Tom McNicholas has written widely on many aspects of urinary disease. He is particularly in demand for teaching on benign prostatic disease and urinary symptoms. He has major interests in the management of prostate cancer, the treatment of urinary stone disease and in making common urological investigations (especially prostatic biopsy) both painless and safer.
He has written over 150 major scientific papers which can be reviewed in the bibliography. Most recently he has been lead author of the chapter on Benign Prostatic Disease in the latest addition of Campbell’s Urology. This 4 volume textbook is the “bible” for urology and is used by urological experts worldwide. He is one of only a small handful of British urologists to have been recognised in this way.




Mens Health Week Q & A on prostate cancer


During the recent Men’s Health Week a patient support website 
(http://www.localcounsellingcentre.co.uk/counselling_news_blog.html#.U80M6LR4xUQ)  
offered the public the chance to ask me questions about their condition (Most enquiries were related to  prostate cancer).
Introduction: At LCC we are often consulted by men who have been diagnosed with prostate cancer and who are concerned. Many worry about the effect this will have, not only on their health, but also on their relationship and sex life. In the UK, about 1 in 8 men (13 per cent) will get prostate cancer at some point in their lives. The risk increases with age, with the majority of men affected being over 50 and the average age of diagnosis being 70-74 years. Some prostate cancers have a genetic pre-disposition and someone who has had a close relative affected is more likely to get prostate cancer than someone who has no affected relatives. Certain ethnic groups are also more likely to be affected with black men being more likely to be diagnosed at the ratio of 1 in 4 at some point in their life. This is thought to be due to genetics. Diet and lifestyle are also thought to be important in preventing the disease.

Many men with early prostate cancer do not have any symptoms as the prostate cancer is slow-growing to start with and may indeed never cause any symptoms or problems in a man’s lifetime. But some men will have cancer that develops more quickly and that is more aggressive, which will need treatment to help prevent, or delay it, spreading outside the prostate.

In reply to the enquiries I am going to repeat the questions and then add my answer below each one:
have been told I will not need surgery and will have hormone injections and radiotherapy. The Doctor mentioned side effects like the menopause but I am not sure I understand what is meant. Can you clarify?
When you were offered hormone therapy following a diagnosis of prostate cancer somebody should have explained to you the side effects to expect.  Usually, a specialist nurse will go through the pros and cons of the treatment so you know what to expect.  A detailed information sheet is usually given as well.  If you did not have any of these then you should ask why not?  However, the hormone therapy causes a reduction in the male hormone and as a result men often have “menopause-like symptoms” such as hot flushes, weight gain and sometimes breast swelling.  If the breast swelling is painful or unsightly then treatment can be given and it needs to be given very early on so this is something to ask your radiotherapist about as soon as possible before you begin treatment.  Most men develop thinning of the bones as well, ie all the symptoms that women are familiar with after the menopause.  There are treatments available for each of these side effects if they occur.
I am having a radical prostatectomy and am concerned about impotence. I am also embarrassed to discuss with my doctor. Is this always a problem and what can I do about it?
If you are having a radical prostatectomy the doctor should have taken the opportunity of going through the issue of sexual side effects with you.  I am surprised if they did not because nearly everybody is embarrassed and it is the doctor’s role (or the specialist nurse if you saw one as well) to go through these issues with you and to describe the treatments that are available to reduce the risk of impotence. A lot depends on just how the surgery is to be done and therefore you do have to discuss it with your doctors performing the treatment and as soon as possible so that they know that this is an issue for you and they can discuss with you whether or not it is possible to preserve the special nerves that help with erections. That is not always possible, but that should be made clear to you up front and then you can discuss what can be done afterwards to regain sexual function. 
I am having a prostatectomy and have not long been married. My wife is younger than me and was hoping to have children. Is this possible?
It depends what form of prostatectomy you are having.  If it is a “radical prostatectomy” for prostate cancer then the whole prostate and various associated tubes are removed and even though you may regain sexual function you will not be fertile. If you are having a “TURP”, ie a telescopic operation for benign prostatic obstruction where a cancer is not the issue then the operation may affect how you ejaculate and that can affect the ability to get sperms into the right place to get your partner pregnant.  There are arrangements that can be made such as harvesting sperms and storing them before any operation, so you need to immediately discuss this with your doctors and especially the specialists who are planning your prostatectomy.  Usually, there will be a specialist nurse who has been assigned to discuss matters with you and he or she is usually the best first option to approach.
Can I pass on the disease through my semen?
It depends what disease you mean.  It is actually very difficult to pass on any significant disease through your semen.  However, drugs can be transmitted e.g. Finasteride and some infections can be transmitted, e.g. sexually transmitted diseases, but there is no risk of passing on either prostate cancer or benign prostatic enlargement.
Is treatment always a prostatectomy? 
No, treatment is not always a prostatectomy.   “Prostatectomy” is an unfortunate phrase that now covers a wide range of different operations.  It is necessary for you to know exactly what form of prostatectomy is being suggested and for what purpose.  If treatment is for prostate cancer then radiotherapy in different forms may be just as effective as total removal of the prostate by "radical prostatectomy”. The treatment has to be carefully customised for your particular needs and may mean one form of prostatectomy, but not another. If the prostate is not cancerous then an entirely different treatment may be better such as a bladder neck incision or the UroLift device for benign prostatic conditions (see www.urolift.uk).
My brother and father have had prostate cancer should I be monitored at regular intervals. I am 43?
I think with a family history such as yours you should have a PSA in the next year or so.  If your PSA is below 0.5 then your risks of a prostate cancer are very low for the foreseeable future and another PSA could be deferred for 3-4 years.  If your PSA is above 0.5 then you should be having a PSA annually in order to give you the opportunity of catching any prostate cancer that develops early when it can be more successfully treated and when men usually get over the treatment more easily.
Should every man over 50 be monitored like with women and breast cancer? If not why not?
Unfortunately, screening the whole population for either prostate cancer or breast cancer has been shown to be counter productive and to turn up too many people who have disease that may never cause them a problem.  Unfortunately finding that sort of "insignificant" or low risk cancer may lead to painful and expensive biopsies and indeed the effects of major treatment that MIGHT be unnecessary.  However, men with a strong family history of prostate cancer i.e. father and uncles or with cousins who have had very early prostate cancers (below the age of 60) should be screened with an early PSA blood test e.g. at about age 40.  Men of Afro-caribbean origin also have a higher risk
My sex life is very important to me. I do not want to be impotent even if my survival is compromised, is there any treatment that will not affect potency?
This depends on whether your treatment is for benign prostatic disease or for prostate cancer. Sexual function is more likely to be preserved, indeed erections can improve after treatment for benign (non-cancerous) conditions of the prostate.  Unfortunately most prostate cancer treatments will significantly affect sexual function.  That is why it is vital to discuss your particular needs with an expert before you go too far with treatment.  There is always room for adjustment and compromise in how treatment is delivered.


Prof Tom McNicholas
Consultant Urological Surgeon
Pinehill Hospital, Hitchin; Spire Hospital, Harpenden; The London Clinic, London WC1and East & North Herts NHS Trust
www.tommcnicholasurology.com
sec:yt@mcnic.globalnet.co.uk

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