Of our many organs, the prostate gland seems to offer the most annoyance to men as we age. The prostate produces most of the fluid that carries semen and so is critical to reproduction. It is located near the bladder outlet and in young men is about the size of a walnut. As men age, the prostate grows. Unlike heart disease, there is nothing one can do with diet or healthy habits that impacts the prostate.

            The two major problems that impact men’s health are prostate cancer and blockage of urine flow from a growing gland.

            Growth of the prostate, called benign prostatic hypertrophy (BPH), is a normal part of aging, and occurs in essentially all men. Because of the location of the gland, it can impede flow of urine out of the bladder. It is a good rule that a 60-year-old man, however healthy, should not expect the urine flow of a 20-year-old.

            What one does about BPH is entirely based on symptoms. The hallmark of BPH is incomplete emptying of the bladder. You may finish urinating and then feel you need to go again. Most older men will get up at night to void. It may cause urgency – the feeling that if you do not get to the bathroom you are going to lose control.

            If these symptoms are mild, no treatment is needed. If they are more severe, medication can help. One class is alpha-blockers, that make it easier to void, that were originally developed to treat high blood pressure. They are generally easy to take, though may be a problem if you tend to have low blood pressure.

            The more definitive treatment is to take a testosterone-blocker. Finasteride in low dose is used to treat male-pattern baldness (Propecia) and in high dose to shrink the prostate. It has been shown to reduce the need for surgery and the likelihood of complete urinary blockage. The downside is reduced sexual drive and erectile dysfunction (ED).

            ED drugs like tadalafil help urinary flow and may be a good option to improve flow while also treating erectile dysfunction. Your insurance may not pay for this, as most still ration these drugs.

            Prostate cancer occurs in the same organ, but otherwise is unrelated. Cancer occurs in small glands and huge ones equally. As men age, prostate cancer occurs more often and at the same time becomes less aggressive. If a 50-year-old has prostate cancer, unless it is surgically cured, he will probably die of this cancer. If an 80-year-old has prostate cancer, he will almost certainly die of something else, with his cancer but not due to his cancer.

            I must also note that African-American men have almost twice the risk of white men.

            While prostate cancer can be detected on a rectal exam, by this time it is usually advanced. Early detection is done with a blood test, the PSA (prostate-specific antigen). To say that PSA testing is controversial is an understatement; arguments for and against have raged in the medical literature for years.

            I can best sum up the thousands of pages written by saying that screening men with regular PSA testing modestly reduces death from prostate cancer but has minimal effects on overall death rates. There is also consensus that PSA testing should stop at advanced age, though exactly when is debated. I would suggest 75.

            If the PSA is elevated, in 2025 the best next step is an MRI of the prostate to detect and quantify any cancer. In low-risk patients, “watchful waiting” is a very viable option. In high-risk men, complete removal of the prostate offers the best chance for cure, with radiation therapy an acceptable alternative. Both treatments have significant side-effects, including bowel and/or urinary incontinence and loss of erection, hence the idea that not all cancers should be treated.

            Prostate disorders are clearly conditions in which dialogue between the patient and doctor are key and second opinions critical. Do not accept the first option offered.

            Edward Hoffer MD is Associate Professor of Medicine, part-time, at Harvard.

What Does The Doctor Say?

By Dr. Edward Hoffer

            Did you ever want to hug a tree? Or just sigh as you admired one?

From colossal sequoia to shapely bonsai, in summer’s finery or winter’s bareness, they make the spirit soar just standing there. The classical oak immortalized in John Constable’s paintings of English pastures; towering walls of ancient cypresses of the Mediterranean; pulsating tropical rainforest canopies; the bent birches of Robert Frost’s poem. I’ve had my share of close encounters of a tree kind.

            I well recall one of those encounters on a street corner in nearby Edgartown. Maybe you have seen it? The tree I speak of came all the way from China as a seedling in a pot. Captain Thomas Milton brought it to the Vineyard during the War of 1812. He decided to settle there, buying the land and building the South Water Street house that the tree now shades. This magnificent pagoda tree is the oldest of its kind on the continent. If you go to Edgartown, you will know it immediately. It’s the one that will leave you awestruck.

            As a child, I was fascinated with the legendary figure Johnny Appleseed. I think I took it quite literally that he was singly responsible for planting all the apple trees in North America. I came to marry a Johnny Appleseed of sorts. He’s consumed with the idea of growing fruit trees, having spent his youth raiding orchards throughout Yorkshire, England. As we’ve added more each year to our back yard, it has become apparent we now have our own little orchard. I must have known what was happening when we spent a hefty sum on an espaliered apple tree. “It bears four different kinds of apples,” my husband said, appealing to my innate practicality.

            My father can take some of the blame for my desire to accumulate trees of every variety. His gardening accomplishments are something of folkloric proportions. When he was a boy, he planted a twig that grew into a massive willow tree – a sort of natural candelabra under which the family relaxed for cookouts. Many a peaceful nap was incurred from its hypnotic tendrils moving in the breeze. To us children it was like a giant cathedral of seemingly infinite height and breadth that totally enveloped our summer visits at my grandmother’s. Years later, the tree had to be cut down as it was suffering from some incurable blight. It had grown to 15 feet in diameter! We were sad to see it go and my grandmother’s backyard never looked the same again. In more recent years and owing to that glorious memory, I planted a willow out back. As I look out from where I now sit, I know it was a good decision. And who knows? Maybe I’m creating memories for grandchildren.

            Over the years, my father has planted innumerable trees – blue spruce, Japanese maple, dogwood, crabapple, catalpa, ginkgo, birch, all sorts of fruit-bearing trees, and pines galore. You name it, he’s grown it, experimenting with grafting and pruning techniques as well as developing a time-saving fertilizing device.

            A while back we revisited our former home, where my parents planted their first gardens while rearing their three young children. Usually when you go back, things seem much smaller. This experience was the opposite. The place had the most magnificent trees, all of them planted by my father who’d bought the house on a blank lot, one of many in a subdivision built in the early 1960s. While clearing land for a new home, the one they presently live in, my father and relatives spent months removing trees. Fifty-five years later, he has replaced them in triplicate.

            Nowadays my Dad is a bona fide tree farmer – although he contends it’s just a hobby. He grows all kinds of trees on his eight acres, including each family member’s Christmas tree and special seedlings he orders from his suppliers. My mother used to say he talked to his trees – a way to decompress from his high stress job as construction manager. There is something to be said for tending plants and watching them grow.

            There have been stumbling blocks – from the deer that used his young concolor white fir saplings for antler rubbing posts to the scourge of gypsy moths. Another year it was the pesky beavers that dammed up the nearby pond, thus interrupting his water source for an irrigation system that feeds his fledgling forests.

            Last Friday marked Arbor Day – dedicated to trees and their preservation. In observation of it, you may want to plant a tree for yourself or another tree-worthy person. Meanwhile, I have the perfect spot for a prunus subhirtella! Maybe the old maxim is true – the apple doesn’t fall far from the tree.

            “Don’t get me wrong…I love trees! There should be more of them. When I use paper, I use both sides.” — Steve Coogan in the film Coffee and Cigarettes.

By Laura McLean