Many men diagnosed with prostate cancer, including those with advanced stages, experience no symptoms at all. This underscores the importance of proactive screening, such as the prostate-specific antigen (PSA) test, which can detect the disease in its early, often asymptomatic phases. However, when symptoms do emerge, they typically involve changes in urinary habits. To shed light on how medical professionals navigate these signs, we consulted Dr. Marc B. Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, who also serves as editor in chief of the Harvard Medical School Guide to Prostate Diseases.
In early-stage prostate cancer, if symptoms appear, they generally affect urination. These are known as lower urinary tract symptoms (LUTS) and can include needing to urinate frequently, feeling a sudden urgency, struggling to start or stop the flow, waking up multiple times at night to pee, or sensing that the bladder never fully empties. Such issues may arise if a tumor grows large enough to physically block the urethra, the tube that carries urine out of the body. Alternatively, an enlarged prostate might press against the bladder, reducing its capacity to hold fluid. Yet, it’s crucial to note that urinary symptoms more commonly stem from other prostate-related conditions rather than cancer.
Benign prostatic hyperplasia (BPH), a natural enlargement of the prostate that affects most men as they age, is a frequent culprit. Inflammation of the prostate and surrounding tissues, called prostatitis, can also lead to LUTS. Additionally, burning sensations during urination often point to bladder issues rather than prostate problems. Men experiencing any urinary symptoms should seek evaluation from a doctor to pinpoint the underlying cause.
When a doctor begins to narrow down a diagnosis, they first rule out prostatitis and bladder diseases. The next step involves differentiating between prostate cancer and BPH. Men with BPH typically exhibit two types of urinary symptoms: voiding symptoms, such as a weak or intermittent stream and incomplete emptying, caused by obstruction at the bladder outlet; and storage symptoms, like a sudden urge to urinate or increased frequency day and night, resulting from an overactive and sensitive bladder. A red flag for prostate cancer would be experiencing only storage symptoms or noticing urinary symptoms that develop very rapidly, which is unusual for BPH-related LUTS.
To assess these symptoms, doctors may use tools like the American Urological Association Symptom Score questionnaire. A digital rectal examination (DRE) can also provide valuable insights. If the prostate feels symmetrically enlarged—meaning the gland is bigger but uniform in shape—it often supports a BPH diagnosis. However, asymmetry or a hard nodule detected during a DRE warrants referral to a urologist for further evaluation. Dr. Garnick emphasizes that DREs, though performed less frequently today and sometimes lacking in training among doctors, remain a critical component of physical exams in his view.
It’s important to recognize that BPH, if left untreated, can lead to serious complications like kidney failure or acute urinary retention, a medical emergency characterized by a sudden inability to urinate. Thus, addressing BPH is essential to prevent these outcomes.
The PSA test can aid in distinguishing between BPH and prostate cancer. PSA levels tend to rise in both conditions because a larger or more irritated prostate gland releases more PSA into the blood. Typically, patients with suspected BPH are started on medications that ease urination and lower PSA. After about six weeks, a follow-up PSA test is conducted. If levels remain high, the next step is often a magnetic resonance imaging (MRI) scan of the prostate. A normal MRI result, combined with PSA levels proportionate to prostate size, can help rule out cancer, potentially avoiding a prostate biopsy—at least temporarily—in favor of continued PSA monitoring.
In cases of more advanced prostate cancer that has metastasized or spread, many patients still show no symptoms. Advances in treatment and imaging have improved outcomes for advanced disease, allowing for better identification and management of small cancer deposits. When symptoms do appear, especially if the cancer has spread to bones, men may experience back or shoulder pain, often where metastases grow near nerve-rich bone surfaces. Persistent or worsening back pain despite treatment should prompt further evaluations, such as x-rays or MRIs.
Symptoms like fatigue and weight loss are more commonly associated with other cancers, such as colon cancer, lung cancer, and lymphoma. They typically do not occur in prostate cancer unless the disease is very advanced with widespread metastases.
Dr. Garnick highlights the challenge for both patients and physicians: identifying the causes of overlapping urinary symptoms, which are prevalent among men with either prostate cancer or BPH. By understanding these nuances, individuals can make informed decisions about their health and seek timely medical advice when needed.
