BPH, Prostatitis and Prostate Cancer Flashcards
List 2 key risk factors for BPH?
- age
- ethnicity: black > white > Asian
How does BPH present?
LUTS:
- Hesitancy
- Weak flow
- Urgency
- Frequency
- Intermittency
- Straining
- Terminal dribbling
- Incomplete emptying
- Nocturia
What scoring system can be used to assess the severity of LUTS
The international prostate symptom score (IPSS)
- 20–35: severely symptomatic
- 8–19: moderately symptomatic
- 0–7: mildly symptomatic
What is included in the initial assessment of men presenting with LUTS?
- DRE
- Abdo exam
- Urinary frequency volume chart, recording 3 days of fluid intake and output
- Urine dipstick
- PSA
Is PSA sensitive or specific?
Sensitive (90%)
List 4 causes of raised PSA?
(DAVE)
- DRE
- Anal sex
- Vigorous exercise
- Ejaculation
- Prostate cancer, BPH, Prostatitis
- UTIs
Compare the examination findings of a benign vs cancerous prostate on DRE
Benign feels smooth, symmetrical and slightly soft, with a maintained central sulcus
Cancerous may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus
First line medication for BPH
- Alpha blockers eg. Tamsulosin
- Indicated for voiding symptoms (IPSS ≥ 8)
- Acts to relax smooth muscle
*May be used in combination with Finasteride
What is an important side effect of alpha-blockers like tamsulosin?
Postural hypotension
What medication may be indicated if there is significant prostate enlargement or high risk of progression?
- 5 alpha-reductase inhibitors eg. Finasteride
- Blocks conversion of testosterone to DHT (known to induce BPH)
- Reduces size of prostate
- Symptoms may not improve for 6 months
Most common side effect of finasteride?
Sexual dysfunction (due to reduced testosterone)
List a surgical options for BPH
- TURP
- Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
- Holmium laser enucleation of the prostate (HoLEP)
- Open prostatectomy
List 4 side effects of TURP
- Bleeding
- Infection
- Incontinence
- Erectile dysfunction
- Retrograde ejaculation
- Urethral strictures
- Failure to resolve symptoms
What is Prostatitis?
Inflammation of the prostate
How can Prostatitis be classified?
Compare these
Acute bacterial prostatitis – acute infection in the prostate, presenting with a more rapid onset of symptoms
Chronic prostatitis – symptoms lasting for at least 3 months
How may chronic prostatitis be sub-divided?
- Chronic prostatitis or chronic pelvic pain syndrome (no infection)
- Chronic bacterial prostatitis (infection)
How does chronic prostatitis present?
At least 3 months of:
- Pelvic pain
- LUTS
- Sexual dysfunction
- Pain with bowel movements
- Tender and enlarged prostate on exam
How does Acute bacterial prostatitis present?
More acute presentation with similar symptoms to chronic prostatitis +/- systemic symptoms such as:
- Fever
- Myalgia
- Nausea
- Fatigue
- Sepsis
What online scoring tool for prostatitis is used to assess severity of symptoms and impact on quality of life
National Institute of Health Chronic Prostatitis Symptom Index
Investigations for chronic prostatitis?
- Urine dipstick
- Urine microscopy, culture and sensitivities
- Chlamydia and gonorrhoea NAAT testing on a first pass urine, if suspected STI
Management of acute bacterial prostatitis?
- 14-day course of a quinolone
- Analgesia
- Laxatives for pain during bowel movements
- Hospital admission if systemically unwell or septic
Management of chronic prostatitis?
- Alpha-blockers (eg. Tamsulosin)
- Trimethoprim or doxycycline if < 6 months or history of infection
What is the analgesia of choice for prostatitis (acute or chronic)
Paracetamol or NSAIDs
What Psychological treatments may be offered for chronic prostatitis?
CBT and/or Antidepressants
List 4 complications of acute bacterial prostatitis?
- Sepsis
- Prostate abscess
- Acute urinary retention
- Chronic prostatitis
What are the 2 most common locations which prostate cancer spreads?
- Lymph nodes
- Bones
What is meant by androgen-dependent feature of prostate cancer?
Relies on androgen hormones (testosterone) to grow
What type of cancer are the majority of prostate cancers
Adenocarcinomas
What are the 3 zones of the prostate?
- Transitional
- Peripheral
- Central
What is the most common zone where prostate cancer grows?
The peripheral zone
List 4 risk factors for prostate cancer?
- Increasing age
- Family history
- Black African or Caribbean origin
- Tall stature
- Anabolic steroids
How does prostate cancer present?
- Asymptomatic
- LUTS (hesitancy, frequency, weak flow, terminal dribbling and nocturia)
- Haematuria, erectile dysfunction
Advanced disease or metastasis → weight loss, bone pain or CES
What is the reliability of PSA?
High rate of false positives (75%) and false negatives (15%)
In the UK, men > 50 can request a PSA test, what counselling would you give your patient?
Benefits:
- Early detection and effective treatment of prostate cancer
Negatives:
- False positives may lead to unnecessary further investigations ie. invasive biopsies, which have complications + unnecessary diagnosis and treatment that would never have caused problem
- False negatives may lead to false reassurance
List 4 causes of a raised PSA?
(DAVE)
- DRE
- Anal sex
- Vigorous exercise
- Ejaculation
- Prostate cancer, BPH, Prostatitis
- UTIs
Findings on DRE of a BPH
Smooth, symmetrical and slightly soft, with a maintained central sulcus
Nay be generalised enlargement (hyperplasia)
Findings on DRE of a Prostatitis
Enlarged, tender and warm
Findings on DRE of a cancerous prostate
Firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus.
May be a hard nodule
First-line investigation for suspected localised prostate cancer?
Interpret the findings?
Multiparametric MRI
- 1 – very low suspicion
- 2 – low suspicion
- 3 – equivocal
- 4 – probable cancer
- 5 – definite cancer
When is a prostate biopsy recommended?
MRI findings (3 or above) and the clinical suspicion (DRE and PSA level)
How accurate are prostate biopsies?
Risk of false-negatives if the biopsy misses the cancerous area
Multiple needles are used to take samples from different areas, MRI results can guide the biopsy
2 options for prostate biopsies?
- Transrectal ultrasound-guided biopsy (TRUS)
- Transperineal biopsy
List 4 risks of a prostate biopsy?
- Pain
- Bleeding
- Infection
- Urinary retention due to short term swelling
- Erectile dysfunction (rare)
How can we asses for bony metastasis?
Isotope Bone Scan (aka radionuclide scan or bone scintigraphy)
What grading system is used for prostate cancer?
Gleason Grading System
- Based on histology from biopsies
- Helps determine appropriate treatment
How is the Gleason score calculated?
Made up of two numbers added together for the total score:
- Grade of the most prevalent pattern in the biopsy
- Grade of the second most prevalent pattern in the biopsy
Interpret the various Gleason scores
- 6 is low risk
- 7 is intermediate risk
- 8 + is high risk
What staging system is used for prostate cancer?
TNM staging
Management of prostate cancer?
- Surveillance or watchful waiting in early cancer
- External beam radiotherapy
- Brachytherapy
- Hormone therapy
- Surgery
What is a key complication of external beam radiotherapy?
Proctitis
Can cause pain, altered bowel habit, rectal bleeding and discharge
Prednisolone suppositories can help reduce inflammation
List 3 hormone therapies used for prostate cancer?
- Androgen-receptor blockers eg. Bicalutamide
- GnRH agonists such as Goserelin
- Bilateral orchidectomy
List 4 side effects of hormone therapy
- Hot flushes
- Sexual dysfunction
- Gynaecomastia
- Fatigue
- Osteoporosis
List 2 complications of a Radical prostatectomy
- Erectile dysfunction
- Urinary incontinence
To who is active surveillance for prostate cancer offered?
Clinical stage T1c
Gleason score 3+3
PSA density < 0.15 ng/ml/ml who have cancer in less than 50% of their biopsy cores, with < 10 mm of any core involved
