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Conditions

Prostate Disease

Benign Prostatic Enlargement

After 50, some men develop prostate enlargement. This may lead to problems with urine flow and bladder control. In severe cases, patients may suddenly experience an inability to pass urine (urinary retention), recurrent urinary infections or bladder stones. Benign prostatic enlargement (BPE) does not make one any more or less likely to develop prostate cancer. However, the symptoms may be similar, hence prostate cancer needs to be excluded in the evaluation.

As the prostate enlarges the urethra gets ‘squeezed’ and greater effort is required to pass urine. In time, the bladder wall thickens and starts to become irritable. All these can lead to symptoms like;

Urinary frequency
Passing urine too often in the day

Nocturne
Passing urine too often in the night

Urgency
Difficulty in holding on when the urge to urinate takes over

Poor stream
Urinary flow speed decreases and tapers off in spurts sometimes

Hesitancy
Difficulty in starting when you want to pass urine

Incomplete emptying
The sense that you have not tempted your bladder fully

Acute urinary retention
The sudden inability to pass urine

If the obstructing prostate is left unchecked, some patients develop a weak and overstretched bladder that loses its ability to contract and empty itself. This then can lead to:

Recurrent infections

Bladder stones

Back pressure to the kidneys leading to kidney damage

There are three main treatment options for BPE:

Regular Monitoring or “watchful waiting” for mild cases

Regular Monitoring or
“watchful waiting” for mild cases

Medication to “relax” or “shrink” the prostate

Medication to “relax” or
“shrink” the prostate

Surgery

Transurethral resection of prostate (TURP)

(TURP) remains the gold standard in treating BPE. In TURP, the surgeon inserts a telescopic tube up the urethra and cuts out pieces of the prostate with a wire loop till the urethra becomes widely patent. After a TURP, one may expect the urinary stream to become much more forceful and fast. However, the symptoms of urinary frequency or waking up to go too many times at night may remain in up to 30% of patients.

A TURP generally requires a 2 day stay. This procedure is painless under general or regional anesthesia. Upon discharge, patients should expect to pass out urine with blood for days to weeks after the procedure. Occassionally, patients also experience a temporary difficulty in controlling their bladder immediately after the TURP. This should resolve in weeks.

One of the bothersome side effects of a TURP is that there is a 70-90% chance of retrograde ejaculation. Ejaculated sperm will go "backwards" into the bladder instead of shooting forwards. This is because the bladder neck does not close during ejaculation as it normally should as it has been cut in a TURP. Because of this, and the perception that it is a major operation, several minimally invasive alternatives to TURP are available. While these may have fewer side effects they may not be as effective or durable.

Minimally invasive options to TURP

There are a few alternatives for patients who do not wish to undergo a TURP. These include radiofrequency ablation (TUNA) or laser vaporization of the prostate. These are less invasive in terms of the amount of tissue removed and the creation of raw exposed areas that are prone to bleeding. This translates to less bleeding and shorter healing times. The results are usually not as dramatic or durable as a TURP but may be satisfactory for some patients.

Transurethral Needle Ablation (TUNA) of Prostate destroys a small volume of prostate at area of application and also destroys some nerves so that the prostate becomes more "relaxed". The "opening up" effect is not as complete as a TURP and recurrence is common.

Greenlight Laser ablation of Prostate which vaporizes the prostatic tissue in a controlled manner to remove the obstructing prostatic lobe.

Treatment for BPE

Treatment choice depends on the severity of symptoms and whether or not there are any of the complications stated above. Doctors often use a questionnaire called the International Prostate Symptom Score (IPSS) to determine the severity of symptoms, how much they bother you, and whether or not you have improved after treatment.

In general, most men can be treated with medications. Urinary flow should improve by about 30% and most of the other symptoms should improve by about 50-60%. Treatment however is lifelong and about 10-15% experience side effects like dizziness, drowsiness and headaches.

Surgery should be considered in the following circumstances:

Where there are complications of BPE eg stones, recurrent infections or urinary retention, bladder or kidney decompensation, recurrent blood in urine

Where medications don’t work and symptoms are still very bothersome

Where the side effects of medication are intolerable and symptoms are still bothersome

Prostatic Cancer

Prostate cancer is now the fifth most common type of cancer affecting Singapore males. These days, it is often detected because patients have their blood PSA tested as part of health screening protocols. Some patients are detected when they develop the symptoms of an enlarged prostate. Others are detected when the specimens of a TURP are found to contain some cancer. In some cases, a medical opinion is sought only after the cancer has affected the bone or surrounding areas, causing discomfort.

When detected early, cure rates are excellent. Currently, one of the ways to detect it early is to undergo prostate health screening. Upon being diagnosed, patients with prostate cancer require furthers tests to determine the extent of disease (staging) before being counselled on treatment options. Treatment options depend on the tumor grade and stage, patient's age and PSA level. Briefly, prostate cancer treatment can be divided according to disease extent ie organ confined, locally advanced and advanced:

Organ confined Prostate cancer

The cancer is confined to the prostate gland only. Treatment options for organ confined cancer include:

Radical prostatectomy (open or laparoscopic)
Radiotherapy : External beam radiotherapy and androgen deprivation
Brachytherapy
Watchful Waiting
Other options like HiFU and cryotherapy which are somewhat experimental and not available in Singapore.

The choice of therapy depends on the patient's fitness for major surgery, his inclinations as well the characteristics of the tumor. For example, some "more aggressive" tumors may not be suitable for brachytherapy.

There have been no head to head comparisons in medical literature to determine what is the best way to treat organ confined prostate cancer. It is best to have a full and frank discussion with your urologist before making a decision. You may also want to seek the opinion of a radiation oncologist.

From a surgeons point of view, there are advantages to a Radical prostatectomy. These include;

Complete removal of the cancer containing prostate: This affords peace of mind and also eliminates a possible source of symptomatic recurrence within the pelvis.
Available specimen for full pathological examination: Prostate cancer is usually diagnosed from a TRUS biopsy which yields tiny specimens. The aggressiveness of the disease is graded based on these specimens. Similarly, the extent of spread (staging) is determined by CT scans of MRIs. Though generally accurate, there is a small margin of error that can lead to under grading or staging. A full examination of the removed prostate by a pathologist can conclusively grade the cancer and tell us if the disease has actually "broken through" the capsule or involved its surroundings microscopically.
A hard end point for treatment and monitoring: After treatment, prostate cancer patients are monitored by blood PSA levels. Unlike radiotherapy, the PSA level after surgery should be zero. Monitoring of this level gives one a better sense of what is happening.
More infomation for prognosis: Information from the pathological examination of the prostate and post surgery PSA levels allows the doctor to project some prognostic data based on available literature.

Locally advanced Prostate cancer: In cancers that have spread to its immediate surroundings but not to the bone and other "far away" places, the best option is to have radiotherapy and androgen deprivation.

Advanced disease /Metastatic Prostate cancer: This is treated with androgen deprivation , supplemented by therapy targeted at symptomatic relief. For those in whom hormonal deprivation no longer work, there are options of chemotherapy.

Prostatitis

The prostate is susceptible to chronic and acute infections called prostatitis. Symptoms overlap with prostate enlargement and urinary tract infections. Long courses of antibiotics are sometimes necessary for effective treatment.

MEDICAL TERMS

RADICAL PROSTATECTOMY

Radical prostatectomy involves surgically removing the prostate gland and the seminal vesicles. It is the most common treatment for localized cancer of the prostate in men under 70 who do not have other health complications.

It is performed through a lower abdominal incision (Open) or laparoscopically. During a laparoscopic prostatectomy, a telescopic instrument called a laparoscope is inserted into the abdomen through a small incision at the belly button. The laparoscope allows surgeons to view inside the abdomen and perform the surgery without having to make a large incision. Usually, four more small incisions are made in the abdomen to accommodate surgical instruments during surgery. This eliminates the need for a large surgical incision to remove the prostate. As a result, the patient may experience less pain and scarring, faster recovery and less risk of infection. In some cases, the surgical procedure may require conversion to the standard open operation if extreme difficulty is encountered during the laparoscopic procedure. Side effects of radical prostatectomy include:

Risk of blood clots

Urinary leakage (incontinence)

dysfunction (impotence)

If the cancer is small, surgeons try to avoid removing or cutting the nerves that control a man's ability to achieve an erection (nerve sparing). Depending on the patient's age and the stage of tumor advancement, nerve-sparing techniques allow about 40 percent to 65 percent of men who were sexually potent before surgery to remain potent after surgery

ANDROGEN DEPRIVATION (HORMONAL TREATMENT)

Androgen deprivation therapy is the gold standard of care for men whose prostate cancer is advanced and has spread throughout the body. The therapy works by shutting down male hormones, principally testosterone, that promotes prostate cancer growth. It is also used in conjunction with radiotherapy for treating organ confined or locally advanced prostate cancer.

Roughly 95% of the male hormones come from the testis and another 5% from the adrenal gland. Androgen deprivation is achieved in 3 ways:

Bilateral Subcapsular Orchiectomy: Removal of the contents of both testis in a minor day operation. This is a permanent and cost effective method for patients with advanced prostate cancer

LHRH agonists: 3 monthly injections that decrease the levels of testosterone circulating in the blood. This is an effective and reversible form of androgen deprivation, but quite costly. It is often used in conjuction with radiotherapy.

Anti-androgens: Anti-androgens specifically block the action of testosterone at the prostate cells. It also acts the same way in the rest of the body to prevent androgens from working at their target sites. Anti-androgens are used alone or in combination with LHRH agonists.This combination is called total androgen blockade (TAB). TAB has not been shown to be more efficacious in increasing survival from prostate cancer.

Side effects of androgen deprivation are similar to "andropause" or male "menopause" and include decreased libido, erectile dysfunction, hot flashes, fatigue, osteoporosis, high cholesterol, anemia, forgetfulness and insomnia

BRACHYTHERAPY

Radioactive seeds are implanted into the prostate under xray guidance to "kill" the cancer cells. This is only suitable for small, less aggressive cancers. Long term results are still pending but it remains an attractive option to those wanting to avoid surgery.

WATCHFUL WAITING

Also known as active surveillance, this is an option for only the few who have very very "non aggressive" type cancers. It is thought that these are slow growing and therefore unlikely to be lethal. Constant monitoring is still necessary to see if things ever change.

TRUS (TRANSRECTAL ULTRASOUND ) BIOPSY

A Transrectal ultrasound (TRUS) of the prostate gland is performed when

a nodule is felt by a physician during a routine physical or prostate cancer screening exam

an elevated blood PSA test result is noted

evaluating a patient with male infertility

In men, the prostate gland is located directly in front of the rectum, so the ultrasound exam is performed transrectally. The cylinder-shaped ultrasound probe is gently placed in the rectum as the patient lies on his left side with the knees bent

The ultrasound probe allows a needle to be advanced into the prostate gland while the urologist watches the ultrasound images. Your doctor will usually follow a set protocol on the site and number of biopsies to take as the prostate ultrasound image can look perfectly normal in early stage cancer. This ultrasound examination is usually completed within 20 minutes and is performed in the clinic or day suite. Preparation includes having an enema and taking some prescribed antibiotics the day before.

PSA (PROSTATE SPECIFIC ANTIGEN)

The PSA test measures the amount of Prostate Specific Antigen (PSA) in the blood PSA is a glycoprotein (a protein with a sugar attached) found in prostate cells. It can be detected at a low level in the blood of all adult men.

Normal values vary with age. Older men typically have slightly higher PSA measurements than younger men. PSA of 4 ng/ml is considered high for most men and may indicate the need for a prostate biopsy. For men younger than 60, PSA have lower normal limits : Age 40 -49 <2.5 ng/mL ; Age 50 – 59 < 3 ng/mL

A high PSA level does not confirm the presence of cancer. It only identifies patients at higher risk of having prostate cancer. Several conditions besides cancer can cause the PSA level to rise. These include urinary tract infections, an enlarged prostate, prostatitis, recent placement of a urinary catheter or surgery on the urinary tract.

A TRUS biopsy of the prostate is required to confirm prostate cancer. Keep in mind that only 1 in 4 men with a PSA level between 4-10 ng/ml have prostate cancer..

Although PSA testing is an important tool for detecting prostate cancer, it is also not foolproof. 1 in 5 men with prostate cancer have a "normal" blood PSA level.

The PSA level is also used to monitor for recurrence after treatment of prostate cancer. For example, after surgical removal of the prostate (radical prostatectomy) PSA should be near zero.

PROSTATE HEALTH SCREENING

While it has not been conclusively shown that a mass screening program will decrease mortality from prostate cancer, it is acknowledged that early prostate cancer is often without symptoms and that prostate cancers detected by screening are often significant cancers. When detected early, cure rates are excellent. It has therefore been recommended that men over 50 (40 in those with first degree relatives with prostate cancer) have a yearly digital rectal examination and PSA test. Men with suspicious results will be counselled about a TRUS biopsy.

Our prostate health screening consists of a consultation with a urologist, examination including a digital rectal examination, assessment of urinary flow and post void residual volume and a PSA test.

DIGITAL RECTAL EXAMINATION (DRE)

This is performed to determine if the prostate is enlarged or abnormally lumpy (nodular).The patients lies on his left with his knees bent while the doctor inserts a gloved lubricated finger into the rectum. Some patients may find this a little uncomfortable but it is neither painful nor harmful. This examination goes hand in hand with PSA testing to determine if a man is at risk for prostate cancer. Patients with suspicious DREs will often be recommended to undergo a TRUS biopsy.

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