BPH & Prostate Cancer Flashcards
What does BPH stand for?
What about BPO?
Benign prostatic hyperplasia
Benign prostatic obstruction
Hyperplasia vs hypertrophy?
Hyperplasia is when there are more cells present
Hypertrophy is when the size of the cells increase
Pathophysiology of BPH?
Increase in size of prostate because of hyperplasia
Normal with advancing age
Caused by presence of testosterone
Likely to be caused by failure of apoptosis
Results in compression and eventual obstruction of the prostatic urethra (called BPO)
Clinical features of BPH?
Lower urinary tract symptoms
Storage symptoms:
- Urinary frequency
- Urgency
- Nocturia
- Incontinence (urge and stress)
Voiding symptoms:
- Hesitancy
- Poor stream
- Intermittency
- Terminal dribbling
- Retention
Investigations of BPH?
Bedside:
- Obs
- Abdominal examination (feel for palpable bladder)
- DRE
- Urine dip
Routine:
- Bloods: FBC, UE, LFTS (bone mets), PSA
- Abdominal XR
- Urinalysis
- Post-void residual bladder volume USS
- USS KUB
Specialist:
- Flow rate assessment
- Flexible cystoscopy
Differential diagnosis of lower urinary tract symptoms?
UTI BPH Prostate cancer Bladder cancer Detrusor instability Urethral structures
What would you find on a PR exam in a patient with BPH?
Enlarged, smooth prostate
Management of BPH?
Conservative:
- reduce caffeine intake
- stop diuretics if can
- advise they take diuretics in morning to lessen nocturia
Medical:
- alpha blockers (tamsulosin)
- 5 alpha-reductase inhibitors
Surgical:
- transurethral resection of prostate (coring out middle of prostate gland)
Describe what drugs are used to manage BPH and how they work?
Alpha blockers
- tamsulosin, doxazosin
- alpha 1 receptor
- these relax the smooth muscle of the prostate reducing constriction of urethra
5-alpha-reductase inhibitors
- finasteride
- stop conversion of testosterone to more potent form dihydrotestosterone which drives hyperplasia
- reduces size of prostate
What’s the name of the potent form of testosterone?
What converts testosterone to this?
Dihydrotestosterone
Converted by 5-alpha reductase enzyme
Hence why 5-alpha reductase drugs are used to treat BPH
What receptors do tamsulosin and doxazosin act on?
Where else are these receptors found?
What are side effects of these drugs?
Alpha-1
Arteries - cause vasoconstriction
Smooth muscle
CNS
Low BP because of blockade of alpha receptors preventing vasoconstriction
Acute vs chronic urinary retention?
Acute is sudden onset. When the bladder is full but NO urine is being passed at all - there is complete obstruction.
Causes bladder distension and pain.
Chronic retention is increased residual volume of urine. They may still pass urine but experience LUTS. No pain
Clinical features of chronic urinary retention?
LUTS, for a long period of time (not acutely)
Storage
- urgency
- incontinence
- frequency
- nocturia
Voiding
- Unable to void
- Poor stream
- Hesitancy
- Terminal dribbling
- Intermittency
- Incomplete emptying of bladder
Complications of chronic urinary retention?
Acute retention
Infection
Hydronephrosis due to back pressure of kidneys resulting in AKI or CKD
Overflow incontinence
Clinical features of acute urinary retention?
Sudden onset
Tender, distended bladder
Unable to pass urine
Complications of acute urinary retention?
UTI
AKI due to backflow
Rupture
Post-obstructive diuresis, haematuria
Causes of acute vs chronic urinary retention?
Acute:
- BPH
- Prostate cancer
- bladder calculi
- bladder cancer
- prolapse
- gynae pelvic mass (ovarian cyst, fibroid)
- cauda equina
Chronic:
- BPH
- Prostate cancer
- Drugs
- Congenital deformities
- Urethral strictures
Which drugs cause urinary retention?
Anti-histamines
Anti-cholinergics
- TCAs
- tiotropium
- oxybutinin
Anti-spasmodics
What can cause urethral strictures?
Infection: STI, TB
Trauma: pelvic fracture
Which region of the prostate is affected in BPH?
Transitional zone, which surrounds the urethra
Which type of cancer is prostate cancer usually?
Which region of prostate is usually affected?
Adenocarcinoma (arising from glandular cells)
Peripheral zone
What can cause PSA level to rise?
BPH Prostate cancer UTI Prostatitis Ejaculation Prostate injury Age
Clinical features of prostate cancer?
LUTS which progress faster than BPH symptoms
Erectile dysfunction
Weight loss, anorexia
Signs of mets: back pain, bone lesions, derranged LFTs
PR exam: hard craggy prostate
Investigations of prostate cancer?
Rule out infection (urine dip)
PR exam: hard craggy prostate
PSA
Transrectal USS (TRUSS) and biopsy
Urinalysis: PCA3 (a genetic marker)
Imaging: CT
In suspected prostate cancer, why do you do these tests?
- U+E
- LFTs
- CT/MRI
- Bone scan
U+E: to check renal function in case of hydronephrosis cause by obstruction
LFTs: liver and bone mets
CT/MRI: to stage
Bone scan: to stage and look for bone mets
Which LFT will tell you if there might be bone mets?
Alkaline phosphatase
How is prostate cancer staged?
TNM
T1 found histologically only
T2: palpable tumour that has not spread beyond prostate capsule
T3: tumour spread through capsule to the seminal vesicles, prostate is mobile on PR exam
T4: tumour has spread to pelvic wall and organs, it is non mobile on PR exam
Management of prostate cancer?
T1-T2
- active surveillance
- radical prostatectomy
- radical radiotherapy
- brachytherapy
T3-T4
- combination of androgen deprivation therapy and radiotherapy
- or watchful waiting
What’s the difference between active surveillance and watchful waiting?
BOTH:
- For men whose cancer isn’t causing problems or symptoms currently.
- To avoid unnecessary treatment
Active surveillance:
- men with localised cancer
- well enough to have surgery and radiotherapy if needed
- Treatment (if given) would be to cure.
- Monitored regularly with biopsies and MRI.
Watchful waiting
- Men with health problems affecting ability to cope with surgery and radiotherapy
- And men whose cancer may never affect them (because other problems will first)
- Fewer tests, and check ups at GP.
A 55 year old man has stage T2 prostate cancer found incidentally.
He is fit and well.
Would you put him on watchful waiting or active surveillance?
Active surveillance
He is asymptomatic so it is good to avoid treatment that’s not necessary at the moment.
He is well so would be able to cope with invasive monitoring and treatment.
A 87 year old man has stage T2 prostate cancer found incidentally.
He has CCF leaving him unable to walk more than a few metres without being SOB.
Would you put him on watchful waiting or active surveillance?
Watchful waiting
He is asymptomatic so good to avoid treatment that’s not necessary at the moment.
He has poor exercise tolerance so probably wouldn’t cope well with invasive monitoring and treatment.
Probably his CCF will cause his death before his prostate cancer will.
What is brachytherapy?
Insertion of radioactive material directly into the affected area.
A high dose of radiation is given to the tumour but not to the healthy tissue.
In prostate cancer, either inserted into the tumour, or into a catheter in the prostate
What is meant by androgen deprivation therapy? What types are there? (Don’t describe)
Is it used in metastatic or non-metastatic cancer?
The growth of metastatic deposits is driven by testosterone
If the testosterone is removed then growth of mets should slow.
Can be done medically or surgically
How does medical androgen deprivation therapy work?
GnRH analogues, specifically LH releasing hormone
Work in the same way as the ones used to put a woman into medical menopause (for endometriosis, fibroids)
The excess LH (after some time) causes downregulation of LH receptors on the testes
They stop producing testosterone
Low testosterone reduces growth of mets
How does surgical androgen deprivation therapy work?
Orchidectomy
removal of testicles
What are complications of TURP?
Bleeding
TURP syndrome: irrigation fluid is absorbed into circulation via cut veins
Indwelling catheter needed until bleeding stopped
Urethral structure
Retrograde ejactulation
ED
Clinical features of TURP syndrome?
CNS: restlessness, headache
N+V
Bradycardia
Hypo or hypertension
Tachypnoea
Hypoxia
Hypothermia
