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Doctor On Call (DOC): Dr Lee Fang Jann – Men’s Health (Part 2)

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Doctor On Call, or DOC for short, is a brand new series brought to you by Medical Channel Asia. This series aims to bring doctors and specialists from various fields to give you an introduction to common health and medical topics that you and the Asian population are interested in. In our 2nd DOC, held on 18 Jun (Friday), from 8pm to 9pm (GMT+8), we have Dr Lee Fang Jann, urologist and renal transplant surgeon from UroDoc, to talk to us about Men’s Health.

For Part 1 of the forum, we have Dr Lee give us a short presentation on the common issues surrounding men’s health, such as the prostate function and sexual health. In Part 2, Dr Lee answers some of the questions posted LIVE by our audience. Read below to find out what are some common questions regarding men’s health that the audience have asked, you may find some relevant to yourself as well!

Question and Answer

Q1: I have already removed the prostate gland with stage 2 prostate cancer in Feb 2021. My problem is that I am still unable to control the outflow of urine. What is your advice?

Dr Lee: Removal of the prostate (prostatectomy) is a form of treatment for prostate cancer. Many times, what is not being discussed during the counselling process when planning for treatment and surgery is the functional impairments on top of the removal of the cancer cells.

The prostate glands are very close to the pelvic floor muscles. When the glands are removed surgically, these muscles will get injured no matter how good and meticulous the surgeon is. Hence, there will be some implication in terms of damage to the pelvic floor, which is important for supporting of the bladder. When the pelvic floor is damaged, one of the consequence will be urinary incontinence. This usually happens when you have increase intra-abdominal pressure (e.g. when sneezing or coughing). When you pelvic muscles are weak, they cannot hold the urine in, leading to urine leaking out.

It is not uncommon. The more aggressive the surgery is (i.e. if the surgeon is aiming to cure the cancer), the margin of surgery is wider, the chances of damaging the pelvic floor muscles will be greater. It is also dependent on age. The older you are, the more likely your pelvic floor will be weaker, and hence a greater consequence of urinary control. You may be encouraged by your surgeon to do Kegel exercises to strengthen your muscles. However, some groups of patients may take up to a year for the improvement in urinary control.

Nerves around the prostate may also damage during surgical process, resulting in another functional impediment which is erectile dysfunction.

Q2: I went for robotics prostate biopsy in Jul 2017 as my PSA was 10.67. Benign tissues, no evidence of malignancy. After biopsy, PSA in Nov 2017 was 6.27, Dec 2019 was 5.48, Dec 2020 was 6.28. Necessary to do repeat biopsy test?

Dr Lee: Assuming your biopsy was done thoroughly (i.e. thorough sampling of the prostate gland), leading to PSA dropping and levelling at about 5 to 6. The usually cut-off for PSA will be less than 4, hence your level is considered slightly above the cut-off. However the silver lining is that your PSA is stable and not increasing.

I understand that there will be a concern: is there underlying cancer, something that was missed initially. Something you may want to discuss with your doctor is to do a repeat MRI scan. It is not as invasive as a biopsy, but it can still help to check for lesions within the prostate gland. If no lesions were picked up, you can continue surveillance. If lesions were picked up, there will be more reasons to do a repeat biopsy to target all these lesions seen on the MRI scans.

Q3: Types of treatment for enlarged prostate and the minimum invasive techniques available

Dr Lee: Enlarged prostate is a very common condition that a urologist sees. The traditional treatment has always been either medical treatment, or a procedure called transurethral resection of the prostate (TURP).

Medical treatment works by relaxing the lining of the prostate to ease the flow, or through means of shrinking the prostate. Problem is some people are reluctant to start on a long-term medications, if not the prostate will grow back and cause issues. Other problems include costs as well as effects on sexual dysfunction. Some of these medications are known to cause lowered sex drive, erectile dysfunction and ejaculatory problems.

TURP is a very efficient and standard way of treating prostate enlargement. An instrument is inserted through the penis, scraping away the prostate that is intruding into the lumen and excavate it out. This requires hospitalisation for 2 to 3 days usually.

Newer techniques over the past 2 years have included more minimally invasive techniques that can be done as day surgery. These are also thought to have fewer sexual side effects. These techniques include using:

  • Water vapour therapy: injecting water vapour into the prostate to cause damage to the tissues
  • Urolift: by using implants to pull the prostate leaves apart to open up the channel, also a day procedure done within 5 to 10 mins.
  • Prolift therapy: by using a balloon to splint the prostate apart, then applying microwave therapy to ablate some of the prostate tissues away.

There are many techniques up and coming. Depending on the prostate size, configurations and what you hope to achieve from the treatments, you can choose from a variety of treatment options available.

Q4: Are you on the panel of any integrated shield plan providers? If so, which ones?

Dr Lee: I’m on Great Eastern, Prudential, NTUC, AXA, Aviva, and Raffles Health.

Q5: Which is more accurate to determine prostate cancer? MRI vs Biopsy

Dr Lee: Typical scenario is that you will have a PSA levels checked. If PSA is elevated, prostate cancer may be suspected. The gold standard to diagnose cancer is biopsy. However, many people may be adverse to it, as it is invasive. Hence, many may choose to do MRI instead.

In many workflows now, with an elevated PSA detected, we do a MRI scan done to image the prostate gland thoroughly. If the MRI shows a suspicious lesions, that is when we move on to doing a biopsy to confirm the diagnosis, and also determine the grade of the cancer, which will in turn decide on the treatments. However, if the MRI shows negative results, the elevated PSA results may be a false elevation.

Other possible reasons for elevated PSA include:

  • Enlarged prostate
  • Prostate inflammation
  • Prostate infections

Q6: Dutasteride – Does this medication for BPH cause cancer?

Dr Lee: Dutasteride belongs to a class of medication called 5-alpha reductase inhibitors (5-ARI). The typical indication for this medication is to reduce the size of the prostate gland over time. Studies done on this class of medication have been shown that it is useful in chemo-prevention. Long duration of use of this medication can actually reduce the chance of you getting prostate cancer.

What is often shown in news is that people who are on this form of therapy, there is a tendency towards higher grade and more aggressive prostate cancer when a biopsy is done on them. However, we need to note that there may be confounding factors. With continuous taking of this medication, the prostate gland shrinks, leading to a higher chance of finding cancer cells as compared to a person with enlarged prostate gland.

To answer the question, prolong taking of this medication does not cause cancer.

Q7: How common is BPH, and what are the likely causes? Are there any correlation between BPH and the chances of getting cancer?

Dr Lee: BPH is very common, especially in older aged people. What I generally tell patients is that BPH typically occurs from age of 40. By 50 years old, half of the population will have some degree of BPH. By 80 years old, the number rises to 90%.

BPH and prostate cancer correlation: short answer is there is no correlation. Prostate enlargement does not cause prostate cancer. However, it is not unusual for patients to see doctors for prostate enlargement issues and find out about prostate cancer diagnosis. One reasons is cause both conditions are very common. Another reason could also be due to the higher rates of checking on the prostate, leading to higher chances of picking up other prostate conditions.

Q8: Can over-exercising cause low libido? I visit the gym about 4-6 times per week, and about 60-90mins per session.

Dr Lee: 60 to 90 mins, depending on how strenuous the session is, you may get fatigue and tired out. However, there should not have any impact with libido. In fact, regular moderate exercises actually help boost the body’s natural production of testosterone, and the opposite.

Q9: What are some lifestyle reasons leading to increased number of prostate cancer in recent years? Are there any preventive measures to minimise this?

Dr Lee: The most definite risk factor of prostate cancer is age. The older you are, the more likely you are to get prostate cancer. We are unable to change this risk factor. Similarly to ethnic group and family history, we are unable to change these factors.

Over long durations (i.e. decades), someone who takes processed meat and high-fat diets has a higher risk of developing prostate cancer, versus someone else with vegetables and fruits-like diet. Obesity and smoking are other lifestyle factors that have correlation. Studies have also shown that prostate cancers in smokers tend to be more aggressive.

Q10: What are the implications of removing the prostate?

Dr Lee: The function of the prostate includes reproduction. Removing the prostate will mean that the reproductive function is affected. Once the reproductive tract is disrupted, there will be no more ejaculation (no semen expulsion).

The other implications are largely functional. The process of removing the prostate will damage the surrounding structure, including the nerves, resulting in erection issues. Damaging the pelvic flow muscles will result in urinary continence issues.

Q11: I have been on prostate enlargement medications for almost a year, but my symptoms have not improved much. Do I need to be on medications long-term, or are there more permanent solutions?

Dr Lee: If you have been on medications for a year but yet have not seen an improvement in symptoms, one reason could be that your medications are not yet optimised. There a few classes of medications that we typically use to treat prostate enlargement:

  • Alpha-blockers: Relaxes lining and ease the flow
  • 5-ARI: shrink prostate over time

If you are on the medication to only relief the passage and not shrink the prostate, your prostate will continue to grow over time. As it grows, the symptoms will not likely improve.

Other reasons may include: the physical configuration of the prostate may have led to poor efficacy of the medication. The next step would be to consider for a more invasive form of treatment to relieve the symptoms and lead to a better quality of life.

Q12: Is surgery an option for prostate enlargement? I’m 65yo and was told that I have a slight enlarged prostate, with frequent urination especially during sleeping time.

Dr Lee: It depends on what is the reason for the frequent urination at night. It is not uncommon to have enlarged prostate at your age. Prostate enlargement can cause frequent urination at night due to the inability to empty the bladder, leading to a retention of small amount of urine in the bladder. In those situations, relieving the obstruction can help with better emptying and gives a longer interval between voids, giving better sleep.

However, there are other reasons for frequent night urination. Some reasons may include:

  • Bladder issue (e.g. lowered capacity)
  • Higher volume of water drank in the evening

Treating the prostate is not going to relief the symptoms. It is necessary for you to have a proper evaluation by your doctor to determine what is the cause of frequent urination, before embarking on invasive procedure such as prostate surgery.

Q13: TURP vs GreenLight laser – which is a better procedure?

Dr Lee: Both are pretty established procedures in treating prostate enlargement. TURP has been around for a long time and evidence has been more established and longstanding.

Advantage of GreenLight over TURP would be for patients who are on blood thinner medications (e.g. for heart conditions). These medications cannot be stopped during the window of operation. We use GreenLight laser to treat patients with prostate enlargement issues so bad that they require catheters. The laser melts the prostate tissues away and results in relief. It helps in situations where bleeding risk tends to be higher. However, GreenLight laser is also more expensive than TURP.

Q14: How to maintain good prostate health?

Dr Lee: I don’t think there are any known good strategies to improve prostate health. In terms of prostate enlargement and prostate cancers, the things we can alter are pretty limited. General tips to improve overall health, such as clean eating, avoiding alcohol, avoiding smoking, regular exercises, can improve your prostate health as well.

What’s next in store?

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