GU Flashcards
Male GU Lateral View - anatomy
anatomy of the prostate
FUNCTION OF THE PROSTATE GLAND
- Exocrine gland
- Store and secrete basic fluid that constitutes 1/3 of semen
- Secretion of proteolytic enzymes and psa as well as zinc and citric acid
- Keeps basic environment within the acidic vagina allowing sperm to survive
- 20-40 gms (size of walnut) rubbery
- Both glandular and smooth muscle allowing expulsion of semen
most common form of cancer in adult males in all age groups
prostate cancer
currently surpasses the incidence of lung cancer
second leading cause of death from cancer in men in the United States.
association of age and likelihood of developing prostate cancer
- likelihood of developing prostate cancer increases from 1 in 2,667 in ages 50 – 54 to 1 in 80 for men aged 80 – 84.
- 85% of all prostate cancers are diagnosed in men older than 65 years (Gronberg, 2003) making this a disease of an older, vulnerable population.
ten-year survival rate for a man diagnosed with localized prostate cancer
approaches 100% (in 2007)
Called an indolent dz - is clinically latent in 70% of men. More die w/dz than of it
What is PSA and when is it elevated?
- Serine protease
- Outstanding semen liquidfier
- Elevated in 3 urologic conditions, not always malignancy
- Prostate cancer
- Infections
- Prostate growth
What is PSA 3?
- Gene testing
- urine based test collected after DRE (sufficient # prostate cells to evaluate pts risk for cancer)
- use if repeat psa remains high, suspicion for prostate cancer w/nl psa
PSA screening and prostate cancer: when to screen, nl values, how to interpret
- Serum test
- Guidelines recommend screening at age 40
- Very inexpensive and routine
- Normal values
- Values > 4 ng/ml relates to 27% positive biopsy 2.5% high risk/
- PSA velocity more accurate diagnosis
How have rates of prostate cancer changed since introduction of PSA screening?
- From 19,000 cases/year before PSA to 200,000/year now
- Rates now stabilized
Cooperberg, Moul and Carroll (2005) state that “A significant proportion of men with prostate cancer may be over diagnosed, in the sense that diagnosis may not improve their lifespan or quality of life. However, the extent to which over diagnosis represents a true problem relates to the consistency with which diagnosis leads invariably to active treatment” (p. 8125).
Risk factors for prostate cancer
- African American men highest
- Family history of male relative
- Diet related (virtually non-existent in countries with low fat diets)
What to do with an abnormal PSA?
Further diagnostic tests for prostate cancer
- Digital rectal exams (routine?)
- Transurethra biopsy
- Transrectal biopsy indications
- False negatives
Prostate
Gleason scoring from biopsy results
- Indicates cellular differentiation
- 2-4 well-differentiated
- 5-7 intermediate differentiated
- 8-10 poorly differentiated – poorer prognosis
- TNM system
- T1 nonpalpable
- T4 metastasis
Prostate Cancer Curative Treatments
- Radical Prostatectomy
- Internal/External Beam Radiation therapy
Complications of prostate surgery
-
impotence:
- rates following radical prostatectomy: 7 - 72%
- rates following brachytherapy: 5 - 51%%
- May be failure to report pre-existing erectile dysfunction (ED) prior to treatment
- Incontinence, and rectal issues
- urinary incontinence: ~25% (Heidenreich, Ohlmann, Ozgur & Engelman, 2006).
- Rectal discomfort following radiation: ~39% (Heidenreich et al., 2006)
- Fecal incontinence between 8 and 56%.
What is BPH?
- Benign Prostatic Hyperplasia (BPH)
- Refers to a histological finding
- No inherent clinical meaning
- Many men will have BPH but no symptoms
- Presence of BPH increases with age
Is BPH the cause of LUTS?
- lower urinary tract symptoms (LUTS) are commonly attributed to enlargement of the prostate.
- BPH is a pathology that leads to enlargement= may obstruct the urethra leading to LUTS.
- Because BPH is a histological finding, it requires a tissue sample for true diagnosis.
- BPH is more prevalent in the more aged population, however not every patient with BPH will have LUTS. Also, not all patients with LUTS have BPH.
Why use the term LUTS instead of BPH?
Removes implication that symptoms have organ specific cause
symptom based diagnosis, instead of a histological one
2 categories of LUTS
- Voiding or obstructive symptoms
- Storage or irritative symptoms
- These divisions then are correlated with particular etiologies.
What is the International prostate symptom score (IPSS)?
Validated subjective questionnaire for LUTS
Seven symptoms evaluated:
- Weak flow of stream -Intermittency
- Difficulty initiating stream -Nocturia
- Straining to void -Frequency Urgency
Each scored 0-5
Total score 0-7 Mild; 8-19 Moderate; 20-35 Severe LUTS
Bother score: Single concluding question evaluating quality of life with LUTS (1 to 6, one being the most pleased, and 6 being the most dissatisfied) heavily weighed when determine whether or not to intervene, scored 1-6
What is Bladder Outlet Obstruction (BOO)?
- may develop from progressive BPH and worsen LUTS, especially voiding symptoms
How to evaluate Bladder Outlet Obstruction?
- Non-invasive uroflowmetry may provide some objective diagnostic data
- Patient voids into weighed receptacle to measure volume and rate of flow
- Post void residual
- Measured in mls, elevated in BOO
- Near 0 in normal voiding, but no specific cut-off for an elevated PVR
- ultrasound or in/out catheterization
- Bladder Scanner: ultrasonic machine dedicated to measurement of bladder volume
- Measured in mls, elevated in BOO
The case for active surveillance of tumors of prostate
In a study of 299 men characterized with indolent tumors and undergoing active surveillance, Klotz (2005) found that after eight years, the disease specific survival rate was 99% and that most men in the sample died of other causes.
For whom is active surveillance recommended?
- active surveillance [AS] has been supported in men
- Over the age of 65
- low grade and stage disease
- low and stable serum prostate specific antigen (PSA) levels.
- However, AS has been associated with illness uncertainty
- Used by about 10% of eligible patients
How often does PSA rise after local treatment?
May occur in 2/3 of patients treated with radical prostatectomy or radiation.
Health maintenance and promotion in Male GU cancer
- Penile Self-exams
- Testicular self-exams
- men > 50 years and men with family history of prostate cancer should check prostate specific antigen (PSA) for screening for prostate cancer {PSA can be elevated with inflammation also}
Some common prostate problems besides prostate cancer
- Benign prostate hyperplasia (BPH) enlargement of prostate secondary to change in sex hormones which causes urethral obstruction so decreased urine outflow & increased potential for urinary tract infection
- This is very common in men > 70 years
- Bacterial prostatitis
- Nonbacterial prostatitis
Clinical presentation of BPH
- As the gland enlarges, there is a resistance to urine flow
- Bladder muscle hypertrophies
- Emptying becomes incomplete
- Increase in residual urine
- Increase in chance of infection
- Sometimes bladder diverticula
- Acute urinary retention
- Painless hematuria
- Weak stream
- Straining
- Hesitancy
- Nocturia
- urgency
Significance of an AUA score
(IPSS)
- Incomplete emptying
- Frequency
- Nocturia
- Straining
- Weak system
- Hesitancy
- Interrupted stream
- AUA SCORE > 8 WARRANTS THERAPY for BPH/LUTS
How to diagnose BPH/LUTS
•Goroll, page 918 AUA symptom index. Use this screening tool to have
patient complete self assessment
- Obtain a urine, check for blood and or infection
- Would need to see urologist for post void amount. May not need to do
In primary care setting, ?? Cost of specialist
•Imaging, but then again, cost?
Medications to avoid in BPH/LUTS
watchful waiting
- Diuretics
- Anticholinergics
- Tricyclic antidepressants
- Watch over the counter meds
- Avoid stimulants before bed
Medications for BPH
- alpha-1-adrenergic antagonists to relax prostate and bladder muscle contractility - Tamsulosin (Flomax) ; terazosin (Hytrin)
- Hypotensive effects
- 5-alpha-reductase inhibitors to reduce size of prostate gland Finasteride (Proscar); dutasteride (Avodart)
- Erectile dysfunction
