Prostate Pathology Flashcards
What age group is benign prostate disease more common?
>50 incidence increases with age
How does benign prostatic hyperplasia present?
Hesitancy
Urgency/urge incontinence
Frequency
Intermittency
Straining to void/poor stream
Terminal dribbling
Incomplete emptying
Enlarged prostate on DRE
What investigations are used in benign prostate disease diagnosis?
Urine dipstick/urinalysis
- Exclude infection
PSA
- Exclude prostate cancer
U&E
TRUS-Guided Prostate Biopsy
- If raised PSA or abnormal digital rectal examination
What is the conservative management of benign prostate disease?
Watchful waiting
Avoid caffeinated, sugary drinks, evening fluids
What is the medical management of benign prostate disease?
Alpha Blockers
5 Alpha Reductase Inhibitors
What is the mechanism of action of alpha blockers?
Decrease smooth muscle tone/relax muscle
Name examples of alpha blockers
Tamsulosin 400mcg once daily
Alfuzosin
Give adverse effects of alpha blockers
Dizziness
Postural hypotension
Dry mouth
Depression
What is the mechanism of action of 5 Alpha Reductase Inhibitors?
Converts testosterone to dihydrotestosterone and reduces size of prostate
Name examples of 5 Alpha Reductase Inhibitors
Finasteride
Dutasteride
Give adverse effects of 5 Alpha Reductase Inhibitors
Erectile dysfunction
Reduced libido
Ejaculation problems
Gynaecomastia
How long do 5 Alpha Reductase Inhibitors take to work?
Up to 6 months
Give risk factors for developing TURP syndrome
Surgical time > 1 hr
Height of bag > 70cm
Resected > 60g
Large blood loss
Perforation
Large amount of fluid used
Poorly controlled CHF
Describe TURP
Involves accessing the prostate through the urethra and ‘shaving’ off prostate tissue from inside using diathermy, in order to create a wider space for urine to flow through, thereby improving symptoms
Give complications of TURP
FIRES
Failure to revolve symptoms
Incontinence
Infection
Retrograde ejaculation
Erectile dysfunction
(Urethral) strictures
TURP syndrome
Name complications of benign prostate disease
Bladder outflow obstruction
Acute urinary retention
Overflow incontinence
Acute renal failure
Bladder stones
Recurrent UTI
What is TURP syndrome?
Rare and life-threatening complication of TURP caused by irrigation with large volumes of glycine, which is systemically absorbed when prostatic venous sinuses are opened up during prostate resection.
This results in hyponatremia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.
What is the surgical managemet of benign prostate disease?
Transurethral resection of the prostate (TURP)
Transurethral electrovaporisation of the prostate (TUVP)
Holmium laser enucleation of the prostate (HoLEP)
Open prostatectomy via abdominal or perineal incision
What is the International Prostate Symptom Score Sheet?
Classifies symptoms out of 35
What score is mild prostate symptoms?
0-7
What score is moderate prostate symptoms?
8-19
What score is severe prostate symptoms?
>20
Describe category 1 prostatitis
Acute infection of the prostate
Describe category 2 prostatitis
Chronic infection of the prostate
Describe category 3 prostatitis
Chronic pelvic pain syndrome, without infection but with or without inflammation
Describe category 4 prostatitis
Asymptomatic inflammatory prostatitis after TURP/prostate biopsy
What pathogens can cause prostatitis?
E-coli
Pseudomonas
Klebsiella
What pathogen is the most common cause of prostatitis?
E coli
Give risk factors for prostatitis
Recent UTI
Urogenital instrumentation
Intermittent bladder catheterisation
Recent prostate biopsy
How does prostatitis present?
Pelvic, urethral, perineal or rectal pain
Frequency
Urgency
Sepsis and urinary retention if category 1
Fever and rigors
Tender, boggy prostate on examination
How is prostatitis managed?
14 day course of quinolone, such as ciprofloxacin
How common is prostate cancer?
Most common cancer in adult males in the UK and is the second most common cause of death due to cancer in men after lung cancer
What are the risk factors for prostate cancer?
Increasing age
Afro-Caribbean ethnicity
Obesity
FH
Diet
Steroids
What is the most common histological type of prostate cancer?
95% adenocarcinoma
How does prostate cancer present?
Mainly asymptomatic
Weak stream
Hesitancy
Sensation of incomplete emptying
Frequency
Urgency/urge incontinence
UTI
Haematuria and Haemospermia
Perineal and Suprapubic pain
Impotence
Incontinence
Loin pain
Bone pain
Weight loss
Paraplegia
Lymph node enlargement
Lymphedema
What investigations are used in prostate cancer diagnosis?
Opportunistic Prostate Specific Antigen Testing (PSA)
Digital rectal examination
- A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular with loss of the central sulcus
Trans-rectal US (TRUS) and biopsy
Multiparametric MRI
What is a normal PSA level?
0-4.0ug/ml
What can cause a rise in PSA other than prostate cancer?
Prostatitis
UTI
BPH
Vigorous DRE
Ejaculation
Exercise
What is the gold standard investigation for prostate cancer?
Multiparametric MRI
What staging is used for prostate cancer?
Gleason staging
How is localised prostate cancer managed?
Active surveillance, monitor PSA and treat if rises
How is localised advanced prostate cancer managed?
Radiotherapy/Brachytherapy
Radical Prostatectomy
Hormonal therapy
How is metastatic prostate cancer managed?
Hormonal therapy
Give adverse effects of radiotherapy for prostate cancer
Radiation proctitis
Rectal, bladder and colon malignancy
Give adverse effects of radical prostatectomy
Erectile dysfunction
Incontinence
Give adverse effects of hormonal therapy
Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis
What is used in hormonal therapy?
GnRH agonists
- Goserelin
GnRH antagonists
- Degarelix
Testosterone antagonists
- Flutamide
- Bicalutamide
What time frame should psa not be done within?
6 weeks of a prostate biopsy
4 weeks following a proven urinary infection/prostatitis
1 week of digital rectal examination
48 hours of vigorous exercise
48 hours of ejaculation
What should be prescribed with GnRH agnosist in prostate cancer management?
Anti-androgen treatment such as cyproterone acetate or flutamide should be co-prescribed 3 day before starting gonadorelin analogues due to the risk of initial symptom/tumour flare
What is the most common site of bone metastases?
in descending order
Spine
Pelvis
Ribs
Skull
Long bones
