BPH and prostate cancer

Question 1

what region of the prostate does BPH effect?

Answer 1

the transitional zone

Question 2

what are then S&S of BPH?

Answer 2

• Storage symptoms, such as frequency, urgency, nocturia, and incontinence.
• Voiding symptoms, including hesitancy, poor stream, intermittency, terminal dribble, and abdominal straining.
• Superimposed infection may cause dysuria and haematuria.
• Incomplete emptying and chronic or acute retention of urine.
• Smooth enlargement of the prostate detected by digital rectal examination.
• Possible palpable bladder if chronic retention.
• Always examine for neurological signs in those with LUTS

Question 3

how is BPH investigated?

Answer 3

PR

Urinalysis – normal in uncomplicated BPH. May show leucocytes, nitrates (UTI) or haematuria (cancer)

PSA – elevated

Urine Flowmetry – looks at maximum flow and post void residual vol.

TRUS + biopsy if cancer suspected.

Renal tract US if obstruction.

Question 4

how is impact of BPH assessed?

Answer 4

international prostate symptoms score
- looks at incomplete emptying, frequency, intermittency, urgency, stream, straining and nocturia

0-7 = mildly symptomatic 
8-19 = moderatety symptomatic 
20-35 = severely symptomatic

Question 5

what is the medical management of BPH?

Answer 5

• Patients with mild symptoms and no complications may be observed (watchful waiting).
• A-adrenergic antagonists (Tamsulosin). Relax smooth muscle of prostatic urethra to decrease outlet resistance; side effects include dizziness and hypotension (especially postural).
• 5A-reductase inhibitors (Finasteride). Block conversion of testosterone to dihydrotestosterone (DHT) and shown to cause involution of BPH; side effects include loss of libido and erectile dysfunction.
• Combination drug therapy with both the above agents. May reduce the clinical progression and decrease the need for surgery.

Question 6

how can BPH be surgically managed?

Answer 6

• Transurethral resection of the prostate (TURP), the most commonly performed procedure for BPH in the UK.
• Open retropubic prostatectomy.
• Transurethral incision in the prostate (TUIP).
• Laser ‘prostatectomy’.
• Microwave thermotherapy ablation of the prostate

Question 7

what are the complications of TURP?

Answer 7

can have the complications of UTI, incontinence, impotence and TURP syndrome (dilutional hyponatraemia cause by the irrigation water getting into the bloodstream)

Question 8

what type of cancer are prostate tumours and where do they arise?

Answer 8

adenocarcinomas

peripheral zone

Question 9

what are the clinical features of prostate cancer?

Answer 9

• The majority of men present with LUTS i.e frequency, hesitancy, dribbling, nocturia
• Bone pain, pathological factures, and features of hypercalcaemia are occasional presenting features due to metastases.
• May be diagnosed by digital rectal examination; areas of firmness or palpable nodules are suggestive of malignant change.

Question 10

what are the InV for prostate cancer?

Answer 10

• Serum PSA. Can be used as a screening test; high sensitivity, but low specificity; elevated age-specific levels are an indication to consider prostate biopsy.
• Transrectal ultrasound (TRUS). Permits detailed imaging of the prostate. Systematic needle biopsy is performed guided by the ultrasound images with antibiotic prophylaxis
• Pelvic MRI. Used to detect the presence of extracapsular extension or the presence of pelvic lymphadenopathy (suggests spread).
• Laparoscopic node biopsy. May be performed to sample enlarged nodes prior to considering radical treatment.
• Isotope bone scan. Will detect the presence of bone metastases.

Question 11

how is prostate CA graded ?

Answer 11

Gleason Grading system

Calculated by adding together the number for the most common cell type seen (1-5) and the number for the least differentiated (most cancerous) cell type seen (1-5) (may only be present in very small amounts). E.g a person with minimal prostate cancer with have a Gleason score of 3+3

Question 12

what is risk stratification in prostate CA ?

Answer 12

based on Gleason, PSA and clinical stage (GPS)

low = PSA <10, Gleason <6, T1-T2a

intermediate = PSA 10-20, Gleason 7, T2b

High = PSA >20, Gleason 8-10, >T2c

Question 13

what are the conservative options for Prostate CA management

Answer 13

Watchful waiting is a symptom-guided approach to prostate cancer management where definitive therapy is often deferred and hormonal therapy is initiated at time of symptomatic disease.

Used for older patients with low life expectancy and offered at any stage

Active surveillance = low risk groups. 3 monthly PSA, 6 monthly DRE and yearly biopsy

Question 14

list the management options for Pros CA?

Answer 14

surgery
radio
chemo
androgen deprivation therapy

Question 15

what are the surgical options for pros CA and complications?

Answer 15

radical prostatectomy.
- removal of the prostate gland, resection of the seminal vesicles, along with the surrounding tissue +/- dissection of the pelvic lymph nodes.

• open approach, laparoscopically or robotically.
• Side effects of radical prostatectomy include erectile dysfunction (affecting 60-90% of men), stress incontinence and bladder neck stenosis.

Question 16

outline androgen deprivation therapy

Answer 16

pros CA growth stimulated by circulating androgens so this therapy tries to reduce that

luteinizing hormone-releasing hormone (LHRH) agonists e.g. goserelin or triptorelin

gonadotrophin-releasing hormone (GnRH) receptor antagonists e.g. degarelix

enzalutamide and abiraterone, acting to lower levels of serum testosterone. Both of these drugs are reserved for patients with metastatic prostate cancer.