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Renal > Prostate Diseases > Flashcards

Prostate Diseases Flashcards

1
Q

What are the sections of the prostate? [4]

Where are most prostate cancers found? [1]

A 
Mcneals Zones
 In --> Out
1) Transition Zone (wraps around urethra
2) Central zone
3) Peripheral Zone *
4) Ant Fibromuscular Stroma
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2
Q

What are the stages of prostate cancer? [4]

A

Localized
Locally Advanced
Metastatic
Hormone Refractory (i.e. resistant to castration)

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3
Q

Risk factors for Prostate Cancer [5]

A

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

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4
Q

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?

A

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

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5
Q

So a 65 yr old man presents with frequency, dysuria and slow to start urination. How would you confirm its prostate cancer? [2]

A

A digital Rectal Exam

Multiparametric MRI has replaced TRUS

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6
Q

What would point to cancer on DRE? [4]
How do you stage Prostate Cancer? [4]
What lab investigations would you order? [4]

A

Asymmetrical, nodular, craggy, hard

Prostate Specific Antigen (PSA)
*Multiparametric MRI
CT pelvis, chest/abdo
Bone scan

Testosterone, LFTs, FBC, U&E and creatinine

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7
Q

What can cause an elevated PSA? [7]

A

Upper limit increases with age

  • UTI
  • Chronic prostatits
  • Instruments e.g. catheter
  • Physiological e.g. ejaculation
  • Recent urological procedure
  • BPH!!
  • Prostate Cancer!!
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8
Q

Mx prostate cancer:
Indications for active surveillance vs watchful waiting [2]
Types: radical prostatectomy involve [3]
Complications [4]

Management for metastatic cancer [2]

A

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

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9
Q

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]

A

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

  1. External Beam RT
  2. Brachytherapy (radioactive material inserted directly into the site)
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10
Q

What are the major types of Hormone therapy? [4]

A

Surgical castration (Bilateral Orchidectomy)

Chemical Castration with LHRH analogue

Anti-androgens

Oestrogens

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11
Q

LHRH MOA [1]

What will you need to watch out for in the first week? [2]

A 
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
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12
Q

How do anti-androgens work? [1]

Give 2 examples

A
  1. Cyproterone acetate, flutamide

2. Inhibit androgen receptors on the Prostate

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13
Q

How do oestrogens treat prostate cancer? [3]

Give one example

A

Diethylboestrol

1) Inhibit LHRH & Testosterone secretion
2) Inactivate Androgens
3) Direct cytotoxic effect on prostatic epithelium

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14
Q 
TMN staging for prostate cancer. Describe:
Localised 
- cT1
- cT2
Locally advanced
- cT3
- cT4
A

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

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15
Q

Management for localized invasion and intermediate risk patients [4]

A

Radical prostatectomy
External beam RT
(+/-brachytherapy)
+/- hormonal therapy

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16
Q

Management for locally advanced cancers [2]

A

ERBT AND hormonal therapy OR

Radical prostatectomy AND ERBT AND hormonal therapy

17
Q

Castrate resistant management [3]

A

Maximal hormonal therapy
Steroids
Docetaxel

18
Q

Benign Prostatic Hyperplasia
Define [3]
Causative factors [3]

A

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
19
Q

Benign Prostatic Hyperplasia
Symptoms [4] Signs [1]
Risk factors [2]

A

Symptoms:

  • LUTS
  • Bladder outlet obstruction (BOO)
  • Urinary retention
  • Complicated UTI

Signs: smooth bilaterally enlarged prostate on DRE

Risk factors: >50yo, FMH

20
Q

BPH

Investigations

A

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
21
Q

Management
If main problem is voiding symptoms…
If main symptom is overactive bladder:

A

If main problem is voiding symptoms…

  1. Mild: behavior management
  2. Moderate to severe: medical management + TURP
  3. If unfit for surgery and refractory to tx: clean intermittent urethral or suprapubic catheterisation

If main symptom is overactive bladder:

  1. Moderate fluid intake, bladder re-training
  2. Antimuscarinic eg oxybutinin OD
  3. Beta-3 adrenergic agent MIRABEGRON
22
Q

Explain difference between urodynamic study vs uroflowmetry [2]

A

Urodynamic study measures bladder pressure & muscle activity during filling and voiding
Uroflowmetry measures peak urine flow rate which is impaired in BPH.

23
Q

Explain what the medical management for mod-severe voiding symptoms [4]

A
  • Alpha blockers (relax smooth muscle) eg Tamsulosin

- 5Alpha Reductase Inhibitors (reduces prostate size by metabolising testosterone) eg Finasteride

24
Q

How can a BPH be complicated? [5]

Side effect of Tamsulosin [1]
Side effects of 5AR inhibitors [2]

A 
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

25
Q

Bladder behavior management [3]

A

Fluid restriction
Bladder training on timed and complete voiding
Management of constipation

26
Q

Surgical mx BPH [2]

Indications [3]

How can we treat a complicated BPH if they’re not fit for TURP?

A

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)
27
Q 
Prostatitis
Ax [2] 
Name 2 causative organisms for each cause 
Classification [2]
Risk factor [2]
A

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
28
Q

Prostatitis
Symptoms [4]
Signs on acute [5] and chronic [1] infection

A

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

29
Q

Prostatitis Ix
Bacterial investigations and results [4]
Chronic non-bacterial clinical definition [3]

A

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)

30
Q

Prostatitis management for:
Acute bacterial [3]
Chronic bacterial [3]
Chronic non-bacterial [3]

A

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

Renal (29 decks)

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