Renal Flashcards
1
Q
UTIs more commonly occur in males or females?
A
Females
2
Q
1 in how many women, by the age of 24, will have had a UTI?
A
1 in 3
3
Q
Which bacteria causes 80% of UTIs?
A
E.coli
4
Q
As well as E.coli, what are the other causes of a UTI? (3 + 1 very rare)
A
- Staphylcoccus species
- Proteus mirabilis
- Enterococci
- Candida albicans (very rarely)
5
Q
If candida albicans is the cause of the UTI, in what people is it most likely to occur/what risk factors is it associated with?
A
Hospitalised patients with risk factors such as indwelling catheter, immunosuppression, diabetes or antibiotic treatment.
6
Q
What are the three routes/classifications of a UTI occurs?
A
- Retrograde - ascending through the urethra into the bladder
- Blood stream (most likely in immunocompromised people)
- Direct - for example upon insertion of a catheter into the bladder, instrumentation or surgery.
7
Q
Although most UTIs aren’t associated with many risk factors, what are the possible risk factors for women? (8)
A
- Sexual intercourse
- Atrophic urethritis & vaginitis
- Abnormalities of the urinary tract function i.e. indwelling catheter, neuropathic bladder, outflow obstruction)
- Anatomical abnormalities
- Incomplete bladder emptying
- Female diaphragm
- Immunocompromised
- Previous UT surgery
8
Q
In men, what are the risk factors associated with UTIs? (5)
A
- Abnormalities of the urinary tract function i.e. indwelling catheter
- Structural abnormalities - urinary stones, renal tract abnormalities
- Incomplete bladder emptying
- Previous UT surgery
- Immunocompromised
9
Q
How does a UTI present? (10)
A
- Increased urinary frequency/urgency and/or strangury (the feeling of needing to pass urine despite having just done so)
- Dysuria
- Urine that smells, is cloudy or contains blood
- Lower abdominal ache
- Non-specific malaise
- Nausea
- Cold sweats
The following are more common in elderly, frail women: - Rigors
- New onset delirium
- Fever > 37.9 (or 1.5 above baseline)
- Costovertebral tenderness
10
Q
What are the signs on examination associated with a UTI/complicated UTI? (2)
A
- Suprapubic tenderness
2. Loin pain and fever (may be pyelonephritis)
11
Q
What investigation is carried out with a suspected UTI, and what will give a positive finding?
A
Urine dipstick
1. Leucocyte esterase
2. Nitrite
If both positive, obviously very highly likely
If neither are positive, UTI is unlikely
If nitrite is positive, UTI is highly likely
If leucocyte esterase is positive, UTI is moderately likely
12
Q
If the symptoms are present but the patient is catheterised, so urine dipstick is not possible, how should the patient be managed?
A
Treat with suspected UTI - it is reasonable to start on empiric antibiotics
13
Q
Why should a urine dipstick not be tested in a person with an indwelling catheter?
A
Research studies have shown that they won’t distinguish between asymptomatic bacteriuria and a UTI
14
Q
When should urine cultures be sent for, in women with a suspected UTI? (3)
A
In women who present for the first time with a UTI, if they have any of the following:
- Impaired renal function
- An abnormal urinary tract (for example renal calculus, vesicoureteric reflux, reflux nephropathy, neurogenic bladder, urinary obstruction, or recent instrumentation).
- Immunosuppression
15
Q
In women presenting with a UTI and positive dipstick testing (or negative dipstick testing but obvious symptoms), what is the recommended treatment? (2)
A
*Paracetamol and/or NSAIDs (ibuprofen/naproxen)
*3-day antibiotic course - either:
- Nitrofurantoin: 50mg 4X daily or 100mg
2X daily
- Trimethoprim: 200mg 2X daily
local guidelines may indicate which is preferred based upon local resistance patterns
16
Q
What is not to be recommended for treatment of a UTI? (2)
A
- Cranberry juice/products
- Urine alkalinising agents
(due to a lack of evidence supporting either of these options)
17
Q
In women with a complicated UTI, how long should the course of antibiotics be?
A
5-10 days
18
Q
What is different about treating a UTI in a pregnant women, compared to not pregnant? (4)
A
- Urine cultures must be sent in all pregnant women with a suspected UTI, before treatment and after, to check it has been cured
- If trimethoprim is prescribed, folic acid must be prescribed alongside it, if the women is in the first trimester of pregnancy
- An alternative antibiotic for use is cefalexin 500mg 2X daily (though this is more broad spectrum so NICE recommends nitrofurantoin over this)
- The course of treatment should be 7 days
19
Q
In pregnant women with asymptomatic bacteriuria, what is the recommended antibiotic to use?
A
- Amoxicillin - 250mg 3X daily; safe during pregnancy
2. Nitrofurantoin (if amoxicillin is not suitable)
20
Q
If a women with a catheter is found to have a UTI, what is the course of action and treatment plan?
A
- Change the catheter before treatment (if it has been in place for > 7 days)
- Paracetamol/NSAIDs
- Either nitrofurantoin or trimethoprim
21
Q
If a women with a catheter is found to have asymptomatic bacteriuria, what is the course of action?
A
Do not treat with antibiotics, offer paracetamol and/or NSAIDs
22
Q
What is pyelonephritis?
A
It is an infection within the renal pelvis, with or without active infection of the renal parenchyma. It is generally caused by bacteria ascending the from the lower urinary tract. Small cortical abscessed and streaks of pus in the renal medulla are often present.
23
Q
What are the most common pathogens known to cause pyelonephritis? (5)
A
- Escherichia coli.
- Klebsiella pneumoniae.
- Proteus species.
- Pseudomonas species.
- Enterococcus species.
24
Q
What are the complications of pyelonephritis? (3)
A
- Impaired renal function or renal failure
- Sepsis
- Pre-term labour in pregnancy
25
The risk of developing a complication of pyelonephritis is increased in people with what? (6)
1. Severe illness
2. Abnormalities of the renal tract anatomy/function
3. Diabetes
4. Pregnancy
5. Over 65 years old
6. Persistent pyelonephritis despite treatment
26
How is acute pyelonephritis diagnosed?
Acute pyelonephritis is diagnosed in a person with a proven UTI who has loin pain and/or fever. (There are no clinical features or routine investigations that conclusively distinguish acute pyelonephritis from cystitis).
A urine culture is normally sent for to determine the pathogen.
27
If a person has loin pain/fever but negative dipstick test for a UTI, what could be the other causes of loin pain? (3)
1. Pelvic inflammatory disease
2. Appendicitis
3. Renal calculi
28
In people with diagnosed pyelonephritis, who can be treated in primary care, rather than be admitted to hospital? (2)
1. In people who are pyrexial but have no risk factors for developing a complication from acute pyelonephritis
2. In people who are apyrexial, with or without risk factors for developing a complication
29
Under what conditions should people be admitted to hospital with acute pyelonephritis? (5)
1. People who are significantly dehydrated or unable to take oral fluids/medications
2. Have signs of sepsis
3. Are pregnant and pyrexial
4. Frail/elderly residents of care homes who have recurrent UTIs
5. Fail to improve significantly within 24 hours of antibiotics
30
What is the treatment for pyelonephritis, in women who are not pregnant, men and people with indwelling catheters? (1 first-line, and 1 alternative)
1. Ciprofloxacin 500mg 2X daily for 7 days
| An alternative = Co-amoxiclav 500/125mg 3X daily for 14 days
31
What is the treatment for pyelonephritis in pregnant women who do not require admission?
Cefalexin 500mg 2X daily for 10-14 days
32
In addition to antibiotics, what other treatment/advise is given regarding pyelonephritis? (3)
1. Take paracetamol for the pain/fever
2. Maintain full hydration
3. Review urine culture and change medication if necessary
33
When is a referral for investigation of underlying abnormality recommended in acute pyelonephritis? (3)
1. In women who have had 2 or more episodes
2. In men following their first episode
3. All people with a UTI caused by a proteus species
34
What is hydronephrosis?
It is the swelling of one or both kidneys due to the build up of urine
35
What are the common causes of hydronephrosis? (3)
The common causes are:
1. Prostatic obstruction
2. Gynaecological cancer
3. Calculi
36
What are the causes of hydronephrosis within the lumen? (4)
1. Calculus
2. Tumour of the renal pelvis/ureter
3. Blood clot
4. Sloughed renal papillae (diabetes, NSAIDs, sickle cell disease/trait)
37
What are the causes of hydronephrosis within the wall of the urinary tract/pressure from outside the wall? (6)
1. Congenital abnormalities of the urinary tract
2. Stricture
3. Neuropathic bladder
4. Diverticulitis
5. Aortic aneurysm
6. Prostatic hypertrophy
38
How does hydronephrosis present if it is caused by an upper UT obstruction? (3)
1. dull ache in the flank/loin which may be provoked by an increase in urine volume (high fluid intake)
2. Complete anuria is strongly suggestive of complete bilateral obstruction
3. Polyuria - due to partial obstruction as a result of tubular damage and impairment of concentrating mechanisms
39
How does hydronephrosis present if it is caused by a bladder outlet obstruction? (4)
1. Poor stream/hesitancy
2. Terminal dribbling and a sense of incomplete emptying
3. Frequent passage of small quantities of urine
4. Infection commonly occurs and may precipitate acute retention of urine
40
What may be the signs on examination of hydronephrosis?
It depends on the site of obstruction - an enlarged bladder or kidney may be felt on examination. Pelvic and rectal examination are important to determine the cause of the obstruction.
41
What investigations are carried out with suspected hydronephrosis? (3)
1. Imaging: ultrasound (although helical/spiral CT scanning has a higher sensitivity) for detecting calculi/details of obstruction. Excretion urography identifies the site of obstruction
2. Radionuclide studies: not useful in acute obstruction, but may help in longstanding obstruction
3. Bloods: to assess creatinine and function of the kidneys
42
What is the treatment for hydronephrosis?
Surgery is the usual treatment for persistent obstruction. If the obstruction cannot be fixed surgically, an alternative solution including either; an indwelling catheter, a stent placed across the obstructing lesion or the formation of an ileal conduit may be considered.
43
How common is acute kidney injury (AKI) formerly known as acute renal failure?
Very common - stage 1 AKI is found in more than 15% of emergency hospital admissions. AKI with plasma creatinine >500micromol/L is diagnosed in 2 to 7.5 per 10,000 adult population per year in the UK.
44
What is AKI characterised by?
A decline in renal excretory function over hours or days that can result in failure to maintain fluid, electrolyte, and acid-base homeostasis
45
What are the three categories causes of AKI can be divided in to?
1. Pre-renal
2. Renal (Intrinsic)
3. Post-renal
46
What are the pre-renal causes of AKI? (2)
1. Hypovolaemia (e.g. haemorrhage, gastrointestinal losses, renal losses, burns)
2. Reduced cardiac output (e.g. cardiac failure, liver failure, sepsis, drugs)
47
What are the renal (intrinsic) causes of AKI? (5)
1. Drugs (e.g. ACE inhibitors, NSAIDs— mechanism of renal damage depends on the type of drug)
2. Vascular (e.g. vasculitis, thrombosis, athero/thromboembolism, dissection)
3. Glomerular (e.g. glomerulonephritis)
4. Tubular (e.g. ischaemia, rhabdomyolysis, myeloma, contrast)
5. Interstitial (e.g. interstitial nephritis)
48
What are the post-renal causes of AKI?
Obstruction (e.g. renal stones, pyonephrosis, blocked catheter, pelvic mass, enlarged prostate, cervical carcinoma, retroperitoneal fibrosis)
49
In addition to surgery, how else is hydronephrosis treated? (1)
1. Urine drained using catheter inserted into kidney through the urethra, or directly through the skin
50
What are the possible complications that can occur from hydronephrosis? (2)
1. Increased chances of UTI
| 2. Scar tissue building up in the kidneys which can reduce kidney function --> kidney failure
51
What is the most common cause of AKI?
Reduction in renal perfusion causing ischaemia of the renal parenchyma
52
Other than poor renal perfusion, name two more common causes of AKI?
1. Sepsis
| 2. Nephrotoxic agents
53
What percentage of adult AKIs are caused by urinary tract obstruction?
10%
54
What are the risk factors/when are people more prone to developing AKI? (9)
1. Aged over 65 years
2. History of AKI
3. CKD
4. Symptoms/history of urological obstruction
5. Sepsis
6. Hypovolaemia
7. Oliguria
8. Nephrotoxic drugs
9. Exposure to iodinated contrast
55
What can commonly develop after an episode of AKI?
CKD
56
What can acute changes in kidney function indicate about the rest of the body?
Severe systemic derangement, and is often a poor prognostic marker
57
If the AKI is uncomplicated, what is the mortality rate?
10%
58
What are the most serious complications of AKI? (4)
1. Hyperkalaemia
2. Pulmonary oedema
3. Metabolic acidosis
4. Uraemic pericarditis
59
When should AKI be suspected in someone?
Patients who have the risk factors present, and present with an acute illness/have symptoms associated with the complications of an AKI i.e. breathlessness, drowsiness and nausea for pulmonary oedema
60
What biochemical abnormalities may be seen in someone with AKI? (5)
1. Hyperkalaemia
2. Metabolic acidosis
3. Hyponatraemia
4. Hypoglycaemia
5. Hyperphosphataemia
61
How is a patient diagnosed with AKI in a primary care setting? (3)
Serum creatinine needs to be measured and compared to baseline results.
1. A rise in serum creatinine of >26micromol/L within 48 hours is significant
2. A 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
3. A fall in urine output to less than 0.5 mL/kg/hour for more than 6 hours
62
What 'volume stats' (vitals) need to be assessed for a person with AKI?
1. Core temperature.
2. Peripheral perfusion.
3. Heart rate/blood pressure (and any postural changes).
4. Jugular venous pressure.
63
What information needs to be known in order to manage a person with AKI?
1. Cause of the AKI - so current or recent symptoms that may suggest underlying cause, e.g. nausea and vomiting = hypovolaemia
2. Drug history
3. Social history (exposure to tropical diseases/rodents)
64
How can signs of renal disease be assessed in a patient with AKI?
Urine dipstick testing:
1. Proteinuria --> suggests intrinsic glomerular disease
2. Haematuria and proteinuria --> glomerular causes of AKI
3. Nitrites + white blood cells --> pyelonephritis
65
How many stages are there of AKI?
3
66
What does stage 1 AKI signify?
Creatinine rise of 26 micromol or more within 48 hours OR Creatinine rise of 50–99% from baseline within 7 days* (1.50–1.99 x baseline) OR Urine output** < 0.5 mL/kg/h for more than 6 hours
67
What does stage 2 AKI signify?
100–199% creatinine rise from baseline within 7 days* (2.00–2.99 x baseline) OR Urine output** < 0.5 mL/kg/hour for more than 12 hours
68
What does stage 3 AKI signify?
200% or more creatinine rise from baseline within 7 days* (3.00 or more x baseline) OR Creatinine rise to 354 micromol/L or more with acute rise of 26 micromol/L or more within 48 hours or 50% or more rise within 7 days OR Urine output** < 0.3 mL/kg/hour for 24 hours or anuria for 12 hours OR Any requirement for renal replacement therapy
69
What is the management for someone with stage 1 AKI with no indication for admission or specialist input? (5)
1. Consider stopping nephrotoxic drugs e.g. ACE inhibitors, NSAIDs, ARBs, spironolactone (risk of stopping needs to be weighed up against renal benefit - e.g. someone with heart failure at risk of fluid overload)
2. Treat underlying sepsis
3. Advise appropriate hydration
4. Adjust doses of medication
5. Monitor creatinine regularly and reconsider hospital admission if even small changes occur
70
When should an urgent admission or same-day referral be made in someone with AKI?
1. The underlying cause requires secondary care management
2. No identifiable cause of AKI
3. There is a risk of urinary tract obstruction
4. There is a deterioration in the patients clinical condition and they require close monitoring
5. A complication of AKI has occurred which requires secondary care management, e.g. pulmonary oedema or severe hyperkalaemia
71
When does the management of AKI need to be discussed with a nephrologist? (2)
1. ASAP if person has stage 3 AKI or stage 4/5 CKD
| 2. The cause needs specialist treatment e.g. tubulointerstitial nephritis, glomerulonephritis
72
In a person with stage 2 AKI, when would the doctor need to seek specialist advice?
If there is uncertainty about the cause or management, or if the person is not responding to treatment
73
What is chronic kidney disease (CKD)?
CKD is an abnormality of kidney function or structure that is present for more than 3 months, with implications for health
74
How is kidney damage detected? (8)
Kidney damage causes leakage of protein and/or blood into the urine, resulting in proteinuria and haematuria. Therefore markers of kidney damage include:
1. Proteinuria
2. Haematuria
3. Albuminuria (albumin:creatinine ratio) of more than 3 mg/mmol
4. Urine sediment abnormalities
5. Electrolyte and other abnormalities due to tubular disorders
6. Abnormalities detected by histology,
7. Structural abnormalities detected by imaging
8. A history of kidney transplantation.
75
What are the 4 categories of causes of CKD?
1. Conditions associated with intrinsic kidney disease
2. Nephrotoxic drugs
3. Conditions associated with obstructive kidney disease
4. Multi-system diseases that may involve the kidney
76
What are the conditions associated with intrinsic kidney disease? (2)
1. Diabetes
| 2. Hypertension
77
What are the nephrotoxic drugs associated with causing CKD? (5)
1. Lithium.
2. Ciclosporin
3. Calcineurin inhibitors (such as tacrolimus).
4. Aminoglycosides.
5. Mesalazine
78
What are the conditions associated with obstructive kidney disease? (3)
1. Bladder voiding dysfunction such as neurogenic bladder, benign prostatic hypertrophy
2. Urinary diversion surgery
3. Recurrent urinary stones
79
What are the multi-system diseases that can cause CKD? (4)
1. Systemic lupus erythematosus (SLE)
2. Vasculitis
3. Myeloma
4. Autosomal dominant polycystic kidney disease, Alport's syndrome, and familial glomerulonephritis
80
In the UK, approximately what percentage of adults have stage 3-5 CKD?
8.5% (10.6% in females and 5.8% in males)
81
What are the complications associated with CKD? (8)
1. Renal disease that requires renal replacement therapy
2. Renal anaemia
3. Renal bone disease
4. Malnutrition
5. Neuropathy
6. Lipid abnormalities
7. Cardiovascular events (increased risk of stroke and MI)
8. Cardiovascular disease
82
It is important to identify and treat CKD in the earlier stages. Therefore people with risk factors are tested for CKD. What are the risk factors? (10)
1. Diabetes (type 1 and 2)
2. Hypertension
3. AKI
4. CVD (ischaemic heart disease, heart failure, peripheral vascular disease, cerebrovascular disease)
5. Obesity with metabolic syndrome
6. Renal calculi/BPH
7. Multi-system diseases e.g. lupus, myeloma
8. Family history of CKD stage 5
9. Those taking nephrotoxic drugs
10. People with incidental findings of haematuria, proteinuria or an eGFR of less than 60 mL/min/1.73 m2.
83
What common risk factors are not alone indicators of CKD? (4)
1. Obesity
2. Age
3. Gender
4. Ethnicity
84
How do you test for CKD?
1. Measure serum creatinine to calculate eGFR
2. Take an early morning urine sample to measure urinary albumin:creatinine ratio (ACR)
3. Dip the urine for haematuria
85
What advise is given to the patient when wanting to measure eGFR?
Not to eat meat for 12 hours before the measurement is taken
86
What is the advise given when calculating the eGFR in a person of African-Caribbean or African ethnicity?
Multiply the eGFR by 1.159 (to correct for difference in muscle mass)
87
How many stages are there of CKD?
G1, G2, G3a, G3b, G4, G5 (each stage can then be further grouped into either A1, A2 or A3).
88
For stage 1 CKD, what is the eGFR measurement?
>=90 normal and high
89
For stage 2 CKD, what is the eGFR measurement?
60–89 mild reduction related to normal range for a young adult
90
For stage 3a CKD, what is the eGFR measurement?
45–59 mild to moderate reduction
91
For stage 3b CKD, what is the eGFR measurement?
30-44 moderate to severe reduction
92
For stage 4 CKD, what is the eGFR measurement?
15–29 severe reduction
93
For stage 5 CKD, what is the eGFR measurement?
<15 kidney failure
94
What blood tests should be taken regularly to monitor the progression of CKD?
FBC - to check for renal anaemia
U&Es - calcium, phosphate, Vit D
Parathyroid hormone (all for bone disease)
95
Which drug is offered to all people with CKD, in the attempt to prevent or thwart the progression of CVD?
Atorvastatin 20mg
96
Which drug type may be offered to someone with CKD, as a secondary prevention of CVD, but not as a primary prevention?
Anti-platelet therapy (the risks and benefits need to be weighed up, as people with CKD can have both thrombotic and bleeding tendencies)
97
What lifestyle advice is offered to someone with CKD? (6)
1. Smoking cessation if necessary
2. Drinking alcohol in moderation
3. Reduced weight if necessary
4. Take regular exercise
5. Eat a healthy diet - do not offer a low protein diet
6. Avoid using over-the-counter NSAIDs
98
How does CKD present? (10)
1. Anaemia (pallor, lethargy, breathlessness)
2. Platelet abnormality (epistaxis, bruising)
3. Skin (pigmentation, pruritis)
4. GI tract - anorexia, nausea, vomiting, diarrhoea
5. Endocrine/gonads - amenorrhoea, erectile dysfunction, infertility
6. Polyneuropathy
7. CNS - confusion, coma, polydipsia
8. CVS - uraemia pericarditis, hypertension, peripheral vascular disease, heart failure
9. Renal - nocturia, polyuria, oedema
10. Renal osteodystrophy - osteomalacia, bone pain, hyperparathyroidism, osteosclerosis
99
For people with hypertension and CKD with urinary albumin:creatinine ratio (ACR) of 30 mg/mmol or more, what treatment is recommended?
A low-cost renin-angiotensin system antagonist, for example lisinopril OR losartan, should not be prescribed both simultaneously.
100
What is benign prostatic hyperplasia (BPH)?
Hyperplasia of both glandular and connective tissue elements, which basically means an enlarged prostate. This can put pressure on the urethra, and lead to problems including polyuria, nocturne, and dribbling.
101
BPH tends to affect who?
Men over 60 years old
102
How common are lower urinary tract symptoms?
Moderate to severe lower urinary tract symptoms are present in about 30% of men older than 50 years of age, and the most common cause is BPH.
103
What are the risk factors for developing BPH? (1)
```
Increasing age
(it has also been linked to metabolic syndromes however the mechanism of association is poorly understood)
```
104
How does BPH present? (5)
1. Increased frequency of micturition
2. Nocturia
3. Delay in initiation of micturition
4. Dribbling
5. Acute urinary retention or retention with overflow incontinence can also occur less commonly
105
On examination, how does BPH present? (1)
An enlarged smooth prostate
106
What investigations are carried out to diagnose BPH? (3)
1. Serum electrolytes
2. Renal ultrasound
- performed to exclude renal damage resulting from obstruction
3. Serum PSA - As prostate cancer can present similarly, serum PSA is tested, although it can be elevated for benign disease, an elevated value is usually an indication for specialist referral and prostate biopsy.
107
What is the first-line treatment for BPH? (1)
1. Alpha-blockers i.e. tamsulosin
108
Why are alpha-blockers effective in treating BPH?
They relax smooth muscle in the bladder neck and prostate, resulting in an increase in urinary flow rate and an improvement in obstructive symptoms.
109
What common side effect is associated with alpha-blocker use?
Postural hypotension
110
Which drug is an alternative to alpha-blockers, that can be used in the treatment of BPH? (1)
5a-reductase inhibitors i.e. finasteride
111
How do 5a-reductase inhibitors treat BPH?
They block the conversion of testosterone to dihydrotestosterone (the androgen responsible for prostatic growth), and so reduce the size of the prostate gland. They are an alternative to alpha-blockers particularly in men with significantly enlarged prostates, however can take several months before any effect is seen, so alpha-blockers may be preferred initially.
112
What type of cancer makes up almost all (95%) of the prostate cancers?
Adenocarcinomas (cancers of glandular cells)
113
What does it mean that prostate cancers are commonly 'multi-focal'?
The different foci may be caused by different genetic mutations, which can differ greatly in growth rate and ability to metastasize.
114
What does it mean if the prostate cancer is localised?
It is confined within the capsule and seldom causes symptoms
115
What does it mean if the prostate cancer is locally advanced?
It extends beyond the capsule of the prostate and is often asymptomatic when diagnosed.
116
Where does metastatic prostate cancer tend to spread to?
Most frequently affects the bones, where it causes pain and fragility fractures
117
Prostate cancer makes up approximately what % of all new cases of cancer in men?
26%
118
What are the four key risk factors associated with prostate cancer?
1. Increasing age
2. Black ethnicity
3. Family history of prostate cancer and genetics
4. Weight (obesity and being overweight)
Men have a 15–20% increased risk of dying from prostate cancer with every 5 kg/m2 increase in BMI
119
Which scoring/grading system is used in prostate cancer?
Gleason score
120
If a patient presents with symptoms suggestive of prostate cancer, what course of action is recommended? (3)
1. Offer prostate specific antigen (PSA) testing
2. DRE
3. Referral urgently to a urology cancer specialist
121
As prostate cancer is often asymptomatic, and metastases cause the first symptoms, what symptoms should alert suspicion of prostate cancer? (6)
1. Unexplained lower back or bone pain
2. Lethargy
3. Erectile dysfunction
4. Haematuria
5. Anorexia/weight loss
6. Lower urinary tract symptoms
122
What may be the findings of a DRE?
A hard, nodular prostate (though a normal DRE would not exclude cancer)
123
What is PSA?
The prostate specific antigen is a protein produced by both normal and cancerous prostate cells.
PSA is secreted by prostate epithelial cells into prostatic fluid, where its function is to liquefy semen and thus allow spermatozoa to move more freely. Small amounts of it are also present in the blood.
124
When offering PSA testing, why is it important to weigh up the risks and benefits, and when should it be offered/not offered? (3)
1. Offer PSA testing to men over 50 years of age who request it
2. Consider a PSA test in men with symptoms including erectile dysfunction, haematuria, weight loss, bone pain
3. Do not offer PSA to men who are asymptomatic - no national screening as the benefits do not outweigh the harms
125
What are the problems with PSA testing?
1. False-negative results (15% of men with a negative result will have prostate cancer)
2. False-positive results (75% have a negative prostate biopsy)
3. Unnecessary investigation
4. Unnecessary treatment
126
In terms of treatment, if the prostate cancer is judged to be low risk, what is the management plan?
Active surveillance can be offered.
Other treatments that can be considered include:
Radical prostatectomy, or radical radiotherapy (external-beam radiotherapy [EBR], or brachytherapy).
127
If the prostate cancer is judged to be an intermediate risk, what is the management plan?
Radical prostatectomy OR
Radical radiotherapy with 6 months of androgen deprivation therapy (before, during or after radiotherapy) can be offered (rather than radical radiotherapy or androgen therapy alone).
128
If the prostate cancer is judged to be high risk, what is the management plan?
Radical prostatectomy OR
Radical radiotherapy with 6 months of androgen deprivation therapy (before, during or after radiotherapy) can be offered (rather than radical radiotherapy or androgen therapy alone) if there is a realistic prospect of long-term disease control.
Androgen deprivation therapy may be continued for up to 3 years
129
Men with prostate cancer who are on long-term androgen suppression may develop hot flushes, what medication is prescribed to manage these?
Medroxyprogesterone acetate (20mg daily)
