Group Teaching - BPH and Prostate Cancer

Question 1

• Patient – Mr Smith, 65-years old
• Presenting symptoms – hesitancy, poor flow, sensation of incomplete emptying. Long standing but symptoms suddenly worsened with episode of constipation.
• Past medical history - Hypertension
• Drug History – Amlodipine
• Social History – Regular smoker, occasional drinking
• Examination – BP 160/95, no swelling of ankles, Chest clear, HS I + II + 0, abdomen soft and non-tender. No palpable bladder. DRE- smooth 30g prostate. Stool in the rectum.
• Investigation – dipstick- nitrate negative, leucocyte negative, blood negative, blood tests – PSA 5, renal function normal.

What is your differential diagnosis?

Answer 1

• Bladder Cancer
• Bowel Cancer
• Prostate hyperplasia (BPH / Cancer / Prostatitis)
• Parasympathetic nerve damage

Question 2

• Patient – Mr Smith, 65-years old
• Presenting symptoms – hesitancy, poor flow, sensation of incomplete emptying. Long standing but symptoms suddenly worsened with episode of constipation.
• Past medical history - Hypertension
• Drug History – Amlodipine
• Social History – Regular smoker, occasional drinking
• Examination – BP 160/95, no swelling of ankles, Chest clear, HS I + II + 0, abdomen soft and non-tender. No palpable bladder. DRE- smooth 30g prostate. Stool in the rectum.
• Investigation – dipstick- nitrate negative, leucocyte negative, blood negative, blood tests – PSA 5, renal function normal.

Which diagnostic tests should he be referred for?

Answer 2

• Cycstoscopy
• CT scan
• Creatinine
• MRI scan
• Repeat PSA
• US kidney
• Urinary flow rate

Question 3

• Patient – Mr Smith, 65-years old
• Presenting symptoms – hesitancy, poor flow, sensation of incomplete emptying. Long standing but symptoms suddenly worsened with episode of constipation.
• Past medical history - Hypertension
• Drug History – Amlodipine
• Social History – Regular smoker, occasional drinking
• Examination – BP 160/95, no swelling of ankles, Chest clear, HS I + II + 0, abdomen soft and non-tender. No palpable bladder. DRE- smooth 30g prostate. Stool in the rectum.
• Investigation – dipstick- nitrate negative, leucocyte negative, blood negative, blood tests – PSA 5, renal function normal.

Following results obtained:
* Multiparametric MRI – reported a homogenous circumscribed nodule in the transition zone of the prostate.
* The patient subsequently underwent trans perineal template prostate biopsies and this demonstrated one core of Gleason 3+3 (1mm) (in the region of the index lesion) and all other biopsies demonstrated BPH only.

What can you infer from these results?

Answer 3

Well differentiated prostate cancer

Question 4

• Patient – Mr Smith, 65-years old
• Presenting symptoms – hesitancy, poor flow, sensation of incomplete emptying. Long standing but symptoms suddenly worsened with episode of constipation.
• Past medical history - Hypertension
• Drug History – Amlodipine
• Social History – Regular smoker, occasional drinking
• Examination – BP 160/95, no swelling of ankles, Chest clear, HS I + II + 0, abdomen soft and non-tender. No palpable bladder. DRE- smooth 30g prostate. Stool in the rectum.
• Investigation – dipstick- nitrate negative, leucocyte negative, blood negative, blood tests – PSA 5, renal function normal.

Following results obtained:
* Multiparametric MRI – reported a homogenous circumscribed nodule in the transition zone of the prostate.
* The patient subsequently underwent trans perineal template prostate biopsies and this demonstrated one core of Gleason 3+3 (1mm) (in the region of the index lesion) and all other biopsies demonstrated BPH only.

What treatment and management plan should be followed?

Answer 4

• Active surveillance (regular PSA, MRI and Bx)

Question 5

• Patient – Mr Smith, 65-years old
• Presenting symptoms – hesitancy, poor flow, sensation of incomplete emptying. Long standing but symptoms suddenly worsened with episode of constipation.
• Past medical history - Hypertension
• Drug History – Amlodipine
• Social History – Regular smoker, occasional drinking
• Examination – BP 160/95, no swelling of ankles, Chest clear, HS I + II + 0, abdomen soft and non-tender. No palpable bladder. DRE- smooth 30g prostate. Stool in the rectum.
• Investigation – dipstick- nitrate negative, leucocyte negative, blood negative, blood tests – PSA 5, renal function normal.

Following results obtained:
* Multiparametric MRI – reported a homogenous circumscribed nodule in the transition zone of the prostate.
* The patient subsequently underwent trans perineal template prostate biopsies and this demonstrated one core of Gleason 3+3 (1mm) (in the region of the index lesion) and all other biopsies demonstrated BPH only.

After 2 years, following results obtained:
* PSA Test – 8
* MRI result – new bilateral lesions in peripheral zone of the prostate
* Biopsy test – Gleason score – 4+3 in several cores bilaterally

What is your inference from analysing these results?

Answer 5

• Cancer has progressed, now moderately differentiated

Question 6

• Patient – Mr Smith, 65-years old
• Presenting symptoms – hesitancy, poor flow, sensation of incomplete emptying. Long standing but symptoms suddenly worsened with episode of constipation.
• Past medical history - Hypertension
• Drug History – Amlodipine
• Social History – Regular smoker, occasional drinking
• Examination – BP 160/95, no swelling of ankles, Chest clear, HS I + II + 0, abdomen soft and non-tender. No palpable bladder. DRE- smooth 30g prostate. Stool in the rectum.
• Investigation – dipstick- nitrate negative, leucocyte negative, blood negative, blood tests – PSA 5, renal function normal.

Following results obtained:
* Multiparametric MRI – reported a homogenous circumscribed nodule in the transition zone of the prostate.
* The patient subsequently underwent trans perineal template prostate biopsies and this demonstrated one core of Gleason 3+3 (1mm) (in the region of the index lesion) and all other biopsies demonstrated BPH only.

After 2 years, following results obtained:
* PSA Test – 8
* MRI result – new bilateral lesions in peripheral zone of the prostate
* Biopsy test – Gleason score – 4+3 in several cores bilaterally

What is your inference from analysing these results?

Answer 6

• Radical prostatectomy

Question 7

• Patient – Mr Smith, 65-years old
• Presenting symptoms – hesitancy, poor flow, sensation of incomplete emptying. Long standing but symptoms suddenly worsened with episode of constipation.
• Past medical history - Hypertension
• Drug History – Amlodipine
• Social History – Regular smoker, occasional drinking
• Examination – BP 160/95, no swelling of ankles, Chest clear, HS I + II + 0, abdomen soft and non-tender. No palpable bladder. DRE- smooth 30g prostate. Stool in the rectum.
• Investigation – dipstick- nitrate negative, leucocyte negative, blood negative, blood tests – PSA 5, renal function normal.

Following results obtained:
* Multiparametric MRI – reported a homogenous circumscribed nodule in the transition zone of the prostate.
* The patient subsequently underwent trans perineal template prostate biopsies and this demonstrated one core of Gleason 3+3 (1mm) (in the region of the index lesion) and all other biopsies demonstrated BPH only.

After 2 years, following results obtained:
* PSA Test – 8
* MRI result – new bilateral lesions in peripheral zone of the prostate
* Biopsy test – Gleason score – 4+3 in several cores bilaterally

The patient decides on a radical prostatectomy and following surgery develops both erectile dysfunction and urinary incontinence.

What is the mechanisms of these post operative complications and how should they be treated?

Answer 7

• Damage to the proximal urethral sphincter and change in urethral length -> urinary incontinece
• Damage to the cavernous nerves -> ED
• Tx:
  
  • Pelvic floor muscle exercises
    
    • Artificial urinary sphincter device if exercises fail
  • Viagra, or prostaglandin E1 and if insufficient - penile prosthesis

Question 8

• Patient – Mr Smith, 65-years old
• Presenting symptoms – hesitancy, poor flow, sensation of incomplete emptying. Long standing but symptoms suddenly worsened with episode of constipation.
• Past medical history - Hypertension
• Drug History – Amlodipine
• Social History – Regular smoker, occasional drinking
• Examination – BP 160/95, no swelling of ankles, Chest clear, HS I + II + 0, abdomen soft and non-tender. No palpable bladder. DRE- smooth 30g prostate. Stool in the rectum.
• Investigation – dipstick- nitrate negative, leucocyte negative, blood negative, blood tests – PSA 5, renal function normal.

Following results obtained:
* Multiparametric MRI – reported a homogenous circumscribed nodule in the transition zone of the prostate.
* The patient subsequently underwent trans perineal template prostate biopsies and this demonstrated one core of Gleason 3+3 (1mm) (in the region of the index lesion) and all other biopsies demonstrated BPH only.

After 2 years, following results obtained:
* PSA Test – 8
* MRI result – new bilateral lesions in peripheral zone of the prostate
* Biopsy test – Gleason score – 4+3 in several cores bilaterally

The patient decides on a radical prostatectomy and following surgery develops both erectile dysfunction and urinary incontinence.

What post operative follow up should the patient undergo?

Answer 8

Regular PSA