There could be an obstruction in the plumbing, no thanks to a condition called benign prostatic hyperplasia. Urologists explain what it is and what help is available.

When it comes to relieving yourself in the washroom, there's nothing to it, right? You simply undo the necessary garment, relax your muscles and in a few seconds, sweet relief is yours. But for some men, the ability to empty their bladder may not come at all no matter how many trips they make to the urinal.

Despite feeling as though their bladders may burst, they may find it difficult to start urinating. When they do manage to, it’s more of a trickle than a satisfying release; the urine stream may even stop and start several times. And there’s always the feeling that there’s something left in the tank no matter how hard they force it.

If you’re one of these men, you might feel that those symptoms seem to point to an obstruction in your plumbing. And you might be right on that count if you have been diagnosed with something that has to do with your prostate, called benign prostatic hyperplasia ( BPH).

WHAT IS THE PROSTATE GLAND IN THE FIRST PLACE?

The term “benign prostatic hyperplasia” refers to the enlarged and non-cancerous state of the prostate gland (we’ll touch on why it gets enlarged in a bit). And nope, this gland doesn’t reside in either of the testicles. The chestnut-sized organ sits within the body, directly below the bladder and surrounds the urethra, the tube that urine passes out from.

The prostate is also located just in front of the rectum, which is why the doctor will perform a digital rectal examination (in case you’re wondering, “digital” here refers to the use of a gloved finger, or digit) to feel for it during your medical check-up.

All is well and good when you’re young. The prostate does its job of producing the thin, milky part of semen – crucial for “the proper functioning of the sperm cells, and therefore also for fertility in men”, according to the National Library of Medicine. And because there are also many muscle cells inside the gland, it plays a part in expelling semen during ejaculation as well.

Things may start to take a downturn as you get older. Interestingly, the prostate continues to grow throughout a man’s life and can get as big as an orange, according to the US Urology Care Foundation. The reason why you don’t feel a protrusion is this: There is a layer of tissue around the prostate that keeps it from growing outward, according to Cedars Sinai. 

But all that growth has to go somewhere and that is when the enlarged gland starts to “press on the urethra like a clamp”, explained the same website. The results are the symptoms described earlier on: Straining to urinate, slow urine flow, frequently waking up at night to urinate and the inability to empty the bladder.

Patients with high degrees of obstruction may even develop urinary tract infections and bladder stones, said Dr Thiruchelvam Jegathesan, a consultant with Tan Tock Seng Hospital’s Department of Urology.

“The exact reason for BPH is not known but is postulated to be related to age and male hormones causing a proliferation of the prostate cells,” he said. “Typically, BPH can happen after 50 years old and it becomes more prevalent with age.”

A study done in Singapore supports the age link that Dr Jegathesan mentioned. As the population ages, the incidence of local patients with moderate to severe BPH symptoms has been increasing – from 10 per cent in 1997 to 14 per cent in 2005, and 16.5 per cent in 2012.

Greater awareness of BPH could have also led to a higher incidence rate recorded over the years, said Dr Fiona Wu, a consultant urologist with Aare Urocare. “Generally, more people are aware of the condition and seeking professional advice earlier. In fact, some of the male patients have seen how their elderly fathers suffered from BPH and are more likely to seek help early,” she said.

WHAT ARE THE TREATMENT OPTIONS?

Since an enlarged prostate is the root of the trouble, the treatment generally focuses on removing or shrinking the organ, or widening the constriction for urine to flow through better. Most options involve minimally invasive procedures that can be performed “through an endoscope inserted through the urethra”, said Dr Wu. “A urinary tube (catheter) to drain urine is usually required post-surgery.”

The not-so-good news is, prostate enlargement and its accompanying urinary issues can recur after treatment. "Sometimes, the urologist may use different methods to treat BPH recurrence such as medical treatment or another surgical option depending on the situation and the patient’s age and fitness level," said Dr Wu.

Here’s a look at the treatment options available and how they work.

An instrument called a resectoscope is inserted into the urethra to reach the prostate. The resectoscope is like a multi-function Swiss Army knife that has a light, camera and tool that uses electric current to cut, remove, or destroy tissue and control bleeding. TURP may be performed under general or regional anaesthesia, said Asst Prof Chua Wei Jin, a senior consultant with the Department of Urology at National University Hospital.

This is the "gold standard surgery that revolutionised BPH surgery", said Dr Colin Teo, a senior consultant urologist with Gleneagles Hospital. And unlike the other methods, TURP allows tissue samples to be taken to test for cancer, he said.

However, TURP has “up to 70 per cent risk of ejaculatory dysfunction, which may concern younger sexually active men”, said Dr Jegathesan.

Who it’s for: Patients with acute or chronic urinary retention, recurrent urinary tract infections, bladder stone, renal insufficiency, large bladder diverticulum/diverticula and/or failed medical therapy.

One or two small cuts are made at the bladder neck, the area where the prostate and the bladder are connected. Doing so widens the urinary channel and allows urine to pass easier. “It has less risk of bleeding and ejaculatory issues when compared to TURP,” said Dr Wu. It can be done as an outpatient procedure.

“TUIP is usually performed as an additional procedure for patients undergoing TURP with small prostates,” said Asst Prof Chua. On its own, TUIP may be less effective than TURP and you may need to be treated again with another BPH therapy.

Who it’s for: Prostates that are less than 30g (a normal one weighs about 20g to 25g) as well as a high or tight bladder neck. Also for patients concerned about fertility as the procedure does not directly involve the prostate gland.

There are two main types of laser surgery. The PVP, for one, uses a form of laser known as GreenLight to vaporise the excess tissue and widen the urinary channel, said Asst Prof Chua.

The second method, he cited, is the HoLEP, which uses holmium laser to free up the enlarged prostate tissue from its outer layer, and deposits it in the bladder where it is suctioned out using an instrument. “It is very unlikely that the prostate will regrow and re-obstruct following this procedure,” said Asst Prof Chua of the second method.

Added Dr Wu: “This method generally removes more prostatic tissue than TURP and with less catheter time (under 24 hours) and less reoperation rates”. However, there is a higher risk of bladder perforation compared to TURP, she said.

Who it’s for: There is less bleeding with laser therapy, so it's better suited for patients who are already on antiplatelet or anticoagulant medicine to reduce their stroke or heart attack risks, said Dr Lie Kwok Ying, a senior consultant urologist from Gleneagles Hospital.

This new treatment method for BPH doesn’t cut or zap off any tissue at all. Instead, it uses tiny, permanently placed, stainless-steel clips to lift or hold the enlarged prostate tissue out of the way, so that urine can flow through the urethra. Different patients will need different numbers of clips, depending on the size and length of their prostate, said Dr Jegathesan. It can be done under local anaesthesia and “most patients will be able to go home without a urinary catheter”, he said.

Dr Wu noted that PUL has much lower risks of bleeding and ejaculatory issues than TURP. “It is useful for males trying to avoid ejaculatory or erectile issues, and for elderly patients who are not fit for general anaesthesia.”

However, Dr Lie highlighted that urinary flow trouble may recur with PUL. In more than one in 10 cases, retreatment is needed at the five-year mark. 

Who it’s for: Prostates that are 30g to 80g. Also suitable for men who wish to preserve their erectile and ejaculatory functions.

It delivers “targeted, controlled doses” of steam directly to the prostate, said Asst Prof Chua, and “gently kills the excess prostate cells”. “Over time, the body's natural healing response removes the dead cells, shrinking the prostate and opening the urethra, thus relieving the BPH symptoms.”

The whole process can take as little as 10 minutes, even with the use of general anaesthesia, said Dr Teo.

However, WVTT may not be suitable for very large prostates and the time required for patients to be on catheter is usually longer than the other procedures, said Dr Wu.

Who it’s for: Moderate BPH symptoms, prostate volume of 30ml to 80ml, failed medical therapy or no desire to be on long-term medication. Also suitable for men who wish to preserve their erectile and ejaculatory functions.

It involves inserting a small antenna through the urethra to reach the prostate gland as well as a rectal temperature monitor through the anus. Once in place, the antenna releases microwave energy at temperatures of 41 degrees Celsius to 46 degrees Celsius to destroy the excess prostate tissue. The procedure is done under local anaesthesia.

“TUMT has a lower complication rate than TURP in general but there is a higher reoperation rate. The improvement in symptoms may not be as good as TURP,” said Dr Wu.

Who it’s for: Small to moderate-sized prostates.

The first line of treatment for BPH using medicine is with alpha-blockers, said Dr Wu, which help to relax the muscles in the bladder neck and prostate. However, they do come with side effects such as hypotension on standing (a form of low blood pressure that happens when you stand up from sitting or lying down) and ejaculatory problems, she said.

For those who are at risk of developing BPH complications, 5-alpha-reductase inhibitors (5-ARIs) can be added. These agents inhibit the body’s conversion of testosterone to dihydrotestosterone (aka DHT, a hormone that stimulates the development of male characteristics, including prostate growth) and in turn, cause DHT levels to drop.

However, the results aren’t as immediate as the procedures mentioned above. For instance, 5-ARIs typically take three to six months to work, said Dr Wu. And even so, they may only reduce prostate size by 18 per cent to 28 per cent. Another downer is that there may be diminished sexual functions such as erectile dysfunction and reduced libido. The medication approach is also a lifetime commitment.

Who it’s for: Prostates above 40ml, moderate to severe BPH symptoms.

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