While men might find themselves embarrassed to talk about erectile dysfunction, the reality is that it’s incredibly common and can be easily treated in virtually all cases.

“The topic of erectile dysfunction is taboo and not much talked about. But it’s important for men to know that the problem is very common and that the risk of developing erectile dysfunction increases with age,” says Mr Giulio Garaffa, Consultant Uro-Andrologist at the University College London Hospitals.

Current statistics show that more than 60% of men aged 50 may suffer from erectile dysfunction and, importantly, it could also be a warning sign that things aren’t right in your cardiovascular system and in your health in general. As the arteries carry blood to the penis, a problem with maintaining an erection warrants a check of your whole cardiovascular health. Since erectile dysfunction often indicates that your cardiovascular system is not healthy, it is not surprising that both heart attacks and strokes are more common in men suffering from erectile dysfunction.

Erectile dysfunction-solving pills might not always be appropriate – check with your GP

Mr Garaffa says men should talk to their GP as soon as they realise that they might suffer from the condition. He says: “There is definitely a need to find the cause of erectile dysfunction and identify any cardiovascular risk factors, such as high blood pressure, raised cholesterol and triglycerides, raised blood sugar, obesity, lack of physical activity, tobacco smoke and excessive alcohol intake. Men with erectile dysfunction are twice as likely to develop heart attacks and strokes as men who do not have erectile dysfunction, so the aim is to slow down cardiovascular disease in general.”

In terms of treating erectile dysfunction there are a variety of options, with PDE5-inhibitor pills being the first line treatment in most men. These medications help to relax the arteries in the penis, which produces an increased blood flow to the organ and ultimately a better erection. Although they are available over the counter, and are effective in a large number of patients, it is still worth seeing your GP to make sure further health checks are carried out – and to make sure that this treatment is appropriate; some health conditions are not compatible with these medications.

There is also a range of injections and topical creams that work by increasing the blood flow to the penis. If the above treatments are ineffective, poorly tolerated or contraindicated, a vacuum pump can be offered to the patient.

Another promising, non-surgical option is low intensity shockwave therapy, which rejuvenates the tissue inside the penis, improving blood flow and ultimately the quality of the erections. Various studies have shown that this treatment is safe and well tolerated. Encouraging results in terms of long-term improvement of erections are common in carefully selected patients.

Surgical solutions after non-invasive options have failed to work

Surgical treatments for erectile dysfunction are recommended for men if the treatments mentioned fail to work or are contraindicated.

Mr Garaffa explains: “In experienced hands, penile prosthesis implantation has a very high success rate and will allow the patient to have the rigidity necessary to resume sexual activity in full confidence preserving completely sensation and climax.  Many men find that the implant is very discreet and from the outside the penis will look perfectly normal. In general, best results are achieved with inflatable penile prostheses, which are designed to create both flaccidity and erect state.”

While surgery is only recommended after other treatments fail, are contraindicated or poorly tolerated, there is often embarrassment from patients who may not be aware that it is still a safe and effective treatment.

“I would suggest that any man interested to know more about the cause and treatments of erectile dysfunction visits the British Society of Urological Surgeons and downloads the free patients’ information leaflets there.”

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Amy Rylance

Head of Improving Care, Prostate Cancer UK

The current COVID-19 pandemic has created unprecedented pressures on the health service, and big drops in cancer referrals.

As the most commonly diagnosed cancer in the UK, the drop-in referrals mean that there are potentially thousands of men with clinically significant prostate cancer who could be cured, but who may now not be diagnosed until curative treatment is no longer possible.

Resuming referrals

Men are still experiencing high levels of anxiety around attending medical appointments and need to be reassured that steps are being taken to minimise their exposure to COVID-19. As most men with prostate cancer don’t have any symptoms, they also need to be made aware of their risk factors and empowered to speak to their GP if they are at risk.

To help men find out whether they are at higher risk, the charity has launched an online risk checker, available at prostatecanceruk.org/check.

There is significant variation across the country in terms of delays to treatment, with many men contacting us concerned that they have been ‘forgotten about’.

Treatment backlogs

There is significant variation across the country in terms of delays to treatment, with many men contacting us concerned that they have been ‘forgotten about’ in the crisis. Good communication is vital for these men, who may simply need reassuring that their individual risk is considered and that there is a low risk of harm from delays.

It is also essential that those most at risk of harm are prioritised as treatments resume, and that new approaches are found that minimise potential exposure to COVID-19.

Planning to rebuild

Many healthcare professionals are finding new digital ways of running clinics that help avoid the viral risk, transport costs, and long waits in crowded rooms for routine appointments. The legacy of this should be greater adoption of risk stratified personalised follow-up pathways to ensure that no man is forgotten, such as the TrueNORTH Supported Self-Management programme.¹

A common thread through these issues is the power of effective communication with men. Men need support to understand their risk, their diagnostic and treatment pathways and how these may be changing as a result of COVID-19, if they are to feel confident engaging with these pathways. This engagement is more important than ever if we are to avoid the COVID-19 crisis becoming a prostate cancer crisis.

Men and their clinicians can also contact Prostate Cancer UK’s specialist nurses on 0800 074 8383 or online via the live chat instant messaging service: www.prostatecanceruk.org

This article was composed in coordination with Trends in Urology and Men’s Health and the team at Prostate Cancer UK.

[1] Frankland J, Brodie H, Cooke D, et al. Follow-up care after treatment for prostate cancer: evaluation of a supported self-management and remote surveillance programme. BMC Cancer 2019;19(1):368. doi.org/10.1186/s12885-019-5561-0.

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Benign prostate enlargement is a normal condition of growing old for most men, with half of over 60s expected to suffer from symptoms such as poor flow and more frequent urination.

Symptoms such as difficulty starting to urinate, not emptying fully or frequently going to the toilet in the day or night are all signs of possible benign prostate enlargement (BPE). This is a normal physiological process, which may not always occur with symptoms.

An enlarged prostate can be indicated by bladder problems

The prostate sits around the urethra at the base of the bladder; its function is to contribute to secretions in the ejaculate, but this gland can enlarge as men get older. This can result in slowing of urinary flow and it being increasingly hard to empty the bladder.

For most men, this results in bothersome urinary symptoms such as taking a long time to wee and needing to go more frequently and during the night. For a small proportion of patients, the failure to empty the bladder properly can result in urinary tract infections, bladder stones or potentially reduction in kidney function if the pressure in the bladder rises. 

Men generally present to their GP if their symptoms are irritating them or if they are concerned about prostate cancer. The GP would review the patient’s symptoms and examine them, as well as sending off a blood test (prostate specific antigen) before referring on a fast track pathway if there was a concern about prostate cancer. For those patients with symptoms consistent with benign prostatic enlargement, patients would be offered lifestyle and drug medications to help improve their flow. 

Treatment options for those with BPE

Men whose symptoms do not improve with medication alone may be offered surgery on their prostate. The most common procedure performed is a transurethral resection of the prostate (TURP) procedure.

Miss Kate Warren is a consultant urological surgeon at Bristol Urological Institute, Southmead Hospital. She explains: “There are a number of options to relieve bladder outflow obstruction caused by benign prostatic enlargement – a TURP is where you resect the central part of the prostate to relieve the obstruction. This was an alternative to removing the whole prostate as an open procedure, which used to be the standard treatment. More recently, there have been other procedures developed to treat BPE – bipolar TURP (PLASMA), prostatic artery embolisation, Urolift, Holep and rezum steam treatment. Each patient should be offered alternatives and be counselled about the risks and benefits to them of each treatment.”

Bipolar TURP uses irrigation fluid, which is isotonic to the body’s fluids, meaning there is less risk of absorbing hypotonic fluids, which used to cause a condition called TUR syndrome. It also allows better coagulation of vessels so the risk of bleeding and needing a urinary catheter for a prolonged period of time is reduced. 

Miss Warren adds: “The prostate is a vascular structure and the risk of bleeding used to keep patients in hospital for a couple of days after the operation. With the PLASMA system, the risk of bleeding is much less, so patients can often go home on the day of surgery. This currently is desirable considering the ongoing coronavirus pandemic; ensuring patients are in elective hospital settings for the shortest time possible.”

FAQs

How successful is the procedure? Most symptoms of poor flow will improve in the vast majority of patients. Around 2-10% of patients may still not empty their bladder fully, rely on a catheter or have to self-catheterise. There is also a small risk of incontinence (approximately  2-10%).

What is the risk of erectile dysfunction? Most men experience retrograde ejaculation after a TURP, where the semen goes back into their bladder instead of going forward, and may alter the sensation of orgasm. This isn’t harmful and the semen will mix with urine to empty naturally. The risk of reduced quality erections would be around 2-10%.

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As COVID-19 continues to dominate most of our lives, and hospitals are caught between preparing for a second wave and getting back to their new normal existence, it is an important time to highlight some of the issues that have been pushed out of the way by coronavirus.

The pandemic, while incredibly serious, hasn’t made urological and other cancers disappear or slowed their growth, but the numbers of patients presenting to primary care remain significantly down on normal across the UK. This means there is a group of patients potentially sitting on a cancer time bomb due to either ignoring their symptoms or feeling too anxious to discuss them, or come to hospital or a GP practice at the current time.

Painless visible blood in the urine leads to about a 30% chance of identifying a cancerous cause

Know the symptoms for cancer

There are some key urological symptoms that could signify important life-threatening cancers and other serious diseases. Perhaps the most obvious of these is visible blood in the urine, medically known as haematuria. This is a particularly significant event if it occurs without other urinary symptoms, which might indicate a urinary infection (burning, stinging and frequent urgent urination); often referred to as painless haematuria.

Painless visible blood in the urine leads to about a 30% chance of identifying a cancerous cause. Painful or symptomatic haematuria can also be a sign of significant issues including cancer as well but is more likely due to a urinary tract infection.

Most commonly painless haematuria can be a sign of bladder or kidney tumours, which are usually curable with early surgery. But, given enough time, these tumours can grow and spread outside their place of origin, so time is critical to ensuring the best outcomes. With this is mind it is vital that people tell their doctors if they experience blood in their urine and get an urgent referral to a urologist on a rapid access pathway.

Safety precautions to encourage hospital visits

To reassure those concerned about coming into hospitals at the current time, there are many precautions in place to ensure the safety of our patients with special precautions in both the diagnostic and treatment protocols for these conditions. In addition, the risks of the underlying problems causing the blood are likely to be far higher than the risk of potentially contracting COVID-19.

After fighting a challenging battle with coronavirus, let’s not lose the war on urological cancer.

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Earlier diagnosis and interventions of prostate cancer help to keep men living longer.

“It’s a common misconception that all men with prostate cancer die with it, rather than because of it, but that’s only true if the cancer has not spread,” says Professor Amit Bahl, consultant oncologist at University Hospitals Bristol NHS Trust. Prostate cancer is the second most common cancer in men. Prostate cancer is the most common cancer in men in the UK¹ and Black African and Caribbean men have double the risk of developing prostate cancer compared to white men².

If men are diagnosed early, before the cancer has metastasised (spread), curative treatment is possible. Later diagnosis or an advanced stage of prostate cancer sometimes results in clinicians switching treatment focus to that of simply prolonging life, reducing pain and the risk of life-changing events, such as bone fractures.

Spouses and partners are often the ones driving the decision to see a GP

Professor Bahl often hears men say that they only saw their GP because their spouses made them go. “We want this to change,” he says, calling for more men to speak up and openly about prostate cancer with loved ones and their doctors.

Common symptoms of early prostate cancer – particularly in the high-risk group of men aged around 70 years old, include changes in urination – such as an increased need to pee, straining, or a feeling that your bladder has not fully emptied. However, many men delay seeing their GP often because they are afraid of the disease and treatment options, which centre on blocking testosterone – or to use its medical term, chemical castration.

The side effects of hormone therapy (androgen deprivation therapy) can include fatigue, weight gain and sexual problems. As Professor Bahl says: “Hormone therapy is a difficult discussion. Counselling and exercise are both strongly recommended to improve people’s wellbeing during hormonal therapy.”

Watch and wait approach

For patients in early stage prostate cancer, where there are no detectable metastases, clinicians keep a close eye on hormone levels of prostate-specific antigen (PSA) for guidance on how a cancer is progressing. In men with non-metastatic prostate cancer, who are receiving hormone therapy, quickly rising PSA levels are a signal that the current hormone therapy is no longer working and development of metastatic disease is likely.

It is important for men to keep having their PSA checked to manage progression. Recently, there have been developments in this field with treatment options showing a significant delay in development of metastatic disease and improving survival along with maintaining quality of life.

Professor Bahl says: “New treatments can give patients significant hope for increased life expectancy. Aside from COVID-19, the two major causes of death, now, are heart disease and cancer. This makes it a key focus of attention for the industry as greater numbers of people will live to be able to benefit from drug innovation.”

Job code: PP-UN-ONC-GB-0041

[1] Prostate Cancer UK. Prostate Cancer and Risk. Available at https://prostatecanceruk.org/prostate-information/ are-you-at-risk [Last accessed July 2020] | [2] Lloyd T. et al. Lifetime risk of being diagnosed with, or dying from, prostate cancer by major ethnic group in England 2008– 2010. BMC Medicine. 2015;13(1): 171. Available at https://bmcmedicine.biomedcentral.com/ articles/10.1186/s12916-015-0405-5 [Last accessed July 2020]

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A survey conducted as part of Urology Week 2020 shows that awareness of erectile dysfunction (ED) is alarmingly low in men and women aged 20 to 70. The majority of the respondents do not know what ED exactly entails, and one in four has never heard of any treatments for ED.

The survey examined the knowledge of and experience with ED of 3,032 men and women of different age groups between 20 and 70 years old in Spain, France, Germany, and the UK. When asked what ED is, the majority of the respondents either gave incorrect answers (34%) or stated they do not know what ED is (17%).

“As ED is actually a common male medical condition, it is surprising that a majority does not know what ED is,” comments Prof. Christopher Chapple, Secretary General of the European Association of Urology (EAU).

Indeed, the EAU Guidelines 2020 on Sexual and Reproductive Health state: “epidemiological data have shown a high prevalence and incidence of ED worldwide.”

“The risk of having ED increases with age, but it affects men of all ages and ethnicities,” Prof. Chapple continues. “As a result, there shouldn’t be any taboo against it. Although I am happy to see that the majority of the respondents who have experience with ED say to talk about it, there is still room for improvement.”

I understand that ED (erectile dysfunction) is regarded as a private matter. But this should not prevent people from addressing this issue and improving their quality of life.

Communication is the key to breaking down the taboo

Of the 17% of the respondents who themselves have ED or have a partner with the condition, approximately one in four (26%) admitted to not talking about it with anyone. Worrisome is that, of those in a relationship, only 29% talk to each other about ED. German respondents most often gave, “feeling uncomfortable to talk about ED,” as the reason for not seeking professional help.

“Clearly, ED is a common medical condition. There’s absolutely no need for shame,” Prof. Chapple emphasises. “As urologists, we need to display that attitude by communicating openly. The patient needs to know that ED is common and that shame about it is understandable but unnecessary. Communication is the key to breaking the taboo.”

One in four respondents has never heard of any treatments

Prof. Chapple refers to another alarming outcome; one in four of the respondents (26%) has never heard of any of the seven treatments for ED listed in the survey: medication, sexual education and relationship therapy, a vacuum erection device, penile injections, penile implants, shockwave therapy, and topical therapies. Knowledge about ED treatment is most limited in the UK; 31% have never heard of any of the treatments listed and only 50% think ED is treatable.

Prof. Chapple says “I understand that ED is regarded as a private matter. But this should not prevent people from addressing this issue and improving their quality of life. We need to increase the public awareness and knowledge about ED. It is a common medical condition that is treatable, nothing more than that. That stigma surrounding ED has to be removed, and we all have a role in developing that mindset. Urology Week is an ideal opportunity to raise awareness of this.”

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COVID-19 has had a profound impact on the diagnosis and treatment of prostate cancer across the UK and the repercussions are likely to continue for some time to come.

Before the pandemic hit, diagnoses had been rising in the UK for many years.

Earlier this year, it was announced that the disease had become the most commonly diagnosed cancer in the UK – a decade earlier than previously predicted.

When combined, the total number of prostate cancer diagnoses for England, Scotland, Wales and Northern Ireland reached 57,192 in 2018, exceeding those of breast, lung and bowel cancers.

This surge in cases is likely to be the direct result of their huge increase in awareness of prostate cancer, fuelled, in part, by campaigns like Movember, as well as high-profile individuals such as Bill Turnbull and Stephen Fry sharing their experience of the disease in the same year.

As services begin to return to normal, it is vital that anyone with concerns about their prostate cancer risk, particularly if they are having symptoms such as difficulty urinating or blood in urine or semen, seek medical advice.

Mass awareness has helped identify more cases of prostate cancer, earlier on

Finding prostate cancer early followed by swift access to the most effective treatment, offers the best chance of survival for most men.

However, during lockdown, it was even harder than normal for some men to get the tests and treatment they needed. In some parts of the country, diagnosis and treatment of prostate cancer stopped altogether, causing a great deal of anxiety for men and their families. 

The number of people being urgently referred for suspected cancers (of all types) dropped by around 75% at the peak of the outbreak, meaning fewer patients being referred for diagnostic tests and specialist consultations.

Although the situation is now improving, there are still fewer people than usual coming forward with potential symptoms. Meanwhile, the backlog of patients requiring diagnostics tests continues to build.

COVID-19 has discouraged many men from seeing their GP

Fear of catching COVID-19 (or worries about bothering their GP) has meant many men have not had conversations with their doctor about their prostate cancer risk. We’re worried this could mean many men have their prostate cancer diagnosed too late – when it is more difficult to treat.

As services begin to return to normal, it is vital that anyone with concerns about their prostate cancer risk, particularly if they are having symptoms such as difficulty urinating or blood in urine or semen, seek medical advice. Men who are most at risk are those aged 50 and over, black men and men with a family history of the disease.

The huge rate of progress in scientific research into new tests and treatments for prostate cancer means that a man diagnosed today has a better chance of survival than someone diagnosed 20 years ago. However, the pandemic has meant that lifesaving prostate cancer research around the world has ground to a halt and we urgently need to help get that research back on track.

With the support of our passionate and dedicated Mo community, we will keep fighting so that men can enjoy the longer, healthier and happier lives they deserve.

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Many men will experience trouble urinating properly as they age. Benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate, is a common cause of this.

The prostate lies between the penis and bladder, and wraps around the urethra (the tube that passes urine out of the body), so by increasing in size, it puts pressure on the bladder making it difficult to pee.

BPH is a gradually progressive disease that often affects men aged 40 and above. It is generally said that 50% of men over 50, and 80% of men over 80 will suffer from it.

In the UK, 25,000 individuals undergo surgery to relieve bladder outflow obstruction caused by BPH every year. In 2008, the estimated total annual direct medical costs of BPH were £180.8 million, with around 60% of these costs incurred in secondary care as a direct result of managing BPH complications. With life expectancy of men rising, this common condition will become even more prevalent.

BPH often requires medication or surgery but some men chose to live with the symptoms

The symptoms of BPH are disruptive and impact on a man’s wellbeing. It often needs to be treated by either medication or surgery. Sometimes it can lead to the inability to pass urine at all, prompting an emergency admission to hospital for insertion of a catheter, often followed by surgery. It causes a reduced quality of life for aging men and is expensive to treat, placing a considerable burden on the health service.

In the UK, 25,000 individuals undergo surgery to relieve bladder outflow obstruction caused by BPH every year.

Some men might be tempted to put up with and live with symptoms, such as getting up frequently in the night to pee, if they are not too bothersome. But, if not treated and monitored, BPH can lead to other problems such as urinary tract infections or even kidney disease. Some of the symptoms of BPH are similar to those for prostate cancer, so men should always see their GP to get checked and to rule this out.

Erectile dysfunction may be a side effect of treatment

There are several treatment options for BPH, from medication through to minimally invasive procedures and surgery. However, in some cases the treatments themselves can also cause side effects, ranging from incontinence to loss of libido or erectile dysfunction, making the choices for men hard. To date there are no options for personalised therapies.

Despite the prevalence of BPH among older men, there is still very little understanding of the disease or who is more prone to suffer. This is why The Urology Foundation is funding a major three-year research study into BPH. Our researchers hope to unlock the genetic drivers of the disease in order to develop personalised and targeted drug treatments that have fewer side effects, and also to identify those men who may have genetic risk factors and who may benefit from earlier treatment, thereby delaying or preventing progression of this pernicious disease.

Signs and symptoms of BPH

• Hesitancy (difficulty starting urination)
• Weak stream
• Straining to pass urine
• Urination taking a long time
• Feeling of incomplete bladder emptying
• Needing to pass urine urgently
• Passing only a little urine despite urgent need
• Needing to pass urine frequently
• Getting up in the night to pass urine
• An increasing (sudden or slow building) inability to pass urine

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