Go Green With Your Prostate

 

What is Benign Prostatic Hypertrophy (BPH)?

Mr Chia (not real name) is a typical patient with benign prostatic hypertrophy (BPH). He had been displaying urinary symptoms for the past few years but had ignored it. He finally developed retention of urine and required a catheter insertion.

The prostate is a gland that lies below the bladder, and produces part of the secretions in semen.

Benign prostatic hypertrophy is a condition that will affect 50% of men at 50 years of age and up to 90% of men, by the time they are 80 years old. It is a condition where the prostate enlarges, leading to gradual obstruction of the urinary flow. As the name implies, it is benign and not a cancer.

Patients presenting with lower urinary tract symptoms can be broadly grouped into two main categories; one issue with voiding (urinating) or the other with storage. The symptoms of voiding include hesitancy, slow flow, dribbling of the urine and incomplete emptying, whereas the symptoms of storage include increased frequency of urination, night-time urination (nocturia) and sometimes incontinence.

If left untreated and allowed to progress, complications can develop. These include repeated urinary tract infections, the formation of bladder stones, the total inability to pass urine (acute retention of urine) and possibly damage to the kidneys.

Can we prevent BPH?

As with many diseases, the development of this condition is a factor of genetics and environment. Genetics cannot be changed, but there is a growing body of evidence to suggest that lifestyle changes can delay and slow down the progression of BPH.

There is a strong correlation between obesity and BPH. In people with a BMI of more than 35, there is a 3.5 times increased risk of BPH. Exercise also seems to delay the progression of BPH. It is recommended that men should exercise at least three times a week for at least 30 minutes.

Diet also plays a role in the development of BPH. High salt, fat and meat diets are associated with BPH, while vegetables, in particular soy products, seem to delay the development of BPH. A high intake of refined sugars has also been shown to accelerate the development of BPH.

Other diseases can influence the development of BPH. For instance, poorly controlled diabetes and hypertension increase the risk of lower urinary tract symptoms by up to 70%.

 

What are the treatment options?

The choice of treatment is largely governed by the severity of the symptoms. Mild symptoms can be managed through lifestyle changes, while moderate to severe symptoms are managed with medication or surgery.

(a) Managing BPH Without Medication 

When symptoms are mild, some lifestyle changes may help. These include:

  • Reducing fluid intake three hours before sleeping
  • Avoiding alcohol and caffeine in the evenings as these are diuretics that increase urine production
  • Elevating your legs before sleep. It improves the circulation of blood in the lower limbs and allows excess water to be cleared by the kidneys before sleep
  • Double voiding
  • Timed voiding
  • Pelvic floor muscle training

Some medication can make the symptoms of BPH worse, and should be avoided:

  • Decongestants, anti-histamines and some cough medication, as it may make urinating more difficult
  • Diuretics will increase urine output

(b) Medication for BPH
The following medication can be started for BPH:

Alpha Blockers 

  • Relaxes the prostate to improve urine flow
  • May cause low blood pressure and giddiness
  • Can lead to abnormal ejaculation, though these side effects often resolve with the stopping of the medications

5-Alpha-Reductase Inhibitors 

  • Reduces the size of the prostate by up to 30%
  • Reduces libido and may lead to sexual dysfunction, ejaculation disorders and erectile dysfunction
  • Gynaecomastia (enlargement of the breast)
 

Sildenafil 

  • Drug normally prescribed for erectile dysfunction. It was found that when taken daily in low doses, it can help relieve some of the symptoms of BPH to a similar degree as alpha blockers.
  • Patients with cardiac medication in particular nitrates, should seek their doctors’ opinion before starting this medication.

    The medication above can be taken in combination, but they only yield a 30% improvement in symptoms. They must also be taken for life, to prevent the recurrence of symptoms.

(c) Surgery 

Surgery for the prostate is often performed for patients who have moderate to severe symptoms, and have developed complications of BPH or do not/cannot take medication for the condition.

The main aim of the surgical procedure is to create a wide and durable channel for the urine to pass out from. As with any surgical procedure, it is important to choose an experienced doctor skilled in this surgery, so as to get the best possible outcome.

Transurethral Resection of the Prostate (TURP)

 

The mainstay of surgical management is the transurethral resection of the prostate (TURP).

A scope is passed down the urine tract to the prostate and the enlarged prostate is cored out with a hot metal loop.

There is a small risk of heavy bleeding that may require blood transfusion. The patient stays with a catheter inserted for about two days, and a wash out is required at least one day after surgery to prevent blood clotting in the bladder.

 

Green Light Laser Vaporisation of the Prostate

Tan Tock Seng Hospital has recently adopted a new technique of treating the enlarged prostate called transurethral vaporisation of the prostate (TUVP). This involves inserting a small scope down the urinary tract while the patient is asleep, and a laser is used to vaporise the prostate.

This procedure has the benefit of less bleeding, as compared to the old method of TURP. With the use of green light vaporisation, the patient often stays in hospital for less than a day and with the catheter removed before going home. As it causes less bleeding, it can also be performed on patients with aspirin and warfarin.

So what happened with Mr Chia? Unfortunately, even with medication, he continued to experience urinary retention. Subsequently, he decided to go for the green light vaporisation of the prostate. His procedure went well and he was discharged after an overnight stay without the catheter. He experienced no pain and had excellent flow of urine on his follow-up visit.

 

Dr Tan Yung Khan is a Consultant in the Department of Urology at Tan Tock Seng Hospital. He is also the Director of Endourology and Co-Director of the Minimally Invasive Urology Fellowship and a clinical lecturer at National University of Singapore Yong Loo Lin School of Medicine.

Dr Tan completed his urology training in Singapore and received the National Medical Research Council (NMRC) scholarship to do advanced research in robotic surgery and minimally invasive surgery at the University of Texas Southwestern Medical Center, Dallas, Texas, USA. He also matched in the Endourology Society training programme in the United States and spent a year at Columbia Medical Center, New York City, focusing on endourology and the management of stone disease.