Prostate health and screening

The prostate sits below the bladder and surrounds the urethra. It contributes most of the fluid in semen, and its posterior surface is reachable through the anterior rectal wall — the basis of prostate stimulation as a source of pleasure (see the anatomy article).

Benign prostatic hyperplasia (BPH)

Non-cancerous enlargement, present histologically in around 50% of men by age 60 and 90% by age 85. Symptoms are urinary: weak stream, hesitancy, incomplete emptying, nocturia.

Treatment has direct sexual consequences and this is often under-discussed:

• Alpha blockers (tamsulosin, alfuzosin) relieve symptoms quickly; tamsulosin causes retrograde or absent ejaculation in a substantial minority (reported 8–30%).
• 5-alpha-reductase inhibitors (finasteride, dutasteride) shrink the prostate over months. Trials report erectile dysfunction in roughly 5–8% and reduced libido in 3–5%. Persistent symptoms after stopping are reported but contested in the literature.
• Surgical options (TURP, and newer approaches such as Rezum, Urolift and aquablation) differ markedly in ejaculatory preservation — Urolift and aquablation preserve antegrade ejaculation better than TURP, which causes retrograde ejaculation in around 65–75%. Ask specifically about this before consenting.

Prostatitis and chronic pelvic pain syndrome

Acute bacterial prostatitis is uncommon and needs urgent antibiotics — fever, rigors and severe pain with urinary retention is an emergency. Far more common is chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), category III, which accounts for over 90% of prostatitis diagnoses and usually involves no infection at all. Symptoms include perineal or ejaculatory pain, urinary discomfort and painful orgasm.

Evidence favours multimodal treatment guided by the UPOINT framework — pelvic floor physiotherapy, neuropathic pain agents, alpha blockers and psychological support — over repeated antibiotic courses, which are usually unhelpful when cultures are negative (Cochrane, 2019; EAU guidelines).

Prostate cancer and PSA screening

Prostate cancer is the most commonly diagnosed cancer in men in the UK and the US. Many cases are slow-growing and would never cause harm, which is what makes screening genuinely difficult.

• The ERSPC trial (Schröder et al., updated 2019) found PSA screening reduced prostate cancer mortality by about 20% at 16 years, with a large number needed to screen and to treat.
• The US PLCO trial found no mortality benefit, though contamination by PSA testing in the control arm limits it.
• The UK CAP/ProtecT trials found a single PSA invitation did not reduce mortality; ProtecT's 15-year results (NEJM, 2023) found prostate cancer mortality of about 3% regardless of whether men had active monitoring, surgery or radiotherapy — but surgery and radiotherapy reduced progression and metastasis, while causing significantly more urinary and sexual dysfunction.

Practical position: PSA is offered as an informed choice from age 50 (earlier, from 45, for Black men and those with a family history, who have roughly double the lifetime risk). The decision hinges on whether you would want treatment for a cancer that might never have troubled you. Multiparametric MRI before biopsy (PROMIS/PRECISION trials) has substantially reduced unnecessary biopsies and overdiagnosis of insignificant disease.

Sexual effects of prostate cancer treatment

Radical prostatectomy causes erectile dysfunction in a majority initially; recovery over 12–24 months depends heavily on nerve-sparing surgery, age and pre-treatment function. Ejaculation is permanently absent after prostatectomy (orgasm is still possible — this is worth knowing in advance). Radiotherapy causes a slower decline in erectile function. Androgen deprivation therapy substantially reduces libido. Penile rehabilitation, PDE5 inhibitors, vacuum devices, intracavernosal injections and implants all have evidence; ask for referral rather than assuming the outcome is fixed.

When to see a clinician

Blood in urine or semen, urinary retention, bone pain, unexplained weight loss, fever with pelvic pain, or new erectile difficulty with urinary symptoms. Erectile dysfunction is also an independent early marker of cardiovascular disease and warrants a cardiovascular check.

Sources

• EAU Guidelines on Non-neurogenic Male LUTS and on Prostate Cancer, 2024.
• Hamdy FC et al., New England Journal of Medicine, 2023 (ProtecT 15-year outcomes).
• Schröder FH et al., ERSPC 16-year follow-up, European Urology, 2019.
• Ahmed HU et al., The Lancet, 2017 (PROMIS); Kasivisvanathan V et al., NEJM, 2018 (PRECISION).
• Franco JVA et al., Cochrane Database of Systematic Reviews, 2019 (CP/CPPS treatments).