Prostate Flashcards
Prostate cancer presentation
rarely symptomatic
PSA & DRE detection
large/extensive - obs
metastasize to bones: back pain
BPH symptoms
obs: hesitancy, decreased force of stream, incomplete voiding, straining, post void dribbling
- can be dynamic or mechanical
irritative: frequency, urgency, nocturia
- response of bladder to increased resistance - detrusor hyperplasia & hypertrophy, collagen deposition
Prostatitis Sx
dysuria frequency urgency fever chills malaise perineal/back/rectal pain
DDx of prostatic nodules
Malignancy ~25% BPH (most common) calculus (very common) Infarction cyst tuberculous/chronic granulomatous previous TURP-biopsy scar
Screening for prostate cancer
early asymptomatic, detected by PSA
DRE - usually detect more advanced (>T2)
PSA screening guideline
Not recommended unless risk factors present, or monitoring rise after age >50
Risk factors: African-Am, fam Hx (1st degree), age ( >55 normal, >50 risk), previous abnormal biopsy
Prostate CA can also present with low PSA
elevated in infection, BPH, inflammation, manipulation of prostate - need to wait 2 weeks after DRE
PSA level
worry when >4
>10 high risk for cancer
velocity rise >0.75/yr
BPH assessment
US for bladder, kidney assessment
PE for prostate
catheterization
Congenital abnormality assessment
UPJ, posterior urethral valves
US first line for children
Anuria with rising creatinine assessment
differentiate btw surgical vs medical renal failure
surgical: obs of both kidneys, bladder obs due to BPH, bladder cancer, urethral stricture
US and catheritization
Sepsis, UT obs assessment
catheterization
cultures , electrolytes, creatinine
US for hydronephrosis
drainage via retrograde stent or pc nephrostomy
Terazosin/Doxasozin
fast alpha1 blocker (selective)
SE: dizziness, fatigue, rhinorrhea, ED
Tamsulosin, alfuzosin, silodosin
alpha1 subtype A selective less SEs than other alpha blockers retrograde ejaculation (Tamsulosin), orthostatic hypotension
alpha blocker for BPH
All similar in efficacy
SEs; CV problems, dizziness, ejaculatory
safe in elderly
need to titrate with anti-HTN meds
subtype A selective meds do not require titration
interaction with PDE5is - mild hypotension, not a concern with selective blockers
long-term use: prostate continues to grow, most grow resistant
5-alpha reductase inhibitors
Blocks prostate growth fueled by DHT
blocks testosterone –> DHT
slower onset of action than alpha blockers
Dutasteride - blocks both
Finasteride - blocks type II - reduce incidence of AUR in surgery in men with large prostate
Prostate CA risk: 25% reduction in dx of low risk cancers
high risk cancers detected more readily
Combination therapy for BPH
alpha blockers + 5-alpha reductase inhibitors
reduce risk of AUR
decrease cumulative incidence of BPH
reduce BPH-related surgery (mostly finasteride)
may also combine with anticholinergics, PDE5is
Indications: men with BPH AND:
- LUTS
- elevated prostate volume (>30cc)
- elevated PSA (>1.4)
- moderate-severe bother
PDE5i
relax smooth muscle
decrease symptoms, no effect on flow
SEs: erections
Anticholinergics - BPH
relax bladder muscle (helpful after removing obs)
decrease symptoms, no effect on flow
Minimally invasive surgery for BPH
botox, alcohol injections
photodynamic surgery (reduce blood supply)
microwave heat
radiowave ablation
TURP
GOLD STANDARD
3-6 weeks of recovery - hematuria, painful urination
Early risks: retrograde ejaculation (70%) transfusion for hematuria (10%) injury - rare prolonged retention (10%) infection, incontinence rare prolonged hematuria obs loss of erection
Late risks:
10-15% will need TURP again in 10-15 yrs
Open prostatectomy
Indications: urinary retention refractory to treatment recurrent UTI renal compromise hematuria bladder stones
Dx of prostate cancer
abnormal PSA/DRE –> biopsy
indications: suspicious DRE, abnormal PSA (>4 or increasing >0.75/y)
10 core sampling
Gleason score & grading (2-6 low, 7 intermediate, 8-10 high risk)
trans-rectal US not specific/sensitive enough (CA often mutlifocal & heterogenous) - use in guide for biopsy, estimate size for BPH
Staging of prostate cancer
PSA
Bone scan - only high risk/bone pain
CT - only high risk
high risk: PSA > 20, Gleason score 8-10, T3
TNM for prostate ca
T1 a/b - TURP only, c - biopsy
T2: palpable on DRE and confined to gland
T3: palpable beyond prostate
T4: well beyond prostate
Tx for prostate cancer
Goal: active surveillance Gleason 2-6 , low risk, Stage up to T2a
Surgery: radical prostatectomy
radiotherapy
watchful waiting
hormonal therapy
Radical prostatectomy
Retropubic: minimal post-op morbidity, no spinal/epidural required
Perineal: obese, other contraindications, higher rates of adverse outcomes
Complications of surgery
Intraoperative - bleeding, dmg to obturator, rectal injury, dmg to ureters and seminal
Postoperative - incontinence, ED - want to spare Neurovascular bundles of Walsh (2 spared - 50-60% erections, 1 spared - 20%)
Radiation therapy for prostate CA
localized
Internal: brachytherapy - radiation source into prostate (low risk)
External: IMRT and proton beams - high risk patients, beams of radiation aimed at tumour location, effects on adjacent tissues (effect on bladder and rectum)
Active surveillance for prostate CA
localized cancer, low risk
periodic DRE and PSA measurements, repeat biopsies
Hormonal therapy for prostate CA
Standard in localized advanced and metastatic
adjuvant with radiation possible
after failure of radiotherapy
Bilateral orchiectomy
GnRH analogues - initial surge in testosterone but downregulation of GnRH receptors on pituitary surface, reduction in LH, reduction in testosterone
GnRH antagonists - block GnRH receptor on pituitary - no testosterone flare
Progestational/estrogenic agonists - severe side effect profile (CV, thrombosis, feminization)
Anti-androgens: competitive inhibition of androgen receptor, not used as monotherapy, combine wiht GnRH analogue to prevent flare
Castration resistance
prostate develops ability to grow even without testosterone
Chemotherapy for prostate CA
Docetaxel (taxel)
standard therapy used in hormone resistant tumours that are metastatic
