Prostate Disease

Benign Prostatic Enlargement

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
  • Nocturia – 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 emptied 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:

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.

To test your IPSS score, click here.

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

Benign Prostatic Enlargement

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:

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.


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.

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