Prostate Flashcards
What is a mobile rectal overlying mucosa on DRE a sign of
Rectal pathology eg ulceration.
Signs of prostate cancer on DRE (5)
Organ- confined disease = BPH clinically, with nodule/hard area palpable in one or both lobes.
Advanced disease = enlarged, hard, irregular, edge poorly defined (extracapsular spread ), overlying rectal mucosa intact.
How do and interpret IPSS (international prostate symptom score)?
FUNWISE •Frequency • urgency • Nocturia • weak stream • intermittency • straining • emptying incomplete
• each symptom graded 0-5 (1-less than 1/5 of time, 2 = less than half, 3 = half, 4 = more than half, 5= almost always )
• 0-7 = mildly symptomatic, manage with watchful waiting and lifestyle modifications.
. 8-19= moderately, medical treatment
• 20-35 = severe, medical and surgical treatment
• screen for BPH
Normal PSA by age?
- 40-50: < 2,5
- 50-60: < 3,5
- 60-70: < 4,5
- > 70: <5,5
Function of PSA?
Liquefaction of ejaculate coagulate to facilitate sperm penetration of ovum
Name 10 causes raised PSA
- prostate cancer
- BPH
- prostatitis
- urinary retention,
- after procedures on prostate (biopsy, prostate surgery )
- prostatic ischaemia/infarction
- prostatic massage (not significant)
- urethral catheter
- cystoscope, TRUS
- strenuous exercise
- perineal trauma
- ejaculation
- acute renal failure
- coronary bypass graft
- radiation therapy
Which PSA level is an indication for prostate biopsy?
> 4 ng/ml
What is free - to-total PSA and what is it used for?
Unbound PSA: bound to macroglobulins
<15%= high risk carcinoma
> 25% = low risk
What PSA level has a 50% risk of prostate cancer on biopsy?
> 10 ng/ml
How can PSA predict cancer metastasis?
- <10 = chance of spread remote
* >100 = metastatic
How can PSA monitor response to treatment?
- After radical prostatectomy, serum PSA should be undetectable <0,01 ng/ml. if not, residual disease
- rapid drop PSA after androgen deprivation therapy for advanced prostate cancer suggests hormone sensitive tumour
Treatment for mild BPH IPSS 0-7?
Expectant active surveillance: annual kidney function tests and ultra sound.
In 5 years 50.% will remain the same, 25.% improve, 25% worsen
Treatment symptomatic BPH without complications? (8)
• Alpha adrenergic blockers: (relax smooth muscle) (pts with small prostate <30 g where anatomical or epithelial component obstruction less. 70% good response)
- prazosin (cheap but more side effects) (minipress!)
- Long acting: tamsulosin (selective alpha 1a receptor) ( flomax! ), doxazosin (cardura!), terazosin, alfuzosin (selective)
• 5 alpha reductase inhibitors (reduce prostate size) (large prostates > 50 g where there’s a larger epithelial component and PSA > 2.5)
- finasteride
- dutasteride
Monotherapy with alpha blocker if IPSS <20, combination if >20 (severe)
• antimuscarinics eg oxybutinin, or b3 agonist eg mirabegron (storage LUTS without elevated PVR)
.Pde5 inhibitors (ED, storage and voiding luts) eg vardenafil
• desmopressin (luts with nocturia) (risk hyponatraemia elderly)
Treatment acute urinary retention? (4)
- initial catheterisation
- removal or treatment precipitating cause
- start alpha blocker eg doxazosin
- remove catheter 5 days later: trial without catheter
Name 8 indications for surgery in BPH
Absolute
• renal failure with obstructive uropathy
• refractory urinary retention
Relative
• recurrent haematuria due to BPH refractory to medical treatment
• severe symptoms unresponsive to medical therapies
• medical treatment contraindicated: severe cardiac or cerebrovascular disease
• renal insufficiency and other complications bladder outflow obstruction
• previous prostatic surgery
• bladder stones
