Prostate Diseases Flashcards
What are the sections of the prostate? [4]
Where are most prostate cancers found? [1]
Mcneals Zones In --> Out 1) Transition Zone (wraps around urethra 2) Central zone 3) Peripheral Zone * 4) Ant Fibromuscular Stroma
What are the stages of prostate cancer? [4]
Localized
Locally Advanced
Metastatic
Hormone Refractory (i.e. resistant to castration)
Risk factors for Prostate Cancer [5]
1) Age
2) African/Afro-carribean or Caucasian
3) FH
4) High fat/processed carb diet
5) Some Drugs actually reduce risk e.g. Finasteride
Presentation of Prostate Ca
Describe the most common symptoms [2]
Describe symptoms of local invasion [6]
Describe metastatic symptoms [6]
What is the precursor of prostate cancer called?
LUTS, UTI
Local invasion:
- Hematuria, haemospermia, perineal suprapubic pain, incontinence, renal failure, tenesmus, acute/chronic urinary obstruction
Metastatic invasion:
- weight loss, lethargy, bone pain, spinal cord compression, lymphedema, ureteric obstruction by lymph nodes
Precursor is high grade prostatic intraepithelial neoplasia
So a 65 yr old man presents with frequency, dysuria and slow to start urination. How would you confirm its prostate cancer? [2]
A digital Rectal Exam
Multiparametric MRI has replaced TRUS
What would point to cancer on DRE? [4]
How do you stage Prostate Cancer? [4]
What lab investigations would you order? [4]
Asymmetrical, nodular, craggy, hard
Prostate Specific Antigen (PSA)
*Multiparametric MRI
CT pelvis, chest/abdo
Bone scan
Testosterone, LFTs, FBC, U&E and creatinine
What can cause an elevated PSA? [7]
Upper limit increases with age
- UTI
- Chronic prostatits
- Instruments e.g. catheter
- Physiological e.g. ejaculation
- Recent urological procedure
- BPH!!
- Prostate Cancer!!
Mx prostate cancer:
Indications for active surveillance vs watchful waiting [2]
Types: radical prostatectomy involve [3]
Complications [4]
Management for metastatic cancer [2]
Multiple comorbs or elderly > watchful waiting
Localised cancer and low risk
- Active surveillance
Open
Laparoscopic
Robotic
Bleeding
Urinary incontinence
Urinary stricture
Erectile dysfunction
Metastatic cancer: Hormone Therapy +/- chemo
Outline management for localized cancer and low risk [3]
What is deemed ‘low risk’? [3]
What is deemed intermediate risk? [3]
Types of RT for prostate cancer? [2]
Localised cancer and low risk
- Active surveillance
- Radical prostatectomy
- External beam RT or brachytherapy
Low risk if PSA <10, GS<6 AND T1-2a
Intermediate risk: PSA 10-20, GS7 OR T2b
- External Beam RT
- Brachytherapy (radioactive material inserted directly into the site)
What are the major types of Hormone therapy? [4]
Surgical castration (Bilateral Orchidectomy)
Chemical Castration with LHRH analogue
Anti-androgens
Oestrogens
LHRH MOA [1]
What will you need to watch out for in the first week? [2]
LHRH analogue (e.g. GOSERELIN) downregulates androgen receptors by -ve feedback. It causes the tumour to flare in the first wk (initial increase in LH) so you need combined anti-androgens
How do anti-androgens work? [1]
Give 2 examples
- Cyproterone acetate, flutamide
2. Inhibit androgen receptors on the Prostate
How do oestrogens treat prostate cancer? [3]
Give one example
Diethylboestrol
1) Inhibit LHRH & Testosterone secretion
2) Inactivate Androgens
3) Direct cytotoxic effect on prostatic epithelium
TMN staging for prostate cancer. Describe: Localised - cT1 - cT2 Locally advanced - cT3 - cT4
Localised
- cT1: clinically impalpable
- cT2: palpable tumor confined within prostate
Locally advanced
- cT3: extra prostatic tumor not fixed, doesn’t invade adj structure
- cT4: tumor invades other adjacent structures
Management for localized invasion and intermediate risk patients [4]
Radical prostatectomy
External beam RT
(+/-brachytherapy)
+/- hormonal therapy
Management for locally advanced cancers [2]
ERBT AND hormonal therapy OR
Radical prostatectomy AND ERBT AND hormonal therapy
Castrate resistant management [3]
Maximal hormonal therapy
Steroids
Docetaxel
Benign Prostatic Hyperplasia
Define [3]
Causative factors [3]
Define: Hyperplasia of epithelial and stromal compartments particularly in transition zone affecting elderly men
Causative factors:
- Age related hormonal changes
- Increased prostatic stem cells
- Changes in stomal-epithelial interactions
Benign Prostatic Hyperplasia
Symptoms [4] Signs [1]
Risk factors [2]
Symptoms:
- LUTS
- Bladder outlet obstruction (BOO)
- Urinary retention
- Complicated UTI
Signs: smooth bilaterally enlarged prostate on DRE
Risk factors: >50yo, FMH
BPH
Investigations
Ix:
- Urinalysis to check for pyuria and hematuria
- PSA
- Scoring (Intl Prostatic Symptom Score)
- Volume charting (polyuria, ddx irritable bladder)
- USS/CT
- Urodynamic study & uroflowmetry
Management
If main problem is voiding symptoms…
If main symptom is overactive bladder:
If main problem is voiding symptoms…
- Mild: behavior management
- Moderate to severe: medical management + TURP
- If unfit for surgery and refractory to tx: clean intermittent urethral or suprapubic catheterisation
If main symptom is overactive bladder:
- Moderate fluid intake, bladder re-training
- Antimuscarinic eg oxybutinin OD
- Beta-3 adrenergic agent MIRABEGRON
Explain difference between urodynamic study vs uroflowmetry [2]
Urodynamic study measures bladder pressure & muscle activity during filling and voiding
Uroflowmetry measures peak urine flow rate which is impaired in BPH.
Explain what the medical management for mod-severe voiding symptoms [4]
- Alpha blockers (relax smooth muscle) eg Tamsulosin
- 5Alpha Reductase Inhibitors (reduces prostate size by metabolising testosterone) eg Finasteride
How can a BPH be complicated? [5]
Side effect of Tamsulosin [1]
Side effects of 5AR inhibitors [2]
Acute or chronic urinary retention Urinary Incontinence UTI Bladder Stone Renal Failure (due to hydronephrosis)
SE tamsulosin: ED
SE 5AR inhibitor: 25% prostate ca risk, ED
Bladder behavior management [3]
Fluid restriction
Bladder training on timed and complete voiding
Management of constipation
Surgical mx BPH [2]
Indications [3]
How can we treat a complicated BPH if they’re not fit for TURP?
Surgical management of BPH:
- TURP (Transurethral Resection of URethra)
- Open Prostatectomy (If >100cc)
Indications for TURP:
- Patient choice, refractory to medical mx
- Complications assoc with bPH
- Prostate >80g
Unfit for surgery [2]
- Long term urethral catheter
- CISC (clean intermittent self Catheterisation)
Prostatitis Ax [2] Name 2 causative organisms for each cause Classification [2] Risk factor [2]
Ax:
• UTI: E. coli, proteus, Enterobacter
• STI: Neisseria gonorrhoea, chlamydia trachomatis
Classification:
Acute bacterial, chronic bacterial
Chronic non-bacterial prostatitis (CPPS) (a = with inflammation, b = without inflammation), asymptomatic inflammation
RF:
- recent UTI or STI
- urogenital instrumentation, intermittent catheterisation, recent prostate biopsy
Prostatitis
Symptoms [4]
Signs on acute [5] and chronic [1] infection
Symptoms:
- fever, malaise, arthralgia, myalgia
- frequency, urgency, dysuria, nocturia, hesitancy, incomplete voiding
- low back or abdo pain, perineal or urethral pain, painful ejaculation
- premature ejaculation, urethral discharge
Signs:
• Acute: tender, warm and boggy swelling on DRE, inguinal lymphadenopathy, systemic infection
• Chronic: normal or hard from calcification
Prostatitis Ix
Bacterial investigations and results [4]
Chronic non-bacterial clinical definition [3]
Ix:
• Bacterial:
- urinalysis (pyuria)
- microscopy (WCC and bacterial count with oval fat bodies and lipid laden macrophages)
- culture (+ FBC, U&E and creatinine and blood cultures if septic)
• Chronic non-bacterial: symptoms for >3m with -ve culture of urine and prostatic fluid (leukocytes in inflammatory type)
Prostatitis management for:
Acute bacterial [3]
Chronic bacterial [3]
Chronic non-bacterial [3]
Mx:
• Acute bacterial: quinolone (CIPROFLOXACIN) or TRIMETHOPRIM for 4w, ix of urinary tract when resolved to excl. structural abnormalities
• Chronic bacterial: CIPROFLOXACIN or TRIMETHOPRIM for 4-6w
• Chronic non-bacterial: PARACETAMOL, NSAIDs and stress mx
