Cut From Steel

He learned on a Friday and was on the table by Wednesday.

Arnold Palmer found out he had prostate cancer on Friday 10 January 1997. He was 67 years old, the most recognisable golfer alive, and a man who had spent forty years being told he looked indestructible.

He did not spend a month getting his head straight. Palmer checked into the Mayo Clinic in Rochester, Minnesota, and had surgery on 15 January... five days after the diagnosis. Surgeons removed the prostate. He was back at a golf tournament within a couple of months.

I keep coming back to those five days. Most men I know would have used them to research, to delay, to wait for a second opinion on the second opinion. Palmer treated the appointment like a tee time. Somebody told him what the problem was, and he went and had it dealt with.

Palmer died on 25 September 2016 at the age of 87. Nineteen more years came after that operating table, and he spent a good part of them lending his name to prostate research and awareness while other men his age stayed silent about it.

You may not be facing anything like what Palmer faced. Odds are you have an enlarged prostate that gets you up at night, which is not cancer at all. The gap between a problem and a fix is usually just an appointment. Palmer closed his in five days.

The ladder nobody showed you

You wake at two and again at four. The stream starts late, stops early, and never quite finishes the job. Somebody your age told you this is simply what happens, and you filed it under ageing.

I want to correct one thing before anything else. An enlarged prostate is not cancer, and it does not raise your risk of cancer. Cleveland Clinic says research shows benign prostatic hyperplasia does not increase your risk of prostate cancer, because the gland grows in a different zone from where cancers usually start.

You have been handed a plumbing problem, and plumbing problems have a ladder of fixes. Most men only ever hear about the top rung.

It's not age. It's these three.

I want to walk you up the ladder in order, because these drugs work in completely different ways and men mix them up constantly.

01 / The Alpha Blocker

Tamsulosin and its relatives relax the smooth muscle in your bladder neck and prostate so urine moves more freely. They do not shrink the gland at all. Cleveland Clinic Journal of Medicine says the effect starts within hours to days and usually peaks in three to seven days, which makes this the fast rung. The trade is real... dizziness on standing, and trouble with ejaculation that is most common with tamsulosin. Anyone with cataract surgery coming should tell the eye surgeon they take one, because of a complication called floppy iris syndrome.

02 / The Shrinker

Finasteride and dutasteride block the conversion of testosterone to DHT, and the gland genuinely gets smaller. The American Urological Association puts the reduction at 15 to 25% at six months, and reserves these drugs for men with a prostate that is actually enlarged. Symptom relief takes about three months, so patience is part of the prescription. These drugs also cut your PSA reading roughly in half... get a baseline before you start, or your future results will read falsely reassuring.

03 / The Two Together

The AUA gives its strongest recommendation to combining both drug classes, but only for men whose prostate is measurably enlarged. Two large trials, MTOPS and CombAT, found the combination cut the risk of acute urinary retention and of ending up in surgery compared with either drug on its own. There is a fourth option worth raising too. The AUA says daily tadalafil at 5mg should be discussed as a treatment, whether or not erection trouble is part of your picture.

Take it back today

You get one free rung before all of that. The AUA's own behavioural list includes limiting fluids before bed or travel, cutting back on caffeine and alcohol, treating constipation, moving more, losing weight, and using a double-voiding technique... going, waiting a moment, and going again. NIDDK adds emptying the bladder fully and not holding urine for long stretches.

I want you sceptical about the aisle that sells you the alternative. The NIH funded a trial called CAMUS, which gave 369 men escalating doses of saw palmetto for 72 weeks and found no advantage over placebo. If anything, the placebo group edged it. The National Center for Complementary and Integrative Health now calls saw palmetto probably not helpful.

You book the appointment this week and you bring two things. Bring a written note of how many times you get up at night, and bring a request for a prostate volume measurement, because that number decides which rung you belong on. Your age is not a treatment plan.

You have been rationing water after six and calling that management. More rungs exist than anybody bothered to show you. Go and ask for the next one.

— Travis

Insider Member's Corner

6 free habits that quieten the nights:

You didn't put in 45 years to settle for beige.

01 / Watch · Seiko Presage Cocktail Time

Seiko's Presage line is where mechanical watchmaking stops being an expensive hobby. The Cocktail Time models take their dial colours from actual drinks, and they are textured in a way that photographs badly and looks superb in person. The Mojito reference SRPE45 runs an automatic movement and lists at $450 on Seiko's US site. A man does not need to spend five figures to wear something with a heartbeat in it.

02 / Smoke · Arturo Fuente Hemingway Short Story

The Fuente family has made this tapered perfecto in the Dominican Republic for decades, usually under a Cameroon wrapper, in small daily batches. The Short Story runs about four inches and roughly seven dollars a stick when you can find it. The point is not the cigar. The point is thirty unhurried minutes on a porch with nothing asked of you, which is harder to buy than tobacco.

03 / Steel · 1969 Chevrolet Camaro SS

Nineteen sixty-nine closed out the first-generation Camaro with squared wheel arches, those stamped rear louvres and the front end everybody still draws from memory. The SS came with the 350 small block or the 396 big block, the 396 rated between 325 and 375 horsepower. Hagerty notes the original list price on an SS 396 was $3,075. Restored driver-quality cars have traded in the mid thirties, with good examples asking well past that. Documented big-block cars go somewhere else entirely.