Prostate Problems Flashcards
What are the clinical features of BPH?
LUTS –> both voiding and storage symptoms
Less commonly:
- haematuria
- haematospermia
On digital rectal exam (DRE):
- firm, smooth, symmetrical prostate
What is the International Prostate Symptom Score?
Questionnaire completed by every patient presenting with likely prostate symptoms
Validated screening tool to evaluate + quantify LUTS
What investigations should be done for suspected BPH?
Urinary frequency + volume chart Urinalysis Post-void bladder scan (chronic retention) Depending on DRE findings --> PSA USS or renal tract
What are you looking for on USS in suspected BPH?
Volume of prostate (>30ml deemed enlarged)
Look for urinary retention or hydronephrosis
What are the management options for BPH?
If asymptomatic --> reassure, no treatment required Medication review Lifestyle advice Medical management Surgical management
What are the medical management options for BPH?
Initial trial of alpha-blocker –> Tamsulosin
If unsuccessful –> 5 alpha-reductase inhibitor e.g. Finasteride
How quickly do alpha blockers work and what are the side effects?
Provide symptomatic benefit within a few days Side effects: - postural hypotension - retrograde ejaculation - Floppy Iris Syndrome
How quickly does finasteride work?
Can take up to 6 months to see symptomatic benefit
When would surgical management be considered for BPH?
Refractory to medical management
Complications e.g. high pressure retention
Which surgical procedure is most commonly used for BPH?
Transurethral resection of the prostate (TURP)
What are the complications of TURP?
Haemorrhage
Sexual dysfunction
Retrograde ejaculation
Urethral stricture
TURP syndrome
What is TURP syndrome?
Rare but life threatening complication of TURP
- -> significant fluid overload + hyponatraemia
- confusion, nausea, agitation or visual changes
What is the main complication of BPH?
High pressure urinary retention –> post renal kidney injury
What is the main type of prostate cancer and where does it occur?
Adenocarcinoma (acinar type)
Usually arises in the peripheral zone of the prostate
What are the symptoms associated with prostate cancer?
Localised disease --> LUTS Advanced localised disease: - haematuria - dysuria - incontinence - haematospermia - suprapubic or loin pain - rectal tenesmus Metastatic disease: - bone pain - lethargy - anorexia - weight loss
What might be felt on DRE in prostate cancer?
Asymmetry
Nodularity
Fixed, irregular mass
What might cause PSA to be artificially raised?
BPH Prostatitis Vigorous exercise Ejaculation Recent DRE
How is prostate cancer diagnosed?
Biopsies of prostatic tissue, two possible methods:
- transperineal (template) biopsy
- transrectal US-guided (TRUS) biopsy
What are the advantages/disadvantages of transperineal biopsy?
Done as a day case under GA
Better access to anterior prostate
Lower risk of infection
What are the advantages/disdvantages of TRUS biopsy?
Done under local anaesthetic
1-2% risk of sepsis
How is a prostate biopsy graded?
Gleason Grading System (based on histological appearance)
- assigned score according to differentiation
- sum of most common growth pattern + second most common growth pattern e.g. 3 + 3
Which modes of imaging are used in prostate cancer?
Multi-parametric MRI can be used to aid in the diagnosis
Staging:
- CT abdo pelvis
- bone scan
How are prostate cancer risk stratified in order to guide treatment?
Combination of:
- PSA
- Gleason score
- Clinical stage of tumour
What are the management options for prostate cancer?
Watchful waiting Active surveillance Surgical management Radiotherapy Chemotherapy + anti-androgen therapy
Which patients would be suitable for watchful waiting in the management of prostate cancer?
Older patient with lower life expectancy
Who would would suitable for active surveillance of prostate cancer and what does it involve?
Low risk disease Monitoring: - 3 monthly PSA - 6 monthly-yearly DRE - re-biopsy at 1-3 yearly intervals (intervene at appropriate time)
What is the surgical management of prostate cancer?
Radical prostatectomy
- removal of prostate gland, seminal vesicles, surrounding tissue +/- pelvic lymph nodes
What are the side effects of prostatectomy?
Erectile dysfunction (60-90%)
Strep incontinence
Bladder neck stenosis
When is radiotherapy used in the management of prostate cancer?
Alternative form of curative intervention for localised prostate cancer
- external beam RT or brachytherapy
When is chemotherapy + anti-androgen therapy indicated for treatment of prostate cancer?
Metastatic disease
What causes acute bacterial prostatitis?
Usually ascending urethral infection
- E. coli most common, other enteric organisms
- STIs are a rarer cause
What are the risk factors for prostatitis?
Indwelling catheters
Phimosis or urethral stricture
Recent surgery e.g. cystoscopy or transrectal prostate biopsy
Immunocompromised
What are the symptoms of acute prostatitis?
LUTS
Systemic infection e.g. pyrexia
Perineal or suprapubic pain
Urethral discharge
What might be found on examination of a patient with prostatitis?
DRE: very tender + boggy prostate
Inguinal lymphadenopathy
Which investigations should be done for prostatitis?
Urine culture –> will guide antibiotics
STI screen + routine bloods
If failed response to antibiotics:
- transrectal prostatic US or CT to rule out abscess
What is the management for prostatitis?
Prolonged antibiotic therapy
- usually quinolone as good penetration into prostate
Analgesia - paracetamol + NSAIDs
