Movember is over at last: the handlebars have gone and the monkey-tail moustache has finally disappeared down the sink. Growing facial hair to raise awareness of, and funds for, men's’ health is a laudable cause; but many of my patients still don’t seem to know what or where their prostate is – although it’s clear they have an inkling from their glum looks if I suggest an examination. Only men have a prostate gland – it makes the fluid that nourishes and transports sperm – yet both sexes are equally likely to refer to it by the wrong name, as in Sue Townsend’s lovely novel Adrian Mole: the Prostrate Years. (Mole eventually gives up trying to promote the correct spelling, bravely submitting to many discussions of his “prostrate” instead.)
If you were to perch a balloon on top of a ring doughnut, that would give you an idea of the relationship of the bladder to the prostate gland. As it fills with urine, the bladder lifts and expands like a balloon filling with air (if it is very full you can feel the top edge of the bladder in the abdomen as it rises out of the pelvis). The tube that carries urine to the outside world – the urethra – hangs out of the bottom of the bladder like the string of a balloon, passing through the middle of the prostate gland. This is why the prostate can affect the way you pee: if it enlarges, it can press on and squash the urethra, interfering with the flow.
Behind the prostate lies the rectum. The rectum and the prostate are so snugly related that you can feel the outside of the gland by pressing on the front wall of the back passage: hence we examine for the prostate “per rectum” – by doing a PR. (If you press on the back wall during a PR you can feel a hard bony mass that initially comes as a surprise: the tail-end of the spine.)
Learning to palpate the prostate is a difficult proposition, given its location. Most of us learnt, initially at least, on models. The urologist who taught me used a plastic tile with three rubber prostates mounted on it. “Have a feel of my three little pigs,” he’d say. One was normal, one benignly enlarged and one had an area of irregular hardness, suggestive of malignancy.
This was the first time I realised that there is a great difference between feeling an object you can see, and feeling something you can’t: your fingers don’t learn in the same way if your eyes are contributing information. It was easy to pick out the malignant piglet when you could see the irregularity. Later, another urologist gave me a better tip for examining the prostate on PR. A benign prostate is soft, like the bottom of your earlobe; a malignant one feels more like the end of your nose.
As with any gland in the body, the prostate can go wrong in a number of ways. Most commonly, it tends to enlarge with age, like a ring doughnut with ambitions to become a round doughnut instead. This condition – benign prostatic hypertrophy, or BPH – is not cancerous, nor does it increase your risk of cancer. It can cause a range of irritating urinary problems – increased frequency, urgency and hesitancy – many of which can be treated medically.
Prostate cancer is a more difficult proposition. It rarely causes symptoms in its early stages, and the only screening test – measuring a protein called prostate specific antigen, or PSA – throws up so many complicated issues that it needs its own column. What is for sure is that, in the prostate’s case, the surgeon’s favourite saying is decidedly true. If you don’t put your finger in it, you’ve put your foot in it.
Sophie Harrison is a hospital doctor in South Yorkshire