Benign Prostatic Hyperplasia, Prostate cancer, Bladder cancer Flashcards
What is BPH (Benign Prostatic Hyperplasia)?
Refers to non-cancerous enlargement of the prostate gland.
→ can lead to lower urinary tract symptoms
How are lower urinary tract symptoms (LUTS) further defined?
Storage symptoms
- frequency
- urgency
- nocturia
- straining
Voiding symptoms
- weak stream
- dribbling
- dysuria
- straining
Cause of BPH?
Static component -increase in benign prostatic tissue narrowing the urethral lumen
Dynamic component -increase in prostatic smooth muscle tone mediated by alpha-adrenergic receptors.
Age
Hormonal changes -dihydrotestosterone (DHT)
Genetics
Lifestyle factors
Presentation of BPH?
Hesitancy
Weak stream
Frequency
Urgency
Nocturia
Sensation of incomplete emptying
Pathophysiology of BPH?
Characterised by the nodular overgrowth of prostatic tissue, predominantly in the transition zone.
→ this growth affects the prostatic urethra, causing dynamic and static obstruction.
→ leads to urinary symptoms.
Investigations for BPH?
IPSS (International Prostate Symptom Score)
→ assess severity of lower urinary tract symptoms.
- Score 20–35: severely symptomatic.
- Score 8–19: moderately symptomatic.
- Score 0–7: mildly symptomatic.
DRE
→ assess prostate size, consistency, and the presence of nodules
PSA test (Prostate-Specific Antigen)
Urinalysis
US + TRUS (transrectal US)
Flow rate and residual:
Qmax >15ml/s = 30% Obstructed
Qmax 10-15ml/s = 60% Obstructed
Qmax <10ml/s = 90% Obstructed
Urodynamics
Management of BPH?
Lifestyle:
- Fluid restriction
- avoid caffeine + alcohol
- timed voiding
Medical:
If IPSS score ≥8, offer:
- Alpha-blockers (for dynamic obstruction)
If pt has enlarged prostate and is at high risk of progression, offer:
- 5-alpha reductase inhibitors (to reduce prostate size)
If pt has moderate-severe voiding symptoms and prostatic enlargement, offer:
- both above drugs
Surgical:
- transurethral resection or laser prostatectomy
What is the 2ww referral criteria?
If prostate feels malignant on DRE.
PSA levels are above the age-specific range.
What is prostate cancer?
Refers to a malignant tumour that arises from the cells of the prostate. It can be asymptomatic in early stages.
Risk factors of prostate cancer?
Non-modifiable risk factors
- African ethnicity
- BRCA gene mutations
- FHx of prostate cancer
- Age (risk increases with advancing age)
Modifiable risk factors
- Obesity
- Smoking
- Diet rich in animal fats and dairy products
Presentation of prostate cancer?
Urinary symptoms, including difficulty initiating or stopping urination
Poor urine stream
Haematospermia (blood in semen)
Pelvic discomfort
Bone pain, potentially indicating metastatic disease
Erectile dysfunction
IVx for prostate cancer?
DRE
- asymmetrical hard/craggy/nodular prostate with loss median sulcus = suspect malignancy.
PSA blood test (not sensitive or specific)
Multi-parametric MRI and biopsy (GOLD STANDARD)
- if metastatic disease suspected, then do CT + bone isotope scan
FBC, U&Es
Reasons for falsely raised PSA?
An active urinary infection or within previous 6 weeks.
Ejaculation in previous 48 hours.
Vigorous exercise, for example cycling, in the previous 48 hours.
Urological intervention such as prostate biopsy in previous 6 weeks.
Staging system for prostate cancer?
TNM
Tumour (size of tumour)
Lymph nodes (cancer in lymph nodes)
Metastasis
Gleason score
- based on histology
Management of prostate cancer?
Depends on survival and grade.
Low risk:
- active surveillance
Moderate risk:
- radiotherapy
- brachytherapy
- external beam radiotherapy
High risk:
- surgical management
How to distinguish bladder and prostate cancer?
Bladder cancer:
May present with haematuria, dysuria, and urinary frequency.
Prostate cancer:
Urinary symptoms, including difficulty initiating or stopping urination
Poor urine stream
How to distinguish prostatitis and prostate cancer?
Prostatitis:
Acute or chronic inflammation of the prostate that can cause pelvic pain, urinary symptoms.
May cause systemic symptoms such as fever and malaise.
What is bladder cancer?
A malignant growth within the urinary bladder.
Most common: transitional cell carcinoma
RFs for bladder cancer?
Smoking
Aromatic amines exposure (rubber, dyes, chemical industry)
Use of Cyclophosphamide
Schistosomiasis infection
Long-term catheterisation
Local bowel cancer
Presentation of bladder cancer?
Painless visible haematuria
Painless haematuria
Recurrent UTIs
Hydronephrosis
Unintended weight loss
Night sweats
IVx for bladder cancer?
Urine dipstick (haematuria)
Urine MCS
CT urogram (distinguish from upper tract pathology)
Flexible cystoscopy (GOLD STANDARD)
Further staging investigations may include radiographs, CT scans, MRI scans, and bone isotope scans.
2ww wait referral criteria for bladder cancer?
≥45years AND:
- Unexplained visible haematuria without urinary tract infection
- Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
≥60years AND:
- unexplained non-visible haematuria
PLUS
- either dysuria OR raised WCC
Non-urgent referral:
- ≥60years
AND
- recurrent or persistent unexplained UTI
How is management of bladder cancer categorised?
Muscle invasive
Non-muscle invasive
Non-muscle invasive management of bladder cancer categorised?
Surgery:
Transurethral resection of the bladder tumour (TURBT) (GOLD STANDARD)
Chemotherapy
Immunotherapy (BCG)
Radical cystectomy
Muscle invasive management of bladder cancer categorised?
radical cystectomy with urinary diversion (GOLD STANDARD)
radiotherapy
chemotherapy
