Prostate swellings Flashcards
Benign nodular hyperplasia:
- AKA
- what is the pathology?
- What is the pathophysiology
AKA benign prostatic hyperplasia
Pathology: irregular proliferation of both glandular and stromal prostatic tissue
Pathophysiology: hormonal imbalance causes alteration of androgen/oestrogen causing proliferation of peri-urethral (central) prostatic tissue as this is oestrogen responsive
= disturbance of bladder sphincter mechanism by physical obstruction and by physiological interference of peri-urethral gland at the internal urethral meatus
What are the -symptoms -complications -management of BPH?
Symptoms: prostatism
-voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal dribbling and incomplete emptying
-storage symptoms (irritative) urgency, frequency, urgency incontinence and nocturia
-post-micturition: dribbling
= acute and chronic urinary retention
Complications:
- bladder hypertrophy = diverticulum formation
- if left untreated can lead to hydroureter, hydronephrosis, infection but NOT pre-malignant
Management:
-watchful waiting
-1st line Alpha blockers (tamsulosin):
decrease smooth muscle tone (prostate and bladder)
considered first-line, improve symptoms in around 70% of men
adverse effects: dizziness, postural hypotension, dry mouth, depression
-5 alpha reductase inhibitors (prevent synthesis of testosterone - finasteride and dutasteride)
block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH
unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months. They may also decrease PSA concentrations by up to 50%
adverse effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
-surgery: transurethral resection of prostate (TURP)
Carcinoma of prostate:
- is this common?
- what patient demographic is affected?
- what genetic mutations have been found to be assoc. with this?
-common: 11% cancer deaths in males
Epidemiology: caucasians, western world, 60-80yrs, risk increases with affected 1st degree relative
Genetics:
- mutations on chromosomes 1p/8p/xp
- mutations of BRCA2 gene
Describe the pathology of carcinoma of prostate
->95% are multifocal adenocarcinomas, arises mainly in peripheral ducts and glands
Spread:
- locally to prostatic capsule, urethra, bladder base and seminal vesicles
- lymphatic - (pelvic) sacral/iliac/paraaortic nodes
- Bones - osteosclerotic met.s, lungs, liver
- perineural invasion along autonomic nerves
Describe the presentation of prostate carcinoma
- asymptomatic (found on DRE/PSA)
- lower urinary tract symptoms
- haematuria
- haematospermia
- bone pain
- anorexia
- weight loss
Describe what is found on DRE of carcinoma of prostate?
Asymmetry/nodule/fixed/craggy
-75% arise in the periphery so can be felt
What is PSA?
prostate specific antigen, normal levels about 4 but it rises with age
GP’s run checks on at risk patients and do blood tests for PSA – if these are raised, then patients are referred to clinic.
If levels are raised but stable, then patients are normally monitored either every 6 or 12 months.
If levels are raised and increasing, then it is more likely to be cancer.
sensitivity of PSA is high but specificity is low. (if they do have a raised PSA they are likely to have cancer but if they dont could also have cancer)
(5-alpha reductase inhibitor)
What could cause a rise in PSA levels?
- prostate carcinoma
- BPH
- prostatits/UTI
- retention
- catheterisation
- DRE
Describe the 4 ways prostate carcinoma is diagnosed?
- DRE
- Imaging
- PSA
- transrectal US biopsy
If they have a positive DRE/positive PSA/clinical suspicion refer for biopsy
What imaging is used to diagnose prostate carcinoma?
USS, skeletal xrays/bone xrays
What is a transrectal US biopsy? when is this done? what are the complicationS?
8-12 needle core biopsies guided by USS - uncomfortable
Indications:
- abnormal DRE, an elevated PSA
- previous biopsies showing PIN (prostatic intraepithelial neoplasia), or ASAP (atypical small acinar proliferation)
Complications:
- haematuria and haematospermia for 2-3weeks after
- 0.5% sepsis risk
- 0.5% rectal bleed
- vaso-vagal syncope
what scoring is used to grade prostate carcinoma? describe this?
gleasons scoring - v. good predictor of prognosis and is widely used
- score based on the architectural appearance of prostate gland
- 2 most abundant cell patterns assessed and then added together to give a score
Graded using the Gleason grading system, two grades awarded 1 for most dominant grade (on scale of 1-5) and 2 for second most dominant grade (scale 1-5). The two added together give the Gleason score. Where 2 is best prognosis and 10 the worst.
How is prostate carcinoma staged?
TNM
Tumour - 1-5
Nodes - 0-1
Met.s - 0-1
What are the different management options for organ confined disease of the prostate?
Watchful waiting/deferred treatment/symptomatic treatment:
-conservative then as systemic/local progression treat palliatively
Active surveillance/active monitoring:
-close surveillence and treat at pre-defined thresholds that classify progression - curative
Radical surgery postatectomy (radical/laparoscopic/robotic)
-complications are erectile dysfunction, incontinence, bladder neck stenosis
Radical radiotherapy: EBRT, brachytherapy
-complications are irritative LUTS, haematuria, GI sx, erectile dysfunction, incontinence
What are the different management options for locally advanced disease?
Radiotherapy with neo-adjuvant hormonal therapy:
-better 5yr survival compared to EBRT alone
Watchful waiting
Hormonal therapy - symptomatic treatment if unfit for curative
