Prostatic Gland Disorders

Question 1

What is the incidence and site of BPH?

Answer 1

Incidence: 90% of all males above age of 80 years has BPH
Site: Median lobe which cancer occurs in posterior lobe

Question 2

What is the clinical picture of BPH?

Answer 2

-Enlarged prostatic gland with a smooth regular surface on PR
-Terminal drippling
-Retention
-Hematuria
-Hesitancy
-Poor flow of urine

N.B: Urine retention and increased intravesical pressure associated with prostatic disorders can lead to bladder diverticulum with residual urine after micturition.

Question 3

What are the investigations of BPH?

Answer 3

-DRE: to examine gland size and surface
-Urine dipstick: to exclude infection
-Uroflowmetry: (N:>15ml/sec) to exclude complications

Question 4

What is the management of BPH?

Answer 4

-Lifestyle modification: alter fluid intake

-Medical:
1-Alpha blocker (Tamsulin):
Advantage: fast onset
Disadvantage: more adverse effects

2- 5 alpha reductase inhibitor
Advantage: slow onset
Disadvantage: low incidence of acute retention

-Surgical: TURP (Transuretheral resection of prostate)+bladder neck incision

Question 5

What is the site and pathology of prostatic cancer?

Answer 5

Site: posterior lobe
Pathology:
-95% adenocarcinoma
-70% multi focal and peripheral

(The tumor is testosterone dependent)

Question 6

How is the prostatic cancer graded?

Answer 6

-Graded by Gleason grading:

About 12 biopsies are taken from the gland and examined. Each sample is scored from 1 to 5. With the best sample written first.

So 3+4 is better than 4+3

Grade 1: score 6 or less
Grade 2: 7(3+4)
Grade 3: 7(4+3)
Grade 4: 8
Grade 5: 9-10

Question 7

What is the modes of spread of prostatic cancer?

Answer 7

-The most common mode is blood spread through the venous plexus to the vertebral venous plexus causing osteosclerotic back pain lesion.

-The first spread happens through lymphatics (to internal iliac and obturator LNs)

Question 8

What are the investigations of prostatic cancer?

Answer 8

-DRE
-Prostatic specific antigen PSA (N:up to 4nl/ml) (but the problem is that PSA is organ specific not tumor specific, so it increases also in: exercise, UTI, BPH, prostatitis, and after ejaculation)
-Prostatic biopsy

Question 9

What is the definitive treatment of the following case:
(Fit patient (<60 years) + localized tumor)

Answer 9

Radical prostatectomy+_ transcrotal orchidectomy

Question 10

What is the definitive treatment of the following case:
(UnFit patient (>60years) + localized tumor)

Answer 10

Watchful waiting

Question 11

What is the definitive treatment of the following case:
(UnFit patient (>60 years) + metastasis)

Answer 11

Palliative radiotherapy or hormonal therapy
(Radiotherapy is better for bony metastasis)

Question 12

…. are anti-testosterones used in treatment of prostatic cancer but they are often associated with flaring up of metastatic symptoms so …. May be given as cyproterone acetate and flutamide.

Answer 12

LHRH analogues
Anti-androgens