Readers' questions are answered as examples of general problems commonly met in practice. It is a good rule in medicine that only their own doctors know the patient well enough to pontificate on the case as there are often other factors unknown to strangers.

I saw your article about radiotherapy in The Times. My husband received radiotherapy but was subjected to an excessive dose which caused fatal internal bleeding. I never see this mentioned as a possible side effect before and wondered if you have come across it? Diane Barnett, London

Radiotherapy is not without its risks, hence the need to support all pleas for additional funds for radiotherapy departments so that they may have the latest equipment (it is improving by leaps and bounds) and a full staff. I was exceptionally lucky in the centre where I received the traditional six weeks of daily radiotherapy without any side effects at all, although I had been warned that some were likely. The prostate is adjacent to both the bladder, the rectum and is often close to other parts of the gut. I assume that your husband received radiotherapy for a prostate cancer. Haemorrhage following this must be exceptionally rare, although I have seen it after head and neck irradiation.

The usual complications of radiotherapy are burning to the rectum or bladder. They are seen less often now, and some people like myself escape all side effects, because of the very detailed planning that goes into conformal computerised controlled radiotherapy. The physicists and radiographers who draw up the plans so as to map out the exact limits of the prostate, and arrange for the external beams to be accurately focused on the gland are of a remarkably high standard. They are so well qualified and technically skilled that I always felt both guilty and slightly humbled by their expertise whenever we met.

As well as the immediate burning there may be later fibrosis, scarring and impotence. The fibrous tissue in the bladder or guts can sometimes bleed later but again I have never heard of the bleeding being so severe as to cause death.

I find it difficult to start urinating. Been to my urologist, twice a year, who said my prostate is small and normal though I am 60. He says there's something to do with some nerves. Tell me what is the problem if you can diagnose it? Joe Amb, USA

I am afraid that we can't diagnose your condition from a distance. This is always a matter for your doctors who seems to be looking after you well. Sometimes even a small degree of enlargement of the prostate will cause urinary tract outflow problems if the increase in its size is in just the wrong area of the gland. I assume that you have had flow studies carried out, and that you keep a careful graph of your PSA so that you can check on its rate of increase, as well as the actual figures. A steep slope, or a slope that starts getting steeper very suddenly, can be as important as the overall PSA figure.

Your doctor may have been referring to the condition in which patients have a very sensitive bladder so that they become aware of the feelings of needing to urinate when the bladder itself is barely distended, this is known as the overactive bladder syndrome. There are several drugs that can be taken to reduce this sensation but, particularly in men, it is necessary to be careful about them as they can increase the risk of retention in people without flow problems.

Sometimes men find it difficult to start urinating, especially if other people are present in the room. This used to be known as psychological anuria, but the term is inaccurate as a normal amount of urine is gathering in the bladder although there is a nervous block on its expulsion. The sound of running water for some reason, little understood, makes urination easier.

I am 57 years of age, in good health and not overweight. I find that I have to get up two to three times a night to urinate (not painful) and several times during the day. I do drink five to six cups tea/ and coffee per day! Is this normal for my age or should I see my doctor re possible prostrate trouble? Name and address withheld

No. This is not normal. It is almost certainly because your prostate is growing bigger and there is outflow obstruction. When patients have to get up at night several times in order to pass urine the cause is nearly always physical. Overactive, over sensitive bladders usually settle down once the patient is asleep. An enlarging prostate shouldn't give rise to painful urination but only to a poor stream, possibly including a forked or splayed stream or stopping and starting - intermittent micturition. The patient may also find it difficult to start or to stop so that they dribble on. You should certainly see your doctor and have both a PSA test, to help exclude any malignant change in the prostate, and urinary flow studies. Urinary flow studies are very simple, it is only a matter of passing urine into a receptacle that measures the rate. The PSA is a simple blood test.

My husband had a radical prostatectomy almost five years ago, a recurrence a year later followed by radiotherapy and a recurrence a year later - his PSA is rising slowly (currently 1.9 from 1.0 a year ago). We have changed diet (no dairy or red meat, lots of veg and fruit, pomegranate juice) in the hope of keeping the growth slow - we understand that hormone therapy is usually recommended when the PSA reaches 4. What is your opinion? Obviously, the hope is to begin hormones before the cancer spreads but how accurate do you think this marker is? Name and address withheld

Doctors will vary about the time at which patients should move on to the next stage of treatment. I was very impressed by statistics that my oncologist showed me that suggested that in general a move to the next stage should be earlier, rather than later. The earlier the better it seems so far as long term results are concerned. After I had had a recurrence as demonstrated by three consecutive increases in the PSA from the less than 0.05, we agreed that I should start on hormones as soon as it reached 1.00. I have now been taking hormones for between three and four years and my PSA hasn't yet started to move again. The PSA at this stage of a cancer is very accurate, only when the tumour becomes very advanced does this accuracy wane. The PSA is less reliable as an initial diagnostic tool than it is as a means of following progress in the cancer's early stages after treatment has been given.

My 87 year old father suffered acute urine retention in 1999, caused by an enlarged prostate. He was extemely ill and hopitalised for seven weeks with acute kidney failure caused by retention. Since then he has had many problems (catheterised for over three years with lots of painful blockages and bladder stones etc). For the last three years he has been on kidney dialysis three times per week and his quality of life improved a lot. In June this year he began having painful spasms and bleeding and was admitted through A&E twice. He then had another operation to reduce the prostate. Last week doctors told us that he has prostate cancer that is not confined to the gland, but is also in the uretha and the bottom of the bladder. Doctors have referred him for ten sessions of radiotherapy. He is in no pain at the moment, and urinating (without a catheter) with no problem. My question is this: in view of my father's age and the fact that he has to endure dialysis three times a week what would be the benefits of external beam radiation for him? We have been told that the cancer is aggresive. We do not want him to be subjected to painful side effects of treatment that may not be of real benefit to him. If it were your father what would you be advising? Name and address withheld

Without seeing your father I couldn't judge the best treatment for him but I would have thought that his best option would be to have the relatively small doses of irradiation that has been planned for him and couple it with surgical castration. He might not welcome the side effects of the anti testosterone drugs but I have known men of your father's age who have felt much better following castration for advanced prostate cancer. Artifical testes are implanted in their place so externally your father would look no different. Advanced cancers of this sort are treated because prostatic cancer can have an unpleasant end, especially if the growth involves the bladder neck or spreads to the bones of the spine. Hormone therapy (or in his case possibly castration) and a small dose of radiation might see him through into his 90s and might spare him avoidable pain. As your father is frail death could well intervene from some simple pain free infection complicating his kidney troubles. You seem to have had excellent advice.

What methods other than surgery (sling) can be used to correct incontinence three years after prostate surgery? Name and address withheld

Bad luck. Only a very small percentage of people have really tiresome persistent incontinence - it is said less than 3 or 4 per cent. Severe incontinence is considerably more common than this in the first few months after surgery. It is possible to have an electrically controlled artificial sphincter. It is a major procedure but although I have always been rather doubtful about recommending it I have fortunately been proved wrong on many occasions for the patients have been very happy with the result. I should discuss this with your own doctor.

Re robotic prostate surgery. What conditions exist for men to qualify for this treatment? What is the cost of treatment? Is approval by NICE and NHS likely? Robyn Grant, Bramley

Robotic prostatic surgery is indicated in exactly the same cases as an open radical prostatectomy would have been considered the treatment of choice. It is an alternative to the older operation. There are only five robotic machines in the country, four of which are in the NHS, but are not necessarily as yet being used. Setting up the team to work them is proving expensive, and the training time-consuming. Talking to urologists the enthusiasm for robotic surgery, as opposed to ordinary laparoscopic surgery that is very difficult to learn and perform, is remarkable and many of them are making great efforts to find the time to go on the necessary courses with their teams. In private medicine, at the moment, robotic surgery is likely to cost about one third more but the patient will remain in hospital for a shorter time so there will some saving from this. At least one of the insurance companies is proving difficult about paying for robotic surgery, but the others seem to be agreeable to it. In time it will be used both by the NHS and approved by NICE. It is already proving very popular in the US.

Is HPV responsible for prostate cancer? Circumcision is reported to halve the risk - comment please. David Hawker, Bodmin

There has been discussion about a possible infective element to prostatic cancer for as long as I can remember. There is undoubtedly a family connection to the likelihood of developing prostatic cancer. It is of course also more frequently found as patients grow older and is more common among men of Afro Caribbean stock. A high fat diet increases the risk, as may low exposure to sunshine, for the type of vitamin D manufactured by the skin in sunlight has a protective factor. It is noticeable that men with very few partners in their life are less likely to develop cancer of the prostate, but paradoxically those who masturbated more than usual are also less likely to be affected. This points to a possible infective factor as well as genetic vulnerability but none has been demonstrated.

I am 68 and was DX'ed with T1c in June, 2006, Gleason 3+3, PSA: 12.3. Since then I have been involved with WW and have been on a strict diet, including herbs and vitamins. My latest PSA (in September) was 4.19. Oh, yes: 2 of the 13 cores were positive, no more than 10 per cent. Am I doing the right thing, in your opinion, in continuing with Watchful Waiting? Ken Clark, Texas, USA

Only you and your doctors can decide this. I am a notorious interventionalist as far as prostate treatment is concerned, but if I had a PSA that had been 12.3, with two positive ultrasound collected specimens and with a Gleason score of six I would book my bed for a radical without more ado. Once herbs have been taken that may contain phyto oestrogens thereafter the relevance of any PSA is difficult to guage.

What treatments are available for cases of benign prostate enlargement, making it difficult to pass water at night? Name and address withheld

The standard treatment for benign prostatic hyperplasia, once malignancy has been excluded, is usually by drugs. There are two groups that are commonly used. The group that I have tended to favour are the 5-alpha reductase inhibitors, but other doctors make an equally good case for the selective alpha blockers. The first group act by actually shrinking the gland. The main disadvantages in my opinion of them is that sometimes for the first few days symptoms may be worse before they improve. The other group, the selective alpha blockers, relax the muscle in the prostate so that the urethra is dilated and urination easier.

Rising PS. I had R/T 1n 1998.ps 14 gleason 3/4. Initial drop in ps 6 (lowest attained), very slow increase in PS over the years (6 month tests) at present PS 8. Greatly value your thoughts on this. Should hormome be considered if so at what PS value? No adverse symptons. Good health, age 81. Many thanks for your advice over the years. I had my first PS test as a result of reading your Times page in 1998. Name and address withheld

I would certainly be taking hormones if I was you but that is my own opinion. Discuss this with your GP and urologist. I started taking hormones when my PSA had recurred and had reached 1. The hormones are not without side effects including painful breasts. Some men, once they reach their 80s, prefer surgical, rather than chemical castration. The objective of treatment is not only to live longer but to avoid possibly painful and disabling bony secondaries in the spine or in the bladder or brain.

I am disturbed by repeated hot flushes which seem to be caused by Casodex 150mgm. Tablets taken daily, and previously by Zolodex. I am now 75 and was found to bave medium risk cancer in July 2004. I was taking Cyprostat then Zolodex and from Febuary 2006 Casodex, and had raadiotherapy in January 2006. My PSA is near zero, but I continue to have hot flushes every 90 to 120 minutes, day and night. Might a zcan help diagnosis? John Atkinson, Preston

Casodex can certainly cause hot flushes, as can Zolodex. The side effects vary from person to person. In the four years that I have taken Casodex 150 mgs daily the most tiresome has been painful breasts, but, like you, my PSA has remained normal. The symptoms tend to stabilise after a year or two. My oncologist says that some of the side effects can be reduced by taking Tamoxifen, the drug used to treat female breast cancer. As yet I have opted not to avoid upsetting the present hormone treatment with Casodex as that seems to be doing its job so well. A scan wouldn't help at this stage but if there is any suggestion of bony secondaries then a whole body scan to detect them so that they can be treated early is well worthwhile.