have testosterone tend have
very small prostates. The prostate requires testosterone to grow.
After the age of 50, that?s when we tend to see problems with low
testosterone, but it?s also the age group where men start to have
enlarged prostates and may develop prostate cancer.
Hugo Verhoeven, MD: Can we say the higher the free testosterone level
in the blood, the higher the risk of BPH, and maybe also the higher
the risk of prostatic cancer, or is there no relation between those
Joel M. Kaufman, MD: There is no correlation at all. There have been a
lot of studies; I referred to them today that show no correlation
between testosterone levels and any prostate parameter.
Hugo Verhoeven, MD: So how can we then screen our patients for the
risk that they are going to have BPH, or later on, prostatic cancer?
Free testosterone will not be a good parameter for that.
Joel M. Kaufman, MD: No, the free testosterone is the way that you?re
diagnosing hypogonadism. But before you start somebody, particularly
men over the age of 50, on testosterone treatment you need to be sure
they don?t have a prostate problem. You can determine that by
symptoms. If a man is having a great deal of difficulty urinating, you
probably would not want to stimulate his prostate with testosterone.
In terms of prostate cancer, the rectal examination is very helpful
and the PSA is probably the most helpful measure to make sure somebody
doesn?t have prostate cancer.?
It would have been prudent to have the biopsy and a PSA drawn BEFORE
you started the testosterone, to know if the testosterone aggravated
your prostate and was the true cause of the elevated PSA. At this
point, we do not know for sure that it the PSA of 7.6 was a true
level, or stimulated by the PSA.
?Risks of Low Testosterone:
Until recently, few men in the United States elected testosterone
replacement because of the fear of prostate cancer. In Europe,
testosterone replacement is much more common. Recent studies imply
that U.S. men are misinformed. Rather, the medical literature
documents that low levels of testosterone are directly correlated to:
· heart disease and myocardial infarction
· strokes and cardiovascular disease
· prostate cancer (yes, low levels are higher risk)
· senile dementia
· osteoporosis and hip fracture
Total testosterone is not as important as the Free or unbound
testosterone, as the latter is bio-available to the tissue. High
levels of estrogen and sex hormone binding globulin reduce
bio-available testosterone. Medical publications show that gels and
patches raise sex hormone binding globulin. High levels of
testosterone from an intramuscular injection raises the estradiol
level. That is why low-level, even release pellets are the best
modality available today for the man who needs testosterone
Normal levels of testosterone
?There is also legitimate concern that testosterone supplementation
may affect prostate cancer. Traditionally, we have viewed the aging
process as a natural occurrence that we have no control over. While we
can?t stop death from occurring and may not even to be able to extend
the natural life span, we certainly can influence our health and
vitality in our later years. If replenishing a hormone that is natural
(and necessary) to our bodies can make us feel and function better,
then that is exciting. If a person feels better and is more pleasant,
he benefits, and the people around him benefit. If he is more
productive, then his family and his society benefit. Is this just
wishful thinking or a developing reality?
Conservative extremists feel testosterone should never be replaced
unless there is a known pathological condition causing hypogonadism, a
condition of the gonads, where testosterone is produced, that results
in low testosterone levels. They argue that lower testosterone levels
are a normal consequence of aging and should not be interfered with.
They also argue that the effects of giving supplemental testosterone
are not well-known and, in particular, may cause prostate cancer. They
argue that a large number of men as they get older harbor potentially
malignant, or even malignant, cells in the prostate, and these could
be stimulated to grow faster by testosterone supplementation.
Advocate extremists argue that the levels of testosterone are highest
during youth, and that is the period of time when one has the most
energy, the most natural muscle development, strong sexual drive and
function, better disease fighting capabilities, and the lowest
incidence of cancer. They then conclude that many of the negative
effects of aging, since they correlate temporally with lowering
testosterone levels and other hormones, can be improved with
supplemental testosterone. They want to see hormone levels raised back
up to youthful levels by way of supplementation.
Neither of these positions can be absolutely established by existing
scientific information, but more and more scientific evidence and
clinical experience are showing that testosterone supplementation can
be a safe method to improve many of the things associated with the
age-related effect of lowered testosterone levels.
Pay attention to this statement:
?The majority of scientific information available does not suggest
that testosterone causes prostate cancer, but if prostate cancer is
present, testosterone can make it grow because it is an androgen.
Androgens can cause prostate cancer cells to grow. Therefore, one of
the main treatments of androgen sensitive prostate cancer is removal
or blocking of androgen effects on the prostate.?
This is an interesting abstract of a study of the effect of testosterone on PSA:
?OBJECTIVES. To determine the relationship between endogenous total
serum testosterone levels and serum prostate-specific antigen (PSA)
concentrations. If a correlation exists between these two parameters,
then use of testosterone-specific reference ranges may enhance the
utility of PSA as a marker for prostate cancer. METHODS. Data were
obtained from 150 men without previous history of prostate cancer. PSA
was measured by the Abbott IMX microparticle enzyme immunoassay and
total testosterone determined by the Coat-A-Count radioimmunoassay.
RESULTS. No correlation was found between testosterone and PSA, even
when corrected for age and weight. CONCLUSIONS. The data suggest that
determination of the total serum testosterone level does not improve
the sensitivity or specificity of PSA as a tumor marker.?
I?m concerned that you may have a few cancer cells that are causing
your PSA to reach 4.0, and that the testosterone stimulates the grow
further. I am NOT saying you DO have cancer cells, as you already
mentioned having prostatitis. Prostatitis itself will give an elevated
PSA. I also believe in watchful waiting, but your DRE may indicate
more aggressive treatment. Your doctor, after reviewing your history
and performing the DRE will decide the next course of therapy. Since
your PSA rose after the testosterone injections, it would be wise to
stay off testosterone until your next appointment and blood test, in
order to get a true reading.
?The normal range for the PSA test is less than 4.0 nanograms per
milliliter (ng/mL) in most men. If you are over 40 years old and have
a family history of prostate disease or if you are an African-American
man over 40 years old, some doctors suggest that a level higher than
2.5 ng/mL should be checked with more tests. These two groups of men
have an increased risk of prostate cancer.
The PSA level may be higher than normal if:
· You have benign prostatic hypertrophy (BPH). BPH is a common
condition of older men that occurs when the prostate grows larger with
aging. BPH is not a form of cancer.
· You have a condition that inflames or irritates the prostate gland
can cause a higher PSA. Examples of such conditions are infection of
the prostate gland, severe infection elsewhere in the body, injury,
biopsy, vigorous massage, heart attack or recent heart bypass surgery,
Foley catheter placement, or endoscopy of the bladder or kidney
through the ureter (the ureter is the tube draining the bladder).
· You ejaculate within 24 hours before the test.
· You have prostate cancer.?
2) ?should I "watchfully" wait and take another test in 6 months??
If you do have a biopsy, and if it were to show cancerous cells, it
will be staged and scored as to severity by a pathologist. In the US,
this is called the Gleason score. If the score is above a certain
point, urologists in the US decide to operate, use radiation, or
cryotherapy. If the score and stage are below a certain point,
watchful waiting may be recommended. Your doctor will determine which
step to take, taking into account your overall health as well.
?It makes much more sense to look at how the body is functioning to
decide whether levels are optimal. Optimal may be much different than
normal. Also, if two people have the same levels of testosterone, or
any other hormone for that matter, their bodies may respond completely
differently. One body may have more cells responsive to that hormone,
more receptors responsive to that hormone, more sensitive receptors,
or different cellular and systemic responses to that hormone. It makes
much more sense to us to look at how the body is functioning. If there
are adverse things happening in the body that are negatively affecting
quality of life and these can be improved with natural hormone
supplementation in a safe and effective manner, maybe it should be
?It is not easy for a man to select the option of Watchful Waiting -
one's natural instinct (particularly when the word cancer is involved)
is to take action and to do so immediately. However, Watchful Waiting
is a viable option and is the proper choice for many men. It becomes a
viable option in view of the following facts that have been made clear
via the many arguments referred to throughout this presentation:
· There is currently no treatment available that has been proven
capable of providing a cure, capable of extending life, or of doing
more good than harm. In addition, all treatments have undesirable side
effects that can seriously detract from the patient's quality of life
for the rest of his days.
· In the United States, only one of every eight men diagnosed is
forecast to die from the disease. The indication is that seven of the
eight men would not benefit from treatment. Unfortunately, it is not
possible today to determine which one of the eight men requires
treatment and there is no assurance that currently available
treatments would be helpful to him even if he could be identified.
· The vast majority of prostate cancers (90%) remain dormant, never
causing clinically evident disease or affecting survival. Those
cancers that do become clinically evident exhibit an indolent course
in most men.
In the Watch and Wait approach, the patient and his physician agree
upon what is to be watched (PSA, PSA velocity, DRE, bone scans, or---)
and what is being waited for (development of a therapy proven capable
of at least doing more good than harm, or development of numerical
values of parameters being watched, progression to symptoms, etc.),
with the intention of taking the next step after the occurrence of
It should be noted that Watchful Waiting, like many of the other
current treatment modalities, will become obsolete after a cure is
discovered. However, unless the Congress becomes convinced that a
drastic increase in research funding is in order, that discovery may
be in the very distant future.?
?A man who has selected watchful waiting is a man who has chosen not
to have immediate prostate cancer treatment. During the watchful
waiting period, the physician keeps the cancer under close watch.
The logic for watchful waiting is simple: prostate cancer often
develops very slowly. With watchful waiting, the patient takes the
time to consider possible treatment options. In some
cases-particularly with older men-the prostate cancer patient will die
of other causes rather than from prostate cancer.
Other factors that motivate men to choose watchful waiting is the
intrusiveness of many available treatments, the potential side
effects, and in some cases limited long-term data. Today, with the
advent of minimally invasive options with fewer side effects, more men
are choosing treatment rather than life with cancer.
Watchful waiting entails regular prostate-specific antigen (PSA)
tests, digital rectal exams (DRE), or other tests. "Waiting" means
being alert for any indication that the cancer has developed to the
point that it may require surgery or other treatment.?
3) ?should I go for a rectal "feel" exam?? and 4) ?go for byopsy??
Yes. Speak to your doctor about having the PSA run again, and see how
the results turn out. Based on the PSA, a DRE may be performed, and
based on the DRE, a biopsy may be called for. From there, you and your
doctor can decide on surgery or watchful waiting! Did you know that
autopsies performed on men over 65, who died of natural causes
(Non-prostate cancer) revealed some stage of prostate cancer?
This site sheds a little different light on the subject:
? Nearly 2 out of 3 cases (63%) are in men aged 70 and over. Age is
the most significant risk factor of all for prostate cancer. The
older you are, the greater the risk. There are some studies, based on
post mortem findings, estimating that all men would have prostate
cancer if they lived to over a hundred.?
Why a DRE is important:
?Detect growths in or enlargement of the prostate glandin men. A tumor
in the prostate can often be felt as a hard lump. This may be done as
part of a regularly scheduled examination or to investigate symptoms
(such as difficulty urinating or a decrease in force of the urine
stream) that may indicate a problem with the prostate gland. However,
the digital rectal exam is not a foolproof method of detecting
prostate cancer because not all abnormalities in the prostate can be
felt through the rectum.?
? A digital rectal exam is an examination of the lower rectum to check
for hemorrhoids, anal fissures, and stool abnormalities such as frank
(evident) or occult (hidden) blood. The term "digital" refers to the
clinician's use of a lubricated finger (digit) to conduct the exam.
This examination is also used to evaluate the prostate gland in
?The doctor will first examine the exterior of the anus for
hemorrhoids or fissures. Then he or she will put on a latex glove and
insert a lubricated finger into the rectum and obtain a small amount
of stool on the gloved finger. The stool is then applied to a
hemoccult test, which is a way of evaluating for occult rectal
5) ?what should I ask my urologist to do, if anything??
One reason I overlapped my answer, instead of breaking it down into
each question, is, the questions overlap!
Ask your doctor to order the PSA and testosterone (If the doctor feel
sit is medically necessary ? it may not be in your case), and have the
DRE. IF the doctor feels a biopsy is indicated after the DRE and the
PSA results are in, he can go ahead and perform one. As I said before,
together you and he can decide on a course of therapy, or wait
?For a prostate biopsy, a needle is inserted through the rectum
(transrectal biopsy), through the urethra, or through the area between
the anus and scrotum (perineum). A transrectal biopsy is the most
common technique used. The tissue samples taken during the biopsy are
examined thoroughly for cancer cells.
A biopsy may be done when a blood test shows a high level of
prostate-specific antigen ( PSA) or after a digital rectal examination
reveals an abnormal prostate or a lump.
Why It Is Done
A prostate biopsy is done to:
· Determine whether a lump found in the prostate gland during a
digital rectal exam (DRE) or transrectal ultrasound (TRUS) is
· Help determine the cause of a high level of prostate-specific
antigen (PSA) in the blood. For more information, see the medical test
Prostate-Specific Antigen (PSA).?
?In the USA, Canada, and much of Europe, your doctor is likely to
treat you by prescribing antibiotics. This is often done whether or
not a culture of your EPS or semen is performed. The antibiotics may
help if your prostatitis is caused by bacteria, or it may help due to
anti-inflammatory effects of antibiotics. Or it may not help at all.
(See Dr. Shoskes interesting newsgroup comment on antibiotic use.) The
quinolone family of antibiotics can cause serious side effects for
?The Gout connection occurs when a man's uric acid metabolism is
disordered. Allopurinol is a prescription drug for uric acid problems,
which helps some prostatitis patients.?
Prostatitis is a term that covers 4 separate conditions:
· ?Acute bacterial prostatitis is the least common of the four types
but also the easiest to diagnose and treat effectively. Men with this
disease often have chills, fever, pain in the lower back and genital
area, urinary frequency and urgency often at night, burning or painful
urination, body aches, and a demonstrable infection of the urinary
tract as evidenced by white blood cells and bacteria in the urine. The
treatment is an appropriate antibiotic.
· Chronic bacterial prostatitis, also relatively uncommon, is acute
prostatitis associated with an underlying defect in the prostate,
which becomes a focal point for bacterial persistence in the urinary
tract. Effective treatment usually requires identifying and removing
the defect and then treating the infection with antibiotics. However,
antibiotics often do not cure this condition.
· Chronic prostatitis/chronic pelvic pain syndrome is the most common
but least understood form of prostatitis. It is found in men of any
age, its symptoms go away and then return without warning, and it may
be inflammatory or noninflammatory. In the inflammatory form, urine,
semen, and other fluids from the prostate show no evidence of a known
infecting organism but do contain the kinds of cells the body usually
produces to fight infection. In the noninflammatory form, no evidence
of inflammation, including infection-fighting cells, is present.
Antibiotics will not help nonbacterial prostatitis. You may have to
work with your doctor to find a treatment that's good for you.
Changing your diet or taking warm baths may help. Your doctor may give
you a medicine called an alpha blocker to relax the muscle tissue in
the prostate. No single solution works for everyone with this
· Asymptomatic inflammatory prostatitis is the diagnosis when the
patient does not complain of pain or discomfort but has
infection-fighting cells in his semen. Doctors usually find this form
of prostatitis when looking for causes of infertility or testing for
Acute bacterial prostatitis is treated with antibiotics such as
flouroquinolones (e.g., Avelox®, Levaquin®) and
trimethoprim-sulfamethoxazole (e.g., Bactrim®, Cotrim®) administered
intravenously, followed by a course of oral antibiotics. Side effects
include the following:
· Stomach pain
Analgesics and warm baths are recommended to alleviate symptoms of
prostatodynia and nonbacterial prostatitis. Treating the underlying
cause (e.g., stones) relieves prostatitis symptoms.
In cases of chronic bacterial prostatitis or prostatodynia, surgery to
remove part of the prostate is a treatment option. It is recommended
for patients who experience chronic pain and serious complications,
such as the following:
· Damage to the kidneys caused by urine backing up
· Frequent urinary tract infections
· Inability to urinate
· Stones in the bladder
TURP Transurethral resection of the prostate (TURP) is performed
under general or regional anesthesia and takes less than 90 minutes.
The surgeon inserts an instrument called a resectoscope into the penis
through the urethra. The resectoscope is about 12 inches long and
one-half inch in diameter. It contains a light, valves for controlling
irrigating fluid, and an electrical loop to remove the obstructing
tissue and seal blood vessels. The surgeon removes the obstructing
tissue and the irrigating fluids carry the tissue to the bladder. This
debris is removed by irrigation and any remaining debris is eliminated
in the urine over time.
Patients usually stay in the hospital for about 3 days, during which
time a catheter is used to drain urine. Most men are able to return to
work within a month. During the recovery period, patients are advised
· avoid heavy lifting, driving, or operating machinery;
· drink plenty of water to flush the bladder;
· eat a balanced diet;
· use a laxative if necessary to prevent constipation and straining
during bowel movements. ?
?What are the risks/benefits of surgery?
Although there are nonsurgical treatments available to treat BPH, an
operation offers the highest chance of alleviating your prostate
problems. But it also can result in postoperative problems that you
should consider. Some of these conditions, which may require
additional treatment, include impotence (small risk), uncontrolled
urine leakage (very small risk), a constriction of the urethra
(stricture), or the necessity of a second operation, at a later date,
in some patients. These risks and benefits must be weighed by anyone
considering a prostate operation, and your doctor can help you make
How to know if an operation is needed:
In determining if and when you should have a prostatectomy to remedy
BPH, your doctor will examine your urine for signs of blood or
infection. The doctor will also perform a blood test to ascertain
whether your kidneys are working in a satisfactory manner. There are
other tests your doctor may require that will help decide which is the
best treatment for you.
Uroflowmetry measures the speed of your urine flow
as well as the volume of urine expelled. This test helps in evaluating
the function of your bladder, and the degree of prostatic obstruction.
A measurement of residual urine in the bladder after it has been
emptied can help determine how severe prostatic obstruction is. This
test can be done by catheterization, whereby a small tube is inserted
into the bladder through the urethra to measure how much urine remains
in the bladder after urination. Measuring pressure in the bladder
during urination can give valuable clues in determining how well the
bladder functions. This test is also done by placing a small catheter
in the bladder.
?Radiation therapy uses high-energy rays to kill prostate cancer
cells, shrink tumors, and prevent cancer cells from dividing and
spreading. It is nearly impossible to direct these rays only at the
cancer cells. As a result, they may damage both cancer cells and
healthy cells nearby. Radiation doses are usually small and spread out
over time. This allows the healthy cells to recover and survive, while
the cancer cells eventually die.
Radiation therapy may be used when prostate cancer has not spread
beyond the prostate. Like prostatectomy, radiation therapy works best
when the cancer is located in a small area, and it can help prevent
the cancer from spreading further. In early stages of prostate cancer,
radiation therapy may cure the disease.
Radiation therapy also may be used for pain relief in prostate cancer
that has spread to the bones (Stage M+) or that is no longer
responding to hormonal therapy.?
?A significant recent development is the introduction of cryotherapy
probes based on argon gas rather than liquid nitrogen. Argon rapidly
cools the probe tip to -187°C (-304.6°F) and can be rapidly exchanged
with helium at 67°C (152.6°F) for an active thawing phase, producing a
faster response to operator input and significantly speeding 2-cycle
treatment (De La Taille, BJU Int, 2000). Moreover, argon-based probes
have a much smaller diameter, thus permitting direct, sharp
transperineal insertion, avoiding the need for tract dilation and
facilitating more conformal cryosurgery by allowing placement of more
probes (Zisman, 2001).
In recent years, cryotherapy has seldom been used in community
urological practice despite the initiation of Medicare reimbursement
for the procedure in 1999. Among 8685 patients followed as of August
2002 in the Cancer of the Prostate Strategic Urologic Research
Endeavor (CaPSURE) registry (a primarily community-based observational
database of patients with prostate cancer treated at 35 practice sites
across the United States), less than 2% of those diagnosed since 1996
received cryotherapy as a primary treatment for their tumor
According to American Urological Association polls, the percent of
urologists performing cryosurgery from 1997-2001 remained constant at
2%, but the average annual number of procedures performed by each
urologist increased from 4 to 24. By comparison, the percent of
urologists performing brachytherapy over the same period rose from 16%
to 51%, with the annual number of procedures per urologist rising from
15 to 16.5 per year (O'Leary, 2002). However, ongoing technical
advances and recently reported results from academic centers suggest
that this modality may have an increased role in the local management
of prostate cancer in more typical years.?
Extra reading on testosterone
These previous answers may be of interest to you:
Keep in mind that this answer if for information purposes only, and
not intended to replace sound medical advice from your physician.
There you go, Tosop! I apologize for not formatting the answer better
in the first place. (Maybe I should not answer questions when I?m
tired!). The other reason was that the questions AND answers did
overlap in content! I went ahead and tried to place the answers point
by point, while maintaning the original content. I have included extra
information in this answer for you! Thank you for your patience-I