BPH, prostate cancer

Question 1

Describe the pathogenesis of benign prostatic hyperplasia.

Answer 1

5-a-reductase increases in activity as men get older and therefore dihydrotestosterone and oestrogen levels rise. These hormones cause prostatic hyperplasia. The prostate starts to obstruct the urethra, causing storage and voiding LUTS.

Question 2

What is BPH?

Answer 2

Benign proliferation of musculofibrous/ glandular tissue in the transitional zone of the prostate gland.
(PTS)

Question 3

Describe the presentation of benign prostatic hyperplasia.

Answer 3

LUTS:
Voiding - hesitancy, poor stream, retention, terminal dribbling, overflow incontinence.
Storage: Frequency, urgency, nocturia
Smooth and enlarged prostate on DRE.
(PTS)

Question 4

What investigations would you do for ?BPH?

Answer 4

1. DRE (smooth, enlarged prostate)
2. PSA (prostate-specific antigen) - raised
3. Transrectal (TR)USS
4. Renal USS
   Biopsy may be used to help exclude cancer.
   (PTS)

Question 5

Describe the management of BPH with examples of drugs.

Answer 5

Exclude cancer.

1. Lifestyle: avoid caffeine and alcohol
2. Behavioural: bladder training - void twice in a row to aid emptying.
3. Medical: First alpha-blockers eg tamsulosin PO, then 5-alpha-reductase inhibitors eg finasteride PO.
4. Surgical: TransUrethral Resection of Prostate/ TransUrethral Incision of Prostate.

Question 6

What 2 things cause retention?

Answer 6

Obstruction
Decreased detrusor power.
(OHCM)

Question 7

Describe the epidemiology of BPH.

Answer 7

24% of 40-64 year olds, 40% of 65+ - age is a big factor

Question 8

Give 2 potential complications of BPH.

Answer 8

Bladder stones
UTI
(OHCM)

Question 9

Give the mechanism of action and 3 side-effects of tamsulosin.

Answer 9

Alpha blocker - acts on alpha-receptors, decreases smooth muscle tone, allowing urine to flow more easily (treats retention). Also causes vasodilation so decreases BP.
SEs: HYPOTENSION, drowsiness, depression, dizziness, dry mouth, ejaculatory failure

Question 10

Give the mechanism of action and 2 side-effects of finasteride.

Answer 10

Inhibits 5-alpha-reductase to decrease levels of dihydrotestosterone. DHT usually promotes prostate growth of finasteride reduces this.
SEs: impotence, decreased libido.

Question 11

Where is the prostate gland and what does it do?

Answer 11

Walnut-sized gland situated around the urethra distal to the bladder, produces components of seminal fluid.

Question 12

Describe the pathophysiology of prostate cancer.

Answer 12

Adenocarcinoma of the peripheral zone of the prostate gland. 85% are multifocal. Spreads locally through prostate capsule. ERG is an oncogene which is upregulated in prostate cancer (causing androgen sensitivity?) (lecture 19.2.18)

Question 13

How is prostate cancer staged?

Answer 13

TNM and gleason staging (lecture 19.2.18)

Question 14

Give 3 risk factors for prostate cancer.

Answer 14

Increasing age
(Male only)
Ind

Question 15

Give 3 risk factors for prostate cancer.

Answer 15

Increasing age
(Male only)
Family history (x3 risk)
High testosterone.

Question 16

What are common sites for prostate cancer to metastasise to?

Answer 16

Lymph nodes
Bone (sclerotic)
Occasionally lung, liver and brain.

Question 17

What is the PSA test?

Answer 17

Prostate specific antigen is a protein produced by the prostate gland to liquify semen. Small amounts of PSA from semen leaks into the bloodstream through venous drainage and can be detected by immunoassay. Serum PSA is raised in BPH and prostate cancer.

Question 18

What is the most sensitive biomarker for prostate cancer?

Answer 18

Tissue biomarkers
Urine biomarkers - PCA3, gene fusion products (TMPRSS2-ERG)
Serum biomarkers - PSA, Prostate specific membrane antigen.

Question 19

What is the most common cause of raised PSA?

Answer 19

Benign prostatic enlargement.

Question 20

What is lead and length time bias?

Answer 20

Lead time is the time between diagnosis and death from prostate cancer. Early diagnosis increases perceived survival time, so even though survival is not increased, it appears to be.

Question 21

What is the difference between grading and staging?

Answer 21

Grade is the biological aggressiveness, stage is the extent of the disease.

Question 22

Describe the management of T2N0M0 prostate cancer. *?

Answer 22

This is localised prostate cancer. Treat with intent to cure. Options:
1. Surgical - radical prostatectomy (can be open, robotic or laparoscopic)
2. Radiotherapy - brachytherapy = seeds of radiotherapy
3. Observation eg watchful waiting or active surveillance.
4. Focal therapy eg high intensity focal ultrasound.*?
(lecture 19.2.18)

Question 23

Give an advantage and disadvantage of radical prostatectomy.

Answer 23

Advantages:
Prostate cancer has high mortality and prostatectomy can cure this
Disadvantages:
If person is elderly, harms may outweigh benefits
Prostate cancer only cause of death in 30% of people with prostate cancer.

Question 24

What investigations would you do if you suspect prostate cancer?

Answer 24

DRE
PSA - raised
MRI
CT
Biopsy - transrectal ultrasound

Question 25

What investigations would you do if you suspect prostate cancer?

Answer 25

DRE - hard, irregular prostate
PSA - raised
MRI
CT
Biopsy - transrectal ultrasound

Question 26

Give 3 symptoms of prostate cancer.

Answer 26

Can be asymptomatic
LUTS: 
Voiding: hesitancy, poor stream, obstruction
Storage: nocturia, terminal dribbling
Weight loss and bone pain suggest mets