80. Prostate (4%) Flashcards
En présence d’un cancer de la prostate, informez-vous des symptômes de quoi ?
d’une récidive locale ou d’envahissement métastatique.
Describe screening PSA
- No screening recommended for all ages as per Canadian Task Force
- Urological associations suggest discussing risks and benefits of PSA screening with patients >50yo (or >40yo if fam hx or african american) with >15y life expectancy
- Use prostate cancer risk calculator with PSA
Can consider PSA screening when ? (4)
- if patient concerned about prostate cancer
- high risk factors
- good health status
- and patient not concerned about risks of urinary incontinence and sexual dysfunction
Name risk factors : BPH
- Age
- obesity
- diabetes
- family history
Name Complications : BPH (5)
- UTI
- bladder stone
- urinary retention
- hydronephrosis
- renal failure
Name : DDx Urinary Retention (8)
- BPH
- Prostate CA
- Urethral stricture
- Urethral diverticulum (women)
- Medication
- Infection
- Trauma
- Neurological (Spinal cord injury)
Describe voiding sx (5)
- predominant in bladder outlet obstruction (BOO) secondary to BPH
- Hesitancy
- Weak Stream
- Intermittence
- Straining
Describe Storage sx (5)
- r/o overactive bladder (OAB)
- Urgency
- Frequency
- Urgency Incontinence
- Nocturia
Describe Postmicturition sx (2)
Dribbling, Incomplete Emptying
Describe : Management of nocturnal polyuria (3)
- Voiding/Frequency chart 2-3 days
- If urine output ≥3L = Decreased intake, aim for urine output 1L
- If nocturnal urine output >33% nocturnal polyuria diagnosed -> Consider Desmopressin
Describe : Management of BPO
Follow IPSS, DRE, PSA (if on 5-ARIs) as response to treatment
Describe investigations for prostate sx (3)
- Urinalysis +/- culture (r/o infection)
- PSA
- PVR if considering anticholinergics (eg. storage symptoms suggesting OAB)
Name score to follow prostate symptoms
International Prostate Symptom Score (IPSS)
Describe scoring : International Prostate Symptom Score (IPSS)
- 0 to 7 points: Mild symptoms
- 8 to 19 points: Moderate symptoms
- 20 to 35 points: Severe symptoms
Describe management BPO sx if MILD (Symptom score <8, or if not bothered by symptoms) (7)
Lifestyle and watchful waiting
* Fluid restriction particularly prior to bedtime
* Avoidance of alcohol, caffeine, spicy foods
* Avoidance/monitoring of some drugs (e.g., diuretics, decongestants, antihistamines, antidepressants)
* Timed or organized voiding (bladder retraining)
* Pelvic floor exercises
* Avoidance or treatment of constipation
* Phytotherapy/herbal medicine (Saw Palmetto) has very weak evidence, although minimal side effects
Describe management BPO sx if MOD-SEVERE (Symptom score <8, or if not bothered by symptoms) (5)
- For smaller prostates, Alpha-blockers alone = Tamsulosin (Flomax) (avoid in sulfa allergy)
- For larger prostates (eg. DRE>25mL or PSA>1.5 ng/dL), combination therapy more effective with **Inhibiteurs de la 5-alpha réductase ** = Finasteride (Proscar)
- After 6-9 months of combination therapy, consider stopping alpha blocker
- Consider addition of PDE-5 inhibitors for LUT symptoms, eg. Tadalafil (Cialis)
- Consider addition of anticholinergics (eg. Tolterodine, Oxybutynin, Mirabegron) especially if component of OAB (storage symptoms), caution if PVR >250mL
Describe : Tamsulosin (Flomax) (5)
- Alpha-blockers
- Rrelax smooth muscle
- Onset 3-5 days
- Avoid in sulfa allergy
- Side effects: Orthostatic hypotension, retrograde ejaculation (ejaculation failure)
Describe : Finasteride (Proscar) (4)
- 5-alpha reductase inhibitors
- Inhibit conversion of testosterone to DHT
- Onset 4-6 months
- Side effects: Decreased libido, erectile dysfunction
When to refer for prostate sx ?
- Failure of symptom control despite combination therapy, for possible Surgery (TURP)
- Complications: Hematuria, recurrent UTIs, urinary retention, renal failure
- Suspect prostate cancer (DRE/elevation in PSA)
When to suspect prostate cancer ?
- PSA<10 low risk (routine), PSA 10-20 (semiurgent referral), PSA>20 high risk (urgent)
- Upgrade urgency if DRE abnormal (firm or irregular)
Describe : Acute Bacterial Prostatitis
Tender prostate
Describe : Chronic Bacterial Prostatitis
Intermittent UTIs with same bacteria
Describe : Chronic Prostatitis / Chronic Pelvic Pain Syndrome
- Inflammatory Chronic Prostatitis
- Non-inflammatory Chronic Prostatitis
Describe : Asymptomatic Inflammatory Prostatitis
Leukocytosis
Name sx : Prostatitis (5)
- Fevers, chills
- Dysuria
- Pelvic or perineal pain
- Cloudy urine
- Obstructive symptoms
Describe physical exam : Prostitis (4)
- Prostate warm
- Firm
- Edematous
- Exquisitely tender (avoid massaging)
Describe investigations : Prostitis (3)
- Urinalysis
- Urine culture and-sensitivity testing,
- Gono/chlam urethral/rectal PCR and culture
Describe tx : Acute/Chronic Bacterial Prostitis (4)
- Septra DS 1 tab q12h x 6 weeks (or 12 weeks for chronic) or Ciprofloxacin 500mg PO q12h x 6 weeks (for both acute and chronic)
- Urine culture to target therapy
- Consider Urine culture at 7 days (if still positive, consider change in management)
- Rule out prostatic abscess in immunosuppressed or poor response to therapy
Describe tx : Non-infectious Prostitis
Target UPOINTS
* Urinary (storage/voiding symptoms) = Tamsulosin PO daily (a-blocker), antimuscarinics
* Psychosocial : CBT, counselling, antidepressants, anxiolytics
* Organ specific (prostate tenderness, hematospermia) = Quercetin, pollen extract
* Infection (positive cultures in prostate sample, previous UTI) = Fluoroquinolone x 6 weeks
* Neurologic / Pain = Acetaminophen, NSAIDs, Gabapentinoids, TCA, acupuncture
* Tenderness (pelvic floor spasm, trigger points) = Physiotherapy (pelvic floor relaxation), exercise, heat therapy
* Sexual dysfunction = PDE-5 inhibitors
Refer to urologist if does not improve significantly with initial treatment
Nommez des classes pharmacologiques utiles dans le traitement des symptômes prostatiques HPB (7)
- Alpha bloquants (Flomax)
- Inhibiteurs 5-alpha reductase (Proscar)
- Combo des deux
- Antimuscariniques
- Agonistes beta3 (mirabegron)
- Inhibiteurs 5-alpha reductase longue action (tadalafil)
- Desmopressine
Avant de partir, M. Thibodeau vous demande une ordonnance pour un médicament couramment utilisé pour traiter la dysfonction érectile. Depuis le décès de son épouse, il s’intéresse moins aux relations et sa nouvelle amie pense qu’un médicament pourrait l’aider.
Qu’allez-vous lui suggérer?
- Psychothérapie / éliminer autre cause psychogénique de perte de libido
- Rechercher autre cause organique de perte de libido
