Benign Prostatic Hyperplasia and Prostate Cancer Tutorial Flashcards
Case 1 - 65M
PC = hesitancy, poor flow, sensation of incomplete emptying. Long standing but symptoms suddenly worsened with episode of constipation
HPC = hypertension DH = Amlodipine SH = Regular smoker, occasional drinking
Examination = BP 160/95, no swelling of ankles, Chest clear, HS I + II + 0, abdomen soft and non-tender. No palpable bladder. DRE- smooth 30g prostate. Stool in the rectum
Investigation = dipstick- nitrate negative, leucocyte negative, blood negative, blood tests – PSA 5, renal function normal
What is your differential diagnosis?
Prostate cancer - rasied PSA, enlarged prostate, symptoms
BPH (benign prostatic hyperplasia) - enlarged prostate
UTI - raised PSA, urinary symptoms
BPE (benign prostatic enlargement) - enlarged prostate
Which diagnostic tests should he be referred for?
Flexible cystoscopy
Flow rate and PVR (postvoid residual) - testing the force of urination and how much urine is left in the bladder after emptying
Bladder diary
Multiparametric MRI - suggested due to negative urine dispstick and slightly raises PSA, and depending on what that shows, perhaps a transperineal prostate biopsy
Multiparametric MRI – reported a homogenous circumscribed nodule in the transition zone of the prostate.
The patient subsequently underwent trans perineal template prostate biopsies and this demonstrated one core of Gleason 3+3 (1mm)(in the region of the index lesion) and all other biopsies demonstrated BPH only
What can you infer from these results?
Low grade prostate cancer
What treatment and management plan should be followed?
Conservative: Lifestyle changes - less caffeine
Active surveillance - regular PSA testing
Medical / pharmacological: Alpha blockers - relaxes the prostate to improve his symptoms
What is the difference between active surveillance and watchful waiting?
Active surveillance used for those fit enough for surgery - so if the prostate cancer progresses, they would be fit for more aggressive treatment e.g. prostatectomy or radiotherapy
Watchful waiting is for those not fit for surgery - so if the prostate cancer progresses, patients are given hormone therapy but not radical treatments
Both, active surveillance and watchful waiting both require regular PSA
What ages are active surveillance used VS watchful waiting?
Not strict - dependent on patient and their health / comorbidities, but generally:
Above 80 = watchful waiting
Below 80 = active surveillance
After 2 years, following results obtained:
PSA Test – 8
MRI result – new bilateral lesions in peripheral zone of the prostate
Biopsy test – Gleason score – 4+3 in several cores bilaterally
What is your inference from analysing these results?
PSA has increased
More lesions
Gleason score = moderate differentiation = less differentiated than before = worse prognosis
What treatment plan should be followed?
Most likely = radical therapy:
Surgery - prostatectomy
Radiotherapy
Maybe hormone therapy - GNRH antagonists
Why is hormone therapy only reserved for those not fit for radical therapy?
Only works for a short period of time as the prostate eventually becomes resistant to it
More so a palliative option
The patient decides on a radical prostatectomy, but following surgery develops both erectile dysfunction and urinary incontinence
What is the mechanisms of these post operative complications and how should they be treated?
Cavernous nerve damage = erectile dysfunction
Loss of function of the proximal sphincter and/or urethra shortening
What post operative follow up should the patient undergo?
For urinary incontinence =
Pelvic floor exercises - improve UI
Change in lifestyle - less caffeine
Surgery - artificial urinary sphincter
For erectile dysfunction =
Protaglandin injections into the penis
Penile prosthesis - 2 cylinders and a pump - pump up when they wish to get an erection
