Prostate Pathology Flashcards by Shauneen Kiernan

What age group is benign prostate disease more common?

>50 incidence increases with age

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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

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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

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What is the conservative management of benign prostate disease?

Watchful waiting

Avoid caffeinated, sugary drinks, evening fluids

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What is the medical management of benign prostate disease?

Alpha Blockers

5 Alpha Reductase Inhibitors

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What is the mechanism of action of alpha blockers?

Decrease smooth muscle tone/relax muscle

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Name examples of alpha blockers

Tamsulosin 400mcg once daily

Alfuzosin

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Give adverse effects of alpha blockers

Dizziness

Postural hypotension

Dry mouth

Depression

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What is the mechanism of action of 5 Alpha Reductase Inhibitors?

Converts testosterone to dihydrotestosterone and reduces size of prostate

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Name examples of 5 Alpha Reductase Inhibitors

Finasteride

Dutasteride

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Give adverse effects of 5 Alpha Reductase Inhibitors

Erectile dysfunction

Reduced libido

Ejaculation problems

Gynaecomastia

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How long do 5 Alpha Reductase Inhibitors take to work?

Up to 6 months

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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

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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

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Give complications of TURP

FIRES

Failure to revolve symptoms

Incontinence

Infection

Retrograde ejaculation

Erectile dysfunction

(Urethral) strictures

TURP syndrome

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Name complications of benign prostate disease

Bladder outflow obstruction

Acute urinary retention

Overflow incontinence

Acute renal failure

Bladder stones

Recurrent UTI

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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.

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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

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What is the International Prostate Symptom Score Sheet?

Classifies symptoms out of 35

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What score is mild prostate symptoms?

0-7

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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