We ‘stage’ prostate cancers in different ways. The doctors’ first task is simply to perform the routine examination of the abdomen that they learned as students, and have perfected with experience. This involves looking for lumps in the groin, ‘tapping’ (percussing one finger against another lying flat on the abdominal surface) for an over-full bladder, looking at the legs for swelling, then placing a linger in the rectum.
The rectal examination is still the best way for the experienced doctor to assess the prostate. In the United Kingdom it is done with the man lying on his left side, the knees drawn up to the chest. In the United States, it is usually performed with the man standing, and leaning forward against a wall. Some doctors now employ a knee-elbow position, on the grounds that it gives a better ‘feel’ of the whole prostate gland. As most tumors arise in the peripheral zone, i.e. the part of the gland that is nearest the finger, rectal examination is remarkably accurate in detecting cancers.
The earliest stage that can be detected is a firm “nodule’ like a hard pea, that is well within the gland, not altering its shape. This is defined as stage T2a or Bl. depending on the system used by the clinic. Stage Tl is a cancer usually found almost by accident, during tests for BPH, with no indication of tumor on rectal examination. It is described below in the paragraph on TURP’.
Stage T2b or B2 cancers feel harder still and are larger and more diffuse, with a less well-defined edge, but remain localized to one side of the gland. Stage T3 (or C) cancers are larger still, and distort the normal prostate outline, but the gland remains mobile and unfixed to the surrounding tissues. Stage T4 (D) cancers lead to hard, misshapen, enlarged prostates that are much less mobile because they are fixed to the surrounding pelvic structures. They are the cancers most likely to be linked to distant metastases.
Experienced family doctors and all specialists in prostate gland disease can usually tell the difference between cancers and BPH by the ‘feel’ of the prostate surface and its texture. BPH feels softer and has more ‘give’ in it than cancer, and the swelling of the gland is much more symmetrical than cancerous masses. However, there are other prostate conditions that are more easily confused with cancer. One is chronic prostatitis.
Chronic prostatitis is the result of recurrent infections (“acute prostatitis”) in the prostate gland. These bouts of acute prostatitis are fairly easy to diagnose. They involve all the usual signs of infection, such as fevers, sweating, and pain in the lower abdomen. The acute illness also causes severe pain on passing urine, sometimes with blood in the urine, and can be mistaken for a urinary infection. However, the give-away sign is a very tender, but soft, prostate on rectal examination. Doctors have to be very careful doing rectal examinations in men with acute prostatitis, as it can elicit extremely severe pain.
The treatment for acute prostatitis is the appropriate antibiotic, but in some cases the infection lingers on. That can eventually lead to hard deposits of calcium (sometimes giving a gritty feeling, or even presenting like a prostate “stone”) that may feel like a cancer. Chronic prostatitis often accompanies BPH. so that the gland is enlarged too, making confusion with cancer even more likely.
Most of the time the rectal examination alone is enough to confirm or rule out prostate cancer, but there are cases when it is impossible to differentiate between chronic prostatitis and prostate cancer. This is one reason for all suspected cases to be subjected to biopsy – a piece of the prostate is removed and examined under the microscope.