Prostate Disease

Question 1

What is the pathology of BPH?

Answer 1

Benign nodular or diffuse proliferation of musculofibrous and glandular layers of the prostate. Inner (transitional) zone enlarges in contrast to peripheral layer expansion seen in prostate carcinoma.

Question 2

What are the symptoms of BPH?

Answer 2

Lower urinary tract symptoms (LUTS) = nocturia, frequency, urgency, post-micturition dribbling, poor stream/flow, hesitancy, overflow incontinence, haematuria, bladder stones, UTI

Question 3

How is BPH initially investigated? (2)

Answer 3

Assess severity of symptoms, DRE

Question 4

What tests and imaging are carried out in BPH?

Answer 4

MSU; U&E; ultrasound, PSA (prior to PR exam), transrectal US ± fine needle aspiration biopsy

Question 5

How is BPH managed?

Answer 5

Lifestyle - Avoid caffeine, alcohol (to urgency/nocturia). Relax when voiding. Void twice in a row to aid emptying. Control urgency by practising distraction methods (eg breathing exercises). Train the bladder by ‘holding on’ to increase time between voiding.

Question 6

What medications can be used in BPH?

Answer 6

Tamsulosin 400mcg/d (alpha blocker)

Finasteride 5mg/d PO (5alpha-reductase inhibitor)

Question 7

What is are surgical interventions used in BPH?

Answer 7

transurethral resection of the prostate (TURP), Transurethral incision of the prostate (TUIP), retropubic prostatectomy

Question 8

What are the signs and symptoms of prostate cancer?

Answer 8

Asymptomatic or nocturia, hesitancy, poor stream, terminal dribbling, or obstruction. Decreased Weight ± bone pain suggests mets.

DRE exam - hard, iregular prostate

Question 9

How is prostate cancer diagnosed?

Answer 9

Increased PSA, transrectal US and biospy, bone scan, CT/MRI

Question 10

How is prostate cancer staged?

Answer 10

Using an MRI

Question 11

What is the gleason score?

Answer 11

Gleason grades (1-5) are decided by analysing histology from two separate areas of tumour specimen, and adding them to get the total Gleason score for the tumour, from 2 to 10. Scores 8–10 suggest an aggressive tumour; 5–7: intermediate; 2–4: indolent

Question 12

What are the management options for low-risk patients?

Answer 12

‘active surveillance’ with PSA tests every 3 months for the first year. Can remove his prostate fully using a Da Vinci surgical robot or refer for radiotherapy

Question 13

How is prostate cancer treated?

Answer 13

1) Radical prostatetcomy
2) radical radiotherapy ± hormonal therapy
3) Hormone therapy - in elderly/high risk

Active surveillane - >70 yrs and low risk

Metastatic disease - hormonal drugs

Question 14

What are the prognostic factors in prostate cancer?

Answer 14

Pre-treatment PSA level, tumour stage (TNM), tumour grade (gleason score)

Question 15

How long should you wait to do PSA after ejaculation or vigorous exercise?

Answer 15

48 hours

Question 16

How long should you wait to do a PSA after a DRE?

Answer 16

1 week

Question 17

What is the best initial management for a 70 year old man who presents with a 6 month history of poor urinary flow and increased nocturnal urinary frequency and who has an IPSS score of 12 and a quality of life score of 4? He has a small, benign feeling prostate, a PSA of 3.5 ng/ml normal U+E and a clinically empty bladder

Answer 17

Tamsulosin (alpha-adrenergic blocker)

Question 18

What is the scoring system used to asses prostate symptoms?

Answer 18

International Prostate Symptom Score (IPSS)

Question 19

What is the management options for high-risk patients?

Answer 19

radical prostatectomy or radical radiotherapy