Did you know that Prostate Cancer is one of the three leading causes of cancer in Singaporean males?
According to the 2015 Annual Registry Report by Singapore Cancer Registry, prostate cancer has become prevalent in Singapore. In fact, prostate cancer accounts for 13% of all cancers amongst the male population in Singapore. 
Dr Ronny Tan is a board-certified Singaporean urologist that shares his advice on how to deal with prostate cancer. Read on to find out about coping with symptoms and treatment side effects.
What Are The Signs And Symptoms?
There are usually no symptoms during the early stages of prostate cancer. However, you should seek medical advice from your doctor if you experience the following signs: 
- Lower limbs feel weak or swollen
- Lumps on your prostate gland
- Urinary Problems
- Wake up to urinate at night (Nocturia)
- Interrupted Urination
- Pain during Ejaculation
- Bone pain, especially in the night, waking you from sleep. This is a sign of bone metastases (ie prostate cancer spread to the bone).
Will Prostate Cancer Improve With Early Diagnosis?
Urinary problems and pain during ejaculation can also be caused by:
- Urinary Tract Infection
- Urinary Stones
- Benign Prostate Hyperplasia
Now, it’s important to have that checked out!
1. Digital Rectal Examination
A digital rectal examination is usually the first step of a prostate cancer diagnosis. During the examination, the doctor will typically look out if you have any lumps or abnormal growth on the prostate. The doctor does so by positioning a lubricated, gloved finger into the rectum.
2. PSA Screening
Prostate-Specific Antigen (PSA) is a substance that is produced by the prostate gland. Going for a PSA test will allow your doctor to determine if the PSA levels in your blood are in the normal or elevated range.
Experts have determined the normal PSA level to be less than 4 ng/mL. However, experts believe that the cutoff levels for younger patients should be lowered to less than 2.5 or 3 ng/mL. The reason for that is because younger men tend to have lower PSA values due to smaller prostates. 
Please note that I do not recommend population screening of men for prostate cancer, because the studies are against it.
However, it has been shown that PSA should be done in men who present to the doctors with urinary symptoms suggestive of an enlarged prostate.
Consult your doctor on the pros and cons of PSA Test screenings!
3. Transrectal or transperineal ultrasound-guided biopsy
The Transrectal procedure is also known as the transperineal ultrasound-guided biopsy. During the procedure, an ultrasound probe, which is about the size of a finger, will be inserted into the rectum to examine the condition of the prostate. Using images from the ultrasound probe, the doctor is able to conduct a systematic sample of your prostate. Tissue samples of the prostate will also be removed with a thin needle under a local anaesthetic and examined under a microscope by a pathologist.
4. MRI Scan of Prostate
A Magnetic Resonance Imaging (MRI) scan of the pelvis can also help you diagnose prostate cancer. It helps to determine the extent of cancer growth in the prostate gland and lymph nodes.
Why Do Some Experts Advise Against PSA Screenings?
In recent years, prostate cancer is detected at an earlier stage and in younger men due to PSA screenings. But there is no evidence on whether PSA screenings are really that beneficial for you. Instead, experts are questioning the relevance of screening for cancers which have no effect on a man’s survival.
On top of that, the National Cancer Institute stated that PSA screenings or digital rectal examination tend to lead to overdiagnosis and overtreatment of prostate cancers. Screenings can also produce false-positive findings. This can cause needless worry and the need to go through unnecessary diagnostic or treatment procedures. , 
The growth rate of prostate cancer varies among men. For some, their prostate cancer develops slowly and may not face any signs or symptoms. In others, prostate cancer can develop quickly and result in pain, other severe complications or even death. Accordingly, treatment methods will also vary among men with different extent of prostate cancer.
For this purpose, here are the 5 different treatments for prostate cancer. Above all, you should keep a lookout for the treatment that best suits you. You should also consider your age and fitness before deciding which treatment to opt for. 
1. Active Surveillance vs Watchful Waiting
If you have slow-growing or low-risk localised prostate cancer, you should consider the active surveillance option.
Rather than immediate treatment, you will be kept under close supervision so as to monitor your condition. Should you develop any signs and symptoms of prostate cancer, you can subsequently choose to undergo other forms of curative treatment.
If you have a short life expectancy (due to old age or other illnesses) and show no symptoms of prostate cancer you should undergo watchful waiting. Some doctors may use this term interchangeably with active surveillance, however, there are some differences.
Watchful waiting usually involves less-intensive follow-up tests compared to active surveillance. Under this approach, treatment will only be deemed necessary if you show any signs and symptoms associated with prostate cancer. This approach is also compatible with you if you are facing certain health conditions, that make you unsuitable to undergo surgery or radiotherapy.
If you have a tumor that is localised at the prostate, surgery is a viable option. Open or robot-assisted radical prostatectomy (RP) is usually recommended. The prostate together with the seminal vesicles will be removed. When indicated, the pelvic lymph nodes will be removed at the same sitting.
Surgery can also be used to treat men with locally advanced prostate cancer. These men may also need to undergo radiotherapy after the surgery as part of the multi-modality treatment regime.
It is important to note that the treatment of prostate cancer is NOT without risk. Similarly, RP procedures have a risk, and you should weigh the benefits against the risks before making your decision.
You could possibly develop the following side effects if you undergo a radical prostatectomy procedure:
- Urinary Incontinence (Loss of bladder control)
- Erectile Dysfunction (Losing the ability to have an erection)
- Inguinal Hernia (Bulging in the groin area which can cause pain in bowel movement, coughing or exercise.)
Whilst the first two side effects are common across other forms of treatment for prostate cancer, an inguinal hernia may occur more often in men treated with radical prostatectomy. Hence, you should always consult your doctor regarding the best course of action to pursue in treating your condition.
Radiotherapy helps to treat prostate cancer through the use of high-energy beams. These beams help you eliminate cancer cells and prevent the growth of cancer cells. You have 3 choices for radiotherapy:
- External beam radiotherapy (EBRT) uses radiation to work on areas affected by cancer. EBRT techniques may include Three-Dimensional Conformal Radiation Therapy (3D-CRT) which pictures the tumor and shape the radiation accordingly for the beams to target the tumor from different directions. The damage to surrounding healthy tissues is also lesser with this technique.
- Stereotactic Body Radiation Therapy (SBRT) uses highly-focused beams of high-dose radiation on the prostate to eliminate cancer cells in the area. This procedure usually takes a day but it might last for several days depending on the progress.
- Brachytherapy involves the surgical placement of implants that will project radiation to the prostate. These implants may either be permanent or temporary.
Take note that the form of radiotherapy that you get ultimately depends on your type and stage of cancer.
Besides urinary incontinence and impotence as mentioned above, men who have undergone radiotherapy may also develop radiation cystitis (bleeding from the bladder) and radiation proctitis (bleeding from the rectum). Although radiation is curative for prostate cancer it can increase the risk of developing cancer in the organs in the pelvis (e.g. bladder, colon, rectum).
4. Hormone (Androgen Deprivation) Therapy
Hormone therapy is often used to interfere with the development of androgen (male sex hormones). The deprivation of androgen in a man with prostate cancer will slow down the growth of prostate cancer cells.
This method is frequently used in treating:
- Prostate cancer that has spread to other areas.
- High-risk or locally advanced prostate cancer, by using it in combination with radiotherapy.
By undergoing hormonal therapy, it can help slow down or stop your growth and spread of prostate cancer. You can choose from these 3 forms of hormonal therapy:
- Drug prescription to prevent the release or interfere with the effects of male hormones on prostate cancer.
- Surgical removal of the testes
- Use of other hormones such as anti-androgens
There may be some side effects ...
If you have undergone hormonal therapy, you should take note of these possible side effects that may arise:
- Hot flushes
- Impaired sexual function
- Loss of desire for sexual activity
- Osteoporosis (bone health issues)
To combat the problem of bone loss due to osteoporosis, men who are started on androgen deprivation therapy will be given other medications to improve their bone health.
If you are in your advanced or metastatic stages of prostate cancer, you will be offered to undergo chemotherapy if you are deemed suitable and fit enough. In some patients, chemotherapy would be given together with androgen deprivation therapy.
This approach uses drugs to eliminate the growth of cancer cells and prevent them from spreading.
If you have received chemotherapy, you may experience the following side effects:
- Hair loss
- Inflammation on the cheeks, gums, tongue, lips, and mouth
- Abnormal blood profile which could increase the risk of infection
Treatment of prostate cancer is not just about improving a man’s survival
There are some risks that you should take note of if you are considering a prostate cancer treatment. Treatments for prostate cancer can incur long-term side effects in you. Specifically, they often lead to conditions like stress urinary incontinence (SUI) and erectile dysfunction (ED). While both conditions can affect your self-esteem and quality of life, an ED can affect both you and your partner as well. 
Erectile Dysfunction is more common in men than Stress Urinary Incontinence
The Prostate Cancer Outcomes Study (PCOS) revealed the following findings concerning erectile dysfunction: 
- 60% of men experienced self-reported erectile dysfunction 18 months after RP
- Only 28% of men reported erections firm enough for intercourse at a 5-year follow-up.
SUI, on the other hand, tends to be less common. Most men would be able to regain their continence after a period of rehabilitation with pelvic floor exercises, commonly known as Kegel’s exercises.
Stress Urinary Incontinence (SUI)
Urinary continence is a blessing that most men take for granted. Unfortunately, most of them only realize this when they face SUI after prostate cancer treatment.
Why Does Urinary Incontinence Occur?
Urinary continence is maintained by two sphincters, namely the internal and external sphincter. The internal sphincter is at the bladder neck, where the urinary bladder meets the prostate. On the other hand, the external sphincter is located at the pelvic floor.
If you have had your prostate removed, your internal sphincter will likewise be removed. For this reason, urinary continence will be maintained by your external sphincter and pelvic floor muscles. As your body may not be accustomed to just relying on the external sphincter and pelvic floor muscles to keep the bladder neck shut to maintain urinary continence, your ability to stay dry will be impaired. In short, this is why most men experience SUI in the initial weeks after prostate cancer surgery. 
Kegel’s Exercise Pre and Post Prostate Removal
If you are planning to undergo prostate surgery, you will usually be educated on the Kegel’s exercises before your surgery. Concurrently, you will also be advised to kickstart on the exercises before your surgery to strengthen your pelvic floor muscles and bladder control.
You should also continue to carry out the exercise regime 1 week after surgery when your urethral catheter (urine tube) has been removed. 
Surgical Options for Persistent SUI
Source: Urethral Sling Illustration, Artificial Urinary Sphincter Illustration
If you face persistent SUI despite efforts to strengthen your pelvic floor muscles, you would usually be offered to undergo surgery. The decision on whether to opt for surgical procedures also depend on how active you are.
If you are constantly engaged in sports (e.g. running, swimming, etc.), you may want to consider surgical intervention if these hobbies result in SUI. If you have decided on a surgical procedure, you have two options. , 
Urethral Sling Procedure
First, you can undergo the placement of a urethral sling, which will be suitable for you if you have mild to moderate SUI. To illustrate how the urethral sling works, the sling works like a hammock to support the urethra (urine tube). The procedure, which is usually done as day surgery, would help strengthen your pelvic floor muscles and provide you with immediate relief from the symptoms of SUI after you recover from the anaesthesia.
Artificial Urinary Sphincter
Second, you can opt for the artificial urinary sphincter (AUS), which is an implanted device that will help those with severe SUI.
The AUS functions based on 3 main components:
- The Urethral Cuff is positioned around the urethra and replicates the function of the external sphincter in maintaining urinary continence.
- The Scrotal Pump is a button for you to release the pressure in the cuff to allow you to pass urine when pressed.
- The Pressure-regulating balloon, which maintains the pressure in the urethral cuff to help maintain urinary continence.
The urethral cuff is kept closed most of the time to prevent you from involuntary urination. When there is a need for urination, you should press the scrotal pump to allow fluid in the cuff to flow into the pressure-regulating balloon thereby deflating the cuff so that the pressure around the urethra is decreased, hence allowing urine to flow through the urethra. The cuff then re-inflates automatically after a minute or so and you will be continent again.
This procedure is more complex than the urethral sling placement and you will be required to stay overnight in the hospital. The AUS is usually deactivated immediately after your surgery. Subsequently, when your body has recovered from the procedure (usually 6 weeks), the AUS will be activated.
Erectile Dysfunction (ED)
We urologists concentrate on these 3 aspects when it comes to treating prostate cancer:
- Cancer Control
- Urinary Continence
- Erectile Function
If you are a prostate cancer survivor, your expectations will also be in line with what we are trying to achieve. First off, you would want your cancer to be adequately treated. Next, you would want to be able to stay dry. When you are continent and well-treated from cancer, the ability to have sexual relations would be likened to the cherry on the cake. 
Effects on the Neurovascular Bundle Can Result In Erectile Dysfunction
If you suffer from erectile dysfunction after a prostate cancer treatment, it is probably due to the effects that the treatment has on your neurovascular bundle.
The neurovascular bundle is the combination of nerves, arteries and veins in a human. Together, it is responsible for the transmission of impulses in a man that will trigger an erection in the penis as well as the amount of blood delivered to the penis that will determine the length and girth of the penis during an erection. 
As your nerves may be cut during non-nerve sparing surgery in order to remove the cancer adequately, you would lose your ability to have an erection after radical prostatectomy. You may experience neuropraxia or temporary damage to your nerves even in the best of hands with nerve sparing resulting in temporary erectile dysfunction or a less optimal erectile function than before.
For this reason, you should always consult your doctor on the potential complications before going for this procedure. What is lost will not return. Likewise, do NOT expect a miracle for your erections to become stronger after surgery.
Recovery of Erectile function depends on…
There are 3 key influences which affect your chances of recovery from Erectile Dysfunction and they are:
- The degree of nerve sparing,
- degree of neuropraxia
- and damage to the accessory pudenal arteries during surgery.
Besides these, the diagnosis of cancer and undergoing a major surgery can also have a psychological effect on your erectile function.
Studies have shown that erectile function can recover up to 2 years after surgery. However, there’s an exception. If you have undergone radiotherapy, it is almost certain that you will face persistent erectile dysfunction as such treatments are non-nerve-sparing. 
Although you may have a chance of recovery (unless you have undergone radiotherapy), waiting 2 years for erections to return may not be acceptable for you. Moreover, your partner may also not be ready after 2 years of sexual abstinence and inactivity! Thus, if you wish to shorten the wait for the return of your manhood, you can consider undergoing penile rehabilitation .
Penile rehabilitation after prostate cancer treatment is NOT merely the treatment of erectile dysfunction. It is the use of any intervention or combination of medication, devices or actions with the goal of restoring the erectile function present before treatment of prostate cancer.
You and your partner need to understand that penile rehabilitation can only restore whatever erectile function you had. In penile rehabilitation, we target not just the muscles responsible for an erection (i.e. the corpus cavernosum) but also the health of the blood vessels supplying the penis.
Through penile rehabilitation, we aim to help you achieve the following:
- Improved oxygenation to the cavernosal bodies
- Preserving your endothelial structure and function so as to prevent smooth muscle structural changes
We should all know that our muscles shrink when we do not use them. Likewise, the penis being a muscular organ, will shrink in size with decreased erections after treatment for prostate cancer. In some cases, it may even result in penile curvatures, which further decreases the functionality of a penis as a sex organ. 
1. Oral Phosphodiesterase 5 (PDE 5) Inhibitors
The most commonly used and best-studied form of penile rehabilitation after nerve-sparing RP would be oral phosphodiesterase 5 (PDE 5) inhibitors. Examples of PDE5 inhibitors include:
- Sildenafil (Viagra)
- Vardenafil (Levitra)
- Tadalafil (Cialis)
PDE5 inhibitors are relatively safe and easy to use. They help to decrease the breakdown of cyclic guanosine monophosphate (cGMP), which increases the outflow of intracellular calcium ions. cGMP also helps you with smooth muscle relaxation and erection, and its effects are heightened with the aid of nitric oxide production stimulated by the cavernous nerves.
Studies have shown that the use of this oral medication as penile rehabilitation after nerve-sparing is effective.
2. Intracavernosal Injection (ICI)
Intracavernosal injection (ICI) of vasoactive agents has been used for the treatment of erectile dysfunction. Agents used include:
- Prostaglandin E1 (PGE1) analogue alprostadil on its own
- or in combination with Papaverine and Phentolamine (commonly referred to as the Bi-mix or Tri-mix concoction).
These agents aid the increase in blood flow to your penis and thereby helping to trigger erections. Locally, ICI alprostadil is more widely used on its own. ICI has been proven effective for the treatment of erectile dysfunction after nerve-sparing RP as monotherapy or in combination with PDE5 inhibitors.
3. Vacuum Erection Device (VED)
The vacuum erection device (VED) causes an erection by creating negative pressure around the penis. This will help draw both venous and arterial blood into the spongy tissue of the penis. In theory, this helps to improve the delivery of oxygen and other nutrients to the tissue in the penis and prevent scarring.
The VED comes with a constriction ring that is positioned on the penile base. It helps to maintain erections that are firm enough for penetrative sex by preventing the outflow of blood from the penis. If you are using VED for penile rehabilitation, you should avoid using the constriction band as it would decrease oxygen saturation upon 30 minutes of usage.
Studies have shown that the use of VED prevents penile shortening. Results are also promising when using VED with PDE5 inhibitors, as it helps you have multiple erections on a daily basis early in your penile rehabilitation period.
4. Low-Intensity Extracorporeal Shockwave Therapy (LiESWT)
There has been a recent interest locally, in the use of low-intensity extracorporeal shockwave therapy (LiESWT) for the treatment of vasculogenic erectile dysfunction.
The procedure involves the application of shockwaves to the corpus cavernosum. This causes mechanical stress and microtrauma, which triggers a chain of biological reactions that result in the formation of new blood vessels in the erectile tissue. It has also been reported that LiESWT can help you regenerate the nerves in your penis, and hence, it is a good option if you are considering to undergo penile rehabilitation.
5. Penile Vibratory Stimulation (PVS)
The newest kid on the block for penile rehabilitation would be penile vibratory stimulation (PVS).
PVS was first used to stimulate penile erection and ejaculation in men with spinal cord injury. Under this approach, PVS works through the stimulation of nerves along the penile shaft, which will help cause an erection.
Some considerations …
At present, we still don’t have the recommended modality for penile rehabilitation. Above all, you should be aware that penile rehabilitation is more effective if you have a relatively good erectile function pre-treatment and has undergone nerve-sparing RP. If you have a poor erectile function or have undergone non-nerve-sparing RP due to oncological reasons, you should consider the placement of a penile prosthesis instead.
The million dollar question for you and your partner is how soon both of you would want to engage in penetrative intercourse after treatment of prostate cancer. Penile rehabilitation takes time. And while you are undergoing penile rehabilitation, your partner, on the other hand, is not undergoing any vaginal rehabilitation!
In these cases, you should keep your options open and especially so if your penile rehabilitation strategies fail to stand the test of time.
Dr Ronny Tan is a Consultant Urologist and Andrologist who is practicing at Advanced Urology. Dr Tan is also a Fellow of the Academy of Medicine, Singapore. He has received his fellowship training in the USA in his area of specialty as well as an SMSNA (Sexual Medicine Society of North America)-accredited clinical fellowship in Tulane University, New Orleans.
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