Prostate cancer is the most common type of cancer in males. It is the most commonly diagnosed malignancy, and 1 in 8 men are expected to be diagnosed with this disease at some point in their lifetime. That doesn’t include males with undiagnosed prostate cancer when it develops later in life. The incidence of this disease increases the older you are. Males who reach 80 years will have an 80% risk of prostate cancer, which is a lot.
Luckily, prostate cancer is not like other types of cancer. Older men are more likely to die from other causes than prostate cancer, and that’s why screening for the disease stops once you turn 70 years. This type of cancer usually grows very slowly, and it doesn’t have enough time to become lethal after this age.
Still, the disease has many signs and symptoms, and most of them involve the urinary tract. What we know as lower urinary tract symptoms (LUTS) in males are likely caused by prostate problems.
In this article, we will cover the most important lower urinary tract symptoms (LUTS) in males and how they can make us suspect prostate cancer. Then, the article will also cover other symptoms of advanced prostate cancer and metastatic disease.
Storage LUTS
Storage symptoms in the lower urinary tract are caused by inflammation. You could say they are symptoms of bladder or urethral irritation. They include:
1. Urgency to urinate
Urinary urgency is the sudden need to urinate immediately. Patients may feel normal at one time and feel the urge to urinate the next minute. This symptom can be accompanied by urinary incontinence, as we will cover below, but it is not always so severe. Urinary urgency is caused by inflammation and irritation of the urinary bladder. The irritated bladder sends signals to the brain in response to minor distention when the bladder is not yet completely full. But patients feel the urge to urinate, even if there’s still space in the urinary bladder.
2. Increased urinary frequency
This is also a classic symptom of prostate cancer but happens in benign prostatic hyperplasia, too. The enlarged prostate takes up space that should be taken by the urinary bladder. Thus, the urinary bladder is subject to additional pressure from the prostate and does not have time to fill. Also, the inflamed tissue of the urinary bladder sends early signals to the brain, even when the bladder is not completely full. As a result, patients need to go to the bathroom several times throughout the day, even if their liquid intake stays unchanged.
3. Nocturia
This is usually the first symptom patients with benign prostatic hyperplasia and prostate cancer report to their healthcare providers. Nocturia is the constant need to urinate at night. Patients wake up in the middle of the night with the urge to urinate, and it usually happens more than once. In some patients, nocturia causes fragmented and inadequate sleep, daytime sleepiness, and other consequences. This symptom responds to the same reason as increased urinary frequency. The urinary bladder fills more rapidly due to the extra space taken by the prostate, and the inflammation of the area contributes to sending the signal to the brain before time.
4. Urgency urinary incontinence
As mentioned above, some patients will have urinary urgency and urinary incontinence at the same time. In this case, the patient will feel not only the urge to urinate but also the sensation that urine will escape if they do not reach the bathroom on time. It actually happens sometimes, and they wet their pants if they do not find a bathroom nearby. As mentioned above, this only happens in more severe cases or when prostate cancer overlaps with other baseline conditions concerning the urinary tract.
Voiding LUTS
These urinary symptoms are mainly due to obstruction of the urinary tract. The urethral lumen is reduced, and the patients start experiencing the following symptoms:
5. Urinary hesitancy
This is a very uncomfortable symptom in males with prostate cancer because they feel the urge to urinate, as mentioned above but have problems starting to urinate once they are in the bathroom. Urinary hesitancy refers to the initial difficulty men experience when they begin to urinate. Once they are in the bathroom, they may take longer than usual to start the urinary stream. In some cases, they need to push very hard to beat the obstruction caused by the prostate. This happens because the prostate is around the urethra and squeezes the urinary tract as it grows.
6. Urinary intermittency
In normal cases, the urinary stream should start without pushing and continue uninterrupted to the end. In patients with prostate cancer, the urinary stream becomes interrupted several times, and not because the patient is cutting the stream halfways. The stream stops and resumes, and every time it stops, some patients may find it hard to restart the stream. In most cases, prostate cancer grows in the posterior portion of the prostate, so these symptoms of prostate cancer are likely caused by advanced disease. It is also a symptom of benign prostatic hyperplasia, and this diagnosis should always be ruled out.
7. Slow urinary stream
This is also a classic sign of prostate enlargement and can be caused by benign prostatic hyperplasia or prostate cancer. A slow urinary stream is also described as a weak urinary stream, and it is caused by a reduction of the urethral lumen. As mentioned above, the prostate is located below the urinary bladder and around the urethra. As it increases in volume, the gland causes an obstruction and reduces the urethral opening. There is a reduced volume of urine circulating through the urethra, which makes the urinary stream slower or weak. This is one of the earliest symptoms, nocturia and the increase in urinary frequency.
8. Straining
We have mentioned above that patients with prostate cancer have urinary hesitancy. This is a sensation of difficulty when they start to urinate, and sometimes they need to push through before the urinary stream initiates. Straining is similar, but in this case, the patient needs to push all the way through, and not only at the beginning of the urinary stream. Straining to urinate and the need to push all the way through make it difficult to void. Patients usually leave the urinary stream halfway or do not achieve a complete voiding of the urinary bladder.
9. Terminal dribble
Once the urinary stream is over, patients with prostate cancer and benign prostatic hyperplasia can have a terminal dribble. Instead of finishing the stream right away, they continue dribbling urine for a while. An obstruction of the urinary bladder also causes this slower urinary stream. In some cases, patients with terminal dribble wet their pants because they think the urinary stream stopped when it was still dribbling.
Post-micturition LUTS
These are common symptoms that show up after patients stop urinating. They are very uncomfortable and lead to nasty consequences, as you will see next:
10. Post-micturition dribble
This symptom is similar to terminal dribble, but the difference is the timeline. Terminal dribble and post-micturition dribble are both further reductions of the urinary stream and are both caused by the obstruction of the prostate gland. However, terminal dribble happens at the end of the urinary stream when it is still happening. In post-micturition dribble, the patient has already finished the urinary stream, and he would likely move on and do something else. But a few seconds or minutes after urinating, there will be drops of urine leaving the urethral opening and wetting the underwear of the patient.
11. The sensation of incomplete bladder emptying
This is also a very uncomfortable symptom and comes in response to all of the above. As noted, the prostate gland surrounds the urinary bladder and creates an obstruction. It won’t let the bladder empty and creates an obstacle that causes a slow urinary stream and terminal dribble. Patients may need to push all the way through to get the urine out. And even after doing so, they still have urine left in the bladder. The volume of urine that remains in the bladder after voiding is higher than usual, and this causes in patients an uncomfortable sensation of incomplete bladder emptying.
Other symptoms
There are also symptoms of advanced prostate cancer that do not have to do with the urinary tract. Once the prostate has grown very large or cancer starts having metabolic consequences, patients may begin experiencing the following signs and symptoms:
12. Back pain
Pain is a classic symptom in cancer in general, but it is not a leading symptom in prostate cancer. Male patients should look for and promptly report the urinary symptoms laid down above instead of waiting for the pain to come. It may never show up or start in the early phase of the disease, depending on what part of the prostate is affected and how the disease progresses. Prostate pain can be felt in different areas, including the back or the groin. It sometimes feels like a painful weight in the rectum, especially when filled with feces in a patient with constipation.
13. Hematuria
One of the features of cancer, in general, is the increase in vascularization of the affected area. Cancer and inflammation prompt the creation of new blood vessels to feed cancer cells. This is also true in the prostate, and these new blood vessels are tortuous and susceptible to breaking. That is why hematuria is a sign of prostate cancer. However, it doesn’t happen in all patients, and it is not indicative of the severity of the disease, either. Instead of looking for hematuria to suspect prostate cancer, we should be aware of the urinary tract symptoms laid down above.
14. Changes in the digital rectal examination
In a digital rectal examination, urologists can detect several abnormalities in the prostate gland. The most noticeable is an increase in size, which is evident for skilled doctors. Another meaningful change is that the prostate gland feels nodular, irregular in shape, or hardened in certain areas. This is a sign of prostate cancer and should be evaluated further with imaging tests and the PSA test. Another finding is the tenderness of the prostate gland, which is more severe when the prostate is more inflamed. Tenderness can also be found in prostatitis, which is a differential diagnosis.
15. Bone pain
One of the most common organs of metastasis in prostate cancer is the bone tissue. So, patients with advanced disease can experience bone pain due to metastasis. This is actually the first sign of prostate cancer metastasis to the bone. It happens because the metastasis areas change the bone structure and cause significant inflammation in the bone tissue. Unlike what people may think, the bones have many blood vessels and nerves, and this causes a dull or sharp ache in the affected area. In some cases, bone pain is not localized but spreads throughout the body.
16. Anemia
This is a symptom of advanced prostate cancer because localized cancer does not typically change the hemoglobin levels. There are many causes, including androgen deprivation, a nutritional problem, an infiltration of the bone marrow, treatment toxicity, or it can be a result of chronic inflammation. Androgen deprivation and treatment toxicity are causes of anemia in patients with ongoing treatment of prostate cancer. They are side effects of the treatment. Infiltration of the bone marrow is a problem that arises in the case of metastasis in large bones and impairs the production of red blood cells. And chronic inflammation is also a problem caused by prostate cancer, more likely in advanced disease.
17. Cachexia
Patients with advanced prostate cancer can also suffer a syndrome known as cancer-related cachexia. It is a wasting syndrome that includes weight loss, loss of appetite, muscle weakness, and fatigue. All of these symptoms are related to each other, and the cause is deeply rooted in metabolic abnormalities caused by cancer cells. What basically happens is that cancer takes up significant energy from the body to keep growing. It robs energy that other organs should have used instead. The inflammatory state also causes loss of appetite, and there is a reduction in the number and quality of nutrients the patient is receiving. Patients lose weight and start feeling fatigued and tired.
18. Neurologic problems
Some patients with advanced prostate cancer will also endure neurologic complications. For example, prostate cancer may metastasize to the lumbar spine and causes a lump that creates spinal cord compression. In some cases, prostate cancer metastasizes to the brain. This is a type of severe cancer known as leptomeningeal carcinomatosis. The most common neurologic problems are caused by spinal cord compression and cause symptoms such as pain and motor problems in the affected areas.
19. Edema in the lower limbs
This is also a consequence of prostate cancer metastasis and advanced prostate cancer. In this case, the prostate gland is very large, compromising the venous or lymphatic return to the heart. When this happens, liquid tends to accumulate in lower areas, and the patient starts to experience swelling and edema. Cancer can also take the adjacent lymph nodes and causes a similar obstruction of the lymphatic or venous return.
Conclusion
Prostate cancer is widespread in males, but it is not always lethal. In most cases, it grows slowly and is limited to the prostate, but there are also many cases of aggressive prostate cancer. Thus, we can’t underestimate the malignancy and aggressiveness of the disease.
The most important symptoms to detect prostate cancer are urinary symptoms such as weak urinary stream, straining, and nocturia. They can also be triggered by prostatitis, and an infection can trigger some urinary symptoms. However, the risk of urinary infections in males is much lower compared to women, and it is less likely to be the cause.
Other symptoms of prostate cancer include bone pain, edema, and back or groin pain. However, these are no early symptoms, and your suspicion of prostate cancer should not be based on them. They are more likely present in patients with advanced disease after many years have passed since prostate cancer started to grow.
Screening methods for prostate cancer include the PSA test, digital rectal examination, and ultrasound scans. However, they are not to be applied to all patients indiscriminately. Patients with a higher risk or those with suggestive urinary tract symptoms should run these tests, especially if they have first-degree relatives with the disease.
In any case, screening recommendations change according to the current public health concerns in a given population and the results of previous attempts to curb the consequences of the disease. Thus, the best idea instead of taking prostate cancer prevention in your own hands is to talk to your doctor and follow his advice.