Prostate Problems

Introduction

The prostate gland is found only in men; it sits just underneath the bladder and the tube that carries urine from the bladder to the penis (the urethra) runs through it. The prostate produces some of the fluid in the semen and hence has a reproductive function.

What problems can the prostate gland cause?

There are three main problems that can arise from the prostate gland.
- Benign prostatic hyperplasia (BPH)
- Prostate cancer
- Prostatitis

With the exception of prostatitis which can affect the younger age group, prostate problems usually affect men above 50 years of age. This article will focus mainly on BPH as it is the more common of the three problems.

Benign prostatic hyperplasia (BPH)

This is a non-cancerous enlargement of the prostate gland. The prostate gland increases in size as men get older, because of the presence of the male hormone testosterone. Prostate enlargement affects almost all men to some extent. In some men, the enlargement causes symptoms due to obstruction of urine flow. Up to 50% of men above 50 years of age will have symptoms due to prostate enlargement.

What are the symptoms of prostate enlargement?

Prostate enlargement may cause the following symptoms:
- Difficulty in initiating urination
- Weak urine stream
- Urine stream stops and starts
- Unable to empty bladder completely
- Frequent urination
- Urgent need to urinate
- Leakage of urine

When the problem is untreated, it can cause serious problems such as:

- Sudden and complete inability to pass urine resulting in severe pain
- Blood in the urine
- Bladder stones
- Kidney failure

How is BPH diagnosed?

Based on the symptoms, the doctor will know that the problem is likely to be BPH. He will go on to perform a rectal examination to feel the prostate, to make sure that the prostate does not have cancer. Other tests to be done may include:
- Urine test to check for blood in the urine
- PSA blood test to check for prostate cancer
- Ultrasound of the prostate to check prostate size and shape
- Ultrasound of the bladder and kidneys to check for stones and obstruction
- Uroflow test to assess the urinary flow rate
- Flexible cystoscopy to check the urethra and bladder

Rectal examination

Ultrasound of the Prostate

Uroflow Test

Flexible Cystoscopy

What is the best treatment for BPH?

Medication

Patients with mild symptoms of BPH are initially treated with medication. There are two main types of medication, one that relaxes the prostate and gives quick relief of symptoms, the other to shrink the prostate and prevent further worsening of the condition.

Surgery

Patients with severe symptoms of BPH may require surgery. Nowadays, the surgery is minimally invasive and there is no incision needed.

Transurethral resection of prostate (TURP)

TURP is the most established minimally invasive treatment for BPH. The prostate gland is cut from within by a special cystoscope with a loop attachment. A urinary catheter is inserted afterwards to allow recovery and is removed after one or two days. As it is minimally invasive, there is minimal pain and the recovery is quick.

The prostate being cut by the loop during TURP

Greenlight laser prostatectomy

Greenlight laser prostatectomy is a newer surgical procedure for BPH. The prostate gland is vaporised from within using laser. It is also a minmally invasive procedure.

The prostate is vaporised during laser prostatectomy

What is the difference between TURP and Greenlight laser?

TURP is suitable for treatment of prostate glands of all sizes. Greenlight laser prostatectomy is suitable only for smaller prostates. The advantage of Greenlight laser is that postoperative bleeding is less.

Prostate cancer

Prostate cancer is the 3rd most common cancer among men in Singapore. The risk of getting prostate cancer increases as one gets older. Prostate cancer can be slow-growing or aggressive. In the early stage, the patient may not experience any symptoms. In the advanced stage, it can lead to difficulty in passing urine, passage of blood in the urine, loss of weight, loss of appetite and low blood count. The cancer may spread to the bones and cause severe pain in the bones.
Prostate cancer is usually diagnosed by checking the blood for abnormal levels of prostate specific antigen (PSA), followed by a needle biopsy of the prostate.

Treatment for prostate cancer is very effective. Depending on the stage of the disease, patients with prostate cancer can be treated with either surgery, external beam radiotherapy, seed implants (brachytherapy) or hormonal therapy. Some elderly patients with very slow-growing cancers may also be monitored closely without treatment.

Patient after recovery from open surgery for prostate cancer

Patient after recovery from laparoscopic surgery for prostate cancer ?scars hardly visible

X-ray of patient after seed implant treatment for prostate cancer (brachytherapy)

Prostatitis

Prostatitis is inflammation of the prostate gland. Patients with prostatitis may experience pain and difficulty in passing urine. Because the prostate gland is situated deep within the pelvis, often the location of the pain is not easy to pin-point. The areas where pain may occur include the lower part of the abdomen, the area between the scrotum and the anus, and the base of the penis.
Prostatitis may be caused by bacterial infection or non-specific inflammation. Depending on the cause, treatments may include antibiotics, painkillers, muscle relaxants and prostate medications.