Prostate disease

Question 1

Risk factors

Answer 1

Family history/ genetic

• Early onset= probably genetic
• BRCA2
• PCA3

Race
- Black men with highest risk

environmental
- Japanese migrate to America showed highest risk

Age
- Older age is strongest rick

Diet
- Lycopene (tomato), protective?

• Dairy protein and dairy calcium increases risk

Question 2

Screening guidelines

Answer 2

<55 with FH or black

55-69= informed decision to screen

Question 3

Pathology of prostate

Answer 3

Adenocarcinoma

- mainly affecting the peripheral zone

Question 4

Prostate cancer spread

• Local
• Lymph
• Bloo

Answer 4

Local

• Seminal vesicles
• Bladder
• Rectum

Lymph
- Para-aortic nodes

Blood
- Sclerotic one lesiosn

Question 5

Clinical assessment

Answer 5

DRE and PSA

Question 6

PSA

• Causes of decrease
• Causes of small increase
• Causes of significant increase

Answer 6

Decrease
- Finasteride, dutasteride (alpha reductase inhibitor)
= Decreases by 50%

Increase

• Ejaculation
• DRE

Significant increaae

• Age
• BPH
• UTI/ prostatitis
• UT instrumentation
• Urinary retension
• protate biopsy

Question 7

Diagnostic pathway

Answer 7

Elevated PSA

MP MRI

• Positive= Biopsy (transperineal)
• Negative= monitor PSA

Question 8

Treatment

• Local
• Locally advanced
• metastatic

Answer 8

Low risk

• Watchful waiting
• Active surveillance where tumour is observed and progression is treated
• Monitor via PSA, DRE, biopsies
• Localised disease= radical prostatectomy

Localised prostate tumour

• External beam radiation
• Brachytherapy (radiotherapy)
• Cryosurgery

Mets
- Palliative

Question 9

PSA

• Description
• Specificity and sensitivity

Answer 9

Proteolytic enzyme in ejaculate

Not very sensitive (70%) but specific for prostate

Question 10

Gleason grade

Answer 10

Grading for prostate Ca prognosis
- Based on microscopic appearance

Higher score= more aggressive Ca, worse prognosis
- 2-10

5-7 score are mainly treatable

8-10 are typically advanced, less likely to be cured

Question 11

Epidemiology

Answer 11

Typically affects older men

- 50+

Question 12

Pathology

Answer 12

Most common

• Adenocarcinoma (from glandular tissue that secrete semen)
• Commonly affects peripheral zone

Question 13

Prostatic intraepithelial neoplasia

Answer 13

Pre-malignant caricnoma

Carcinoma in situ, that is localised before developing into prostate adenocarcinoma.

Question 14

Loal Invasion of prostate cancer

Answer 14

Seminal vesicles

Peri-prostatic tissue
- Rectum

Bladder neck

Question 15

Prostate ca investigations

Answer 15

PSA and DRE are required first line

Testosterone
- Should be normal

Prostate needle biopsy
- Transrectal ultrasound guided (TRUS) or with MRI

Pelvic CT/ MRI
- Staging

Question 16

Signs and symptoms

Answer 16

Urinary retention

Dysuria

Question 17

Signs and symptoms

Answer 17

Urinary hesitancy/ frequency

Abnormal DRE

Dysuria

Nocturia

Question 18

Benign prostatic hyperplasia

• Definition
• Age incidence
• Complications

Answer 18

Non-malignant enlargement of prostate
- increase in stromal AND glandular tissue

Incidence
- 40-60 ys

Complications

• Urinary retention–> renal
• UTI
• LUTS
• Haematuria
• Overflow incontinence

Question 19

Examination of BPH

Answer 19

Smooth enlargement of prostate on DRE

PSA
- not elevated

Urine analysis

Consider

• Cystoscopy (bladder disease)
• USS if cancer suspected

Question 20

BPH treatment indications

Answer 20

LUTS

Question 21

BPH medical management

Answer 21

Alpha-antagonist

• Terazosin
• Relaxes muscle
• SE: postural hypotension

5-alpha reductase inhibitors

• Finasteride
• Blocks testosterone conversion to DHT
• SE: reduced libido, erectile dysfunction.

Question 22

BPH surgical management

Answer 22

Indicated in those not responding to medical therapy/ has complications

Transurethral resection of prostate (TURP)