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 is a common type of cancer 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. He will share his advice on how to deal with prostate cancer. Read on to find out about how you can cope with its symptoms as well as the treatment’s side effects.
What Are The Signs And Symptoms?
Most of the time, symptoms do not show itself in the early stages of prostate cancer. However, you should seek medical advice from your doctor if you experience any of 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 that wakes you up from your sleep. This is a sign of bone metastases (eg prostate cancer that has spread to the bone).
Will Prostate Cancer Improve with Early Diagnosis?
Prostate cancer can share the same symptoms as a few other conditions. These symptoms include urinary problems as well as pain during ejaculation. Here are some of the conditions that may also cause these symptoms:
- Urinary tract infection (UTI)
- Urinary stones
- Benign prostate hyperplasia
It is important to have these checked out.
1. Digital Rectal Examination
The first step when your doctor wants to diagnose prostate cancer is to conduct a digital rectal examination. This process is done by inserting a lubricated gloved finger into the rectum. Your doctor will look out for any lumps or abnormal growths on the prostate.
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 that the normal PSA level is 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 being is that younger men tend to have lower PSA values due to having smaller prostates. 
Furthermore, do note that I do not recommend population screening of men for prostate cancer. There are studies that are against it.
However, it has been shown that PSA should be done in men who present urinary symptoms that suggest an enlarged prostate.
You should discuss with your doctor on the pros and cons of PSA test screenings!
3. Transrectal or transperineal ultrasound-guided biopsy
A transrectal procedure is also known as a transperineal ultrasound-guided biopsy.
During this procedure, your doctor will insert an ultrasound probe into your rectum. This probe will be about the size of a finger. With this procedure, your doctor will be able to examine your prostate’s condition.
We are able to conduct a systematic sample of your prostate using the images from the ultrasound probe. Doctors may remove tissue samples from your rectum by using a thin needle. It will then be taken to the pathologist for them to examine.
4. MRI Scan of Prostate
A Magnetic Resonance Imaging (MRI) scan of your pelvis can also help your doctor to diagnose prostate cancer. It helps to determine the extent of the cancer's growth in the prostate gland and lymph nodes.
Why Do Some Experts Advise Against PSA Screenings?
In recent years, prostate cancer is being detected in their earlier stages as well as in younger men due to PSA screenings. With that said, there is no evidence to support if PSA screenings are really beneficial to you. Instead, experts are questioning the relevance of screening for cancers that have no effect on a man’s survival rate.
On top of that, the National Cancer Institute has stated that PSA screenings or digital rectal examinations tend to lead to an overdiagnosis and overtreatment of prostate cancers. Screenings may also produce false-positive findings. This may cause needless worry in men and to their families. It also causes them to go through unnecessary diagnostic or treatment procedures. , 
What Are the Treatment Options for Prostate Cancer?
The growth rate of prostate cancer varies among men. For some, their prostate cancer develops slowly and they may not face any signs or symptoms. Whereas in others, prostate cancer may develop quickly and result in pain, severe complications or death. Thus, treatment methods will depend on men with different extents of prostate cancer.
For this purpose, here are five different methods to treat prostate cancer. Above all, you should keep a lookout for a treatment that best suits you. You should also consider your age and how fit you are before deciding on which treatment to embark on. 
1. Active Surveillance vs Watchful Waiting
If you have a slow-growing or low-risk localised prostate cancer, you should consider the active surveillance option.
Instead of going through with treatment immediately, you will be kept under close supervision to monitor your condition. If any signs and symptoms of prostate cancer are shown, you may then choose which forms of curative treatment you want to go through.
If you have a short life expectancy that is due to old age or other illnesses and you show no signs of prostate cancer, you should take the path of watchful waiting. Some doctors may use this term interchangeably with active surveillance. However, there are some differences to it.
Most of the time, watchful waiting involves less-intensive follow-up tests than active surveillance.
It will only be deemed necessary for you to go through treatment when you show signs and symptoms of this cancer. This approach would be best if you are facing certain health conditions that do not allow you to go through surgery or radiotherapy.
Surgery is one option you can choose to take if you have a tumour near the prostate. 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 in the same sitting.
Surgery can also be used to treat men with locally advanced prostate cancer. They may also have to go through radiotherapy after the surgery. The reason for this is due to the multi-modality treatment regime.
It is important to note that the treatment of prostate cancer comes with risks. Similarly, RP procedures have their own set of risks as well. You should weigh out the risks and benefits before making your decision.
Listed below are the side effects you may have if you go through 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.)
The first two side effects are common across other forms of treatment. However, an inguinal hernia may occur more often in men going through radical prostatectomy. With that said, you should always consult your doctor regarding the best course of action to pursue when treating your condition.
Radiotherapy helps to treat prostate cancer through the use of high-energy beams. These beams help to eliminate as well as prevent the growth of cancer cells. There are three choices:
- External beam radiotherapy (EBRT)
This form of treatment uses radiation to work on the areas affected by cancer. This technique may include Three-Dimensional Conformal Radiation Therapy (3D-CRT). A 3D-CRT will spot the tumour and shape the radiation accordingly. It will target the tumour from different directions. This technique does not damage the surrounding healthy tissue as much as the other treatments do.
- Stereotactic Body Radiation Therapy (SBRT)
It uses highly focused beams on the prostate to eliminate cancer cells in the area. This procedure takes up to a day. However, it might also last for several days depending on the progress.
An implant will be surgically placed to give off radiation to the prostate. They may either be temporary or permanent implants
You should take note that the form of radiotherapy you choose depends on the type and stage of cancer you have.
The Possible Complications
Like with most treatments out there, there are some possible complications that may occur. Men who have undergone radiotherapy may also develop:
- radiation cystitis (bleeding from the bladder)
- radiation proctitis (bleeding from the rectum).
Although radiation helps to cure 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 helps to prevent the development of androgen, the male sex hormone. When the level of androgen is low, the growth of the prostate cancer cells will slow down
This method is frequently used to treat:
- Prostate cancer which has spread to other areas
- High-risk or locally advanced prostate cancer
By undergoing hormonal therapy, it can help to slow down or stop the growth of your prostate cancer. It can also help to prevent the cancer from spreading. You can choose from these three forms of hormonal therapy:
- Drug prescription. To prevent the release of male hormones
- Surgical removal of the testes
- Use of other hormones such as anti-androgens
If you have gone through hormonal therapy, you should take note of these possible side effects:
- Hot flushes
- Impaired sexual function
- A loss of or no desire for sexual activity
- Osteoporosis (bone health issues)
Men are given medications to improve their bone health after they have gone through this treatment. It will help to combat bone loss due to osteoporosis.
If you are in the advanced stage of prostate cancer, you may need to go through chemotherapy. In addition, some patients would need to go through androgen deprivation therapy as well.
This approach of using drugs helps to stop the growth of cancer cells and prevent them from spreading.
If you have gone through 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
The Treatment of Prostate Cancer Is Not Just about Improving a Man’s Survival Rate
When considering a treatment for prostate cancer, you should take note of the risks that come with it. The treatments for prostate cancer can incur long-term side effects. Often, they lead to conditions such as stress urinary incontinence (SUI) and erectile dysfunction (ED). While both these conditions can affect your self-esteem and quality of life, an ED can affect both you and your partner. 
The Prostate Cancer Outcomes Study (PCOS) revealed the following findings of erectile dysfunction: 
- 60% of men experienced self-reported erectile dysfunction 18 months after RP
- At a 5-year-follow up, only 28% of men reported to have erections which are firm enough for intercourse
SUI, on the other hand, tends to be less common. Most men are able to regain their continence after a period of rehabilitation with pelvic floor exercises. These exercises are commonly known as Kegel exercises.
Stress Urinary Incontinence (SUI)
Urinary continence is a blessing that most men take for granted. Most of them will only start to realise this when they face SUI after a prostate cancer treatment.
Why Does Urinary Incontinence Occur in Men with Prostate Cancer?
Urinary continence is maintained by two sphincters. They are mainly the internal and external sphincter. The internal sphincter is located at the bladder neck, where the urinary bladder meets the prostate. Whereas for the external sphincter, it is found at the pelvic floor.
If you have had your prostate removed, your internal sphincter will most likely be removed as well. Your external sphincter along with your pelvic floor muscles will then have to maintain your urinary continence. As your body may not be used to solely relying on the external sphincter and the pelvic floor muscles to keep the bladder neck shut, your ability to stay dry will be weakened. In short, losing the internal sphincter is the reason 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 a prostate surgery, you will most likely be informed about Kegel’s exercises. At the same time, you will also be advised to start on these exercises before you go for the surgery. This allows you to strengthen your pelvic floor muscles and improve your bladder control.
After your urine tube has been removed, you should also continue to carry out the exercise regime for at least a week after the surgery. 
What Are the Surgical Options for Persistent SUI?
If SUI still persists despite your efforts to strengthen your pelvic floor muscles, surgery may be needed. This decision on whether to opt for the surgical procedures also depends on how active you are.
If you are constantly engaged in sports such as running or swimming, you may want to consider a surgical intervention if these hobbies result in SUI. You would have two options if you decided to opt for a surgical procedure. You may choose to go for these surgeries: , 
- Urethral Sling Procedure
- Artificial Urinary Sphincter
Urethral Sling Procedure
You can undergo the placement of a urethral sling. This would be suitable for you if you have a mild to moderate case of SUI. To help you understand how a urethral sling works, think of the sling like a hammock. It supports the urine tube. The day-light procedure would help to strengthen your pelvic floor muscles. As a result, it provides you with an immediate relief from the symptoms of SUI after you have recovered from anaesthesia.
Artificial Urinary Sphincter
You can opt for an artificial urinary sphincter (AUS). It is an implanted device that will help those with severe cases of SUI.
The AUS functions based on three main components:
- The Urethral Cuff. This is placed around the urethra. It replicates the function of the external sphincter in maintaining urinary continence.
- The Scrotal Pump. There will be a button for you to press to release the pressure in the cuff. Releasing this pressure will allow you to pass urine.
- The Pressure-regulating Balloon. This balloon controls the pressure of the urethral cuff. It helps to maintain the urinary continence.
Most of the time, the urethral cuff is kept closed to prevent you from having an accidental urination. When you have to urinate, you would have to press on the scrotal pump to allow the fluid in the cuff to flow into the pressure-regulating balloon. The balloon causes the deflation of the cuff. Thus, there is a decrease in pressure. This will allow your urine to flow through your urethra. After a minute or so, the cuff then re-inflates automatically and you will be continent again.
This procedure is much more complex than a urethral sling placement. You would have to stay overnight in the hospital to have it be done. Immediately after your surgery, the AUS would be deactivated. After six weeks when your body has recovered from the procedure, the AUS will be activated.
Erectile Dysfunction (ED) in Men When Treating Prostate Cancer
We mostly concentrate on these three 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 want to achieve. First off, you would want your cancer to be adequately treated. Next, you would want to be able to stay dry. Lastly, the ability to have sexual relations would be the icing on the cake when you are continent and well-treated from cancer. 
Erectile Dysfunction Can Result Due to the Effects on the Neurovascular Bundle
If you have problems with having an erection, it is most likely due to the effects of the treatment on your neurovascular bundle.
This bundle is a combination of nerves, arteries, and veins in the human body. Together, they send out impulses in a man that triggers an erection. During an erection, the amount of blood sent to the penis will also determine its length and girth. 
In non-nerve sparing surgery, the cancer will be removed. However, during the surgery, your nerves may also be cut. This may lead to losing your ability to have an erection. Even in the best of hands, temporary nerve damage may occur. As a result, this can cause temporary erectile dysfunction or a weaker erection.
For this reason, you should always discuss with your doctor on the risks before going for this procedure. What is lost will not be returned. You also should not expect your erection to be stronger after surgery.
What Does the Recovery of Erectile Function Depend On?
There are three types of key influences that will affect your chances of recovery. They include:
- The degree of nerve sparing
- The extent of neuropraxia
- The damage taken during the surgery
Besides these factors, the diagnosis of this cancer as well as going through a huge surgery may also play a part in your erection.
In most cases, studies have also shown that recovery can take up to two years after surgery. If you have gone through radiotherapy, it will be almost certain that you will face persistent erectile dysfunction. As such, the treatments are non-nerve-sparing. 
With that said, you may have a chance to recover. However, having to wait two years may not be ideal for both you and your partner. Thus, if you wish to speed up your recovery process, you may consider going through with penile rehabilitation.
Penile Rehabilitation in Men with Prostate Cancer
Penile rehabilitation is in no way a treatment for erectile dysfunction. It uses medications, devices or other actions to help gain back its function. A combination of these three might even be used.
You and your partner will need to understand that penile rehabilitation may only restore whatever erectile function you had. In this rehab, we target the muscles that are responsible for your erection. We also target the health of your blood vessels that supply blood to your penis.
Through penile rehabilitation, we aim to help you in:
- Improving the oxygen flow to the cavernosal bodies
- Helping to preserve your endothelial structure and function. This is to prevent smooth muscle structural changes
We should all know that our muscles shrink in size when we do not use them. Likewise, the penis will also shrink in size with infrequent erections after treatment for prostate cancer. In some cases, it may even result in penile curvatures. This can further decrease the functionality of a penis. 
1. Oral Phosphodiesterase 5 (PDE 5) Inhibitors
The medication that is most used would be the oral phosphodiesterase 5 (PDE 5) inhibitors. Here are some examples of it:
- Sildenafil (Viagra)
- Vardenafil (Levitra)
- Tadalafil (Cialis)
PDE5 inhibitors are safe and easy to use. They can help to decrease the breakdown of the cyclic guanosine monophosphate (cGMP). This leads to an increased flow of intracellular calcium ions. As such, they help you to relax the muscles which in turn, causes an erection.
In the end, it has been shown that the use of this oral medication after nerve-sparing is effective.
2. Intracavernosal Injection (ICI)
One of the methods used to treat erectile dysfunction is ICI. The vasoactive agents used in ICI are:
- Prostaglandin E1 (PGE1) analogue alprostadil on its own
- A combination of Papaverine and Phentolamine. They are commonly known as Bi-mix or Tri-mix.
They aid in increasing the flow of blood to your penis. This helps to trigger erections and has been shown to be effective.
3. Vacuum Erection Device (VED)
The VED causes an erection by creating a negative pressure around the penis. This helps to draw both the venous and arterial blood into the tissue of the penis. Oxygen, along with other nutrients are encouraged to pass. This thus prevents scarring.
A VED comes with a constriction ring. The ring will be placed at the base of the penis. It helps to maintain erections that are firm enough to have sex with by preventing blood from flowing out the penis. If you are using this tool for penile rehabilitation, you should avoid using the constriction band. Consequently, it can decrease the amount of oxygen in the penis after 30 minutes of usage.
The use of this device has been shown to stop penile shortening. When using VED with PDE5 inhibitors, it will allow you to have multiple erections on a daily basis.
4. Low-Intensity Extracorporeal Shockwave Therapy (LiESWT)
Recently, there has been an interest with the use of LiESWT.
During this procedure, the corpus cavernosum will have shockwaves applied to it. This causes mechanical stress and microtrauma which then creates a chain of biological reactions. This allows blood vessels to form in the erectile tissue. LiESWT may also help you to regenerate the nerves in your penis. With all this being said, LiESWT can be considered a good choice.
5. Penile Vibratory Stimulation (PVS)
The newest kid on the block would be PVS.
PVS was first used in men with spinal cord injuries to help them with having erections and ejaculations. With this same approach, PVS works by arousing the nerves along the penile shaft. In doing so, this can help to cause an erection.
A Few Things to Consider
As of yet, we still do not have the recommended modality for penile rehabilitation. You should be aware that treatment will be more effective if you have had a good erection pre-treatment as well as have gone through a nerve-sparing RP. If you have a poor erectile function or have gone through a non-nerve-sparing RP, you should consider a penile prosthesis instead.
Now, the question left for both you and your partner is "how soon would you want to engage in sex after the treatment of prostate cancer?
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.
Would you like to ask any related health questions?
1. Singapore Cancer Registry Annual Registry Report 2015 National Registry of Diseases Office (NRDO). Accessed July 2, 2019.
2. Prostate Cancer. Singaporecancersociety.org.sg. Published 2015. Accessed July 2, 2019.
3. Prostate Cancer Screening. National Cancer Institute. Published 2019. Accessed July 2, 2019.
4. PSA Test. Mayo Clinic. Published May 4, 2019. Accessed July 5, 2019.
5. Prostate Cancer Screening. National Cancer Institute. Published 2012. Accessed July 2, 2019.
6. Carter HB, Albertsen PC, Barry MJ, et al. Early Detection of Prostate Cancer: AUA Guideline. Journal of Urology. 2013;190(2):419-426. doi:10.1016/j.juro.2013.04.119
7. Prostate Cancer Treatment. National Cancer Institute. Published 2019. Accessed July 2, 2019.
8. Potosky AL, Davis WW, Hoffman RM, et al. Five-Year Outcomes After Prostatectomy or Radiotherapy for Prostate Cancer: The Prostate Cancer Outcomes Study. JNCI Journal of the National Cancer Institute. 2004;96(18):1358-1367. doi:10.1093/jnci/djh259
9. Prostate Cancer Outcomes Study - SEER Landmark Studies. SEER. Published 2019. Accessed July 2, 2019.
10. Bo K. Urinary Incontinence, Pelvic Floor Dysfunction, Exercise and Sport. Sports Medicine. 2004;34(7):451-464. doi:10.2165/00007256-200434070-00004
11. Herschorn S, Bruschini H, Comiter C, et al. Surgical treatment of stress incontinence in men. Neurourology and Urodynamics. 2010;29(1):179-190. doi:10.1002/nau.20844
12. Artificial Urinary Sphincter Versus Male Sling for Post-Prostatectomy Incontinence—What Do Patients Choose? | Journal of Urology. The Journal of Urology. Published 2009. Accessed July 2, 2019.
13. Erectile Dysfunction | NEJM. New England Journal of Medicine. Published 2019. Accessed July 2, 2019.
14. Costello AJ, Brooks M, Cole OJ. Anatomical studies of the neurovascular bundle and cavernosal nerves. BJU International. 2004;94(7):1071-1076. doi:10.1111/j.1464-410x.2004.05106.x
15. Marien T, Sankin A, Lepor H. Factors Predicting Preservation of Erectile Function in Men Undergoing Open Radical Retropubic Prostatectomy. Journal of Urology. 2009;181(4):1817-1822. doi:10.1016/j.juro.2008.11.105
16. Fode M, Ohl DA, Ralph D, Sønksen J. Penile rehabilitation after radical prostatectomy: what the evidence really says. BJU International. July 2013:n/a-n/a. doi:10.1111/bju.12228