A sudden increase in PSA

I became concerned about my prostate following a sudden increase in my PSA reading from 5 to 13. I was at the time a full time professor at Newcastle University coming up to retirement age. I had an examination of my prostate in the Urology Dept at the Newcastle Freeman Hospital which indicated I had an enlarged prostate. This was then followed up by a proper biopsy on my prostate at Gloucester Royal Infirmary when I moved to Gloucestershire shortly after my retirement. No cancer was shown up. I followed it up with a CPA3 test at the Spire Hospital in Bristol, which confirmed there was no cancer. My consultant urologist then put me on several tablets: Finasteride, Tamulosin and Oxybutynin to shrink my prostate and relax the bladder. I also had 6 monthly blood tests to keep an eye on my prostate PSA levels. 

Difficulty urinating and poor flow

The tablets seemed to work initially but over a period of several years their effectiveness wore off. It meant that I had difficulty urinating, very poor flow with frequent trips to the toilet along with uncontrolled leakages. My sleep was frequently interrupted with visits to the toilet 4 or 5 times a night.  My flow rate was very weak, with an uncontrollable urgency to urinate along with frequent leakages. These had become more frequent and embarrassing, my trousers and underwear smelling of urine. I put myself down on the list for a TURPS op on the NHS where however the waiting list seemed to be increasing to infinity, with no chance of having the operation done in an acceptable time. I in fact waited 18 months with no date for a TURPS in sight and realised that the only way to solve the problem was to have the TURPS OP done privately. During that time my wife read an article in a daily newspaper on PAE and how effective it was, that the operation could be carried out in a day with no side effects and relatively painless.  It was much better all-round than having a TURPs. 

Referred for PAE by the consultant urologist

My consultant referred me to the Urology Dept at Southampton General Hospital which is one the major centres where PAEs are carried out along with TURPs and other prostate related procedures. After an initial consultation I had a detailed series of urodynamics tests to measure my urine flow rate and bladder function. My IPSS total score was 22 which meant my prostate problems were severely symptomatic. Following a discussion with the Urologist on the results, and best way to proceed, he thought the best and most successful way forward was a PAE to be carried out by Dr Nigel Hacking consultant interventional radiologist in the Radiology dept. in Spire Hospital Southampton. I was encouraged by the fact that Dr Hacking is a pioneer in the development of PAE.

The procedure was carried out in due course depending on Dr. Hacking’s availability. The whole procedure took place over a 2 day procedure, the first day taken up with the initial CT investigation of the network of arteries surrounding the prostate and their suitability for embolisation, followed by a second day where the actual embolisation was carried out. I was given a local anaesthetic and whilst he was carrying out the delicate embolisation procedure, Dr Hacking talked me through procedure showing me what arteries he had identified as suitable for injecting the little plastic beads.  

Restoring normal urine function – between prostate and bladder

The whole operation took less than two hours and following a brief discussion with Dr Hacking, I returned home. I texted Dr. Hacking on my progress over the next 5 months. At the beginning I had hardly any flow at all but that gradually improved until at the end of it, the flow was a torrent rather than a trickle. It was so great I could not control it, and there were frequent leakages, far worse than they had been before, so much so that I regarded the PAE as a failure. I filled in the IPSS score with a lack of enthusiasm. 

Prostate reduced by 50%

Having returned my completed IPSS score in advance, I returned to Southampton to find out in detail what progress, if at all, had been made since the embolisation 5 months previous. This began with an MRI scan of my prostate which was then examined by Dr Hacking. I was greeted in fact by Dr Hacking saying “I’m so glad you filled in the IPSS. It has been most useful.’” He told me that the embolisation had reduced the size of my prostate by nearly 50% and that the embolisation as far as he was concerned, had been a total success. He showed me the MRI scan results and where the shrinkage of my prostate had occurred. I was most surprised because the uncontrollable releases and leakages were worse than before the operation. Dr Hacking then said,” it’s not a prostate problem anymore but a bladder problem”.

Re-educating the bladder

My bladder can’t control the flow rate, it’s in a constant state of tension. I do recall the Southampton Urologist saying the bladder will have to be re-educated after the PAE. Dr Hacking then said there are some tablets you can take to relax the bladder called Oxybutynin. I replied that those were the tablets I was prescribed for my prostate but had stopped taking them for a couple of weeks prior to the embolisation. He suggested I start taking them again which I have ever since, twice a day.

The improvement has been dramatic

The improvement has been dramatic. The flow rate has reduced to a controllable stream rather than a torrent and I have had no leakages worth commenting on, no more trouser and underpants smelling of urine. I can go for much longer periods without the urgency to urinate. I wake in the night at most once to relieve myself and now get a good night’s sleep of 7-8 hours. My total IPSS score now is 4. The embolisation thanks to the skill of Dr Hacking has been a total success. I am still living in a period of post embolisation elation. 

Please note I am currently 74 years of age

Best regards

MWR

Update 4th June 2020

“Just to let you know that my PAE has been a total success. I no longer need the Oxybutanin to relax my bladder and I hardly  ever wakes up in the night to urgently go for a pee. PAE is vastly better than having a TURPS op.”

I am a 70 year old male and have suffered from the common problem of my age group-increasing frequency and difficulty in urinating, for about ten years. A couple of years ago my GP identified the cause as an enlarged prostate gland, or Benign Prostatic Hyperplasia (BPH), and I was prescribed Tamsulosin, a drug which relaxes the muscles controlling urination. The problem continued and became quite severe last autumn when, coupled with a urinary infection, sleeping became very difficult. At the beginning of October 2019 I was put on the waiting list to see an NHS Urologist, possibly involving a wait of twelve months for an appointment, and a further eighteen months for the standard TURP operation.

 The prospect of 30 months of nocturia, and surgery with side-effects led me to make an online search for an alternative. PAE- Prostate Artery Embolization, blocking some of the prostate arteries with minute plastic spheres sounded promising. The idea of creeping up on the offending gland and gently cutting off its blood supply seemed more appealing than slicing away at it directly through the urethra, even though PAE is still regarded as an experimental procedure by the NHS. I emailed the College of Interventional Radiology and received a very encouraging reply from Dr Nigel Hacking at Southampton Spire Hospital offering to give me the procedure privately if I could have a referral from both my GP and a Urologist. The GP’s referral was no problem, and he in turn referred me privately to a local Urologist of my own choosing. For the PAE I had to satisfy the criteria of having no signs of cancer or other complications, and a suitably enlarged prostate. This is where I came up against something which I had not considered- rivalry between Urologists, who seem most interested in offering surgery, and Interventional Radiologists specialising in passing catheters through blood vessels. Thus even though I fulfilled all the criteria for PAE, the Urologist did not recommend it instead of the TURP. I persisted and he eventually agreed to refer me to Dr Hacking.

So, twenty days after I had decided that I wanted to have a PAE, and thanks to a last minute cancellation in Dr Hacking’s list, I found myself driving to Southampton. I had to spend two days there. On day one I had a CT Angiogram, which involved an Xray scan to make a map of my prostate arteries (their anatomy varies between people), followed by a consultation to explain the procedure. On the morning of day two, after no breakfast and clad only in a hospital gown, I walked into the cath lab and climbed onto the Xray table and lay on my back. The coolness of the room surprised me- maintained for the most efficient functioning of the equipment and to minimise infection, I was told. A cannula was inserted into my arm for sedation if needed-it transpired that didn’t. Unlike the TURP operation, a urinary catheter was not used.  The procedure started with an injection of local anaesthetic in the right groin, then the arterial catheter was inserted painlessly into the main artery. No general or spinal anaesthetic was used. As Dr Hacking manipulated the catheter through the arteries he closely followed their progress on a screen. The Xray machine hovered overhead and sometimes moved along a circular rail to make detailed 3D images. The procedure took two hours-a little longer than average due to my complex arterial anatomy, during which I was completely conscious, and felt no pain or discomfort.  Occasionally Xray opaque fluid would be passed down the catheter and I was asked if I felt it, and where. It felt a little warm. My biggest surprise was that the arteries appear to have no sensation, as I felt nothing as the catheter passed through them. At the end of the procedure the catheter was removed and a soluble plug put in its place and covered with a dressing. Even though I felt like leaping off the table, I was told to keep lying still and pushed back to the ward on a trolley. After a four hour resting recovery period lying down, I was able to urinate and allowed to walk out of the hospital clutching a pack of antibiotics and analgesics, but not drive a car for four days (my wife came in useful here).

I did not need the analgesics, and noticed an improvement in urination in the first week. I did have some interesting but painless bruising in the groin and right leg due to blood leakage, and this disappeared after a week or so. The easing of urination  continued over the ensuing weeks and at week three I stopped the Tamsulosin. At the three month follow up MRI scan in Southampton my prostate was the same size as that of a young man- down from 58mls to 26mls. In the daytime my urination is now pretty well normal. At night I still have to get up about twice a night, but I can live with that, and there is the possibility of further progress. I am very happy with the outcome, glad that I had a PAE, and feel very grateful for the help of Dr Hacking and his team in Southampton. Oh, and four months on, I am still waiting to hear when my NHS Urology appointment will be.
With Best Wishes,
Mr DW

Deposition on Prostate Artery Embolisation (PAE) from Mr WH – Born 10th March 1942

The initial issues
From year 2014, I very occasionally experienced a difficulty in urinating during the night hours almost always after having had a few pints of beer or even after a long passenger flight. After alcohol consumption the retention issue always subsided by about 5am in the morning, and I now realise it was because of alcohol intake causing prostatic swelling. This was particularly evidenced at the time because my prostate was considered by the medical profession to be “large”.

In early June 2019 I was unable to urinate, requiring me to call for medical assistance during the night, when after 9 hours of retention a bladder catheter was inserted and I had this fitted for nearly three months. Several visits were made to Trial Without Catheter (TWOC) Clinics at hospital during the period but to no effect. Various surgeons considered laser treatment on the prostate and major surgery for removal in part or totally.

Prostate Artery Embolisation
The Surgeon Head of Urology at my local hospital considered a PAE

Procedure to be advisable to reduce the size of my prostate which was compressing the urethra and causing total retention. Long term Side-effects are zero compared with surgery such as Holmium laser enucleation or retropubic enucleation, which may result in incontinence.

After discussion and with the possibility of failure to solve the retention issue and bladder catheter removal, I was introduced to Dr. Nigel Hacking at The Spire Hospital, Southampton for possible PAE treatment. A CT scan was conducted showing scattered areas of calcification within the enlarged gland consistent with previous or chronic prostatitis, also showing a prostate size of 194mls. in volume. Subsequently, a day appointment was made on 22nd August 2019 for the PAE procedure itself. My bladder catheter remained in place throughout the process, which was conducted under sedation with me being conscious throughout, although I may have slept on occasion during the 1.5-hour procedure. The two arteries supplying my prostate were entered via the groin. No pain was experienced throughout the actual PAE procedure and I walked back to my room after the PAE.

Post-Prostate Artery Embolisation
3 hours after the procedure in my day-room at the hospital I started to endure referred perianal pain and at the end of the penis. This pain was quite severe and as a result I was given intravenous morphine overnight at the hospital. Pain dissipated by early morning and I was discharged home. I was informed by Dr. Hacking that this referred pain for me was not unique but rather unusual.

After discharge I was prescribed non-steroidal anti-inflammatory pain relief. Urination and defecating was painful during the initial 7 days post PAE with some blood staining in the urine. The bladder catheter remained in place. I felt quite tired during the first 10 days and I did not engage in much physical activity.

After 10 days (4th Sept. 2019) the catheter was removed at my local surgery and it took some six hours for me to pass any urine. Over a period of some days, urination became more frequent and regulated, most likely because I had not had self-controlled urination for some months. Urination and defecation were commensurate for a number of days. Residual pain in the penis, but reducing, remained for about a month.

Finality
An MRI Scan was undertaken on 31st October and Dr. Hacking assessed my prostate to be 60% of its original size and that it would likely reduce further.

Urination became quite normal in regularity and with some  ”force”, as it remains at the time of writing this resumé.

A further MRI scan, on 7th May 2020, showed my prostate to have a volume of 94mls./ccs. (less than half the size of 9 months previously).

In my opinion PAE is quite definitely a better option than surgery if it is considered clinically advisable.