BPH and Prostate Cancer Flashcards
Name the different zones of the prostate
Transition zone
Central zone
Peripheral zone
Anterior fibromuscular stroma
List the anatomical areas of the prostate in order of likelihood of cancer development
Peripheral zone (PZ):
- Is the zone that is palpable on rectal exam
- 75% of prostate carcinomas occur here
Transitional zone (TZ)
- Wraps around the urethra and is the part that predominantly is affected by hyperplasia
- 20% of prostate carcinomas occur here
What are the 3 common conditions that affect the prostate gland?
- Nodular hyperplasia (Benign prostatic hyperplasia)
- Prostate neoplasia
- Inflammatory conditions (prostatitis)
What is the physiological role of the prostate gland?
- Fibrous capsule holding many glandular structures
- Contributes 30% of seminal volume
- Held up via pelvic diaphragm
- Houses liquefying enzyme that break down coagulum (sperm grouping) from the seminal vesicles
Give a brief overview of BPH, including anatomical area affected and epidemiology
- Affects the TZ (compresses urethra, difficulty in passing urine)
-
NO relationship to prostate cancer
Young male prostate weighs ~12g (size of walnut) - Most common condition of the prostate
- Very common after age 50
- Uncommon before 40 yo
- ~5-10% clinically significant at 70 years old
Aetiology of BPH
- Cause unknown
- Theory is an imbalance of estrogen/testosterone/dihydrotestosterone
Presenting symptoms of BPH?
Lower urinary tract symtpoms (LUTS):
1. Dysuria
2. Frequency
3. Nocturia
4. Urgency and incontinence
5. Slow/weak stream
6. Difficultly initiating and stopping urine flow (dribbling)
List the pathogenesis process/es of BPH
- Aging/Hormonal changes
- Cellular proliferation: hyperplasia of both the epithelial and stromal components of the prostate, mainly in the TZ
- Inflammation
- Extracellular matrix remodelling
List the complications of BPH (5):
Chronic obstruction of urine output results in:
1. Bladder hypertrophy
2. Urinary stasis
3. Recurrent UTIs
4. Prolonged obstruction causes backpressure, leading to hydroureter & hydronephrosis
5. Renal failure and death are the end result of this continuum
Treatment/Management of BPH:
- Lifestyle modifications
- Pharmacological treatments
- Minimally invasive procedures
- Surigcal treatment
What lifestyle management protocols are recommended in BPH?
- Fluid Management: Reduce intake of fluids, especially before bedtime.
- Dietary Changes: Avoid caffeine and alcohol, which can exacerbate symptoms.
- Bladder Training: Techniques to improve bladder control and reduce urgency.
- Targeted Exercises:
What are the pharmacological managements of BPH, and their MOA?
- Alpha-blockers
- Alpha-1 receptors in the prostate, prostatic capsule and neck of bladder
- These therapies relax the smooth muscle around the urethral sphincters
- Examples: Prazosin, Terazosin, Tamsulosin - 5-alpha reductase inhibitors
- MOA: Inhibit the conversion of testosterone to dihydrotestosterone (DHT), reducing prostate size
- Examples: Finasteride (selective), Dutasteride (non-selective)
What are the adverse effects of pharmacological therapies for BPH?
Alpha blockers:
Usually mild, seen in up to 15% of patients
1. BP drop
2. Postural hypotension, dizziness, syncope
3. Tiredness
4. Headache
5. Ejaculatory dysfunction (tamsulosin)
Drug-Drug Interaction:
Interaction with PDE-5 inhibitors (sildenafil)
When used in conjunction ++ postural hypotension potentiation
5-alpha reductase:
Adverse effects (Increased testosterone conversion to estradiol, and no DHT effects):
1. Erectile dysfunction
2. Gynaecomastia
3. Reduced libido
4. Ejaculatory disorders
List the minimally invasive procedures for BPH management
Considered when medications are ineffective or not tolerated, and symptoms are moderate to severe.
- Transurethral Microwave Therapy (TUMT)
- Transurethral Needle Ablation (TUNA)
- Prostatic Urethral Lift (UroLift)
- Water Vapor Therapy (Rezum)
List the surgical management options for BPH
Surgery is considered for severe symptoms, significant obstruction, or complications such as recurrent urinary retention or bladder stones.
- Transurethral Resection of Prostate (TURP)
- Transurethral Incision of the Prostate (TUIP)
- Open or Robot-Assisted Prostatectomy
- Laser therapies (Holmium Laser Enucleation of the Prostate (HoLEP) & Photoselective Vaporization of the Prostate (PVP))
What is the most common prostate cancer and what anatomical location does it arise from?
Prostate adenocarcinoma
75% from the peripheral zone (PZ)
The main histological features of prostate cancer are? (4):
- Infiltrative glands that are too small, too crowded or too clear
- Absent basal cell layer
- Large nuclei
- Prominent nucleoli
“Prostate carcinoma is a heterogenous disease”. What does this refer to?
- Many patients will have an indolent disease that will not threaten their health during their life
- Small percentage of others will have an aggressive disease with quick progression, metastasis and death
What is the incidence of prostate cancer in Australia?
- Very common
- Most common cause of cancer in men
- 2nd most common cause of cancer related death in men
- In Australia; 1 in 6 lifetime risk of being diagnosed
- In Australia; 1 in 30 lifetime risk of dying from prostate adenocarcinoma
List the risk factors for Prostate cancer (5):
- Increasing age
- Ethnicity: (Asian males = rare, Black males = most common)
- Family history: Risk increased 2x when first degree related has prostate adenocarcinoma
- Genetic factors: Especially germline mutations in DNA repair genes (BRCA1 & BRCA2)
- Dietary factors: Obesity
What is PSA and what can cause elevated levels
- Prostate specific antigen (PSA) is a protein made only in the prostate
- Produced by the secretory cells of prostate glands and prostate carcinoma cells
- PSA rises with age normally
- Many causes of an elevated PSA
- Nodular hyperplasia (BPH)
- Prostatitis
- Perineal trauma (cycling)
- Prostate carcinoma
When should PSA be used in a clinical context?
- PSA production is increased in prostate carcinoma, however, PSA is not a screening tool for prostate cancer
- RACGP recommendations for PSA screening:
- no use in asymptomatic screening
- for those experiencing LUTS: Not recommended before 50 and after 70 years of age.
What is the Gleason scoring system?
- Developed by Dr. Donald Gleason in the 1960s
- It is a histopathological grading system used to assess the aggressiveness of prostate cancer
- Tissue biopsy is graded into primary and secondary pattern and given a number between 1 & 5 for each
- Grade 1: Cancer cells closely resemble normal cells (well-differentiated).
Grade 5: Cancer cells do not resemble normal cells at all (poorly differentiated). - Primary + Secondary = Gleason score
What factors make up a pathology report for a prostate biopsy ?cancer (5):
- Type of tumour
- Size of tumour (volume and % of the gland involved)
- Grade (Gleason score)
- Stage (TNM)
T - IS there extraprostatic extension?
N - Lymph node status
M - Distant metastases; Y/N - Margins
